Congress needs to immediately lift the ban on federal funding for needle exchange programs to counter the threat of HIV outbreaks among injection drug users like the one that has seen an alarming number of new cases erupt in a single rural Indiana county.
So say Johns Hopkins Bloomberg School of Public Health Professor Chris Beyrer, MD, MPH, and Steffanie A. Strathdee, PhD, director of the Institute of Global Health at the University of California-San Diego, in a commentary published online June 24 in The New England Journal of Medicine.
"There are going to be more of these outbreaks and what's urgently needed is a public health response before things get even worse," says Beyrer, who is also president of the International AIDS Society. "Now is the time to implement needle and syringe exchange programs, wherever they are needed. We can't put politics above public health. We have a cheap tool to prevent this."
The story of Scott County, Ind., a rural region of the state near the Kentucky border, is one that public health officials had feared. In the past decade, the face of drug abuse has changed. No longer is it an exclusively urban, male, African-American problem. It is now mainly concentrated mainly in rural white communities and roughly equally among men and women.
Often, they start out abusing prescription drugs, sometimes by mouth but often by injection, which then can be a gateway to heroin. In 25 states, over-the-counter syringe purchase is illegal without a prescription. Across the country, in states where needle exchanges are legal, programs are prohibited from using federal funds due to a ban that was lifted, in 2009, and then reinstated by Congress in 2011. It's a recipe ripe for HIV and hepatitis C infections to be transmitted quickly through a community, the researchers say.
Southeast Indiana had previously recorded only about five new cases of HIV a year. By June 10 of this year, 169 people had been newly diagnosed and more than 80 percent were also infected with the hepatitis C virus.
Needle exchanges are illegal in Indiana.
The state's governor has made an exception to allow for needle exchanges in the affected county, but says he will only allow other counties to start programs once they show a need.
"Regrettably in the case of NEPs [needle exchange programs], other Indiana counties contemplating authorizing them must first demonstrate the existence of a public health emergency - a requirement that ensures that they can only respond to, rather than prevent, new outbreaks," they write.
Another troubling aspect, the authors note, is that to get clean needles, people must give their initials and date of birth, a registration process that could deter use. And the programs are only open until 6 p.m. most evenings.
Other ways to counter the epidemic, Beyrer says, are to screen more people for HIV and ask them about their drug use, including white women, a demographic that may have been overlooked in prior screening. Beyrer says poor screening efforts mean fewer people in treatment for HIV. Identifying those with HIV earlier can lead to earlier treatment and suppression of viral load, making those with HIV less infectious to others.
Greater use of opioid replacement therapies - that is, replacing those drugs with methadone and buprenorphine, which are less dangerous - could also aid the battle.
These types of actions have worked in the past, Beyrer says. An explosive HIV outbreak among injection drug users that hit Vancouver, British Columbia, was controlled by the expansion of needle exchange programs, providing opioid replacement therapy and providing highly active antiretroviral therapy (HAART) free of charge through Canada's universal health care system.
"Drug use is changing and before this gets any worse, we need to change our approach to fighting it," Beyrer says.
"Threading the Needle - How to Stop the HIV Outbreak in Rural Indiana" was written by Steffanie A. Strathdee and Chris Beyrer.