opinion

Indiana’s HIV crisis

Dr. Shane Avery of Scottsburg, Ind., recently testified before the Indiana General Assembly about the HIV outbreak in Southern Indiana and the benefits of a needle exchange. Here are his comments.

As a family physician of 16 years in my community, I wish to thank Gov. Mike Pence for signing an emergency order with the Indiana State Department of Health for Scott County. The ISDH should be commended for the effort they have put forth in just a few short weeks. The ISDH has been a great partner in working with us to respond to this epidemic. As a result of the resources placed by the ISDH and the “One Stop Shop,” we have been able to offer free HIV testing, where no testing was available. We have been able to increase the numbers enrolled in insurance. We have been able to develop better networking among professionals to respond to the needs of the community. We have been able to bring in a team of infectious disease doctors from Indiana University to begin treating patients with HIV. We have been able to point individuals to substance abuse treatment. We have been able to go out into the homes and identify those in need and offer hope.

Scott County’s HIV epidemic has gained international attention. It has occurred in one of the most underserved, rural areas of the state in which resources are limited, and includes significant social and economic obstacles. I know I am here today to discuss needle exchange, but I want to take a few moments to emphasize the importance of continuing emergency aid to Scott County. Despite my praise of the efforts over the last 2 weeks, it is a fragile young system, without roots, and will perish quickly without continued nurturing. It is going to take much longer to put the necessary pieces into place. HIV is a deadly, incurable disease. We will have to provide care for the infected for the rest of their lives. We will need much more time and resources to respond to this crisis, especially if we hope to limit its spread within Indiana.

There is no doubt in my mind that this has spread beyond the borders of Scott County. Scott County is not an island. It is surrounded by land on 4 sides and has an interstate down the middle. The infected have different social networks, outside of the county. We have public testimony of at least one commercial sex worker, who knew she had HIV, and had gone on to have sex with over 70 individuals off the interstate. Another example is that a colleague of mine reported to me that injection drug users from Austin told him they regularly went up to Seymour to buy drugs and “shoot up.” My third example is that I was just over at the casino in French Lick a couple weeks ago and was told by one of the managers they are on the lookout for people with sores and prostitutes. HIV is bad for business. When will the ISDH decide to make an effort to systematically test injection drug users (IDU’s) in outlying counties?

The emergency order is a response similar to what happened when a tornado devastated the community of Henryville a few years ago, just a few miles south of Scott County. The government came in for a few months, provided aid, and they rebuilt. Except this HIV epidemic is not something that will go away in a few months. It is here to stay. He has not quarantined the infected; they travel in and out of county. It is the governor’s refusal to address this situation that will result in Indiana’s most historic failure in public health. It is preventable. We have a workable solution. Yet I believe it will become an unforgivable mark on the governor’s legacy and this legislature if we don’t take the proper action.

Clean Needle Exchange

Now my comments on needle exchange. The director of the CDC, Dr. Tom Frieden, at the Prescription Drug Abuse Summit in Atlanta 2 weeks ago, described the HIV outbreak in Austin, Indiana as a sentinel event in the opioid prescription epidemic. His comment to the Indiana delegation was that the CDC has not seen anything like this in our country. The reason is that the ISDH reports that in Indiana, less than 3 percent of new cases of HIV are spread by injection drug use, and that number is less than 10 percent for the United States. Yet the CDC reports that over 90 percent of the new cases in Scott County are spread by injection drug use. It is not that Scott County is unique; it’s that Scott County is the first place that we have seen this rate of growth of HIV in this type of population of injection drug users. The CDC reported last year that Indiana has one of the fasting growing rates of hepatitis C in the country, among a rural injection drug users who share needles. Hepatitis C is a marker for HIV transmission. Injection drug use with shared needles in rural areas is common and on the rise in the state. Other counties in Indiana are known for an alarming rise in cases of hepatitis C and heroin usage. The CDC has issued that warning. Indiana simply has not heeded it. Kentucky has listened to the CDC by passing their needle exchange program. For the governor to think that he can contain this epidemic in Scott County with an emergency order is reckless and will cost the lives of thousands of Hoosiers.

The CDC is concerned about the risk in this unique population because they have seen the same pattern repeatedly in other countries. The World Health Organization (WHO) has published a guide for responding to those who use drugs in Asia and the Pacific: http://www.who.int/hiv/pub/idu/idu_searo_wpro_treatment.pdf In it, the WHO describes EXPLOSIVE growth of HIV in populations of injection drug users (IDUs) where access to prevention and treatment are limited, where there are no needle exchange programs, and where law enforcement is the dominant response to drug use. They also report widespread perception among individuals that they were at low risk of contracting HIV. The CDC believes that we are seeing the same scenario in Scott County. The WHO describes the typical pattern of spread of HIV among IDU’s and commercial sex workers, then to the general population through sexual intercourse and finally through mothers to their unborn babies. An additional warning is that newly infected individuals have a much higher likelihood of transmitting the virus in the first few months of infection. The results in these countries are rates of HIV as high as 20-70 percent among IDUs.

One unknown is how many IDU’s there are in Austin. Dr. Frieden shared with our Indiana delegation that the CDC estimates that number to be about 10 percent of the population of Austin. Given a population of 4,300, this would be 430 IDUs. We had 21 confirmed cases of HIV in Scott County prior to December 2014; these should be added to the new cases in the last 4 months. Since December, we have had 130 new cases of HIV. Public health officials have stated that they believe that number will rise to 200. With our known 151 cases, this is a case rate of 35 perent. If we go with the officials’ estimate of 221 cases, our case rate would be a staggering 51 percent of IDU’s in the town of Austin. This is similar to rates reported in Southeast Asia and the Pacific by the WHO. Perhaps this helps clarify for legislators the intense interest the CDC has had in our epidemic in Indiana and the need to contain it.

It is also unknown how many IDU’s there are in Indiana. The most consistent data we have access to is compiled yearly by the School of Public Health at Indiana University, entitled “The Consumption and Consequences of Alcohol, Tobacco, and Drugs in Indiana: A State Epidemiological Profile”. However, only injection of heroin is compiled in that report. No attempt is made to quantify the number of IDU’s statewide or at a county level for all substances. This same group, however, made an attempt at an estimate in 2010: http://www.healthpolicy.iupui.edu/PubsPDFs/Injection%20Drug%20Use%20in%20Indiana%20(2010).pdf They suggested that nearly 10,800 Hoosiers injected drugs in 2009. We know those numbers are rising due to the increasing problems with heroin in our state, but I will use it as a basis for my next comment.

Taking that 10,800 number for reference, let us assume that the state of Indiana persists in its current response to the HIV epidemic.. We cannot compare what is happening here to anything else in America. According to the CDC this is unprecedented in this country. Compared to other what the WHO has reported in other nations who have lacked needle exchange programs and who have poor access to treatment, we should expect to see an additional 3700 to 5400 cases of HIV as this spreads throughout the state. This is in addition to the 11,500 cases we already had as of December 2014 per the ISDH. These numbers are close to those reported for those infected with hepatitis C today by the Rural Center for AIDS/STD Prevention at Indiana University. There are between 4400 and 5700 infected with hepatitis C in this state. We know that as many as 50 to 90percent of IDUs are co-infected with both hepatitis C and HIV. I have heard from the CDC that as many as 80 percent of our newly infected HIV patients in Scott County are co-infected with hepatitis C.

That number of 10,800 injection drug users is almost certainly far too low an estimate. Let me remind you that the CDC believes that over 400 IDUs alone are in Austin, Indiana. I have already shared with you the fact that IDUs from Austin are traveling to Seymour, a community of nearly 20,000. The CDC assumes 10 percent of the population in Austin are IDUs. For benefit of the doubters, let’s assume that only 2 percent of the population in Seymour are IDUs. That is an additional 400 IDUs. That is a total of 800 IDUs in 2 towns, to account for 10,800 total in the state. That 10,800 number is no longer believable.

The same 2010 report I listed above with Indiana University, reports an IDU prevalence rate of 0.17 perecent for the United States population. This is based on the National Survey on Drug Use and Health (NSDUH) data. Using these numbers, we would expect the numbers of IDU’s in the state to be about 110,000. Using the 35 to 50 percent rate of infection of IDUs we are seeing in Scott County, we would expect another 38,000 to 55,000 cases of HIV. This is probably a high-end estimate, but would mean a tripling or quadrupling of current cases in Indiana. In addition, let me point out that we are counting IDUs only. We are not taking into account the eventual spread through sexual intercourse and maternal transmission to unborn children, which the WHO says is inevitable during these epidemics. HIV could then infect tens of thousands more Hoosiers.

My attempt with these numbers is to help you understand the magnitude of this epidemic as seen in the eyes of the medical profession and CDC. There will unfortunately be many opportunities for researchers to report on what is happening here in Indiana, and we will be reading about it for years to come. The world is now focused on the decisions we are making here today. As legislators, you should not be questioning the efficacy of clean needle programs. That has long been established by medical organizations such as the CDC and the American Medical Association. The question for you is whether you are ready to move forward and do what is necessary to protect the citizens of Indiana. We are not just talking about injection drug users and commercial sex workers. I am also referring to the healthcare workers who administer care to these individuals in our hospitals and clinics. It is the law enforcement officers and case workers who serve these individuals, putting them in harm’s way. It is the families who come into contact with dirty needles lying on the street or in city parks. It is the children who play in the homes of addicts and are exposed to the paraphernalia. It is the unborn babies of pregnant mothers with HIV.

The Challenge Ahead

You must also understand that needle exchange is only the beginning. We must also address the following issues in relation to the epidemic:

•The federal government has banned funding of needle exchange programs, so that even if you pass this amendment, each community will be responsible for coming up with its own funding source. This must change at the federal level.

•The ISDH also remains vastly underfunded. This is not popular to talk about with tight budgets. But the reality is that the majority of your rural communities do not even have the ability to offer HIV testing. The question is not if, but when you are going to find other outbreaks of HIV infection throughout the state. Not just from Scott County, but from other cities where injection drug users interact with those infected with HIV.

•The ISDH will also need to vastly expand public education on prevention such as safe practices and treatment options for people who inject drugs.

•Many of these individuals have mental illness that has not been properly diagnosed or treated, due to poor access to care. Let us also not forget that our goal is to heal the person of the addiction through substance abuse counseling, which remains difficult to access throughout the state, and with high rates of relapse.

•We also have a high burden of hepatitis C, which makes treatment of HIV even more difficult. We also need to address those individuals who have hepatitis C, which has serious health consequences and adds huge costs to the healthcare system. Unlike HIV, hepatitis C is curable, but again access and affordability of that care are key issues.

•Access to providers in rural areas who can treat HIV is a challenge, and fortunately the IU School of Medicine has established a clinic in Austin. But could they offer the same kind of response throughout the state of Indiana as we see this spread in other rural communities?

•Fortunately HIP 2.0 is a step in the right direction for getting injection drug users the right care. As the state takes on the increasing responsibility for paying for that care, how will we gain control over those escalating expenses for treatment?

•We need to once again address the poverty and hopelessness that results in substance abuse. We will always have the poor with us. But we must not ignore them to the extent that we allow an epidemic that garners international recognition. Indiana must do a better job of protecting its most vulnerable citizens.

The challenges are formidable. They do not end with this bill. But this bill is an integral part of the response. Clean needle exchange is simply the most effective way to curb the spread immediately, while the state government ponders how to respond to all these other issues.

Prior to this epidemic, the CDC had been warning about the threat that this unique and rapid mode of transmission among rural injection drug users posed to the community. It has now become reality in Scott County. The state of Kentucky headed that warning and passed statewide needle exchange. Indiana cannot afford to wait any longer. The presence of the core HIV team from the CDC in our state in response to this epidemic should not go unnoticed. It is an omen of the significance of this event. If Gov. Pence and the Indiana General Assembly fail to act, then God have mercy on us.