Activists and drug addiction counselors say the HIV outbreak in Scott County, Indiana, is the result of state officials burying their heads in the sand about opiate addiction and the risk of HIV.
Meanwhile, a type of test for the AIDS virus could help pinpoint where the new infections came from. It could also help identify outbreak clusters that might be occurring elsewhere in the state.
The Indiana State Department of Health has not updated the number of HIV cases in the outbreak since they issued a news release last week. As of March 27, the tally stood at 81 people infected since February, primarily by sharing needles while injecting the painkiller Opana.
Indiana Gov. Mike Pence declared an emergency in Scott County, the epicenter of the outbreak, and gave the green light to a temporary needle exchange program there. Such programs are considered controversial in conservative Indiana.
“Scott County is facing an epidemic of HIV, but this is not a Scott County problem; this is an Indiana problem,” Pence said in the news release.
However, activists point out the needle exchange he created only lasts 30 days and only applies to Scott County. Scott County, population 25,000, is located along Interstate 65, which is known to authorities as a drug trafficking corridor.
Representatives of the Indiana State Department of Health did not return emails or phone calls this week from Healthline seeking comment.
There is concern that some HIV-positive drug users have also passed along the virus sexually. The U.S. Centers for Disease Control and Prevention has assisted the state in setting up testing sites and gathering information about who else may have been exposed.
At the Crossroads of a Public Health Crisis
Four factors have conspired in Scott County to fuel the dozens of HIV infections, according to experts.
They include a lack of available testing locations, lack of education for the public about HIV prevention, a long-established injection drug use problem in the community, and no state-wide needle exchange.
Some have argued state laws that criminalize knowingly spreading HIV have discouraged those at risk from coming forward and getting tested. The high infection tally may include people who have been infected for several years but were only diagnosed recently, experts stressed.
Dr. Amesh Adalja of the University of Pittsburgh Medical Center told Healthline the primary task right now for public health officials is to stop transmission.
“The spread of HIV through injection drug use is not hard to stop, and there’s not any controversy over how you stop it,” Adalja said. “You set up needle exchanges.”
Meanwhile, a Republican legislator in Indiana has amended current legislation in an effort to make the needle exchange program permanent.
“Thirty days is better than zero,” Adalja said. “What we’d like to see is the state of Indiana embrace needle exchange and institute it for all its counties. This is what happens when you don’t take this virus seriously.”
‘HIV Is Still Among Us,’ Scientist Warns
Gerald Schochetman is senior director of infectious disease research and development for Abbott Diagnostics. Abbott has developed a new HIV test called Abbott Architect that shows whether a person has recently been infected.
“Education is paramount,” Scochetman said. “HIV is still among us. There are about 1.2 million people living with the virus and 50,000 to 60,000 new infections each year. People need to understand what their risk factors are and people need to get tested.”
Most HIV prevention experts agree that HIV isn’t being taken seriously by the groups who continue to get infected, or they know so little about the virus they don’t understand they are at risk.
“Every kid I’ve ever had in treatment, if they are IV users, we have them screened for hepatitis C and HIV as part of the standard protocol,” said Joe Schrank, founder of The Fix, a website offering news and information about addiction. “They’re all shocked to learn they’re positive for one or the other, or sometimes both. ‘I was so careful,’ they say.”
Filtering heroin through a cigarette butt or trying to sterilize your own needles “is a really bad plan and a great way to spread disease,” added Schrank, who now operates Loft 107, a Brooklyn recovery center does that not turn anyone away.
As public health workers get more people into treatment and take their investigation to a higher level, answers about the Indiana outbreak may begin to emerge.
Phylogenetic testing to analyze strains of HIV among the infected could be used to determine where the infections came from.
“It’s a way of seeing how infections cluster together, how A is related to B, to work out a transmission tree along with standard epidemiological information from who injected who,” Adalja said. “You could use that to understand, is this one big outbreak from one strain, or multiple strains?”Substance Abuse Rates by Drug - Label | HealthGrove
Dr. Otto Yang of the UCLA AIDS Institute told Healthline that phylogenetic testing can show linkages but not absolute, direct connections.
“If you look back to the case of the dentist in Florida who was infecting his patients, they used this type of tool to show he was responsible, but even they had to rely on circumstantial evidence that it was all his patients who had viruses related to his, and either they were all infected by each other, which was extremely unlikely, or he was the common source,” Yang said.
Officials also hope to get people into treatment as soon as possible. The New York Times on Monday reported that none of the three people so far funneled into treatment at an HIV clinic in Louisville, Kentucky have shown up. That is the nearest clinic to the epicenter of the outbreak, 35 miles away.
Bad Timing for Outbreak, ‘Religious Freedom’ Law
During the HIV outbreak, Indiana has also been involved in a controversy over a religious freedom law, which has largely been perceived as a tool to discriminate against gay and lesbian people.
“Indiana is an absurd place,” said Schrank. “Being HIV-positive is looked at as … you’re gay.”
HIV-positive activist Josh Robbins operates Imstilljosh.com, a website offering encouragement and support to people newly diagnosed with HIV.
“What is happening is a culture of deeply held stigma and wrong opinions surrounding HIV and who can contract the virus and allowing stereotypes to dictate the state's previous lack of attention,” Robbins told Healthline. “The result is not a shock to those of us working in the field. They now have an HIV emergency. In 2014, the state had free HIV testing in only 20 of their 92 counties.
“HIV prevention, recognizing equality, and targeting drug addiction in that part of the state was not a priority previously, and now when the governor has asked for help with one hand, he is slapping activists and other allies with his other hand by defiantly reminding us that it is not on his agenda to give a damn about people like me,” Robbins added. “It’s pretty shameful, honestly.”
On Thursday, Indiana officials did an about-face on the religious freedom law and amended it to bar businesses from refusing service to gay and lesbian people. USA Today quoted the mayor of Indianapolis as saying that for the first time, Indiana law contains language such as “sexual orientation” and “gender identify.”