February 25th, 2016
One year ago today, an HIV outbreak in Indiana prompted a frenzy of headlines in outlets across the country: More than 20 cases of HIV in southeastern Indiana had been identified, with the majority linked to injecting drug use. The opioid epidemic in the United States appeared to have reached a tipping point.
In the year since, the spread of infectious disease among Indiana’s injecting drug users has continued. Several county health departments declared states of emergency regarding Hepatitis C, and four counties received special state approval to open up syringe exchange programs to combat the problem.
But whether the rates of Hepatitis C and HIV are now decreasing is difficult to determine. Public health experts lack access to real-time data, and the data available may not necessarily present a clear, comprehensive picture of reality, as Dr. Carrie Lawrence, director of Indiana University School of Public Health’s Project Cultivate, which helps counties work through the process of opening syringe exchange programs, tells The Influence.
“We know that as soon as our local hospital increased testing, more positives showed up, “ Dr. Lawrence says, “whereas in lower resource communities, who don’t have resources to increase testing or don’t have local hospitals to ask to help, that’s not an option. There might be more cases out there but counties don’t have the capacity to test.”
If a county does have the resources to provide access to testing, declaring an epidemic is a discretionary decision that could be influenced by a variety of factors, from local politics to stigma and staffing strains.
“Rural communities don’t have the tax base to fund multiple staff to go out and actually gather surveillance data, and then actually provide the services,” Dr. Lawrence says. “The time that it takes to even pull things together takes away from something else in these smaller communities, but it hasn’t necessarily deterred them.”
A map provided by the Rural Center for STD/AIDS prevention shows how some counties are moving forward:
The state does not provide any funding for these services, so the counties often rely on donations and partnerships with local and national organizations. Mobile vans are more common than store-front operations because they can bring services to populations as required, but they still may only operate for a handful of hours a week.
Christopher Abert, founder of Indiana Recovery Alliance, the group operating syringe exchange in Monroe County, says he is concerned that the reactionary approach to HIV and Hepatitis C will not be enough to stop the transmission of these preventable diseases. “My understanding and strong belief is this could happen anywhere else at anytime. There’s nothing specific about Indiana,” he continues. “Any place where there is not access to harm reduction supplies, where possession of paraphernalia so highly criminalized [is at risk].”
In Indiana, treatment—particularly medication assisted treatment like methadone and buprenorphine—is also difficult to access, says Daniel Raymond, policy director at Harm Reduction Coalition, a group working with Indiana advocates to bring their expertise to those looking for help. “The treatment gap around medicated-assisted treatment is fueling these crises where it could be part of the solution.”
Possession of syringes for drug-injection purposes is a felony in Indiana, and syringe exchange programs are a huge step forward not just for the state, but the region.
“We’re seeing similar movements in other states so I think these programs are actually at the forefront of a renaissance in change,” says Raymond, noting that the first wave of programs back in the late 1980s and 1990s tended to be coastal, and in urban areas.
“Some of these newer programs in Indiana and elsewhere, they’re actually showing us how to do syringe exchange in very different environments—not just more conservative environments, but less urban environments and with different challenges,” Raymond continues. “So I think that they’re paving the way. It’s not just that they are following suit of what New York or San Francisco did—they’re having to adapt and reinvent syringe exchange for different kinds of communities with different kinds of challenges, and I think that one of the most important and exciting things is, we have a lot to learn from them.”