In February 2015, reports surfaced of an outbreak of new HIV cases in Scott County, Indiana. The initial 26 cases of HIV, first confirmed in December, were followed by more cases (now nearly 90 cases with the majority involving hepatitis C [HCV] co-infection). The cause was the injection of the prescription painkiller Opana. In an effort to combat the outbreak -- the largest in the state's history -- Indiana Governor Mike Pence authorized an emergency 30 day needle exchange program in Scott County, administered by state health officials, which opened earlier this week. This was a major development from a Governor who has not supported this intervention in a state where needle exchange programs have long been outlawed. Yet in the face of an historic HIV (and HCV) outbreak, Governor Pence recognized the need for a public health approach guided by the evidence, just as numerous physicians, health departments, and countless community-based and national organizations have before him.
Impact of Preventable HIV and Hepatitis Outbreaks in States
The Indiana outbreak has made clear that absent a strong public health infrastructure that prioritizes prevention, public health and client-centered approaches to substance use, outbreaks of HIV and HCV will become the norm. In fact, in recent years, health departments have seen an alarming increase in new HCV cases among people under the age of 30 in many states, representing 75% of new HCV cases. Public health experts have warned that the presence of HCV in drug using networks was foreshadowing the return of HIV in this population. What is occurring in Indiana further emphasizes this warning. Unlike historical trends of HCV infections in most jurisdictions (i.e., concentration in larger, urban city centers), new HCV infections are increasingly found in suburban and rural settings, especially in Appalachia. The epidemic has caused such great concern that in March, Kentucky legalized needle exchanges as part of larger legislation addressing the heroin epidemic in the state, joining at least 33 other states in the United States in acknowledging the critical role of syringe services programs.
To highlight opportunities for health department infectious disease programs to better meet the health needs of people who inject drugs (PWIDs), NASTAD released Maximizing Health, Minimizing Harm: The Role of Public Health Programs in Drug User Health. Maximizing Health, Minimizing Harm explores a range of drug user health issues, identifies potential collaborators and provides recommendations for health department programs.
Recommendations for health departments are included here, including:
- Provide HIV, hepatitis B and hepatitis C testing to people who inject drugs
- Provide hepatitis A and B vaccination to people who inject drugs
- Provide sterile drug preparation and injection equipment for people who inject drugs
- Ensure state and local policies support access to sterile needles, syringes and other drug preparation equipment
- Ensure there are appropriate and accessible disposal systems for drug preparation equipment
- Provide access to substance use treatment for people who inject drugs
- Ensure people who inject drugs are linked to insurance services and a medical home equipped to respond to their needs
What Can We Do to Prevent Future Epidemics?
Unfortunately, despite calls from the National HIV/AIDS Strategy, the HHS Viral Hepatitis Action Plan, and the IOM Report Brief: Reducing Harm, in addition to the U.S. Substance Abuse and Mental Health Services Administration, to implement Syringe Services Programs (SSPs) in the context of comprehensive HIV and hepatitis prevention services, the Congress continues to maintain a federal funding ban on needle exchange programs dating back to the 1980s, with the exception of a brief period from 2010 to 2011.
In 1992, NASTAD issued the policy statement Reducing Transmission of HIV through Increased Access to Clean Needles and Syringes. The actions called for in that policy statement are just as relevant today. In 2011, NASTAD issued a Statement of Commitment: Promoting Injecting Drug User Health, demonstrating the responsibility of health departments to champion programs and initiatives that promote the health of injecting drug users (IDUs). NASTAD has continued that work through technical assistance, advocacy for policies that support IDU health -- including lifting the federal funding ban on syringe exchange programs -- and work within coalitions.
We have significantly reduced new HIV infections among PWIDs over the past 20 years. Unfortunately there has been an HCV epidemic among this population that has not received adequate attention or national response. As the events in Indiana, Kentucky, and many other states show, we risk an enormous setback if we do not abandon reactive policies in favor of prevention strategies guided by sound science.
To learn more about how a public health, client-centered approach to drug user health can lead to reduction of HIV and hepatitis transmission among IDUs, please check out the resources below: