The next HIV epidemic in America is likely brewing in rural areas suffering under the nationwide opioid crisis, with many of the highest risk communities in deep red states that voted for President Donald Trump.

Federal and state health officials say they are unprepared for such an outbreak, and don’t have the programs or the funding to deal with a surge in HIV cases. And given how little screening for HIV there is in some rural counties, they worry it may have already begun.


Scott County, Ind., was Ground Zero for an outbreak two years ago. Nearly 200 opioid users in poor, rural Austin became infected with HIV, primarily as a result of shooting up powerful prescription opioids with contaminated needles.

Health officials believe it’s a harbinger of things to come as opioid abuse — painkillers, heroin, fentanyl and other drugs — rages on.

“I am very concerned about something like that happening again,” new Surgeon General Jerome Adams, who was Indiana’s health commissioner during the outbreak, told POLITICO. “It’s a tragedy and we don’t want that to happen in any other communities ."

"We are using what happened in Scott County as both a warning to folks but also an example of how to respond to an opioid epidemic, " he said.

Late last year, the CDC identified 220 specific counties at high risk of a spike in HIV infections tied to intravenous drug use. They point to worrisome trends that reinforces their concerns: the number of fatal overdoses, and the skyrocketing number of intravenous opioid users contracting hepatitis C. That’s another blood-borne infection spread through contaminated needles, and it’s “a canary in a coal mine for HIV,” said Alana Sharp, research policy associate at the Foundation for AIDS Research.

“The nightmare that wakes me up at 3 a.m. is a Scott County-level HIV outbreak happening here in Alaska,” said Jay Butler, director of the Division of Public Health in the state’s health department and the lead official tasked with responding to the opioid crisis.

The report of at risk counties was to a great extent a map of the Trump heartland — Appalachian and Rust Belt communities in Kentucky, West Virginia, Indiana, Ohio, Michigan, Missouri and Tennessee. Like Austin, Ind., most of the communities are predominantly white with high unemployment rates and even higher rates of overdose deaths. They lack the public health infrastructure to deal with an epidemic.

Yet despite the CDC’s warnings, there is no indication that federal or state health officials are getting the problem under control.

Two month ago, Trump said that he considered the opioid crisis, which is killing 142 Americans every day, to be “a national emergency,” but he has yet to formally declare one — although it may be coming next week. It’s not clear yet precisely what or how much Trump’s emergency declaration would do, but it could allow millions of dollars in federal aid to flow to states for prevention programs and make it easier for states to take steps like distributing naloxone, the life-saving overdose antidote.

“It’s not good that it hasn’t been done yet,” New Jersey Gov. Chris Christie, who heads Trump’s commission on opioid addiction, said earlier this month at a news conference in Trenton, citing “legal issues” slowing down the emergency declaration.

West Virginia Health Commissioner Rahul Gupta is also getting impatient. His state leads the nation in overdose deaths — 818 died last year and deaths are mounting this year. And with 28 West Virginia counties identified as at high risk of HIV outbreaks, he said people need more than “just the rhetoric."

“We need to look at the programs that are working and invest in them,” he said.

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The prospect that HIV is transforming itself from a disease that primarily affected gay men and minorities in urban centers to one that targets rural, red-state America could have huge political, as well as public health implications.

Such a health scourge could upend GOP orthodoxy, which has traditionally opposed government distribution of sterile needles (arguing it promotes drug abuse) and mandated coverage of mental health services, including substance abuse treatment (arguing that too many mandates raise the cost of insurance and people shouldn’t be forced to buy services they don’t want or think they’ll need).

Little is known about how Trump might respond to outbreaks of HIV or AIDS in rural, red-state America. His budget blueprint would have cut or eliminated funding for the big HIV and AIDS programs, although Congress rejected his approach and kept funding flat.

Vice President Mike Pence, as governor of Indiana, was heavily criticized for dragging his feet before allowing the distribution of sterile needles as part of a program endorsed by the CDC to prevent the spread of HIV and hepatitis C among intravenous drug users.

Stickers are given to clients after they get tested for HIV at the One-Stop Shop in Austin, Ind., in 2015. | Darron Cummings/AP Photo

But the Indiana experience — especially the speed with which the infection swept through one, tiny community — has already changed how many Republicans regard clean needle programs.

Kentucky Republican Rep. Hal Rogers, a former Appropriations chairman, was behind Congress's ban on federal funding for needle exchanges in 2012. The outbreak in his state changed his thinking.

Soon after, he authored an appropriations bill that lifted the ban, allowing federal funding to help local governments set up needle exchanges — as long as the money doesn't pay for the needles themselves.

"Some of the most vulnerable counties are in my district," Rogers told POLITICO, referring to the CDC report. He added that needle exchange programs in his state have also screened people for HIV and hepatitis C and refers them to substance abuse treatment programs. "It's a holistic approach to the problem and that’s what we’re advocating here."

Sen. Shelley Moore Capito of West Virginia, who once thought needle exchanges were tantamount to “turning a blind eye to shooting up heroin” has also changed her mind. “I came around to the realization that this is a public health crisis and through needle sharing programs, you can lessen the probability of having an HIV or hepatitis C infection,” she told POLITICO. “And that, in and of itself, is a victory.”

The heightened support for needle exchange isn’t universal. Indiana’s Attorney General Curtis Hill has publicly disavowed programs set up across the state as a ”needle giveaway.” At least two Indiana counties, Lawrence and Madison, have recently decided to end their programs after local council members opposed funding them, saying they promoted drug use.

“One of the things we learned in Scott County is that you can’t force anything on a community. We can’t force a community to take up a syringe program if they’re not ready,” the surgeon general said, reflecting on his experience in this state.

Many public health experts regard another outbreak like Scott County as only a matter of time.

“I expect we will likely see similar outbreaks of injection drug-related HIV,” Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said this summer. "There’s nothing particularly different about the Indiana community than other communities throughout the country.”

The sharp rise in hepatitis C cases is a potential signal of worse things to come.

But while new hepatitis C cases shot up to an estimated 34,000 nationally in 2015 — nearly triple the number in 2010 — new HIV infections actually declined from 45,700 in 2008 to 37,000 in 2014, according to the latest available CDC figures. Injection drug users accounted for about 10 percent of the new infections, according to amfAR.

State officials say they’re skeptical of the HIV numbers. They think there are likely more HIV infections that simply haven’t been detected because many rural areas don’t provide adequate screening and not everyone agrees to be screened.

“Our fear is that the numbers have not actually gone down, but rather that the number of cases diagnosed have fallen due to the lack of testing,” said Kentucky State Health Commissioner Hiram Polk. “It is our belief that the need and the importance of testing has fallen off the radar screen for some providers.”

Detection is crucial, both to get that individual into treatment, and to prevent spread. But resources are needed to expand screenings, added Polk. In Kentucky, 54 of the 120 counties are listed as high-risk for HIV outbreaks. And only 20 permit distribution of clean needles.

The holes in the public health preparedness mean a crisis can spread quickly.

Sen. Shelley Moore Capito of West Virginia, who once thought needle exchanges were tantamount to “turning a blind eye to shooting up heroin” has changed her mind. | Pablo Martinez Monsivais/AP Photo

"We are trying to make sure people have access to prevention programs,” said the CDC’s Debra Houry, who leads the National Center for Injury Prevention and Control. “ That can be syringe exchange it can also be linking to medication assisted treatment. It can also be doing HIV and Hepatitis screening and administering naloxone. It’s nice to have that whole portfolio,”

But it's not always available.

The outbreak in Scott County was “notable for the absence, or minimal availability” of addiction treatment, medication-assisted therapy and needle exchange programs, other CDC researchers have said. When things went south, they did so fast.

“When folks start to use drugs, and they use drugs in groups, it starts to become a really bad situation,” said Matt Brooks, chief executive officer of Indiana Council of Community Mental Health Centers.

A number of counties ravaged by drug abuse are already distributing sterile needles, but the programs are few and far between, mostly underfunded and don’t enjoy broad support from their communities.

“Syringe service programs are really hurting,” said Carl Schmid, deputy executive director for the AIDS Institute. There are only 221 syringe exchanges nationwide, according to amfAR.

Advocates took it as a good sign that the president nominated Adams for Surgeon General, since it was Adams who ultimately convinced Pence to back a needle exchange program.

But many aren’t confident that Adams will wield the same kind of influence in Washington, and they still have concerns about the Trump administration’s commitment to addressing HIV/AIDS infections.

They note that the website for the Office of National AIDS Policy was shuttered days after Trump took office. He still hasn’t tapped anyone to lead the White House Office of National AIDS policy.

“It pretty much says that’s not something that is on their radar,” said Lucy Bradley-Springer, associate professor of the University of Colorado Denver’s Division of Infectious Diseases and former member of the Presidential Advisory Council on HIV/AIDS. She was one of six expert who have resigned from the panel this year in protest of Trump’s policies.