HIV/AIDS in Taiwan

Overview of (typically) sexually transmitted disease in Taiwan

Taiwan's epidemic of HIV/AIDS began with the first case reported in December 1984. On 17 December 1990 the government promulgated the AIDS Prevention and Control Act. On 11 July 2007, the AIDS Prevention and Control Act was renamed the HIV Infection Control and Patient Rights Protection Act. As of March 2016, there are 31,620 reported cases of Taiwanese testing positive, and 1,020 foreigners testing positive. Until January 2015, the original HIV Infection Control and Patient Rights Protection Act required foreigners who tested positive to be deported, therefore most of the reported foreigners are no longer in Taiwan. This policy was repealed in January 2015, allowing HIV/AIDS infected foreign individuals to remain in Taiwan. HIV/AIDS patients' medical treatment costs are covered by Taiwan's National Health Insurance (NHI). Of all cases:
93.39% are male, 6.61% female
72.24% are 20–49 years old, 20.08% are 15–24 years old

Another 893 foreigners have tested positive, most of whom have been deported by the Taiwan government before the policy change. The CDC has not published an analysis of foreigners who tested positive. The ratio of patients of drug users increases rapidly. Since 1984, incidence of infections through sexual contacts had accounted for 90% of all cases for most of time. But in 2005, drug using patients accounted for more than 50%. To prevent the disease from spreading to general population rapidly, the CDC announced the "Harm Reduction Pilot Projects for IDUs". The program includes expansion of the existing education and rehabilitation network, and the establishment of a harm reduction program unprecedented to the country.

Taiwan is entering a new and dangerous phase of its HIV 1/AIDS epidemic, which by far accounts for the majority of its total number of HIV infection cases. By the end of 2006, 13,702 individuals (including 599 foreigners) had been reported as infected with HIV 1 to the Centers for Disease Control of Taiwan. In 2003, HIV 1 rates in first time blood donors, military conscripts, and pregnant women were measured at 5.2, 57.0, and 12.0 per 100,000, respectively. A risk factor analysis of reported cases showed that the proportion of intravenous drug users infected with HIV 1 increased from 1.7% (13/772) in 2002, to 8.1% (70/862) in 2003, to 41.3% (628/1520) in 2004, to 72.4% (2461/3399) in 2005, and dropped to 68.6% (2017/2974) in 2006. A molecular epidemiological study showed that more than 95% of intravenous drug users with newly diagnosed HIV 1 in 2004 and 2005 were infected with CRF07 BC, a circulating recombinant form of subtypes B' and C. Previously, several studies suggested that CRF07 BC originated in China's Yunnan province as a mix of subtype B' from Thailand and subtype C from India. The subtype is believed to have moved to Xinjiang in China's northwest along a major heroin trafficking route. Of the 60,000–100,000 injecting drug users in Taiwan, 10–15% may be infected with CRF07 BC. If so, they probably represent the largest group of such intravenous drug users in northeast Asia. The circulating recombinant form might have followed a separate drug trafficking route to Taiwan from Yunnan via southeast China, Guangxi, and Hong Kong. There have been enormous increases in the amount of heroin smuggled into Taiwan and in the number of intravenous drug users since 2002, when five intravenous drug users from southern Taiwan were diagnosed as the country's first HIV 1 seropositive cases infected with CRF07 BC. The same population has high rates of syphilis, 8.1–13.8%, depending on the city. Furthermore, the percentage of homosexual or bisexual HIV 1/AIDS patients under the age of 20 years is significantly higher than that of heterosexual patients, 3.0% versus 1.7%. One of the primary factors that leads to HIV risk is the lack of accurate information on risky behaviors that lead to HIV contraction increases the risk of contracting HIV and other sexually transmitted infections. Taiwan's clinical spectrum of AIDS patients is similar to those reported in other developed countries, but significant differences have been noted in incidences of opportunistic infections. For example, the incidence of tuberculosis in patients with advanced illness is high in Taiwan (24.6%) and the rate of endemic fungal (Penicillium marneffei) infections is increasing. On the positive side, the effort by the Taiwanese Government since April 1997, to distribute highly active antiretroviral therapy for free has resulted in dramatic decreases in morbidity and mortality from HIV 1 infection. Because of their high background prevalence, HBV and HCV coinfections with HIV are particularly important in Asian countries in terms of HIV transmission via injecting drug use. In a survey of 459 intravenous drug users infected with HIV 1, one of us (Y MAC) found that 456 (99.6%) also had anti HCV antibodies and 77 (16.8%) were seropositive for HBsAg. The long term impact of hepatitis coinfections on HIV and on morbidity and mortality from liver disease requires monitoring.

By the end of 2006, 19 confirmed cases of vertical HIV 1 transmission have been reported to the Taiwan Centers for Disease Control. In 2013, CDC Deputy Director Chuang Jen hsiang (莊仁祥) said that the rise in the rate of HIV/AIDS cases was outstripping public funds, and that the NHI was NT$600 million (US$2 million) in debt due to treating HIV/AIDS patients. Chuang added that the Ministry of Health and Welfare was still considering a plan to reducing coverage for HIV positive Taiwan nationals from their current full coverage, in addition to requiring foreign nationals to pay in full for their treatment. Other STIs and illnesses were covered under National Health Insurance during this time of debate. Criticism of reducing coverage and expecting HIV/AIDS related treatments to be paid by the individuals, included that it further promoted the faulty idea that HIV/AIDS contraction is the fault of the individual.

Currently, HIV/AIDS patients are eligible for organ transplants. Plans exist to allow HIV/AIDS positive patients to donate organs to other HIV/AIDS positive patients by the end of 2016. Until March 2016, HIV/AIDS patients were "ineligible to receive organ transplants, including transplants of the heart, lungs, liver, kidney, pancreas, cornea and small intestines."

Several positive responses to the HIV/AIDS epidemic in Taiwan should be mentioned. Since 1992, 16 non governmental organizations registered or established in Taiwan have provided shelter, care, counselling, anonymous testing, and AIDS education. One in particular, the People Living with HIV/AIDS Rights' Advocacy Association, has been addressing human rights issues related to HIV/AIDS since 1997. However, most such organizations have their headquarters and facilities in northern Taiwan, and two thirds of the country's intravenous drug users live in central and southern parts. In addition, many social workers employed by non governmental organizations are still unfamiliar with issues related to drug abuse and inexperienced in interacting with intravenous drug users. There is a clear and immediate need for counselling workshops for medical staff and social workers. In the long term, there is need for more funding for AIDS research, especially vaccine development.

While Article 6 1 of original 1990 AIDS Prevention and Control Act stated that "HIV infected individuals shall not be discriminated against, nor shall they be deprived of their rights," a lack of specifying what those individuals' rights were left many loopholes open in the interpretation of the Act. In addition, the Japanese era 1944 Communicable Disease Control Act contained articles that could be used to circumvent the protections intended by the 1990 AIDS Prevention and Control Act, particularly Article 35 and Article 40. Some institutions would cite the 1944 Act as a legal defense for discriminatory practices, including a school which turned away a student. As the HIV 1 infection threat increases, there are many signs of persistent denial and resurgent discrimination in Taiwan. Several important issues need to be addressed: sentinel surveillance of female sex workers, social welfare institutions and housing for homeless people with HIV/AIDS, financial support for non governmental organizations, training and re education programs aimed at changing the attitudes of medical staff toward people with HIV/AIDS.

The original 1990 AIDS Prevention and Control Act did not explicitly protect the right to work and had no penalties for refusing employment to HIV positive people. Work discrimination in Taiwan became common, with even some state run enterprises and government agencies requiring mandatory HIV blood tests. Examples of discrimination include the discharging of a Taipei police officer in 2001, the lay ing off a healthcare worker in 2002, and a Taipei Metro driver who came under pressure and gave up his job.

Identification of HIV/AIDS positive foreigners usually occurs during mandatory blood test for teachers, government agencies workers and some state run enterprises employees. There are no penalties for enterprises refusing to hire a foreign person carrying HIV thus allowing work and employment discrimination.

In 1990, the government of Taiwan promulgated the AIDS Prevention and Control Act (後天免疫缺乏症候群防治條例). Under the AIDS Prevention and Control Act, foreigners who tested positive for HIV were required to be deported. The AIDS Prevention and Control Act was renamed the HIV Infection Control and Patient Rights Protection Act (人類免疫缺乏病毒傳染防治及感染者權益保障條例) on July 11, 2007, During the process of deportation, "their visas [were] annulled and their names [were] permanently listed in official records, resulting in automatic refusal of any future application for an entry visa." Foreigners infected by their Taiwanese spouse or from medical procedures conducted in Taiwan could appeal to be taken off of the black list, but only from abroad after being deported. The strict requirements for appeal were laid out in Article 20 of the HIV Infection Control and Patient Rights Protection Act. As summarized by the Taipei Times, "foreign nationals who were infected by spouses who are Taiwanese nationals, or who were infected while receiving medical care in Taiwan, and who have relatives within two degrees of kinship who have household registration and current residency in Taiwan may ask those relatives to prepare a written petition—only once—within six months of their deportation." Petitions appear to have been infrequently approved. Even in cases where both spouses tested positive for HIV/AIDS, petitions could fail if the couple was unable to prove that it was the Taiwanese spouse who infected the foreign spouse. The revision came under criticism by patient groups and health experts as being only a small change that did not address the central issues of human rights and the lack of evidence showing a link between deportation and decreasing the HIV infection rate.

On January 20, 2015, the Legislative Yuan passed an amendment that repealed the requirement for foreign nationals diagnosed with HIV/AIDS to be subject to deportation. However, foreign residents are subject to additional barriers from treatment. In addition to being a legal resident, joining the NHI after staying in Taiwan for a minimum of six months, and having their HIV status confirmed by a hospital, foreign residents are required to pay the full costs of their HIV/AIDS treatment for two years, after which the costs will be covered by the NHI. The CDC estimates that two years of treatment costs approximately US$.