HIV-1 CRF07_BC infections, injecting drug users, Taiwan.

To the Editor: To date, Taiwan's human immunodeficiency virus type 1 (HIV-1) epidemic has primarily spread via sexual contact. The subtype B and circulating recombinant form (CRF) 01_AE account for >95% of all infections (1). However, since 2003 Taiwan has experienced a major outbreak of CRF07_BC among injecting drug users (IDUs).

The first wave of HIV-1 infections in Taiwan can be traced to the early 1980s, when a group of hemophilia patients received imported HIV-1-contaminated antihemophilia medications. By the time these medications had been replaced by heat-treated factor VIII concentrates, at least 53 patients had contracted HIV-1 infections (2). According to Taiwan's Center for Disease Control (CDC), HIV infections have been diagnosed in 9,229 persons (including 523 foreigners) as of July 31, 2005 (3). The number of persons living with HIV-1/AIDS has increased rapidly in the past few years, with a 77% increase in 2004, compared to 11% in 2003 (online Table, available at http:// www.cdc.gov/ncidod/EID/vol12no04 /05-0762.htm#table). According to the results of a risk factor analysis of people living with HIV-1/AIDS reported to the Taiwan CDC, the proportion of IDUs increased from 1.7% (13/773) in 2002 to 8.1% (70/861) in 2003 to 30.3% (462/1,521) in 2004 (online Table). The Taiwan CDC received reports of 1,241 IDUs diagnosed with HIV-1 infections from January 1 to July 31, 2005; these account for >75% of all reported HIV-1 infections in 2005 (3). The evidence points to an explosive epidemic of HIV-1 infections among IDUs in Taiwan since 2003, with no indication of a slowdown.

Taiwan has [approximately equal to] 60,000 IDUs (1). According to the Republic of China Ministry of Justice, the number of incarcerated drug offenders increased from 5,988 in 2003 to 9,303 in 2004; the rate of HIV-1 seropositive inmates increased from 13.3/100,000 in 2002 to 56.8/100,000 in 2004 (Y-M. Wu, Ministry of Justice, pers. comm.). Since all inmates are routinely tested for HIV-1 in detention centers, and all infected inmates are separated from HIV-1-seronegative inmates, the potential of HIV-1 transmission in prisons is remote. We therefore suggest that the Taiwanese IDU population and its HIV-1 seropositive rate have both increased rapidly in the past few years.

To identify the primary HIV-1 strains in the current epidemic, we collected blood specimens from HIV-1-infected inmates in 3 detention centers (1 each located in the northern, central and southern regions of Taiwan). HIV-1 subtypes were determined by polymerase chain reaction, DNA sequencing, and phylogenetic analyses of pol or env genes. Our results indicate that 145 (96%) of 151 IDUs were infected with CRF07_BC and 6 (4%) were infected with subtype B; 97% of the CRF07_BC cases were diagnosed in 2003 or 2004. According to our phylogenetic analysis of the env gene, the Taiwanese CRF07_BC strains clustered with CRF07_BC strains drawn from IDUs in China (Figure).

CRF07_BC is a recombinant of the B' and C subtypes. Several studies have suggested that CRF07_BC originated in China's Yunnan Province, with subtype B' from Thailand mixing with subtype C from India before moving northwestward to Xinjiang Province along a major Chinese heroin trafficking route (4-6). To our knowledge, this is the first report of a large group of IDUs in northeastern Asia having CRF07_BC infections. It may have followed another drug trafficking route from Yunnan Province to southeast China, moving through Guangxi Province and Hong Kong to Taiwan (7-9). In a bid to combat skyrocketing HIV/AIDS infection rates among IDUs, the Taiwan CDC has proposed a 5-year harm reduction program to the Republic of China Executive Yuan.

Acknowledgments

We thank Yi-Ru Chang for her technical assistance, the Sequencing Core Facility of National Yang-Ming University's Genome Research Center for its technical assistance, and professor Kathleen Ahrens of National Taiwan University for her help in preparing this letter.

This research is partially supported by funds from the AIDS Molecular Virology Laboratory Program of the Taiwan CDC (CDC-94-RM- 102, DOH93-DC-1043) and the ROC National Science Council's National Research Program for Genomic Medicine (95-0324-19-F-01-00-00-00-35).

Yi-Ming Arthur Chan, * Yu-Ching Lan, * Shu-Fen Lai,* Jyh-Yuan Yang, ([dagger]) Su-Fen Tsai, ([dagger]) and Steve Hsu-Sung Kuo ([dagger])

* National Yang-Ming University, Taipei, Taiwan, Republic of China; and ([dagger]) Center for Disease Control, Taipei, Taiwan, Republic of China

References

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Address for correspondence: Yi-Ming Arthur Chen, AIDS Prevention and Research Center, National Yang-Ming University, 155 Li-Nong St, Sec. 2, Yaipei, Taiwan 112; fax: [phone]; email: [e-mail]