[dropcap]A[/dropcap]t a news briefing on April 24, the Centers for Disease Control and Prevention said that urgent action was needed to control the outbreak of HIV and hepatitis C in Indiana’s Scott County, a sparsely populated area in the hilly southeast corner of the state.
At the conference State Health Commissioner Dr. Jerome Adams indicated that other cities and towns in rural Indiana and in other states were vulnerable and that the outbreak in Scott County was the “tip of an iceberg” in the United States.
The CDC’s statistics for the outbreak are shocking:
• As of April 24, 135 people in a county of about 24,000 tested positive for HIV since January 1, with the number of new infections increasing daily. For perspective, the entire state sees about 500 new HIV cases a year.
• Nearly nine in ten people who tested positive for HIV in the county have also been diagnosed with the hepatitis C virus (HCV).
• There was a 150 percent increase in reports of hepatitis C between 2010 and 2013, the majority attributable to injecting drug use.
A week after the conference the Indiana legislature sent Governor Mike Pence a bill that would give communities flexibility to implement needle-exchange programs if they experience epidemics similar to Scott County’s. Community leaders would have to get approval from the state health commissioner to launch a needle exchange.
Pence, who continues to be opposed to needle exchanges as permanent public policy, said he would sign the legislation into law. That the bill passed by wide margins in the conservative state Senate and House shows state lawmakers in both parties are very concerned about new outbreaks like the one in Scott County.
They have reason for concern, health advocates say.
The Scott County crisis marks a new chapter in HIV transmission. It is the first documented HIV outbreak in the U.S. associated with the injection of a prescription painkiller.
In the U.S., HIV rates associated with injection drug use declined substantially over the last twenty years. But HCV infections, which had also been declining, are now rising across the country. The CDC estimates that HCV infection rates rose seventy-five percent between 2010 and 2012, as more opioid users began injecting the drugs. For several years health advocates warn that if hepatitis C is spreading among people who inject drugs, HIV won’t be far behind. And if Scott County can be considered a canary in the coal mine, it’s very likely that HIV rates from IV drug use will be rising elsewhere. But it won’t necessarily be the inner cities that lead the way. This time it will be America’s heartland.
A perfect storm
Looking back, the combination of poverty and unemployment, easily available prescription painkillers, and cutbacks in social services created a perfect storm that should have been easy to predict.
The picture on the ground in Scott County was ominous long before the spike in HIV and HCV. It has long suffered from high unemployment (8.9 percent now), and almost twenty percent of the proportion of the population living in poverty. Addiction specialists say that, as with impoverished inner cities, idleness, despair and unemployment are key indicators of who is susceptible to abusing heroin and other opioids.
Dr. Joan Duwve, the chief medical consultant for Indiana’s state health department, said prescription drug abuse has been rising in Scott County for more than a decade. The drug at the heart of the Scott County epidemic is Opana, also known as Oxymorphone, which became the drug of choice for a heroin-like high after Oxycontin was changed in 2010 to make it more difficult to snort or inject.
Per milligram, Opana is more potent than Oxycontin, and users who are not familiar with its effects are vulnerable to overdosing. Because of this, in addition to allowing needle exchange, Governor Pence recently signed a bill making it easier to access the overdose-intervention drug Narcan.
Not only is Opana more potent, the way it’s used—communally—helped HIV and HCV speed through social networks.
“There are children and parents and grandchildren who use in the same house and are injecting drugs together as sort of a community activity,” Duwve said at the April 24 conference.
People are paying $150 for 40 ml of the drug, according to health workers responding to the crisis, and users inject the drug several times a day. With the expense—and this is one of the poorest counties in the state—users pool their resources to buy it. Then they split the doses and share their syringes.
The third leg of the outbreak stool is the underfunding of health care infrastructure in the state.
According to data from Trust for America’s Health, Indiana is now dead last in the nation in per capita investment dollars it pulls down from the CDC and forty-seventh of all states in per capita dollars from HERSA.
That means limited health facilities for the poor in rural areas. HIV funding cannot cover every county for testing. Right now there are thirty-seven HIV test sites for ninety-two counties in the state, and the primary care system does not routinely screen for HIV and other STDs.
Abortion politics & Planned Parenthood
Until 2013, the sole provider of HIV and STD testing and services in Scott County was a Planned Parenthood clinic—a clinic that did not offer abortion services. That clinic and four other Planned Parenthood facilities in Indiana, all of which provided HIV testing and information, closed down since 2011, mainly due to across-the-board funding cuts to the state’s public health infrastructure, and partly because of politics.
Although Governor Mike Pence, a Republican, wasn’t directly responsible for the Planned Parenthood closures—he was in the U.S. House of Representatives in 2011, when the state cuts went through—that year he did push an amendment in the House to defund the organization nationwide. And Republicans in the Indiana state house, where they’ve held significant majorities for years, have been generally hostile to abortion rights.
The funds Planned Parenthood received from all government sources, including family planning and grants for HIV and STD services, decreased forty-two percent between 2005 and 2011.
Patti Stauffer, President and Chief Executive of Planned Parenthood of Indiana and Kentucky, believes conservative lawmakers’ hostility to abortion and the organization have led to unintended and adverse consequences for public health.
“Much of it the overall reduction [in funding] was targeted at Planned Parenthood because we provide abortions at some of our health facilities,” Stauffer tells A&U. “This goes to the frustrating and unfortunate reality that goes along with the stigmatization of abortion and the marginalization of centers and doctors who provide them.”
Although Stauffer is hesitant to make a direct correlation between the closure of a particular health center and the Scott County outbreak, she says the lack of testing facilities does speak to the larger issue of a lack of public health infrastructure in rural areas. “These areas don’t have the population densities that sustain a non-subsidized practice.”
Stauffer points out that in Scott County, and in many rural areas across the U.S., Planned Parenthood facilities, whether or not they offer abortions, are—or were—the closest places for any health services.
What’s the matter with Scott County?
The response to the HIV/HCV outbreak has been fast and furious. In March, Governor Pence issued a temporary executive order that made it possible for federal state and county governments to collaborate in ways they hadn’t before. Foundations stepped forward to pay for needle exchange. Many disease specialists are giving time for free. Eligibility for state’s new state health care exchange, Healthy Indiana Plan (HIP) 2.0, was sped up.
And there is a new clinic in downtown Austin, a town of 4,200 about an hour’s drive north of Louisville, Kentucky. That’s where the temporary needle exchange effort, based on Pence’s March order, is centered, and where HIV testing will presumably continue after the order expires.
Despite federal dollars and outreach help from groups like the California-based AIDS Healthcare Foundation and testing services from the Damien Center in Indianapolis, officials admit the underlying conditions in the region will still be there when the HIV surge stabilizes.
“The state health department is doing a great job with two hands tied behind their back,” says Beth Meyerson, Assistant Professor of Health Policy and Management and the Co-Director of the Rural Center for AIDS/STD Prevention at Indiana University.
“I think an outbreak would have been prevented if we had presence as healthcare groups and community outreach there. We have gutted our state of reproductive health services, which many people use for primary medical care because their doors are always open. Now in Indiana we have a crappy, underfunded health care system burdened by addiction.”
Meyerson says what’s needed, long-term, is funding for primary care and for testing. “We are not testing for HIV. When they do test, it’s because you’re symptomatic. By definition, that’s not routine. Routine screening is, ‘I’m running labs on x y z, let’s check for HIV too.’”
Meyerson points out that the area has long been underserved by primary care. “Many of these men and women have had zero health care for their whole lives. The community itself is not served from a primary care standpoint.”
Workers in the area, many who came from out of state, say that they’ve run into a big obstacle in doing outreach and prevention: Scott County.
Dan Bigg, who leads the Chicago Recovery Alliance, went to Scott County to consult with Opana users to find out what they might want and, eventually, provide a model for the state on how to scale up services and engage users. He tells A&U that the effort, especially needle exchange, was a success, exchanging about 50,000 syringes in five hours, until the county shut the whole thing down, in a violation of the Governor’s order.
“The state department of health is very competent and gets what needs to be done, but Scott County has been making the same mistakes that caused this problem,” Bigg tells A&U. He points to the county health department, which is allowing syringe exchange again, though with strict limits, and mistakes that have compromised the anonymity of users. And worse, law enforcement in the county is still arresting people for possessing hypodermic needles.
“Arresting people for needles, when we’re trying to give them clean needles, that’s as counterproductive as you can get. They act like locking up people is the way to stop this crisis, when in fact the oppressive stance toward drugs caused this health disaster.”
Preventing the next outbreak
It remains to be seen whether the state legislators appreciate that what’s happening in Scott County can happen, and may be happening, in other counties. Stauffer is cautiously optimistic.
“I think this has opened up an opportunity for dialogue and I give credit for lawmakers who are now willing to enter discussions about public health delivery in the state,” Stauffer says.
She adds that there needs to be more funding, soon, plus a larger culture shift. “We need community-wide embracement of promotion of healthy behaviors and willingness to meet people where they are with access to care.”
Meyerson is slightly less optimistic that the outbreak will be a true wake-up call.
“We’re not screening anywhere else. HIV funding cannot cover every county for testing. We don’t have the resources to fan out to other communities like Scott throughout the state. I know that Wayne County, just north of Scott, has a heroin problem and they are worried about HIV in their community. But again there is no screening and we don’t know what we don’t know. We have to invest in the system to identify health needs and I’m not sure enough lawmakers are learning any of those lessons.”
And even if the state ups its game, the culture of rural Indiana may still present roadblocks to helping addicts recover and reduce their risk of HIV and HCV. Meyerson points out that Scott County, Indiana, until a few weeks ago, was not that different from rural counties in many parts of the country: underfunded, neglected, without health care and addiction services and ripe for the spread of disease.
“There are two Scott Counties,” she says. “One county that’s stuck in the 1960s, and one that’s a userville, a ghost town with men and women lost in addiction and their families affected by it.”
And she adds the demographics of Scott County are not too different from many other counties across the nation.
Larry Buhl is a radio news reporter, screenwriter, and novelist living in Los Angeles. His podcast on employment issues, “Labor Pains,” can be found at www.laborpainspodcast.com.