Often called the “Crossroads of America,” Indiana has also recently become a place where health and politics intersect with striking consequences: One of the largest outbreaks of human immunodeficiency virus (HIV) ever identified in the U.S. continues to unfold in the state.
As of May 7, 2015, public health authorities have diagnosed new HIV infections in 150 individuals among a community of 4,200 (an astounding 3.6 percent of the population). Of the case patients identified so far, more than 80 percent report injection drug use often with widespread needle sharing. Emerging details are unsettling; an official report describes a community where up to three generations of a single family crush, cook, and inject prescription opioid pain medications together.
According to the same report, nearly 85 percent of those newly identified with HIV are also infected with hepatitis C. At least ten female patients have been identified as commercial sex workers. The ongoing epidemic raises many thorny questions while further underscoring the interplay between poverty and health.
In addition to a public education campaign, Indiana Governor Mike Pence activated a temporary needle exchange program to help stem additional infections. However, this exchange program was intended to be a short term measure (30 days) limited to Scott County, the outbreak’s epicenter. When it became clear that the outbreak was not waning and in fact, had reached beyond Scott County’s borders, the state legislature passed Indiana Senate Bill 461 in order to permit other counties to activate needle exchange programs.
The one big caveat: county officials had to prove there was an ongoing epidemic linked to drug use. Governor Pence signed the measure on May 5, despite his repeatedly voiced opposition for such programs as part of his anti-drug policy.
Pence’s support is long overdue. For years public health advocates and medical experts including the Infectious Diseases Society of America (IDSA) and the HIV Medical Association (HIVMA) have called for more progressive policies surrounding needle exchange programs. Wendy Armstrong, MD, professor of medicine at Emory University and vice president of HIVMA, summarizes the situation in Indiana as “tragic on so many levels, especially since these cases could have been prevented or at least minimized.”
The Long-Term Price Of Cutting Costs
Armstrong cites the lack of a “comprehensive HIV prevention package” for an at-risk population as contributing to the Indiana disaster. She also notes that the apparent widespread use of drugs (particularly among multiple individuals within a single family), reflects an utter lack of resources to effectively address substance use. Armstrong explains that needle exchange programs can offer a critical point of health care access for underserved populations.
Besides increasing access to addiction treatment and drug replacement therapy for people who inject drugs, needle exchange programs provide education, counseling, and testing for HIV and hepatitis C. Such programs also provide adjunctive benefits to society by reducing the number of improperly disposed needles and decreasing the risk of injuries to law enforcement and other first responders.
However, needle exchange programs have been wrongly equated to supporting and even promoting drug use. Starting in the late ’80s, Congress had imposed a ban on the use of federal dollars for needle exchange programs. After two decades Congress overturned that ban in 2009, only to reinstate it again in 2011.
Multiple studies demonstrate that comprehensive substance abuse programs can decrease HIV acquisition. This is a key consideration as the demographics of heroin use in the U.S. are shifting. A generation ago, heroin was used predominantly by young men in large cities, today widespread use is seen among older individuals living in rural areas; most of whom are introduced to heroin through prescription drugs.
Access to substance abuse treatment is not the only resource limitation in affected areas. Other barriers include the lack of a trained workforce to provide HIV-related specialty care. In many underserved regions in the U.S., there is not a single health care provider capable of treating HIV. Armstrong deems these areas “HIV provider deserts” — analogous to so-called food deserts. Effective (and creative) programs to increase the number of formally trained HIV providers are essential. Unfortunately, Infectious Diseases fellowship applications continue to decline, suggesting that this will be an uphill battle.
Missed Diagnoses
Universal testing with an option to “opt-out” was recommended by the Centers for Disease Control and Prevention in 2006. Yet, for many people, the diagnosis of HIV is still not made in a timely manner. Stigma about HIV and even HIV testing remains, not just among patients, but among health care workers.
“It’s impressive how often we miss the diagnosis of HIV. We continue to assume [that certain patients are not at risk],” says Armstrong, who also notes that testing programs must extend their focus beyond the perceived “high risk” populations.
“HIV is not gone from this country. We remain vulnerable. Events like this are likely occurring all over the place,” explains Armstrong, who adds that these cases only became apparent because this community had a very low incidence of HIV — that is, fewer than five new HIV diagnoses were made there in 2014. “This type of transmission could be happening in Atlanta, and we wouldn’t pick it up.”
When an urgent public health crisis such as that evolving in southern Indiana is viewed through the lens of politics instead of science, the most vulnerable suffer. Surrounding counties in Indiana and neighboring states share more than geography. If there is a lesson to be gleaned from this tragedy, it is the clear demonstration that prevention based on best evidence is essential to the health of all citizens.
The catastrophe in southern Indiana provides an opportunity to implement effective approaches to prevent both HIV and substance abuse. Needle exchange programs are essential. But expanding access to addiction counseling and treatment, especially in areas where health indicators are among the lowest, is the crucial next step.
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