Indiana’s HIV Outbreak: A Cautionary Tale for Injectable Drug Users Everywhere

New cases of HIV and hepatitis C, which can occur with HIV, in Scott County, Indiana, have only begun to slow in the last few weeks. The outbreak that began earlier this year — the worst in the state’s history — has now climbed to 170 cases and state and national health officials link the crisis to shared needles by users of illegal injectable drugs.

The recent slowing in case numbers is likely the result of concerted efforts by the state, including an emergency needle exchange program. But even as the reported cases fall to a trickle, health experts say this is no time for Indiana or any other state to slow down prevention and assistance efforts. Specifically, states should help drug users find treatment to stop their drug use; and promote safer ways to inject drugs, such as needle exchanges and frequent HIV testing to identify and begin treating HIV cases quickly, when treatment is most effective and can reduce the severity of the virus. Soon after the outbreak began in February 2015, Indiana Governor Mike Pence declared a public health emergency and authorized an emergency needle exchange program.

Not Just a Problem for Indiana

“The HIV and related hepatitis C (HCV) outbreak among people who inject drugs, particularly oxymorphone in Scott County, is an unprecedented situation,” says Hilary N. McQuie, a senior program analyst at the National Association of County and City Health Officials (NACCHO). “However, the conditions that led to the outbreak are not unique to Scott County, which highlights the potential for a similar situation to occur elsewhere.” The U.S. Centers for Disease Control (CDC) issued a health advisory shortly after the outbreak began to alert local health departments and healthcare providers nationwide of the possibility of HIV and hepatitis C outbreaks among people who use drugs to provide guidance to assist in the identification and prevention of such outbreaks. Oxymorphone is sold under the brand names Opana and Numorphan.

McQuie says health officials have been preparing for outbreaks like this in response to recent rising numbers of fatal overdoses from opioids in recent years. “The increase of prescription pain medication use by both people using it as directed by their doctors and those using it outside of supervised medical care is well-documented nationally,” she notes. According to the CDC, overdose rates have increased roughly five-fold since 1990 as a result of increased opioid use, and drug overdose is the leading cause of accidental death in the U.S., causing more deaths than car crashes. And while recent data show that overdoses from prescription opioids appear to be leveling off, there’s been a dramatic increase in heroin overdose deaths between2012 and 2013. Paul Jarris, MD, executive director of the Association of State and Territorial Health Officers, says this is because local, state and national efforts have made it harder to get prescription opioids, which has pushed many of those who are addict to pain pills to try heroin which can be cheaper and easier to get than prescription medication.

Indiana’s HIV Outbreak: A Cautionary Tale for Injectable Drug Users EverywhereMcQuie says that factors that contributed to the outbreak in Indiana could result in the same type of outbreak in other parts of the country. These include rural poverty; doctor shortages; stigma and discrimination of those who abuse drugs; syringe shortages (this leads to needle-sharing and re-use); and a lack of HIV-related funding, services and awareness.

At a recent briefing for lawmakers in Washington, DC, Indiana State Health Commissioner Jerome M. Adams, MD, MPH offered several recommendations to help other states and regions prevent similar outbreaks, including:

  • Increase or initiate overdose prevention education, including distribution of naloxone (brand name: Narcan), a drug that can reverse an overdose, and training in its use to friends and family members of drug users when possible and to first responders. (Find local overdose prevention programs distributing naloxone by accessing the Overdose Prevention Alliance program locator.)
  • Pass Good Samaritan-type laws, which allow overdose bystanders to call 911 without worrying about arrest for drug charges if the police find them in possession of illegal drugs.
  • Set up syringe distribution and disposal programs.
  • Support the scale-up of drug treatment efforts, especially medication-assisted treatment with methadone and buprenorphine to treat opioid dependence. According to NACCHO, a recent University of Washington study found that 30 million Americans lived in counties without a single doctor certified to prescribe buprenorphine and naloxone (brand name: Suboxone). The majority of these counties were in rural areas.

Health officials are also calling for a federal response to the drug abuse crisis in the U.S. The Big Cities Health Coalition, a NACCHO project that brings together the health directors of 20 large American cities, recently called on the federal government to do more. “Cities have been on the front lines of dealing with opioids and overdose since the first wave of serious abuse hit in the 1990s,” said Barbara Ferrer, executive director of the Boston Public Health Commission and chair of the coalition, speaking during a briefing in Washington, DC, in 2014. “While they have made significant gains in saving lives that would have otherwise been lost to fatal overdoses, city and county governments have been stymied by state and federal budget cuts that limit the capacity of local governments to provide emergency care and conduct community outreach.” Examples, according to Ferrer, include Medicaid regulations that prevent drug treatment services from billing for more than 16 beds and restrictions on medication-assisted therapy for opioid addiction.

Efforts around the country recently got a funding boost, though: On July 1, the CDC announced that it had awarded $216 million over five years to 90 community-based organizations to provide HIV-prevention strategies to those at greatest risk, including people who inject illicit drugs.

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