CDC Urges States To Adopt Needle Exchanges To Avoid HIV Outbreaks


While driving down through Indiana, past the cornfields and
small towns, Chris Abert didn’t think he’d be surprised by
Scott County. He knew poor young people were turning to
injecting drugs in small towns across the US.

Abert, after all, was an expert on setting up needle exchanges,
where people who use injectable drugs can trade dirty needles
for clean ones to prevent disease. But he still wasn’t ready
for what he found on on March 31, 2015 — it was, he said,
“absolutely extraordinary.”

Scott County, a rural locale that had previously seen just five
cases of HIV a year, was now in the midst of an explosive
outbreak of nearly 100 diagnoses in the span of just four
months. Some 80% would be co-infected with hepatitis C, another
bloodborne virus.

Abert was accompanying the Chicago Recovery Alliance on a trip
to the southeast edge of Indiana as the first group to provide
a sterile needle exchange option to the town. For months, then
governor Mike Pence had been a staunch opponent of needle
exchanges, which are illegal in the state of Indiana. But as
the HIV cases in the town rapidly multiplied and public health
officials pleaded with him to consider
decades of
evidence, he “prayed
on it” and then finally signed an executive order allowing
an initial 30-day lift of the ban. “This is all hands on deck,”
Pence
said.

Within a couple of hours of parking their white syringe
exchange truck downtown, Abert said, the Chicago Recovery
Alliance had distributed almost 50,000 clean needles to the
county of 24,000 people.

“We talked to one participant, everyone knew he was HIV
positive, but needles were so hard to obtain that they would
still buy his used syringes to use,” said Abert. Used syringes
often develop a small barb at the tip, Abert explained, and the
needles that people were giving them had clearly been shaved
down and sharpened with nail files or matchbook covers over and
over again as they were passed around. “They were terrible. It
showed the desperation of the people down there.”

Pence
eventually allowed Scott County to extend their needle
exchange for a year to respond to the public health emergency.
As of now, the number of HIV cases in Scott County has leveled
off to around 210, a “success story” according to Indiana’s
deputy health commissioner, Jennifer Walthall. But Abert, now
the director of the newly launched Indiana Recovery Alliance,
says that there’s still plenty of reason to worry. “I just
don’t want it to seem like Scott County was a fluke. It’s a
direct result of systemic failure.”

A
new report released this week by the CDC largely agrees.
Looking at needle sharing behaviors and HIV risk among people
who inject drugs in 22 cities across the country, the study
authors warned that the opioid crisis threatens to undo the
progress that’s been made to curb HIV’s spread across the US.
The report urged states to start up needle exchange programs,
or else brace for consequences like the epidemic in Scott
County.

“Life while injecting drugs is hard,” Jonathan Mermin, director
of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD,
and TB Prevention, said in a press conference announcing the
study results this week. “Avoiding HIV and hepatitis shouldn’t
be.”

Stigma has overshadowed the science of needle exchange programs
for decades, say experts such as Steffanie Strathdee, professor
of global public health at the University of San Diego. Despite
clear evidence that the programs cut disease rates for HIV and
hepatitis, politicians ranging from Ronald Reagan to Bill
Clinton have bowed to widespread disdain for providing clean
needles to “addicts” or “junkies.”

The first needle exchanges cropped up in large urban areas of
the US at the beginning of the AIDS epidemic in the 1980’s,
when nearly 17% of the nation’s nearly 16,000 identified AIDS
cases were due to
people injecting drugs. By 1995, that climbed to 30% of the
over 500,000 people diagnosed with AIDS.

But in 1984, while New York City’s health department was
developing plans for a formal study of needle exchange
programs, the US government turned its focus to the “war
on drugs.” Needle exchange programs, initially considered
to prevent drug users from spreading HIV, were seen as enabling
and even encouraging drug use with government money. In 1988, a
ban on federal funds supporting needle exchanges was
put into law.

Facing increased evidence strongly suggesting that needle
exchanges were an effective way to lower HIV rates, and that
they helped get drug users into treatment, President Barack
Obama in 2009 reversed the long-standing federal ban on funding
needle exchanges.

Still, by 2015, people who inject drugs made up nearly 9% of
the nearly 40,000 new HIV cases in the US.

The new CDC analysis released this week aimed to figure out
why, by looking more closely at who exactly is injecting drugs
and how.

Looking at people who inject illicit drugs from 22 cities
across the US, they showed that one in three had reported
sharing a needle in the last year.

The report’s look at needle sharing matches the changing
demographics of injectable drug use in the last decade, which
is shifting toward misuse of opioid painkillers and heroin by
white people in rural areas. While the percentage of new
injectable drug users who were black decreased by 51% from
2005-2015, the percentage of white ones increased by 40%.

That shift also seemed to correlate with drug-seeking
behaviors. While needle sharing decreased by 34% among black
drug users and by 12% among Hispanics, it remained unchanged
among whites. Similarly, while the percentage of black drug
users who got all of their needles from sterile sources
increased by 48%, the number of white ones who did so did not
change.

Nearly 54% of people who reported first trying out injecting
drugs in 2015 were white, 21% were hispanic, and 19% were
black. The vast majority had reported using prescription
opioids in the previous year.

The report, the authors wrote, underscored the need to change
prevention efforts to match the rise of the opioid epidemic,
which “might challenge the decades of progress in HIV
prevention.”

Though the study looked at cities, the study authors point out
that predominantly white rural areas are the new hotbeds for
injection drug use, and are at the highest risk for HIV
outbreaks. They have the greatest unmet need for needle
exchanges, which they said were a “critical component” of HIV
prevention among people who inject drugs.

“The window of opportunity for implementing [needle exchanges]
that provide comprehensive services to prevent, rather than
respond to, HIV outbreaks might be closing,” the authors wrote.

A
CDC report released last year identified 220 counties in 26
states across the US that were most at risk of an HIV outbreak
like Scott County’s. This week’s report underscored the urgent
need for states to “meet people where they are” and reduce
legal barriers currently blocking needle exchanges from setting
up in those communities.

“The bottom line of what we’ve found is that opiates are
threatening progress that we have made fighting HIV in this
country,” said Tom Frieden, director of the CDC, at a press
conference on Tuesday. “The science shows that syringe services
programs work. They save lives and they save money.”

View this image ›

Indiana’s State Health
Commissioner, Jerome Adams (left), and Deputy State Health
Commissioner, Jennifer Walthall. Rick
Callahan / AP

ID: 10098222

For many experts, Pence’s months-long delay in Scott County,
and even the subsequent law that was signed, has become the
case study for how misguided public health policies can
endanger lives.

Some, such as Gregg Gonsalves, co-director of the Yale global
health justice partnership, stress the numerous warning signs.
In
2011, a cluster of hepatitis C cases in southeastern
Indiana alerted health officials to the prescription opioid
injection that was sweeping that part of the state. In 2013,
Pence’s budget cuts nevertheless prompted
five rural Planned Parenthood clinics to close, including
the only HIV testing center that served Scott County.

“Pence ignored warning signs that there was a potential for an
infectious disease outbreak of HIV in his state, because
hepatitis C had already happened, and then he basically put a
bag over his head by closing the Planned Parenthood site,”
Gonsalves told BuzzFeed News. “If an HIV outbreak occurred,
nobody was going to see it unless it was too late.”

Recent cuts to the overall health budget have devastated the
state, said Carrie Lawrence, assistant research scientist at
the Rural Center for AIDS/STD Prevention at Indiana University.
Indiana now ranks
46th in the country for spending on public health. “Our
public health spending went down after an outbreak,” Lawrence
said. “And we don’t even tend to access the resources available
to us by the federal government. That’s politically driven.”

The ban on needle exchange services, as well as the lack of
methadone treatment programs, made the problem inevitable, said
Strathdee, professor of global public health at the University
of San Diego. “It was not just inaction, it was actively
promoting barriers to prevention and treatment,” Strathdee told
BuzzFeed News. “You can kind of see now that this is a recipe
for an HIV outbreak.”

Perhaps most importantly for other counties in the state,
Pence’s law did not lift the ban on state funding, so local
health groups have
been struggling to get private donations and grants to run
needle exchange programs in the places that need it most. It
also only allowed needle exchange programs to be made available
in counties that declared public
health emergencies, despite the fact that the most
successful programs work as preventative measures. And it’s
still a felony to possess a syringe in Indiana, even if you
obtained your needle from a state-sanctioned exchange program.

“It’s not only short-sighted, it really committed whole
communities of people to death,” said Strathdee.

Indiana state health officials defended the difficulty of
starting up such programs from scratch in rural areas with
little to no resources, and that are poorly equipped to deal
with the new twin epidemics of opioid use and HIV outbreaks. “I
will definitely take criticism. I don’t think there is a
syringe exchange law that’s perfect, and certainly ours doesn’t
fit that criteria either,” Walthall, Indiana’s deputy health
commissioner, told BuzzFeed News. “But it’s a reasonable space
to start.”

Lawrence is currently working with 28 counties around the state
on local HIV prevention initiatives, including needle exchange.
“I get the same call every time—’We don’t want to become Scott
County, so what should we consider?’” Eight counties in Indiana
have currently declared public health emergencies over either
Hepatitis C or HIV, and have active needle exchanges.

But for Abert and the Indiana Recovery Alliance, who get their
funding from an amalgamation of private donations and grants,
the current law poses a huge barrier to helping people stay
uninfected. “Legislatively, we are forced to be reactive. And
if we help lower disease rates to non-epidemic levels, then we
will not be allowed to continue to do needle exchange,” he
said.

The result is that Abert’s group is bracing itself for more
epidemics in Indiana and across Appalachia. And the growth of
needle exchanges nationwide rests on the new Trump
administration where, ironically enough, Gov. Mike Pence will
sit as vice president.

“If the new administration decreases affordable access to
public healthcare and further criminalizes people who use drugs
in the name of law and order, then we have real reason to
believe that these incidences will repeat themselves, and that
these epidemics will re-emerge,” Abert said. “It’s not really a
matter of if — it’s a matter of when.”



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