Federal, state and local public officials are working to get an HIV outbreak in rural Southern Indiana under control, but new cases are still being reported every day and they don't believe that the outbreak has peaked yet.
The state began an investigation on Jan. 13 after 11 HIV cases were confirmed in Scout County, a community that typically has five or fewer cases identified in an entire year. As of April 24, 142 individuals have tested positive for HIV and 136 of those diagnoses have been confirmed.
But what is happening in Indiana is “really only the tip of the iceberg of a drug abuse problem we see in the United States,” Dr. Jonathan Mermin of the Centers for Disease Control and Prevention said during a news conference Friday.
Mermin, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, noted that opioid prescriptions have quadrupled in the U.S. since 1999.
About 2 million U.S. residents are dependent on or abuse opioid prescription drugs, and there were 16,235 deaths related to prescription opioid overdoses in 2013.
This is the first outbreak of its type in recent years, and Mermin noted that many of the new HIV patients are too young to remember the HIV outbreaks linked to injected drug use in the 1980s and early 1990s.
The CDC detailed the outbreak in Scott County in an early release of its Morbidity and Mortality Weekly Report. It reported that 135 patients were identified as of April 21, in a small community of 4,200 people. At least five patients were reported from neighboring Jackson County.
The patients ranged in ages from 18 to 57, 74 were male, “a small number" were pregnant women, 108 reported injected-drug use, 114 were also infected with the hepatitis C virus, and 10 female patients were identified as commercial sex workers.
All 108 who admitted to injecting drugs reported dissolving and injecting oxymorphone, an opioid sold under the brand name Opana that is meant to be taken orally. Some of the infected people also reported injecting heroin, methamphetamines or other drugs.
Indiana's Republican governor, Mike Pence, has stated his personal belief is that needle-exchange programs are not an effective strategy for preventing drug abuse, but he issued and recently extended a 30-day executive order allowing them in Scott County to address the public health emergency.
State Health Commissioner Dr. Jerome Adams, however, said the role of the needle exchange in stemming the outbreak has been “overstated,” and noted that it was only one part of a comprehensive strategy. Other parts include the opening of a “one-stop shop” where needles can be exchanged, and where free HIV testing, and tetanus and hepatitis A and B vaccinations are provided. Also, insurance coverage connections are explored, and healthcare coordination services and referrals are given.
There has also been a public awareness campaign with the message “You are not alone.”
“Hopefully, this could be a model response other communities can use in the future,” Adams said.
He emphasized that needle exchanges remain illegal in Indiana, are only being allowed 30 days at a time, and that operation of needle exchanges is included in a bill before the Indiana Legislature.
“The governor is not at all hesitant about addressing HIV and drug abuse in the state,” Adams said. “Needle exchange alone is not a panacea.”
Indiana does have a prescription drug-monitoring program and the state quickly identified the providers who have been prescribing Opana, Adams said. He added that said doctors have been “more than willing” to reassess their prescribing patterns.
Adams said the state has spent $2.1 million on combating the outbreak and cannot continue to fund the entire effort. But he added that it has received an “outpouring of support” from private groups, foundations and drug companies offering to help.
There are no HIV specialists in the region, and Dr. Joan Duwve, chief medical consultant for the state health department, said experts from Indiana University have come to the community weekly to see patients. They've seen more than 30 patients and people have been knocking on doors to alert the community of the available health service.
Duwve, one of the authors of the CDC report, said public health officials have seen prescription opioid pills "flooding the market,” and not only in Indiana, but all along the Ohio River. Many family members use drugs together with children, parents and grandparents taking part, she said. The number of daily injections ranged from four to 10 with the number of people injecting at one time ranging from one to six. The effects typically last for about four hours before people begin to get sick from withdrawal symptoms.
Scott County has an 8.9% unemployment rate, 21.3% of adults didn't complete high school, and 19% of the population lives in poverty.
“The outbreak highlights the vulnerability of many rural, resource-poor populations to drug use, misuse and addiction, in the context of a high prevalence of unaddressed comorbid conditions,” Duwve and her colleagues wrote. “The outbreak points to the need for expanded mental health and substance-use treatment programs in medically underserved rural areas.”