National public health advisory issued on HIV, hepatitis C

Though one official from the CDC said they’ve not been in contact with Indiana Gov. Mike Pence, the alert outlined a clear message about needle exchanges — access to clean needles will help contain the spread of HIV as seen in Scott County, where cases of the AIDS-causing disease now number 142.

Pence has said he doesn’t believe in needle exchanges as effective drug policy. But Dr. Jonathan Mermin, director for the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, said during a conference call Friday with reporters that the idea behind such a program extends beyond curbing drug use; it’s about curbing the rate of infection.

“This outbreak that we’re seeing in Indiana is really the tip of an iceberg of a drug abuse problem that we see in the United States that is actually not only causing problems because of the abuse of drugs, but also because of putting people at very high risk for infectious diseases,” Mermin said. “In this case, you have HIV and hepatitis C, both of which can be mortal infections without treatment.

“We’re facing a severe outbreak and the situation is powerful reminder — people who inject drugs are at a high risk.”

HOW IT’S SPREADING

According to the alert issued by the CDC, 11 new HIV infections were identified in Scott County from November 2014 to January 2015. Previously, fewer than five infections were identified annually. Of the 112 people they interviewed, 96 percent reported injecting Opana and sharing needles and other drug preparation materials. As of Friday, there were 136 confirmed cases of HIV and six preliminary positives for the disease.

The alert goes on to recommend that health departments tell active users the dangers of sharing needles and giving access to sterile needles from a reliable source.

Dr. Jerome Adams, Indiana State Health Commissioner, said part of the reason the infection has a better chance to spread is because of the kind of drugs used in this instance and the risk that comes with sharing them.

“We found that when people are using oral medications and crushing them up, it’s not as dissolvable as for instance heroin would be,” Mermin said. “It’s requiring the users to utilize a higher gauge needle to inject. That is making the sharing of needles an even higher risk activity because you’re being inoculated with higher amounts of HIV virus when you’re sharing needles as compared to the smaller gauge needle typically use for heroin.”

Adams — who noted that about $2.1 million has been spent so far on the Southeast Indiana outbreak from a variety of funding sources — said in the conference call that while the governor is serious about curbing drug use and the spread of disease, needle exchanges need support from the people who live in the communities where they’re recommended for implementation.

“One of the important things to note about needle exchanges is that you need local buy-in for it to be effective,” Adams said. “It really has to be a local decision with local buy-in because no one wants needles being passed out in their backyard.”

Needle exchanges are illegal in the state. Pence has authorized them in Scott County — as part of a multifaceted approach — via executive order, but can only do so in 30-day increments, renewing them before they expire. Scott County’s program is locally run and state supervised.

Mermin said a major cause of the problem is the availability of prescription pain medication via overprescription. He added that the HIV outbreak also may be attributed to a lack of education in rural areas on the dangers of IV drug use in terms of spreading infectious diseases.

“We haven’t seen this type of opiod in rural areas until the past few years,” he said. “It’s also the age of the people infected; they are younger people. They weren’t around during the [AIDS outbreak in] the 1980s

MORE NEEDED

Beth Meyerson, co-director of the Rural Center for AIDS/STD Prevention at Indiana University, said continuing the program in 30-day intervals isn’t enough. She said long-term programs not only have 30 years of science to back up their ability curb infection rates, but also in drug use over time. She said though it may fly in the face of governor’s ideals, it’s what research supports.

This week, Indiana Attorney General Greg Zoeller also came out in support of needle-exchange measure proposed by state Rep. Ed Clere, R-New Albany.

“Having to sign a bill, [Pence is] not the kind of guy who wants to be signing a bill for needle exchange, it’s just not in his constitution to want,” Meyerson said. “I have to say he’s been willing to extend the executive order in 30 day pieces, which is better than nothing, but it’s not great.”

She said that also doesn’t build trust among the IV drug users that the program will persist beyond the month-long intervals.

“I think that’s just not a long-term solution,” Meyerson said. “A syringe exchange that is run based on the evidence of public health science with the engagement for the community all around is a good, safe program. Kind of done on the fly, well, it’s not consistent and probably doesn’t send a good signal to the community.”

While the state legislature is considering needle-exchange legislation, Meyerson said several county health departments in the state have already agreed to implement needle exchanges if a law is enacted. She said that speaks volumes for the need.

Five confirmed cases of HIV have been detected outside of Scott County in neighboring Jackson County. Adams said those were related to the Scott County cases and believes the state has a good hold on containing those, but other medical professionals aren’t so confident.

Dr. Shane Avery, a family physician in Scottsburg who treats some of the HIV-infected patients, said while the governor’s office may feel like the infection has been contained to a 10-block radius in and around Austin, he needs to implement a statewide program, not just something limited to one or a handful of counties.

“The CDC has long-supported clean needle exchange,” Avery said. “It’s simply the most effective way immediately to help reduce the spread of HIV and hepatitis C. Long term, we want a more comprehensive program and that’s what the Indiana Department of Health is trying to do in Scott County.”

OTHER SERVICES

Adams said as part of a comprehensive program in Scott County, they’re working on trying to help with mental health services, addiction counseling, access to insurance and helping with identification.

But Avery said focusing in one county isn’t enough, especially as testimony from sex workers and others at risk in Scott County report going out-of-county to purchase drugs.

“I’m very pleased with the response within Scott County, but my criticism is that we’re not looking for cases in surrounding counties,” Avery said. “We don’t have good access to testing in other areas aside from Clark County.

“Who’s looking in Washington County? Who’s looking in Jefferson County? Nobody. There are no facilities where you can get free or reduced testing for hepatitis C or HIV.”

Kevin Burke, a health officer at the Clark County Department of Health, said he’s glad the governor has renewed the exchange through May 24, but if the needle exchange legislation doesn’t pass, it’d be nice to know what his commitment is to keeping the executive orders coming.

Adams said the state has a commitment to curb the outbreak and help, but all future steps have to point toward a sustainable program.

“I want to assure everyone that the state of Indiana will not abandon this community once the executive order is over,” Adams said. “Every step we take to end this outbreak is taken with sustainability in mind and that’s why it’s so important that the CDC has been involved with local partners to figure out not only what to do at the very moment, but to make that response sustainable.”

Meyerson said needle exchanges are cost-effective. While they don’t solve the drug issue immediately, they still help the people and communities suffering from them.

“If I’m seeing someone drown and I’m not sure my boat can have the two of us in it, will I not still throw them a life preserver?” Meyerson said. “I will, because they’ll still have the life preserver.”