Since January 2018, there has been a dramatic spike in HIV infections in the small city of Huntington in Cabell County, West Virginia. With 71 new cases as of this writing among a population of roughly 46,000 residents, the HIV incidence rate is now more than 10 times higher in Huntington than the national average.
Local public health officials are calling the spike in HIV cases a "cluster," but Lauren Canary, director of the National Viral Hepatitis Roundtable (NVHR), considers the situation in Cabell County to be an "outbreak" reminiscent of the 2015 outbreak in Scott County, Indiana.
Like Scott County, Cabell County has been hard-hit by the opioid epidemic. It was named among 220 other "hot spots" vulnerable to an HIV outbreak because of injection drug use, according to a 2016 analysis prepared by officials at the U.S. Centers for Disease Control and Prevention (CDC) in the wake of the Scott County emergency.
"We've recognized our community for having an injection drug use problem, and we've been working in a very comprehensive manner since early 2015, late 2014, to really address that problem," said Michael E. Kilkenny, M.D., physician director at Cabell-Huntington Health Department.
Unfortunately, Kilkenny said, despite the local health department's "reasonable success" in addressing overdose deaths and controlling hepatitis C, new HIV infections have increased in Cabell County since 2018.
According to CDC guidance, the term "outbreak" is only used to describe situations that require an "urgent or emergency-level public health response." A "cluster of concern" is defined as a group of at least five new diagnoses of a genetically similar HIV strain within a 12-month period.
"We're currently calling it a cluster," said Kilkenny, "but what's more important than the terminology of whether it's a cluster or an outbreak is how important this is to our community, and how aggressively we are working to stop the spread of HIV in the community."
According to Kilkenny, those steps include increased testing among at-risk populations, bolstering primary care availability of PrEP, developing a responsive linkage-to-care system and supporting retention in care.
At the state level, West Virginia's health department is working closely with the local Cabell-Huntington health department, and in consultation with CDC, "to further understand the extent of the cluster" and "understand connections between cases," said Allison C. Adler, from the office of the cabinet secretary of the West Virginia Department of Health and Human Resources.
Canary, who served for five years as a viral hepatitis epidemiologist at CDC before becoming director of NVHR, expressed concern about the limited access to syringe services programs (SSPs) in West Virginia.
SSPs, also called needle-exchange programs, are community-based clinics where people who inject drugs (PWID) can obtain clean, sterile needles -- reducing the likelihood of spreading infectious disease within a community.
SSPs are controversial because they follow the principle of "harm reduction": helping people with addiction disorders use drugs in safer ways, rather than requiring abstinence to receive services.
At a national level, Canary noted, "there is a ton of support for SSPs," including from the U.S. surgeon general, Vice Adm. Jerome Adams, M.D., M.P.H.; Adm. Brett P. Giroir, M.D., U.S. Department of Health and Human Services' assistant secretary for health; and longtime National Institute of Allergy and Infectious Diseases director Anthony Fauci, M.D.
However, local health departments often face backlash for SSPs from community members, politicians, and local media. For example, last year, an SSP operating out of Charleston, West Virginia, closed its doors due to community uproar over syringe litter.
Although Cabell County has a syringe exchange program, the program has certain self-imposed restrictions to make it "more politically palatable," Canary said. Specifically, it employs a one-to-one exchange program, in which PWID are asked to bring in used syringes in exchange for clean ones.
These restrictions are thought to reduce the volume of syringe litter in the community, but run counter to research that suggests more flexibility in SSPs improves public health overall.
"Limiting to one-to-one exchange is tough," said Canary. "It limits the amount of clean works people can get out into the community through peer-to-peer exchange."
"We call it a one-for-one-plus," said Kilkenny. "It's very, very important to our community that we reduce syringe litter, so our role of taking these syringes and disposing of them properly is really, really important to our community. We encourage -- through any number of methods -- that [PWID] bring syringes to us."
According to Adler, harm reduction programs (HRPs) would be untenable without local community buy-in and support.
"Community understanding and support is critical to HRP success," she said. "HRPs are encouraged to work with community partners to apply these practices in locally applicable ways."
According to Kilkenny, Cabell County's HRP offers the flexibility to serve people who do not come in with used syringes.
"We have discretion," he said, "and we use that to be as responsive to the needs of the clients as we are to the communities."
Kilkenny added: "Like other harm reduction programs, we do operate in an economic and political environment that, in order to be responsive to some of your partners, you may not do everything you wish you could do."
This tension between abstinence-based policies and harm reduction policies may be sowing confusion among PWID. For example, according to West Virginia's Medicaid policy, people with hepatitis C are only permitted to start drug treatment once they are sober for three months.
According to Canary and Kilkenny, some West Virginians with HIV falsely believe that sobriety is a requirement to receive HIV treatment and services.
Broadly, SSPs and other harm reduction approaches to the opioid epidemic continue to be controversial in many local communities. That means, despite advanced warning from the CDC's report of 220 vulnerable counties, Cabell County and other at-risk communities in the U.S. may still be at risk for an HIV outbreak, Canary said.
Thankfully, Adler noted, so far data suggest the HIV cluster is confined to Cabell County, and does not appear to be spreading to surrounding areas.
"Like any group of people, individuals with infectious disease may move and change locations," she said. "As other states do, West Virginia routinely monitors the number of individuals newly diagnosed with HIV across the state. Ongoing surveillance data in other areas of the state do not identify any other clusters at present outside the Cabell County cluster."
The state is continuing to monitor the situation, and is encouraging HIV testing among at-risk populations statewide.
Canary praised the work of local health officials in Cabell County, who were quick to identify this cluster and implement more robust testing, treatment and prevention programs.
"I think communities need to be aware -- especially communities at risk -- that the time to develop response programs is not after the event, but before," said Kilkenny. "Even if the program may be smaller than you might like it to be, it is easier to scale up a program that exists than it is to start one."
Huntington, nestled on the tri-state border area of West Virginia, Ohio and Kentucky, has been called the epicenter of the opioid epidemic, according to Kilkenny.
"We've owned our problems for a long time," he said. "We're working to solve them. We really want to be known as the 'center of solutions.'"