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Evaluation of the Control of HIV After a Prison Amnesty in Taiwan

Taipei, Taiwan


The injection of illicit drugs (IDU) is a major risk behavior for the transmission and acquisition of HIV-1 infection. Globally IDUs account for over 10% of persons with HIV/AIDS. However, in some areas in SE Asia and Eastern Europe, especially, injection drug use is the major behavior accounting for a rapidly expanding HIV epidemic. This situation is characteristic of the HIV/AIDS epidemic in Taiwan in the past 3 years. Recently the numbers of reported cases of HIV/AIDS expanded substantially and about 70% of recent cases have been in IDUs. Also, IDUs have been infected with a new recombinant HIV-1 subtype (CRF07_BC), which was imported from mainland China along with significant increased quantities of heroin. It is estimated that there are over 100,000 persons who inject heroin in Taiwan. There are 30,000 HIV/AIDS cases in Taiwan. In an effort to deal with this epidemic, the Taiwan Health Department has instituted a major Harm Reduction Program including 61 methadone maintenance clinics, 1181 needle exchange sites, HIV testing and counseling and other services. In July, 2007 a large prison amnesty was enacted and over 10,000 prisoners were released, including 4,878 with a history of IDU of whom 15% were HIV-positive. In this research project we plan to evaluate the health effects of the prisoner release, its effect on the prisoners and society and the effectiveness of the harm reduction program in dealing with this challenge. Our specific aims are to: 1. Evaluate the overall and cause specific mortality in prisoners with an IDU history after their release in comparison to those in the general population of similar age and sex, 2. Compare the characteristics of prisoners who use with those who do not use harm reduction services after their release 3. Evaluate the knowledge and attitudes about harm reduction services in a sample of 1000-1500 released prisoners, 4. Estimate the high risk drug use and sexual behavior among a cohort of released prisoners by their HIV infection status and their use/non-use of harm reduction services, and 5. Evaluate the incidence of HIV, HCV, HBV and syphilis infections according to their use or non-use of harm reduction services. The results of this research should be very useful to Taiwan and many other countries having significant HIV/AIDS epidemics in IDU populations. Many developing and developed countries have substantial populations of incarcerated prisoners, many of whom are injection drug users. When these populations are released from prison they are at increased risk of mortality and acquisition or transmission of HIV. This study will evaluate the effectiveness of a comprehensive harm reduction program in mitigating these risks. This project will evaluate the effect of a major harm reduction program instituted by the Taiwan Health Department on prisoners who were IDUs released as part of an amnesty program. To deal with the HIV epidemic among IDUs (who have accounted for about 70% of recent cases of HIV), the Taiwan government instituted many harm reduction services, including methadone maintenance clinics, NEPs and HIV testing and counseling. In 2007, a large prison amnesty was enacted, and Taiwan released over 10,000 prisoners, including about 5,000 with a history of IDU of whom 15% were HIV+. The aim of this project is to evaluate the impact of the prevention program by interviewing and obtaining biological samples from 1,000-1,500 randomly selected released prisoners with an IDU history, in order to: (1) evaluate mortality in prisoners after their release; (2) compare characteristics of prisoners who use and do not use harm reduction services; (3) evaluate their knowledge and attitudes about harm reduction; (4) estimate drug and sexual risk behavior by HIV status and harm reduction use; and (5) evaluate the incidence of HIV, HCV, HBV and syphilis in relation to use of harm reduction services. The addresses of the released prisoners are available and the 3 most populous geographic areas (north, south, and on the central west coast) will be selected, targeting approximately 1500 individuals. Subjects will be contacted for an interview regarding risk behaviors, use of harm reduction services, and testing for HIV, HCV, syphilis and HBV. Overall and cause-specific mortality rates will be assessed by searching official death records for the entire cohort of prisoners with a history of illicit drug use, and comparing their rates with that of similar other persons and with other former prisoners without a known drug use history. The collaboration is between the Bloomberg School of Public Health of Johns Hopkins University and the Center for Disease Control in Taiwan.


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