West Virginia health officials are investigating an increase in HIV cases spread through needle-sharing among people who inject drugs.
State health officials began investigating a group of related HIV cases in Cabell County in January. They don’t know if the virus, which is treatable, has spread beyond Cabell County and, if so, how far it has spread.
“I don’t have any specific information on any of that, but how big of a state are we?” said Dr. Michael Kilkenny, physician director of the Cabell-Huntington Health Department. “And where do people travel in our state?”
Public health officials have known much of West Virginia was particularly susceptible to an HIV outbreak for years, due to the high rate of injection drug use, access to health care, and the prevalence of poverty. In 2016, the Centers for Disease Control and Prevention reported that of 220 counties most vulnerable to an HIV outbreak, 28 were in West Virginia, most in the southern part of the state.
In 2017, health officials detected an HIV outbreak in Raleigh, Wyoming and Summers counties that eventually spread to 57 people in 15 counties. Health officials believe that virus was spread by men having sex with men.
In January, health officials detected an HIV cluster in Cabell County. Officials at the state Department of Health and Human Services said the term “cluster” is used when officials don’t yet know the geographic area of related cases.
This time, the cases are linked to injection drug use. They continue to detect related cases. Kilkenny first reported 28 cases. Monday, the state Department of Health and Human Services reported 30 cases. Later in the week, DHHR said that 31 cases had been detected.
Shannon McBee, senior epidemiologist within the Division of Infectious Disease Epidemiology at DHHR, said all, so far, are either Cabell County residents or people who are homeless and were tested in Cabell County.
“In this instance, we’re still trying to gather information on what exactly is going on so we don’t know how much this expands beyond Cabell County or if it does,” she said. “We just don’t know that information. It’s too early on.
“You might want to check back in a month,” she added.
Dr. Judith Feinberg, a professor in the West Virginia University School of Medicine and an HIV health care provider and researcher of more than 30 years, said that attitudes about people with HIV and people who use drugs continue to hinder access to services that could prevent infectious disease from spreading.
She noted that infectious diseases also rarely remain within the population most at risk – in this case, injection drug users. Others, such as sexual partners, may also become infected. HIV can also be spread from mother to baby.
“What gets in the way?” she said. “Lack of knowledge on the part of both consumers and providers, and the other thing is stigma, which afflicts everything that’s got to do with sex in this country or sexually transmitted diseases, and is also a huge issue around the drug epidemic.”
Public health officials have known for more than 30 years that needle exchanges stop the spread of HIV by reducing the chances that people will share dirty needles.
Sometimes called harm reduction programs, needle exchanges provide clean needles, and sometimes other services, such as birth control or the opioid antidote naloxone, to intravenous drug users. They may also include referrals to drug treatment providers.
Harm reduction programs are programs that reduce the harm inflicted by engaging in risky behaviors. Other examples of harm reduction include using condoms when one’s partner’s sexually transmitted infection status is unknown, or cutting back on alcohol or cigarettes.
West Virginia has 17 needle exchanges, most at county health departments, according to DHHR. That includes locations at health departments in Raleigh, Fayette, Greenbrier, and Wyoming counties.
But Feinberg said that’s nowhere near enough. The federal CDC completed a report on the 2017 outbreak, and found that none of the three counties where the outbreak started – Raleigh, Wyoming or Summers – had established needle exchange programs prior to the outbreak.
Feinberg said that while state health officials support needle exchanges, they are often met with local resistance.
She noted that addiction alters brain function.
“People whose brains tell them, ‘inject, inject, inject, you need more drug’ – they’re going to use whatever they can find, and if they don’t have a sterile syringe or clean syringe or clean supplies to do the injection with, they’re not going to care, because that’s not how their brains work,” she said. “Their brains are telling them, ‘better get some more drug right now.’ This concept of enabling comes from people who aren’t thinking like addicted people.
“They’re thinking like people not struggling with that disease and of course if your brain isn’t telling you ‘inject, inject, inject,’ of course you see it differently but the reality is that it’s got nothing to do with enabling, because you’re not stopping people by not having a clean syringe. You’re not stopping people from injecting. You’re just forcing them to pick them out of the garbage.”
Feinberg said that the closure of the Kanawha-Charleston Health Department needle exchange in Charleston last year affected harm reduction services throughout the state and nation. At the time, Charleston city officials blamed an increase in clients, some from out of town, at the exchange for what they said was an excess of public needle litter.
“It was that crazy mayor and the chief of police,” she said. “It was all nasty local politics.”
Now, many needle exchanges are open only to county residents who must show ID, she said.
She noted that county commissioners serve on county health boards and are making their own political decisions.
“I mean people everywhere were using this as political fodder to not develop the harm reduction programs they needed,” she said. “...You know there’s HIV in Charleston, too. There’s just not enough testing going on to show it. It’s nothing unique about Huntington.
“My terror is that there’s a lot more HIV in this state than anybody knows about.”
Feinberg said the providers who are most knowledgeable about HIV live in Morgantown and Charleston. She said some providers work in more rural areas, but not enough.
She said Medicaid and most commercial insurance covers pre-exposure prophylaxis, medicine that can prevent HIV among at-risk people, such as sex workers or those who inject drugs. She also noted that HIV is treatable.
But patients are less likely to show up for treatment if they can tell their providers are judging them, she added, and many providers still don’t feel comfortable treating the condition.
“There were years when it was very, very difficult, and you needed to be a specialist because the drugs were so complicated, and there were so many drug interactions and so many side effects and you really needed to know a great deal in order to do a good job, offer patients something that would work and not make them sick, but those days are over,” she said. “Now most people, newly diagnosed, they take one pill once a day, they have almost no side effects and they live to be 70.”
She suggested providers reach out to West Virginia University about the free ECHO HepC/HIV training program. Continuing education credits are available.
Feinberg predicted many HIV-positive people in West Virginia are unaware. She came to the state to help to work on issues related to HIV and drug use.
“I’m so passionate about this really, because I’ve been doing HIV care and research since 1982, since the very beginning of this epidemic and so I started when everyone died,” she said, “and 25 years later everybody lives.
“It’s one of the most fabulous medical stories of the last century and then along comes this heroin problem, and I’m an infectious disease doctor, and I know what’s going to happen.”
Last week, the state Department of Health and Human Resources sent an alert to health care providers in the state, asking them to increase testing of HIV, Hepatitis B and C and other sexually transmitted infections among people who use drugs and link them to needle exchanges and other care.
The alert said that while Cabell County typically sees eight new cases of HIV a year, it had detected 30 related cases from the last quarter of 2018.
“We know that our substance abuse epidemic increases risk,” said Dr. Cathy Slemp, state health officer. “We’ve known that for a long time. We’ve seen infectious diseases emerge as secondary consequences of that, and we know that HIV is one of those, and I don’t think we can put our head in the sand and think that it can’t happen here.”
DHHR is planning testing events in Charleston and Huntington. It also plans to reach out to emergency rooms and urgent cares, is keeping a closer eye on HIV reports from local health departments, has devoted more staff toward investigating the increase, and also plans to assist in linking people who have been diagnosed to care, according to McBee, senior epidemiologist within the Division of Infectious Disease Epidemiology at DHHR.
She also recommended people who use drugs seek clean needles from harm reduction programs where available.
“It’s been determined that harm reduction programs, when part of a comprehensive prevention strategy, can play a critical role in preventing HIV among people who inject drugs, and can facilitate entry into treatment services and other medical services and that they do not increase unsafe illegal injection practices,” she said. “But you have to give them the chance to work.”
State Health Officer Slemp noted that harm reduction services help health care providers build relationships with the population that is at high risk. She said the stigma of drug addiction is not helpful.
“It’s a disease,” she said of addiction. “It changes how our brains work and we need to link people into care with respect and support.”
Slemp said policies that require ID may prevent some of the most vulnerable people at risk, those who are homeless, from receiving services.
“They only work if you can access them,” she said.
Asked for specific ways the department is working to increase the number of syringe exchanges in the state, Slemp said, “We are looking for more resources to support harm reduction.
“We talk about it where we can,” she said. “There’s a harm reduction coalition. I think the more people understand how these programs work and the more we can have open and honest dialogue around them, the better.”
She added that her office has a harm reduction coordinator, and said they’re happy to support communities that want to start harm reduction programs.
“I think it’s always important that we work to put them in context of the community locally and that we do it with education and explanation of why and how,” Slemp said. “We’ve also got 30 years of experience with harm reduction programs around the country, so it’s not a new intervention, and we know what works.”
McBee, the epidemiologist, also said drug users can reduce chances by no longer injecting or by using only sterile needles, never sharing needles, cleaning their skin with a new alcohol swab before injecting, making sure not to get someone’s blood on their hand or their needle, disposing properly after one use, not giving needles away, getting tested at least once a year, and talking to their health care providers about pre-exposure prophylaxis, or PrEP.
Everyone should know their status, she added.
All health departments in the state offer HIV testing, she said. They don’t offer PrEP but can make referrals.
Health officials don’t yet know whether people involved in the HIV cluster in Cabell County were needle exchange participants.
Dr. Michael Kilkenny noted it’s early in the investigation.
But following the controversy in Charleston, Cabell-Huntington Health Department tightened up its own rules for accessing the exchange.
Kilkenny said that so far, health officials have put up a billboard to encourage testing and will be distributing fliers and using social media. He said local agencies will also be reaching out to the homeless.
He noted that the virus “cannot be spread by hugs and handshakes and toilet seats and doorknobs.”
“Back in the ‘80s, when this disease was in its first epidemic, cities closed swimming pools over this disease,” he said. “That’s not helpful. It’s not necessary.”
He noted that health officials are not aware of any cases of HIV that have been spread by an accidental needle-stick outside of a health care facility.
He added that everyone deserves respect.
“Stigma prevents people from engaging in health care,” he said. “It prevents them from living their full life, and it causes harm.”
He said he doesn’t think that hating any other person improves anybody’s life, and is more likely to cause harm to both people.
“Hate’s a very heavy burden to carry,” he said, “and we recommend putting that aside.”
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