A perspective article in the current NEJM, entitled Threading the Needle - How to Stop the HIV Outbreak in Rural Indiana, evaluates the root causes and the delayed and inadequate public health response to a smoldering HIV epidemic among IV drug users in poor rural Scott County, Indiana over the past two years. The authors, Steffanie Strathdee PhD and Chris Beyrer, MD MPH, from UCSD in San Diego, and Johns Hopkins-Bloomberg School of Public Health, Baltimore, respectively, discuss in detail each contributory factor to this preventable contagion, which is still an ongoing threat, unbelievably, thanks to governmental policies antithetical to public health.
We have discussed this sad story before, initially to point out how mindless the official response to the epidemic was and how that delayed, inadequate response enabled it to progress. Subsequently we gave perhaps premature plaudits to Gov. Spence for, at last, allowing some semblance of urgent public health efforts, funding, to be devoted to limiting HIV s (and its companion epidemic, hepatitis C) onslaught.
The point-by-point analysis focuses on the unusual nature of the IN epidemic, being confined largely to younger, white, and often female patients: a sign of the method of transmission, shared contaminated needles, rather than the typical HIV pattern involving sexual transmission. One important point that eluded us in our prior discussions: the easy availability of various addictive drugs was not matched by accessible sterile needles, since possession of un-prescribed needles is a serious felony in IN. So the scarce needles were shared, much more often than in other venues.
Further, combined with Pence s own fundamentalist attitudes towards addicts and their illnesses, the federal policy proscribes the use of federal funds for needles exchange, a form of harm reduction. Indiana s government passed an enabling act to permit clean-needle exchanges, but only for one year. The authors note the folly of this approach:
However, the current provision extends for only 1 year, a limit that ignores the reality that three interrelated chronic diseases addiction, HIV, and HCV will continue to challenge this community and others like it for decades unless a very aggressive, multipronged public health prevention strategy is implemented that includes continuous access to needle-exchange programs, expanded access to medication-assisted therapies for opioid use disorders, and seek, test, treat, and retain interventions for HIV and HCV in substance users. Regrettably, other Indiana counties contemplating authorizing needle-exchange programs must first demonstrate the existence of a public health emergency a requirement that ensures that they can only respond to, rather than prevent, outbreaks.
And of course, as we recently commented upon in the context of methadone maintenance right here in New York, ....[S]ubstance-use treatment in rural Indiana remains woefully inadequate, reflecting a failure to provide adequate access that applies statewide, nationally, and globally. The opioid-agonist therapies methadone and buprenorphine are considered essential medicines by the World Health Organization, but only a small percentage of opiate users have access to them. Beyond their proven effectiveness and cost-effectiveness in addiction treatment, opioid-agonist therapies are also effective as HIV prevention.
The parallel spread of hepatitis C is another factor easily predictable and largely preventable via needle-exchange programs. How many people will be affected by this outbreak and I am not just talking about drug users, but their families and friends who might contract one of these devastating infections; and what can be done to prevent it? Again, the authors give some good advice:
Permanently lifting the ban on using federal funds to support needle-exchange programs will be a critical component of HIV prevention, since these programs reduce HIV incidence and front-line exchange workers are often the first people injection-drug users reach out to for help. There are currently 228 known needle-exchange programs in 35 U.S. states, the District of Columbia, the Commonwealth of Puerto Rico, and Indian Nations. However, the federal funding ban limits their scalability and quality of services, including their ability to provide critical ancillary services (e.g., on-site HIV and HCV testing and referrals for drug treatment). States can adapt prescription-drug monitoring programs so they are secure, enable searches in real time, and are used as clinical and public health tools rather than law-enforcement weapons. But such supply-reduction measures will work best when complemented by the harm reduction achievable with opioid-agonist therapy and needle-exchange programs.