Taiwan reaches crossroads in handling HIV epidemic

Top health officials say WHO membership needed

AIDS Alert International

When international health organizations and public officials sound the alarm about the growing HIV menace in Asia, little attention is paid to the epidemic’s growth and the resulting response in northern industrial regions, such as Taiwan. The AIDS epidemic, which first made its way to Taiwan in 1984, has resulted in 759 deaths and 3,674 known cases of HIV infection. However, Taiwan’s Center for Disease Control within the Department of Health in Taipei estimates that 20,000 people in Taiwan are infected with the virus.

Meanwhile, Taiwan has never received support for its HIV prevention and treatment programs from the international community, says Shiing-Jer Twu, MD, MPH, PhD, director-general of the Center for Disease Control. The political problem between Taiwan and China has resulted in China’s interference with Taiwan’s international diplomacy, Twu says. One of the problems is that, so far, China has successfully prevented Taiwan from being permitted to join the World Health Organization (WHO), and this has prevented the possibility of a mutual sharing of HIV prevention and treatment resources and experiences between Taiwan and other countries in the area, Twu says.

Taiwan’s public health care response to the epidemic has been well-orchestrated, Twu says. "Since the discovery of the first reported AIDS case in 1982, Taiwan has put forward a considerable amount of effort in the domestic AIDS prevention and public education program," Twu says.

Taiwan’s public health response includes the following elements:

• Free medical therapy is provided by the Department of Health (DOH) for all HIV-infected citizens.

• People who suspect they are infected are encouraged to go to public health centers across the island or to the 25 hospitals authorized by the DOH to conduct free HIV tests.

• Screening for HIV began in 1985, making the nation one of the first in the world to conduct general screening of blood for transfusion and blood products, as well as screening of high-risk groups, military draftees, prison inmates, and foreign laborers. "The ROC Public Health Association has been asked to develop a new method of mailing blood specimens on filter paper for more anonymous screenings," Twu says.

• Citizens with questions about HIV may call special telephone lines at the DOH, local health bureaus, and designated hospitals. These lines, called the Master Chang Line, the Life Lines, and the Makay Safety Line, also provide counseling on AIDS.

• Pregnant women are offered free antenatal HIV tests, sponsored by the CDC Taiwan. Of 30,058 pregnant women who were tested during September to November 2000, four were found to be HIV-positive, Twu says. "The infection rate among pregnant women had shown an increase in 2000 compared with the rate in 1997, which was around three out of 100,000 people," Twu says.

AIDS prevention work began in Taiwan in 1985 when public health authorities set up an AIDS committee to promote educational programs and to establish an official documentation system, Twu says. From 1994 to 1996, the country’s AIDS committee implemented an initial plan for AIDS prevention and treatment, and from 1997 to 2001, the committee implemented a second five-year plan for AIDS prevention and treatment. 

"Although under these two plans the work of testing, investigation, research, and medical therapy has proven quite successful, the work of controlling spread of the disease has proven much less satisfactory," Twu says. "It is hoped, therefore, that within a framework of interagency cooperation, the third five-year plan for AIDS prevention and treatment commencing in 2002 will focus on prevention work as its No. 1 mission."

Moving from passivity to active engagement

The goal is to bring about effective epidemiological control of the disease in Taiwan and to transform the character of public health efforts from one of passive provision of medical care to one of active engagement in preventing spread of the disease, Twu says.

The chief mode of HIV transmission in Taiwan is through sexual relations, with 91.5% of those infected reporting that risk behavior. About 1.6% were infected through contaminated needles shared by injection drug users. Transmission through blood transfusion is 0.3%, and mother-to-child transmission is 0.2%, with about seven known HIV-infected babies born through December 2001, Twu says. "Analyzed in terms of time period, the predominant route of transmission was via blood transfusion prior to 1987, via homosexual relations after 1988, and via heterosexual relations beginning in 1992," Twu says.

The greatest at-risk group for infection is the 20-29 age group, which has 1,334 recorded cases, accounting for 36.3% of all cases. Next is the 30-39 age group with 1,230 cases (33.5%), and the group at third-highest risk is the 40-49 age group with 480 cases (13.1%). "As this combined age range represents the most productive years of life, it is clear that unless AIDS prevention work can be carried out in an effective and timely fashion, the disease will have a devastating impact upon families and entire societies," Twu says.

Public health officials also are very concerned about the marked trend toward increased incidence of HIV infection among youths, Twu says. "It is increasingly imperative to learn from the strengths and weaknesses of control programs in other countries," Twu maintains. "And we need to enlist the active participation of all departments of government whose help may be of assistance in order to make a more concerted, united effort in halting the multiplication of new cases and averting the catastrophe which continued spread of the disease poses for the nation."

One barrier to HIV prevention has been the cultural passivity on the part of women, who are reluctant to ask their husbands or sexual partners to use condoms. According to CDC data through November 2000, of 227 HIV-infected females, 164 were married, and 52 of them had husbands who admitted to having sex with prostitutes. Furthermore, women in the childbearing years of 20-39 are at the greatest risk of infection, with this age group accounting for 61% of all HIV infections among females.

CDC statistics show that the rate of HIV infection among women in Taiwan has increased sharply since the 1980s. While the HIV infection ratio of men to women was 41 to 1 in 1989, by 2001 the ratio had reached 11 to 1. "In order to raise women’s awareness of HIV and AIDS, the CDC appealed to women to use condoms during sex and called for more research on women and AIDS in Taiwan," Twu says.