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Ind. could have avoided HIV outbreak, study shows

Lexy Gross
@lexygross
Matt Stone/The Courier-Journal
Bobbie Jo Spencer, shown sitting outside the Austin, Ind., home she rents with six other people, said she is addicted to the painkiller Opana. She said she has tested negative for HIV, but she?s still nervous.
Sitting outside the Austin home she rents with six other people, Bobby Jo Spencer is addicted to opana, which she uses regularly. She's been addicted to drugs for years. By Matt Stone, The C-J April 26, 2015

Not only was the nationally publicized HIV crisis in rural Indiana last year preventable, but other U.S. communities are at high risk for nearly identical outbreaks, according to a recently released study from the prestigious New England Journal of Medicine.

The study, published last week, also reveals contradictions between what Indiana public health officials think is best for the state and the response to Indiana's epidemic. And as Indiana Gov. Mike Pence follows the campaign trail of his now-running mate and GOP presidential candidate Donald Trump, Hoosiers have wondered if different policies or preparedness could have at least lessened the impact.

In conclusion, the study found that Scott County's public health crisis -- which left 181 people in Southeastern Indiana HIV positive -- was caused by a "close network" of residents injecting opioid Opana and sharing needles. It suggests that Indiana and other largely rural states should focus on prevention measures such as more HIV testing, identifying networks of intravenous drug users, increasing access to treatment, considering syringe-exchange programs and education.

"Although the magnitude of the outbreak was alarming, the introduction of HIV into a rural community in the United States was not unexpected when considered in the context of increasing trends in injection use of prescription opioid (painkillers)," the study says.

Dr. William Cooke, the lone physician in Austin, Ind., the town at the epicenter of the outbreak, said Scott County had every indication for years that the spread of HIV was possible. Cooke pointed to poverty, high unemployment, a steady flow of opioids into the community, high hepatitis C rates and adverse childhood experience.

"If we knew there was a population at risk based on the indicators mentioned, why wait for HIV to hit?" Cooke said Thursday. "... That's what we see right now with Clark and all of these other counties."

A recent Centers for Disease Control and Prevention study showed, according to the Wall Street Journal, that 220 counties across the U.S. are vulnerable to the spread of HIV and hepatitis C. The Journal reported that 56 percent of those counties are in Kentucky, Tennessee and West Virginia. The New England Journal of Medicine also cited the Appalachian region as one most susceptible to an outbreak.

At least two Indiana State Department of Health officials are cited as authors in the study, which strongly suggests that local, state and federal governments eliminate barriers to needle exchange programs and treatment.

But one of those officials named as an author -- Deputy Health Commissioner Dr. Jennifer Walthall -- testified on behalf of the Indiana governor during a hearing on the legislation, according to Indiana General Assembly archived video and the state representative who organized it, saying the governor was still opposed to needle exchange programs and stood by the former law banning them.

What did Indiana's HIV outbreak look like?

"To be clear as we hear this amendment to the bill before us today, Gov. Pence opposes needle exchange as anti-drug policy," Walthall said in the March hearing, according to the state department of health. "With regard to needle exchange, (Pence) is considering a focused, limited program for the sole purpose of addressing this epidemic in Scott County for the duration of the declared emergency."

Dr. Jerome Adams, the Indiana State Department of Health commissioner, said in a statement Thursday that the department is proud of the work done in Scott County and believes the state's rapid response saved countless lives.

"The HIV outbreak in Scott County is a tragic reminder of what can happen when a national opioid epidemic and vulnerable populations collide, but it is also an example of how a successful, comprehensive response that connects people with treatment, insurance and other vital services can change the course of a community," Adams said.

As part of the state's multifaceted response to the outbreak, Pence signed an executive order in March 2015 that allowed Scott County to implement an emergency needle exchange for 30 days.

Indiana Rep. Ed Clere, R-New Albany -- who wrote legislation ending Indiana's ban of syringe exchanges while chairman of the House public health committee -- has said he had to make compromises to get the bill passed in Indiana's legislature and signed by the governor, including a one-year limit on programs and the requirement that a public health emergency be declared. Pence signed the bill into law in the spring, effectively ending the ban on needle exchanges in Indiana.

Matt Stone/The C-J
The town of Austin in rural Indiana has seen a large increase in HIV-positive cases.
Rural Street in Austin has been the place where women addicted to drugs often walk the street in daylight as well as night, trading sexual favors for money or drugs. Austin, Indiana has seen a large increase in HIV positive cases. By Matt Stone, The C-J April 26, 2015

The study says "proactive health interventions are needed to prevent or limit future HIV outbreaks," where communities potentially combine syringe-exchange programs with other efforts.

"Substantial barriers to syringe exchange (i.e. laws prohibiting syringe exchange or syringe possession, lack of funding or of a community organization to implement the syringe exchange, and stigma) existed in this community before this outbreak," the article states.

Clere said Wednesday that the current legislation is more reactive than proactive and it's not ideal to implement a preventative measure after an epidemic has already erupted in a community. The state legislature needs to put more of a focus on funding and supporting public health in Indiana, Clere said Wednesday.

"We’re still way short of where we need to be," Clere said.

Opponents to needle-exchange programs say they could help intravenous drug use proliferate in communities.

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According to the study, syringe exchange programs are associated with a 56 percent reduction in the risk of HIV infection and "opioid-replacement therapy" proved a 64 percent reduction.  A chart detailing the public health response to the HIV crisis shows that HIV diagnoses in Scott County began tapering off shortly after the emergency syringe program began and other services arrived.

Brittany Combs, Scott County's public health nurse and an author on the study, said in a previous Courier-Journal interview that since the needle exchange began in Spring 2015 through early summer 2016, the Scott County Health Department's exchange had given out nearly 240,000 needles and had collected more than 225,000. More than 425 people had signed up for the program.

"We have had great success in our needle exchange," Combs told the Courier-Journal in June. "We know that we have pretty much stopped the spread of HIV. ... We know it's helped get people into rehab, we've linked them to (treatment). ... I know it's working because I see it every day."

The study also notes that HIV testing should be a major focus of prevention in rural areas.

"Before this outbreak, free HIV testing had not been available in this community since a Planned Parenthood clinic closed in 2013," the article states.

Federal and state funding cuts prompted five rural clinics in Indiana to close, according to an IndyStar report. Last year, vice president of public policy for Planned Parenthood of Indiana and Kentucky Patti Stauffer told the Star she couldn't make a direct link between the closure of the Scottsburg, Ind., clinic and the HIV outbreak, "but that health center was providing HIV tests in Scott County, and any positive tests would have been reported to the state."

Matt Stone/The C-J
 Stickers and HIV pamphlets at the Austin Community Outreach Center.
Matt Stone/The C-J
Stickers and HIV pamphlets at the testing room of the Austin Community Outreach Center due to the response to the HIV outbreak in and bear Austin, Ind. The media were invited to tour the Community Center's "One-Stop Shop and needle exchange." Stickers and HIV pamphlets at the testing room of the Austin Community Outreach Center due to the  response to the HIV outbreak in Austin, Ind. The media was invited to tour the Community Center's "One-Stop Shop and needle exchange" program at the community center. By Matt Stone, The C-J April 21, 20155

Carrie Lawrence, with the Indiana University School of Public Health Rural Center for HIV/STD Prevention, said Wednesday she doesn't think the closure of Planned Parenthood played a major role in the outbreak. Because of the stigma surrounding intravenous drug use and HIV, Lawrence said, it's not likely that many people were seeking out testing over the last year.

Adams expressed a similar sentiment Thursday, saying people with substance abuse disorder often don't seek out medical care and "all the testing facilities in the world won't identify an outbreak if people don't come in."

But Lawrence said she has tried to advocate with the state department of health for more lay HIV testers in rural areas and to get more training for medical professionals to provide testing to folks who are already comfortable with them.

"The state of Indiana does not invest adequately in public health," Lawrence said. "I think (the HIV outbreak) could've been prevented, and that's a common narrative across the board. We need to strengthen all sorts of systems."

Indiana community's HIV outbreak a warning to rural America

Dr. Richard Feldman, former Indiana health commissioner under Democratic Gov. Frank O'Bannon, echoed Lawrence Thursday, saying the lack of funding and lack of focus on public health in the state has negatively affected Hoosiers.

"We are a state that says we value the health of our citizens, but we don’t act like it," Feldman said.

Marc Lotter, press secretary for Pence’s vice presidential campaign, said Thursday that Pence has consistently talked about lessons he’s learned as governor on the campaign trail with his new running mate.

Lotter said Thursday Pence hopes to use his “record of accomplishments in the state to bring common-sense solutions” to the national problem of opioid abuse. Lotter deferred questions about specific policies and the state’s HIV preparedness to the governor’s office in Indianapolis.

A spokeswoman from Pence’s office said Thursday the state has dedicated at least $267 million in the 2017 budget toward public health through the state health department and other agencies, not including millions of federal dollars the state leverages for public health.

The study was supported financially by the state of Indiana, the Scott and Clark County health departments, and the U.S. Department of Health and Human Services. The authors include Centers for Disease Control and Prevention health officers specializing in HIV prevention, Indiana State Department of Health officials, experts who have examined Scott County's HIV outbreak and the response previously, and several others.

Reporter Lexy Gross can be reached at 502-582-4087, or via email at lgross@courier-journal.com.