Hep C, HIV spur needle exchange talk in Clark
First, Scott County became the epicenter of Indiana's largest-ever HIV outbreak. Now, the health officer in the next county south — Clark — says he is leaning toward declaring a public health emergency given high rates of HIV and hepatitis C there.
Some worry it's only a matter of time before these drug-fueled diseases spike higher in nearby Louisville amid a rising tide of heroin abuse.
"We'd like to think these problems don't cross the county lines, but certainly they do," said Dr. Kevin Burke, Clark County's public health officer, adding that a current HIV case in his county was linked this week to the Scott County outbreak. "Any community that has IV drug abuse has increased
Needle exchanges are one controversial answer. Scott County started one in response to its outbreak. Clark County's proposed emergency declaration would pave the way to start one there. And Louisville last month became the first city in Kentucky to offer one under a state law to combat the state's heroin epidemic.
Proponents say these programs, which number 228 nationally, effectively curb the spread of disease and offer an opportunity to get addicts into treatment. But opponents argue they enable drug use, and U.S. law forbids using federal funds to pay for them.
A federal spending bill for next year maintains the ban but allows communities with rapidly rising rates of HIV and hepatitis to get federal funding for related services such as substance abuse counseling and treatment referrals. U.S. Rep. Hal Rogers, a Republican who represents Kentucky 5th District and is House appropriations chairman, championed this proposed change because of rising disease rates.
"Harm reduction measures, such as needle exchange programs that are complicit in or which condone illicit drug use, have not been a preferred course of action," Rogers spokeswoman Danielle Smoot said in a statement. But Rogers "has no intention of opposing any such programs that may be implemented at the state or local level, as long as they are coupled with treatment referrals and appropriate education about the dangers of drug use."
But two experts writing in the current issue of the New England Journal of Medicine call for lifting the funding ban in light of Indiana's outbreak, saying needle exchanges are a crucial part of an overall disease-prevention strategy.
"There are going to be more of these outbreaks, and what's urgently needed is a public health response before things get even worse," said Dr. Chris Beyrer, a professor at Johns Hopkins Bloomberg School of Public Health and co-author of the commentary in the journal. "Now is the time to implement needle and syringe exchange programs, wherever they are needed. We can't put politics above public health. We have a cheap tool to prevent this."
Dr. Jerome Adams, Indiana's state health commissioner, said needle exchanges can help but are only one part of a larger solution that also educates addicts and connects them with medical testing and drug treatment. "A syringe exchange is a last resort, quite frankly," he said.
Scourge grows in Indiana
If ever a place needed a full range of solutions, public health experts say it's Scott County, especially the small city of Austin, ground zero in the outbreak. By last count, the outbreak reached 170 confirmed HIV cases and two preliminary ones, most rooted in abuse of the powerful painkiller Opana. Austin, population 4,200, has a higher incidence of HIV than any country in sub-Saharan Africa, according to Dr. Tom Frieden, director of the U.S. Centers for Disease Control and Prevention. About 86 percent of the newly diagnosed HIV patients also have hepatitis C.
The state and CDC have responded with a one-stop shop offering HIV testing, substance abuse treatment
While Clark County's latest statistics, from 2014, showed far lower numbers, Burke considers them increasingly alarming and worries for his
Community leaders say drug use and addiction are rampant, touching nearly every family. Barbara Anderson, executive director of the homeless shelter Haven House in Clark County, recalled the day a homeless client who likes to clean up local roads gathered and disposed of more than 200 needles along his route. Anderson asked Burke to declare a state of emergency, which is necessary before the state will allow a needle exchange. "Wouldn't it be nice to get ahead of the problem?" she said.
Burke hasn't decided for sure to make the emergency declaration. But if he decides to go ahead, he will need to follow a process outlined in a new state law. That involves getting permission from county commissioners, who must hold a public hearing, adopt the declaration, describe other unsuccessful actions that have been taken and ask Adams to officially declare the emergency.
Madison County in Central Indiana requested an emergency declaration for a hepatitis C epidemic on June 17 and saw it approved less than a week later.
Johns Hopkins' Beyrer, who is also president of the International AIDS Society, criticized Indiana's approach to needle exchanges. Research shows they're effective at curbing disease and play a vital role in outreach, he said, and "the idea we should have this only if we have an emergency is a flawed idea."
But Adams said needle exchanges need community buy-in — and an outbreak response tailored to small-town realities in a place like Austin.
"This is a national problem," he said, "but it's going to be very local in terms of response."
Kentucky at risk
Dr. Sarah Moyer, interim director of the Louisville Metro Department of Public Health and Wellness, said Southern Indiana's growing HIV and hepatitis C problems have boosted support for Louisville's needle exchange.
"People who inject drugs can spread HIV and hepatitis C by sharing infected needles," she said. "The fact that Clark County, Indiana, directly across the Ohio River from Louisville, is now considering a syringe exchange program and that Scott County, Indiana, has already set up such an exchange underscores the wisdom" of allowing them.
Kentucky's drug problem is large and growing; preliminary state statistics from 2014 show there were about 230 heroin deaths out of more than 1,000 drug overdose deaths overall.
Although Indiana's HIV outbreak has not reached Louisville, the city already has 45 percent of Kentucky's HIV diagnoses, even though it represents only 17 percent of the state's population. In 2012, the region containing Louisville had 18.5 HIV diagnoses per 100,000 people, more than twice the state average of 9.1. And federal figures from 2013 show Kentucky had the highest rate of hepatitis C in the nation.
An outbreak like the one in Austin would, proportionally, mean 30,600 new HIV cases and more than 26,000 new hepatitis C cases in Louisville, Moyer said, adding: "We want to prevent that from happening."
Kentucky's law allowing exchanges, like Indiana's, requires buy-in from local officials, with the final authority to approve needle exchanges resting with city councils and county fiscal courts. With the approval of the Metro Council, Louisville's program is housed in a "semi-permanent" RV parked outside health department headquarters on Gray Street, and provides free syringes, HIV testing and prevention supplies, and education on disease prevention and proper syringe disposal.
The program costs about $275,000 a year — more than $400,000 counting in-kind services. In its first 2 1/2 weeks, 111 people participated in the program, 22 got tested for HIV and 12 were referred for drug treatment.
Adams said he understands why health officials in Louisville are acting.
"We're always concerned about spread first and foremost," he said. "The opioid epidemic is a national one, and as long as there's an epidemic, there's potential for outbreaks to pop up anywhere and everywhere."
Reporter Laura Ungar, who also covers public health for USA Today, can be reached at (502-582-7190) or on Twitter @laura_ungar.