NEWS

Now 55 cases in HIV outbreak in southeastern Indiana

Shari Rudavsky
shari.rudavsky@indystar.com

Updated Friday, March 20, 4:01 p.m.: State health officials say the number of HIV cases in an outbreak among intravenous drug users in southeastern Indiana has risen to 55 confirmed with an additional 13 preliminary positive cases.

All of the cases are connected to injection of the powerful painkiller Opana, although some involved have said that sexual transmission of the virus also may have played a role, according to the Indiana State Department of Health. The cases span Scott, Clark, Jackson, Perry and Washington counties.

A team of two doctors and an epidemiologist from the Centers for Disease Control and Prevention will head to Scott County on Monday to help state officials try to contain the outbreak.

Typically about 500 people a year in Indiana receive a new diagnosis of HIV.

The state has created a public awareness campaign, called You Are Not Alone, to educate those in the affected region about drug abuse, safe sex, needle disposal and HIV testing and treatment.

The following story originally appeared online Feb. 23:

People in southeastern Indiana thought that they had put at least a small dent in their prescription painkiller problem and that heroin was now outpacing opioids as the drug of choice.

But then came shocking news Wednesday from state health officials: At least 26 people in the region were diagnosed with HIV in a three-month period, and most of them contracted it after injecting the potent painkiller Opana for a quick high.

These cases, plus four others considered preliminary cases, could be just the start. State health officials are interviewing newly identified HIV patients and urging them to reach out to their sexual partners as well as anyone with whom they shared needles, as both forms of contact can spread the disease. A few of the cases already identified were sexually transmitted.

The first case in the outbreak, primarily in southeastern Indiana, was diagnosed in early December, said Dr. Jennifer Walthall, deputy commissioner and director for health outcomes at the Indiana State Department of Health.

By Jan. 23, the tally of new HIV cases had risen to 11, a red flag for a region that typically sees fewer than five new cases annually.

Since then, more cases have been diagnosed in Clark, Jackson, Scott and Washington counties, as well as in Perry County. The town of Austin in Scott County was the most affected, Walthall said.

Plagued with poverty and unemployment, southeastern Indiana has long known it has a prescription drug abuse problem.

As state and county health officials investigated, they learned that many of those infected with HIV, the virus that causes AIDS, had injected Opana. State health officials say they do not know whether this is the first time that prescription drug abuse has sparked an HIV outbreak, but they say it is not a common occurrence.

"I think unfortunately we're dealing with a relatively novel situation," Walthall said.

Federal officials agree.

"I am not aware of any similar instances like this related to this or any other specific opioid pain reliever," said Dr. Melinda Campopiano, a medical officer with the federal Substance Abuse and Mental Health Services Administration. "I am so sorry to learn this is going on."

Opana — which contains oxymorphone, an opioid more potent per milligram than Oxycontin — came into vogue about four or five years ago when Oxycontin's makers reformulated that drug to make it harder to abuse. A few years ago, Endo Pharmaceuticals, the makers of Opana, took similar steps, but people have continued to find ways to transform Opana pills into an injectable high.

Experts say the prevalence of Opana abuse varies widely across the country; just one or two doctors prescribing the drug in large quantities can have an impact.

Kentucky, for instance, saw a spike in Opana overdose deaths in 2011, said Van Ingram, executive director of the Kentucky Office for Drug Control Policy. But it has not been an issue since the drug became tamper-resistant and the state closed a number of so-called pill mills, clinics that dispense prescription narcotics all too freely and not always for legitimate medical reasons.

Health and law enforcement officials have fought back against Opana in southeastern Indiana as well, said Dr. Shane Avery, a Scottsburg family medicine doctor who is active in the fight against prescription drug abuse. Some pain pill mills in the area were closed, and some protocols were instituted to help doctors limit how many prescriptions they write for Opana.

Statistics showed that the number of prescriptions had dropped. But at the same time, heroin use in the area has risen, said Indiana State Police Sgt. Jerry Goodin, public information officer for the Sellersburg District.

"People have turned to heroin because they can get it as cheap or cheaper," Goodin said.

However, "the pills have been a problem for us for years," he said. "They continue to be a problem."

The recent outbreak has brought that home to many. In the 16 years that Avery practiced in the area, he had diagnosed only one case of HIV. In the past three months, two of his patients were among those to test positive for the virus.

One of those had been using Opana for a few months.

Experts agree there's nothing specific about this drug to link it to HIV. Anytime someone shares a needle, he or she runs the risk of contracting whatever disease the previous user had. Still, whenever anyone injects a substance such as Opana, bigger wounds and more bleeding can ensue, which can increase the chance of contamination, Campopiano said.

Heroin users have long been cautioned about the need to use clean needles. But those involved with this outbreak might not have been aware of the need — or thought they were safe because they were using a licensed pharmaceutical and knew those with whom they shared the needle, said Dr. Jan Scaglione, a clinical toxicologist with the Cincinnati Drug and Poison Information Center.

"We don't question heroin and its association to HIV," she said. "These 26 people ... are probably interconnected, they know one another, they're in the same circle of users, there's some common denominator most likely since they're all new HIV-onset patients."

In addition, clean needles can be difficult to come by, Avery said.

"It's probably easier to get ahold of the Opana than it is the needles," he said. "This sounds almost unbelievable, but the issue is education. ... So many of them don't appreciate or understand the dangers of sharing needles."

Now, those in health care must bring that message home. State health officials are trying to get the word out about the importance of cleaning needles. They also are providing harm-reduction kits to those who use drugs intravenously, Walthall said, and are encouraging them to seek treatment.

Others note that the outbreak — and the work — has just begun.

"We're probably in the very early stages of this," said Kristin Adams, president and chief executive officer of the Indiana Family Health Council, which administers state and federal funds for family planning services, including HIV testing.

By midday Wednesday, Adams told the clinics with which her organization works to be prepared to test patients in the region worried about contracting HIV through sexual partners.

Resources in the region are limited, she said, so many entities, including churches, clinics and counselors, will have to come together to help care for those affected by this outbreak.

"This is going to need a lot of effort for the public health system," she said. "Now we're all impacted by this."

Star reporters Madeline Buckley and Justin Mack contributed to this story. Call Star reporter Shari Rudavsky at (317) 444-6354. Follow her on Twitter: @srudavsky.