As the number of HIV cases tied to injection drug use in Cabell County continues to climb, officials at several local needle exchange programs, which stop the spread of HIV by reducing needle sharing, say they are only serving a small portion of the people most vulnerable to infection.
About three weeks ago, health officials reported 31 related HIV cases detected in Cabell County. They said the virus had been spread through needle sharing, and that the diagnoses were of people who live in Cabell County or people who are homeless but were tested in Cabell County.
Last week, Allison Adler, spokeswoman for the state Department of Health and Human Resources, said that health officials are now aware of 41 related cases – a 32 percent increase. DHHR has said Cabell County typically sees about eight new cases of HIV a year. They declined to release the cities where the 41 people had been tested, citing privacy protection.
Public health experts say infectious diseases like HIV rarely stay within the most at-risk population – in this case, drug users. HIV can also be spread from mother to baby, and through sexual partners.
HIV is treatable. Testing is available at health departments and at health care providers. Health officials recommend pre-exposure prophylaxis (PrEP), a preventative treatment, for people at high risk, such as sex workers, people who have a sexual partner with HIV and people who share needles.
Health officials also recommend using needle exchange programs where available. 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 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.
Public health officials have also 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 2010, West Virginia became the state with the highest per capita drug overdose death rate, stemming mainly from the use of pain pills. By 2015, most overdose deaths involved heroin, fentanyl or both.
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.
West Virginia currently has 16 needle exchanges, most at county health departments, according to DHHR. That includes locations at health departments in Raleigh, Fayette, Greenbrier and Wyoming counties.
But interviews last week suggest that many people who use drugs in West Virginia still lack access to them.
Officials at local health departments that operate needle exchanges said that because their programs are new, they haven't yet gained full trust from people who use drugs, so a minority of people who use drugs are using the programs.
It's unclear how many people who inject drugs live in the state, but the 2016-2017 National Survey on Drug Use and Health found an estimated 11,000 West Virginians had used heroin, which can be injected, snorted or smoked, in the past year, and an estimated 59,000 had misused pain pills, which can be injected.
Fred Cox, administrator of the Wyoming County Health Department, said their mobile harm reduction program, which started in April of last year, serves two locations in Wyoming County on Fridays. They served 147 people in March, he said.
"Honestly we're scratching the service, and it takes time to build up a large population that you're serving," he said. "I think that we're not even coming close.
"We're talking about folks that are, honestly, they're just barely surviving in many cases, and transportation is a big issue," he said.
Julie Mundell, a nurse and administrator for the Monroe County Health Department, said they offer HIV testing and have been trying to identify at-risk people.
"It's concerning because it's certainly something that it's easier to get ahead of it than try to play catch-up with it," she said.
But not everyone tells health department workers that they inject drugs.
"If they tell us no, we have to accept that," she said.
Testing is infrequent as of now, she said, although she said free testing will be offered at the Monroe Health Center women's health fair planned for next month.
Monroe County lacks a needle exchange.
"We have discussed it before," she said, adding that finances and logistics play a role. "It's just never really progressed beyond that."
Summers County also lacks a program, according to DHHR.
Cliff Massey, quick response team director and harm reduction coordinator for the Fayette County Health Department, noted that the syringe exchange program, which has been in operation since 2017, is located near city police, the sheriff's department and the magistrate court.
He believes that outlying areas of Fayette County are going unserved, although he noted that Montgomery General has agreed to host them one week.
"I don't think we reach enough clients, and I think there's a lot that won't come in because of our location," he said. “Those people need help, too."
Candance Hurd, administrator of the Raleigh County Health Department, said they have a provider who will prescribe PrEP, and offer testing from 7 a.m. to 5 p.m. Monday through Friday.
She said their needle program, which has been up for a few months, is seeing a handful of people.
She, too, noted that it takes time to build trust.
None of the local health departments contacted reported an increase in HIV cases, at least as of now.
But Christine Teague, program director for the Charleston Area Medical Center Ryan White program, said that Kanawha County is seeing an above average number of new HIV cases this year – about eight or nine cases in the first quarter of the year, while the county typically sees 15 to 20 cases per year.
It's unknown if those people were previously clients at the Kanawha-Charleston Health Department's needle exchange, which closed last year, after city officials blamed the exchange for what they said was an excess of used needles in the city.
"I can talk until I'm blue in the face about the scientific evidence of the benefit of programs, and the fear factor is just too great of an opposition right now," Teague said.
Charleston's free clinic, Health Right, and the nonprofit Covenant House offer much smaller needle exchanges in Charleston.
"It's such a polarizing issue," Teague said. "There were other programs that were set to start, and because of what happened here, they pulled back on it."
Matt Sutton, chief of staff for Charleston Mayor Amy Goodwin, said the mayor's team is in the information-gathering phase concerning HIV in Charleston, but is working as quickly as possible.
Teague noted that while HIV is treatable, and those diagnosed can live a long life, they may still have to deal with other people who have negative attitudes about people with HIV.
"It is the No. 1 barrier to HIV prevention and care in the United States, period," she said.
The Ryan White program can help them afford care, she said. And she noted HIV isn't spread through casual contact (such as kissing or hugging) and is very difficult to spread through needle-sticks.
But people may still be shunned, she said, especially in rural areas.
"They're ostracized," she said. "They might be evicted from their apartment or fired from their job, which is illegal, but in order for the person to pursue legal defense, that would require money and a lawyer, time and a lot of people don't have those resources to put up a fight."
She worries that health workers aren't reaching some at-risk people and getting them screened and into treatment. People who feel they'll be judged, she said, also may not reach out for testing.
"If you don't get the treatment, it will kill you in a matter of about ten years," she said. "It is a fatal disease if it's not treated. So if you don't know your status, therefore you're not in care, or you know your status and choose not to be in care, you will die."
Her program is open to people who live in 19 counties in southern West Virginia and they help people pay for transportation to Charleston, she said. She said for more information, people can call 304-388-8106.
Jay Adams, HIV care coordinator for the Ryan White Part B program and employed by the Wheeling-based AIDS Task Force, called back after working his shift at the needle exchange program in Wheeling.
His program employs case managers in Beckley, Morgantown, Huntington, Charleston and Wheeling.
In Cabell County, a local case manager has struggled to link those diagnosed with treatment, and keep them in treatment, according to Adams.
"The folks I've met – I can't think of a single one that wasn't hungry," he said. "Health care is not always your top priority, particularly if you're hungry."
He said Marshall University's infectious disease doctors have adjusted their schedules to take patients.
But the majority of those diagnosed have been homeless.
They're dealing with the shock of an HIV diagnosis, he said, which they may mistakenly believe is an automatic death sentence.
At the same time, they also have to think about things like drug treatment, where to get their next meal, and where to keep a few possessions safe.
"They're just facing an awful lot in life right now and an HIV diagnosis does not make any of those things better," he said.
The Beckley case manager can be reached at 304-763-5257. He also said there is a Beckley physician at Beckley Appalachian Regional Hospital who does a "phenomenal" job treating people with HIV, Dr. Zonaira Gul.
While Adams said the state has made "remarkable progress" in recent years, he remembers talk of the need for needle exchange programs 10 to 15 years ago.
"I cannot actually say to you for sure that if we opened them earlier we’d have fewer people infected,” he said, "but we’d definitely have fewer people at risk.”
Email: firstname.lastname@example.org and follow on Twitter @3littleredbones