A spike in intravenous drug use in a growing number of U.S. counties has led to soaring infection rates of hepatitis C and HIV in communities across the country. Increasingly these counties are pushing for the creation of needle exchange programs, but politics and bureaucracy appears to be slowing the spread of such harm reduction programs.

By enabling access to health care, rehab facilities and addressing social inequalities that exacerbate substance abuse, advocates say harm reduction programs, like needle exchanges, help to reduce the negative health effects of drug injection.

“There has been a big change in how state legislators view overdose and view drug-related harm in general,” said Corey Davis, the deputy director of the National Health Law Program.

But despite renewed interest in clinics where people can receive treatment and drop off contaminated wares in exchange for clean ones, political and bureaucratic hurdles are preventing widespread implementation — even after epidemics in Indiana, Ohio, Kentucky and elsewhere raised national alarm.

In April, an HIV outbreak in Scott County, Indiana grabbed headlines when health officials there recorded more than 100 cases in a month. The number grew to 169 by June — more than 30 times the county’s yearly average. Most infections occurred from injecting Opana, a popular painkiller containing oxymorphone, with contaminated needles.

Following the outbreak, Indiana Gov. Mike Pence waived the state’s anti-needle ban that criminalized the possession of a syringe without a medical reason and signed a law allowing county officials to request permission to establish their own needle exchange programs — though these clinics were not eligible for state funding.

While some saw this as opening the door for harm reduction clinics across the state, the reaction so far has been muted. Only two counties have made use of the new rules, though a third county is considering establishing an exchange, according to local reports.

Health officials in Scott County, Indiana, declared a health emergency and established a needle exchange program in April to slow the spread of HIV.

In June, health officials in Madison County, just northeast of Indianapolis, successfully petitioned the state for a needle exchange program after health officials discovered 130 individuals with hepatitis C. Again, intravenous drug use was the primary mode of transmission, according to the Madison County Health Department.

Madison County has the third-highest prescription drug overdose rate in Indiana, after Starke County and Scott County, where the state’s first needle exchange program was established, the department added.

Still, despite the evidence of an ongoing statewide opioid epidemic, Davis said the dearth of counties making use of the new rules likely means their implementation is being “tied up in politics.”

The new laws are “a step in the right direction, but they are still pretty restrictive,” Davis said. “There are all these hoops that have to be jumped through.”

The Indiana legislation requires law enforcement, county and state officials to collaborate on the syringe exchange programs and mandates that municipal officials adopt a local health officer’s request to declare a medical emergency at a public hearing, allowing for public testimony, after which the state health commissioner must endorse the declaration.

“If it was truly a public health decision, it would just be a decision of the public health department,” Davis said. “It’s telling that there are only two counties that have initiated these programs, even though we have this clear evidence that there is an epidemic of HIV.”

“Epidemics don't follow county lines,” he added.

Lawmakers from Indiana’s southern neighbor Kentucky signed a bill in March legalizing needle exchanges amid increasing rates of hepatitis C and HIV . More than 1,300 syringes were distributed in the first week of the state's first needle exchange program in June, WLKY Louisville News reported.

But as in Indiana, a needle exchange clinic in Louisville required the approval of the local health department and city and county administrators, according to state guidelines for local health departments. And the president of the Kentucky’s state senate, Robert Stivers, says the needle exchange program is not keeping the public safe and may be violating state law by sometimes handing out clean needles without receiving a contaminated one in return.

Communities in Indiana and Kentucky aren’t the only ones in the region mulling changes to how they deal with injection drug use and the spread of infectious disease.

In Franklin County, Ohio, where Columbus is located, health officials recorded 1,369 cases of hepatitis C in 2014, nearly double that statistic from five years prior, according to data from the Columbus Health Department.

That evidence is leading local Ohio officials to consider opening a needle exchange clinic in the county. Exchange programs are legal in the state, but there are only a handful.

“We are looking at harm reduction plans that have been put in place in the state and throughout the country,” said Jose Rodriguez, a spokesman for the Columbus Public Health Department, “so that we can learn about best practices.”

Rodriguez was unable to confirm the cause of the surge in infections, but Judith Feinberg, a professor of clinical medicine at the University of Cincinnati, who spearheaded the opening of one of Ohio’s few needle exchange clinics last year, said the increase in infections almost certainly came from the intravenous drug user community.

“It’s the only thing that makes sense,” she said. “The primary way for people to get hepatitis C is through blood,” she added. “This isn’t something you get from food. It has to be drug use.”

Hepatitis C, in contrast to HIV, can live on for days on contaminated equipment. About 80 percent of intravenous drug users generally will eventually contract the disease, according to Feinberg.

“There is a massive need,” she said. “This is an incredible epidemic [of hepatitis C]. This is the only way to have an impact from a public health perspective.”

Feinberg said the traditional method of detaining and imprisoning drug users to take them off the street had failed.

“This isn’t something you’ll arrest your way out of. It’s a chronic brain disease, and it needs to be treated as such,” she said.