NEWS

Needle exchange can help stop HIV spread, experts say

Shari Rudavsky
shari.rudavsky@indystar.com

As an epidemic of prescription drug use spread into rural communities across the nation in recent years, experts braced themselves for something they had seen years earlier in urban drug-using populations: an outbreak of HIV/AIDS.

They couldn't predict where or when it would happen. But they did know, based on what they had seen since the earliest days of in AIDS in cities, that if it did happen, it would be ugly.

Scott County, Ind., has proven these fears right.

Like many other rural communities, Scott County had few substance abuse programs, HIV treatment experts or any other services in place to battle the outbreak. And because needle exchange programs were illegal here — as they are in many states — there was no effort to ensure users had access to clean needles to protect them from spreading diseases, such as HIV and hepatitis.

With a lack of such a program, the outbreak expanded rapidly. Starting with a handful of cases, by Friday it had grown to 142 positive cases. Last month, Gov. Mike Pence declared an emergency public health order that included allowing local authorities to establish a temporary needle exchange program. Last week, he extended the program for at least another 30 days.

But experts say such stop-gap measures in the long run will have little impact against an HIV outbreak. Even if the program helps curb the spread in the short term, once it ends — if it does — so will most of the advantage of having had it.

"It would be really a terrible public health tragedy to stop this service and help the outbreak propagate," said Chris Beyrer, president of the International AIDS Society and a professor of epidemiology at the Johns Hopkins University Bloomberg School of Public Health. "It takes sometimes a crisis and an emergency, but needle exchange is part of the basic package."

Changing attitudes

When Pence signed the emergency order, he made his distaste for needle exchange programs clear, saying that he was opposed to them as "anti-drug policy."

There are some signs that more recently the tide may be turning toward allowing for more permanent needle exchange programs. Lawmakers are considering a measure that would allow the counties at the highest risk of an HIV outbreak — as gauged by hepatitis C rates — to opt for needle exchange programs.

On Friday, Indiana Attorney General Greg Zoeller issued a statement, urging the legislature to pass this measure. While he gave a nod to Pence's "sound policy position" of not wanting to enable drug abuse, he added that preventing HIV outbreaks may require special measures.

This is because of the dynamics involved with injecting drugs and blood-borne viruses such as HIV or hepatitis C. Such viruses can be spread through many other bodily fluids, but one of the most effective ways they spread is by direct injection into your bloodstream, which happens when two IV drug users, one of whom is infected, share the same needle.

"The more blood involved, the more likelihood that HIV is there and it goes directly into your bloodstream," said Crystal Fuller Lewis, an associate professor in the department of epidemiology at the Mailman School of Public Health at Columbia University.

Since the temporary needle exchange began in Austin, Ind., the heart of the HIV epidemic in Scott County, local health officials have been stunned by what they have heard. Some people have told Brittany Combs, a public health nurse with the Scott County Health Department, that needles were so scarce that they sometimes used the same needle hundreds of times, until it broke.

The numbers of cases that stacked up in a short period may sound dramatic, but experts in public health like Lewis do not find them surprising.

"You know, all it takes is one case (of HIV)," she said. "It's probably one of these things. It was going to happen. It's just a matter of when, especially with no prevention in place."

Support services needed

Needle exchange alone will not do the trick, experts say. While such programs may help reduce the spread of disease, other services such as substance abuse counseling, HIV and hepatitis testing, and treatment also need to be in place to help decrease drug use.

In the wake of the outbreak, the state has put in place a number of wrap-around services to help not just drug users in Scott County, but also the entire community. At a newly opened Community Outreach Center, visitors can be tested for HIV and hepatitis, get immunizations against diseases that commonly strike IV drug users, get substance abuse counseling and enroll in the Healthy Indiana Plan.

State health officials have said they're exploring whether they can set up similar services in other counties that are at high risk of HIV outbreaks. And other states that have seen rates of IV drug use soar would do well to follow suit, experts say.

"As it stands right now, needle exchange in Indiana is like throwing a life preserver to a man who is drowning and then leaving him in the sea," said Greg Millett, vice president for amfAR, the Foundation for Aids Research. "I think that Scott County, Ind., is the canary in the coal mine. I think we're going to be seeing more of these HIV diagnoses in rural areas, where there are not comprehensive services for injection drug use."

HIV outbreaks among drug users have happened since the beginning of the HIV/AIDS epidemic more than a quarter of a century ago. During the late 1980s, almost 35,000 IV drug user were diagnosed with HIV each year. In 2010, that number dipped to 3,900. In 2013 there were an estimated 1,942 new cases of HIV among this population,

While other factors besides needle exchange programs have contributed to this decline, experts say needle exchange remains an integral piece of the solution.

Hot-button issue

In New York City, more than half of people who injected drugs in the early 1990s contracted HIV. Once needle exchange programs entered the picture, the numbers dropped dramatically.

Today, about 100,000 people or about four times the entire population of Scott County inject drugs in New York City. However, since the beginning of this year, Scott County has seen almost three times as many HIV cases as New York City's drug-injecting population saw in all of 2013.

"It's a whopping difference, and it really shows that this program works," Millett said. "This is unfortunate because in many ways HIV diagnoses among injection drug users has been a success story. ... But right now, we're on the cusp of reversing those trends, primarily in rural areas."

Public health experts cite hundreds of studies that prove that needle exchange does lower HIV infection rates. But in the United States, it has remained a political hot-button issue.

Aside for a brief period of just over a year during the early part of Barack Obama's presidency, federal funds could not support such programs. Many states, however, allowed local authorities to establish such programs with local funding and or private donations.

Worldwide, multiple countries with high numbers of HIV/AIDS linked to IV drug use have instituted needle exchange programs. The World Health Organization recommends such programs, as do the Centers for Disease Control and Prevention in the U.S.

"There is no controversy in the field about this," Beyrer, of the International AIDS Society, said. "It's uniquely an American political issue."

And outbreaks such as the one Scott County is facing likely could have been prevented, experts like Columbia's Lewis say.

"We're going into the fourth decade of this disease; there's really no reason for it. ... We have tackled this issue in terms of knowing what we need to do to prevent it," she said. "I could see it if we were in the '80s, or even '90s. But this is 2015. It's kind of embarrassing actually."

Call Star reporter Shari Rudavsky at (317) 444-6354. Follow her on Twitter: @srudavsky.