For years, public health officials and HIV advocates in Northern Kentucky have sounded the alarm, warning anyone who would listen of the very real threat of an injection drug use-fueled HIV outbreak in the region. They stressed the need for additional resources and syringe access programs to prevent it from happening. Local government officials listened to their concerns but did not act on them and, as a result, the long-feared HIV outbreak is on the verge of becoming a reality.
I grew up in Cincinnati, worked with the dedicated and passionate employees of the Northern Kentucky Health Department, and have been lucky enough to be a part of the substance use recovery community on both sides of the Ohio River. It has been my fervent hope that local governments in the region would respond to the opioid epidemic and the threat of an injection drug use-driven HIV outbreak with compassion, foresight, and a reliance on the abundant evidence that demonstrates the efficacy of syringe access programs in preventing the spread of HIV, as well as building relationships between injection drug users and local public health workers that can lead to engagement in drug treatment.
But it hasn't happened. And, now more than ever, it needs to.
Earlier this week, the Northern Kentucky Health Department announced that the number of newly diagnosed HIV-positive residents reporting injection drug use as a risk factor more than tripled over the past year -- jumping from a range of zero to five such reports a year between 2009 and 2016 to 18 in 2017. At the same time, public health officials from across the Ohio River in Cincinnati reported a nearly 250% increase in injection drug use-related HIV diagnoses in 2017.
Related: How Discriminatory Public Health Policies Created Indiana's HIV Outbreak
Recipe for an HIV Outbreak
Northern Kentucky Health Department officials are referring to it as a "cluster" of cases. And, while these marked increases in injection drug use-related HIV infections do not yet reach the proportions of the HIV outbreak we saw in Scott County, Indiana, in 2014 during Vice President Mike Pence's reign as that state's governor, the situation will almost surely develop into one if the region's approach does not quickly change.
Few places in the U.S. are as vulnerable to a sudden and sustained HIV outbreak as Northern Kentucky and, to a slightly lesser extent, the Greater Cincinnati region. Located in what is arguably the heart of the country's burgeoning opioid epidemic, Northern Kentucky has been struggling to cope with injection drug use for years. In 2016, the three northernmost Kentucky counties (Boone, Campbell, and Kenton) were listed among the state's top five for heroin and fentanyl-related overdose deaths.
The number of non-fatal overdoses that have been reversed in this area with the opioid antagonist naloxone is absolutely mind-boggling. During a 72-hour period in March of last year, emergency departments in Northern Kentucky saw at least 51 people who had overdosed on opioids.
At the same time, hepatitis C infections -- which are often considered the canary in the coal mine for future HIV outbreaks -- are at epidemic levels in Northern Kentucky. The U.S. Centers for Disease Control and Prevention (CDC) recently reported that Kentucky has the highest rate of new hepatitis C infections in the nation, and Northern Kentucky has by far the heaviest concentration of new cases.
Last year, the CDC included the region in a report identifying the 220 rural U.S. counties most at risk of a Scott County-like outbreak.
A Straightforward Remedy That's Anything but Simple
As we saw in Scott County, a lack of access to sterile needles for people who inject drugs can serve as the catalyst for sudden and devastating HIV outbreaks, but the swift implementation of syringe exchanges can squash an HIV outbreak almost as quickly.
There are currently no syringe access programs operating in the three most at-risk counties in Northern Kentucky. Should the number of syringe access programs in those counties remain at zero, it will not be a question of if Northern Kentucky will see a major HIV outbreak, but when.
This remedy for containing any further increase in Northern Kentucky's HIV infection rate from injection drug use is straightforward, but it is anything but simple. It's syringe exchange.
There is no debate left to be had on this issue. Syringe access programs save lives: period, end of discussion. But even though study after study after study shows this, vulnerable regions like Northern Kentucky are still obstinate in their opposition to these lifesaving programs.
In 2015, the Kentucky state legislature finally got the memo and passed legislation permitting the creation of "clean needle exchanges," but required the approval of local jurisdictions for it to become operational. This means that both county and city governments need to sign off on a proposed syringe exchange, something that is much more difficult than it should be.
And in the nearly three years since the state legislature approved their creation, only one syringe exchange has been established in Northern Kentucky. The lone working exchange, located in rural Grant County, has been a success: 275 residents have used the program to exchange used needles for clean ones, and some have also used the exchange to obtain referrals to drug treatment programs or access other HIV prevention tools such as condoms. There were no new HIV infections last year among people who inject drugs in Grant County and neighboring Pendleton County, both of which have operational syringe access programs.
So, if syringe exchanges are proven to reduce HIV and hepatitis C infection rates in numerous studies across the country and are proving effective in neighboring Kentucky counties, what is stopping Boone, Campbell, and Kenton Counties from instituting their own needle exchanges? More than likely, the answer lies in some combination of stigma, misinformation, and NIMBYism (not in my back yard).
Whether it's due to the persistent belief in disproved myths -- such as the notion that syringe access programs encourage drug use (they do not) or that programs aimed at helping injection drug users increase crime in a neighborhood (a gas station or convenience store is much more likely to drive crime up than a methadone clinic) -- or plain old garden-variety ignorance, far too many local governments and populations in at-risk areas like Northern Kentucky still oppose the creation of syringe access programs.
There is still time for government officials in Northern Kentucky to rise the occasion and let the men and women of the Northern Kentucky Health Department put a stop to this increase in injection drug use-related HIV infections before it gets out of control -- but that time is almost up.