An HIV outbreak in the rural midwest has lessons for us all

One is apt to think of an HIV epidemic in large cities or in under-developed areas around the world. On March 26, 2015, however, Indiana’s Governor Mike Pence proclaimed a public health emergency in the small town of Austin, Indiana. At that time, 74 cases of HIV had been confirmed there in three months. As of July 14, the number of confirmed cases had more than doubled, bringing the total to 174. This town of 4,200 people in rural Scott County Indiana now has an HIV infection rate comparable to that of sub-Saharan Africa.

Austin is like many other rural communities in America. A few downtown businesses line Main Street, while farmland and forest stretch out in all directions. Like many other small towns, Austin appears to have had much better, but still modest times. Unemployment is 3.5 percent higher than the national average and the annual per capita income is $16,000. The median age is 35.

Opana and Needle-sharing

The intravenous use of Opana (oxymorphone) is said to be the force behind Austin’s HIV epidemic. It is an oral prescription painkiller easily crushed and dissolved for injection. In Austin, it is thought that the number of injections per day can be as many as 15 per person.

The Centers for Disease Control and Prevention (CDC) investigated the outbreak and found up to six “injection partners” were present at a single “injection event.” Among those confirmed HIV positive, an average of nine high-risk contacts per person were reported. In some families, three generations have been found sharing syringes and injection preparation materials. Some have reported using a syringe until the needle point becomes too dull and the numbers on the barrel are worn off.

Unprecedented Events

State Health Commissioner Dr. Jerome Adams said there are three epidemics in Scott County: HIV, hepatitis C (HCV) and addiction. Eighty-six percent of those who are HIV positive have co-occurring HCV and 10 percent of the population is thought to be addicted.

Deputy Commissioner Dr. Jennifer Walthall said, “There’s nothing that makes Scott County different than any other rural county in America. It…happens to be the first that brought this constellation of events. There is an opiate epidemic across the United States. The sharing of needles for injected drug use is not limited to Austin. It’s Indiana’s problem. It’s the United States’ problem.”

On March 26 of this year, Governor Pence issued an executive order to begin a needle exchange program in Scott County. He called the action a commitment to compassion. Getting sterile syringes to those in need was slow going at first, however. Because many feared stigmatization and arrest, they were reluctant to go to the needle exchange and the medical clinic. The clinic, run by Dr. Will Cooke, has been at the center of this public health crisis since the beginning.

foundations

Foundations Family Medicine, run by Dr. William Cooke, provides services to prevent or treat HIV and other infectious disease. Credit: Marie Monroe Doutaz

But over time, those in need have come forward wanting help, particularly in the needle exchange program. Syringes are given based upon an individual’s reported need for one week and at last report, over 32,000 sterile syringes had been distributed, with almost that same amount returned.

Cooke said the epidemic began when “a patient zero came into the community…sharing dirty needles”. Patient zero is a term used to identify the carrier of infection into an unaffected population. It has been estimated that the strain of infection in Austin may have been only six months old by the time the epidemic was evident.

An Overwhelmed Community

“There is an opiate epidemic across the United States. The sharing of needles for injected drug use is not limited to Austin.”

Cooke reported repeatedly and unsuccessfully seeking help for the community’s addiction problem that has accelerated over the last decade. After the HIV epidemic was declared, however, Austin received help from local, state, private and federal sources very quickly. Comprehensive best practice services were well under way in just weeks.

These services included:

-A One Stop Shop offering sterile syringes, HIV testing, condoms, hepatitis immunizations, harm reduction and addiction education, and help securing identification in order to apply for healthcare and other benefits

-Medication for reducing the HIV viral load

-Mobile outreach

-Referrals to addiction treatment facilities

-Transportation assistance to services

-Additional staff for direct care, state-level interventions and oversight

-Outpatient addiction counseling

-Public awareness campaigns

The community’s response has been varied and at times volatile. Media exposure, obvious prostitution, and needles found in public places have angered many. Some fear services will enable more addiction. Some are very vocal; Cooke’s clinic has received death threats and those who are addicted have been told to leave the community. Others have publicly prayed for healing, done needle clean up on the streets and offered transportation to services.

The Crossroads of America

Indiana identifies itself as the Crossroads of America and welcome signs greet travelers on I-65 saying so. The interstate runs from Chicago to Mobile, Alabama with Austin sitting not far from it. I-65 is busy with U.S. travel, commerce and for decades now, drug trafficking. It connects many other similar corridors that criss-cross America.

crossroads

Credit: Marie Monroe Doutaz

Of particular concern has been the number of long distance truckers up and down this interstate and its alternate route, U.S. 31, which runs straight through the middle of Austin. Just as “patient zero” is thought to have brought HIV to Austin, the fear is that truckers will take it to other communities. A public education campaign has targeted truck plazas and rest stops along the highway.

This tragedy has many stories and lessons for all of us. Chief among them seems to be that if it can happen in Austin, a rural town not dissimilar to countless others in the U.S., it can happen anywhere. It has also become apparent that we can mobilize prevention, containment and treatment swiftly. As of July 18, one other Indiana county has started a needle exchange program and two more are preparing to ask for one.

Marie Monroe Doutaz is a psychotherapist and writer living in Louisville, KY.

Resources

Centers for Disease Control and Prevention – Community Outbreak of HIV Infection Linked to Injection Drug Use of Oxymorphone—Indiana, 2015

Centers for Disease Control and Prevention – Official Health Advisory: Outbreak of Recent HIV and HCV Infections among Persons Who Inject Drugs

Indiana State Department of Health – HIV Outbreak in Southeastern Indiana

SAMHSA – Syringe Exchange Program Studies

U.S. Surgeon General – Determination That a Demonstration Needle Exchange Program Would be Effective in Reducing Drug Abuse and the Risk of Acquired Immune Deficiency Syndrome Infection among Intravenous Drug Users

World Health Organization – Effectiveness of Sterile Needle and Syringe Programming In Reducing HIV/AIDS among Injecting Drug Users