Indiana Gov. Mike Pence signed a pledge last month, along with most of the nation’s governors, to combat the opioid crisis, calling it “one of the deadliest drug epidemics in our nation’s history.” But when confronted with a spiraling HIV outbreak in his home state as a result of opioid addicts sharing contaminated needles, Pence dragged his feet before agreeing to lift a ban on programs that distribute sterile needles.

Indiana became a national flash point for the opioid epidemic last year when nearly 200 people in rural Scott County became infected with HIV primarily as a result of injecting Opana, a powerful prescription opioid, using dirty needles. Those needles spawned one of the biggest outbreaks of HIV in decades, with more than 20 new cases being diagnosed every week at the height of the outbreak last year.


Public health experts from around the country advised immediately lifting the state’s ban on needle exchange programs as a way to stop the spread of the disease — an approach that has proved effective in other places.

The governor resisted, but, under enormous pressure, he eventually agreed to a partial lifting of the ban. But critics say the statewide compromise has been ineffective because it offered little financial help to cash-strapped counties and permitted only “limited and accountable" exchange programs, as Pence described it.

The GOP vice-presidential nominee's response to Indiana’s opioid scourge offers a window into his approach to handling a crisis, showing someone deeply wedded to conventional conservative ideas but also a pragmatist who gave ground in an emergency. That approach helped quell the crisis in Scott County but did little for other communities struggling with clusters of hepatitis C and HIV infections from addicts sharing dirty needles. Public health experts also worry about additional HIV outbreaks without more effective prevention policies.

“We must give Gov. Pence credit for finally doing the right thing in the end,” said Gregorio Millett, director of public policy at amfAR, the Foundation for AIDS Research, an advocacy and research group.

Nonetheless, Millett called Indiana’s HIV outbreak “entirely preventable.”

“Indiana taxpayers could have been saved millions of dollars for treating those affected by the HIV outbreak if effective prevention policies were already in place,” he said.

'They had to twist his arm'

State Rep. Ed Clere, a Republican who chaired the House public health committee, led the effort to legalize needle-exchange programs in response to the HIV outbreak. He initially proposed allowing counties with the highest hepatitis C infection rates to put such programs in place — something Pence and many others rejected out of hand.

After meeting with federal health officials who warned him of the rapidly growing epidemic, Pence initially authorized a 30-day amnesty from the state’s needle exchange prohibition in March 2015, but that was limited to Scott County. "I am opposed to needle exchange as anti-drug policy," Pence said then. "But this is a public health emergency and, as governor of the state of Indiana, I'm going to put the lives of the people of Indiana first."

Critics complained the response was insufficient.

“They had to twist his arm to get the one in Scott County,” said Carrie Ann Lawrence, of Indiana University’s Rural Center for AIDS/STD Prevention. “The [Centers for Disease Control and Prevention] pretty much said you need to do this.”

With new cases mounting, Pence eventually agreed to extend the amnesty in Scott County beyond 30 days and to sign statewide legislation lifting the state ban on exchange programs. That compromise did not give counties a green light to distribute sterile needles to intravenous drug users, however. Instead, it requires officials from counties experiencing increasing HIV or hepatitis C infections to declare a public health emergency and then submit a plan for state approval to set up needle exchange programs for up to one year.

The legislation didn’t include any money to assist counties, many of which are rural and already struggling. And it explicitly prohibited using state funds to purchase syringes.

“He was dragged kicking and screaming into signing the bill that we got passed,” said Rep. Patrick Bauer, a Democrat who serves on the public health committee.

The end result: More than a year after the law was enacted, just five counties have put needle exchange programs in place, although two dozen took steps to set them up, according to the Rural Center for AIDS/STD Prevention.

“I’m not surprised,” Clere said of the slow uptake by counties. “I’m disappointed, because I know that there’s numerous counties in crisis that would benefit from syringe exchange.”

“I think it was just set up to fail from the get-go,” said Lawrence, who has worked with several counties trying to set up programs.

Clark County, which adjoins Scott County in southeastern Indiana, has had an application to run a needle exchange program pending before the state for a year but has yet to gain approval.

"I don't care what the problems are," said Barb Anderson, a Clark County activist. "The people in my community are dying."

Defending Pence

But Indiana State Health Commissioner Jerome Adams disputes that the Pence administration dragged its feet in response to the crisis. “Nothing could be further from the truth, and that’s not just my opinion,” Adams said. “Public health folks who know how long it takes to mount a response are frankly blown away by the speed on which we got on top of this thing.”

Adams said the green lighting of needle exchange programs in Scott County was just one piece of the state's intervention. Officials have also worked to sign up people for health insurance so that they could get screened for infectious diseases and treated for substance abuse problems.

And he emphasized that needle exchange programs are controversial in many conservative communities.

“You can’t go into, particularly middle America, and just point your finger at folks and say, ‘You need to have a syringe exchange and we’re going to pay for it with your tax dollars,’” Adams said.

The dearth of funding for needle exchange programs comes as overall public health funding in Indiana has cratered during Pence’s tenure. During the 2012 fiscal year, Indiana spent $17.43 per person on the state’s public health budget despite high rates of cancer deaths and low vaccination rates, according to the Trust for America’s Health, ranking it 36th in expenditures nationwide. Last year, per capita public health expenditures dropped to $12.40. Just five states had a lower level of funding.

Pence agreed to lift a ban on a program that distributed sterile needles after a spiraling HIV outbreak due to opioid addicts sharing contaminated needles resulted in his home state. | AP Photo

The Pence administration contends that public health has been a priority.

"Governor Pence and his administration takes the health and public safety of Hoosiers very seriously and we dedicate numerous resources to public health activities," the administration said in a statement to POLITICO. "We have dedicated at least $276,637,498 for FY 17 towards public health activities through the Indiana State Department of Health and other agencies."

The figures appear to be far higher than those used by the Trust for America’s Health, but a more detailed breakdown was not made available.

Even counties that have successfully launched needle exchange programs say they’re unable to meet addicts’ needs because of funding issues.

Christopher Abert, project coordinator for the Indiana Recovery Alliance, which runs the program in Monroe County, estimates that the group has given out nearly 100,000 syringes since launching in February. The alliance has cobbled together funding for the program primarily through individual contributions in a county that includes Bloomington, where Indiana University’s flagship campus is located.

“The state, county and city have given absolutely no money,” Abert said. “Every bit of progress we’ve made has been because of grass-roots efforts.”

Scramble to get programs off the ground

Madison County was one of the first counties in the state to take advantage of the state’s new needle-exchange law. Roughly 70 individuals get clean needles through the program, according to Stephenie Grimes, the county’s public health coordinator.

“I feel like we still, even a year into it, are just scratching the surface of this community,” Grimes said. “Every day someone calls and asks about the program.”

Madison County was able to get the program running largely by redirecting existing resources. But the county has also benefited from a grant from the Health Foundation of Greater Indianapolis, and occasionally it will get donations of syringes after a person dies from an overdose.

“There are other counties in the state that I know are worse off than us in terms of [hepatitis C],” Grimes said. “They simply don’t have the resources to put together a program, let alone the personnel to run it.”

Allen County is one jurisdiction currently wrestling with generating support and resources for a needle exchange program. Last year, it had 23 new HIV infections, a 30 percent increase over the prior year. In addition, hepatitis C cases spiked by 60 percent, with 350 infections. The county commission has granted approval for a needle exchange but is still trying to figure out a way to pay for it.

Meanwhile, Clere, who championed the needle exchange legislation, was ousted in November as chair of the House’s public health committee by Speaker of the House Brian Bosma. Bosma told local reporters at the time that the move was due to Clere’s “rudeness.”

But Clere and many others believe the decision stemmed at least in part from his bucking GOP orthodoxy on needle exchange and other public health issues. And most believe that Pence was at least in the loop on that decision.

“I don’t think things happen in that party without him knowing,” said Bauer.

Clere says he is comfortable with what he did.

“The syringe exchange legislation was the most difficult political battle during my time in office,” he said. “I don’t regret it at all because I know it’s working and I know it’s saving lives.”