A needle in a haystack – finding the elusive solution to Indiana’s HIV Outbreak

By Nicolas Wilhelm, JD

Scott County, Indiana, which only has a few thousand residents, has historically had an average of five HIV cases per year. Since December 2014, however, the county has seen an outbreak, with more than 140 newly diagnosed cases. Dr. Jonathan Mermin, the director of the National Center for HIV/AIDs, Viral Hepatitis, STD and TB Prevention at the Center for Disease Control (CDC) calls this “one of the worst documented outbreaks of HIV among IV users in the past two decades.” Dr. Joan Duwve, the chief medical consultant with the Indiana State Department of Health, explained that the abuse of the prescription drug Opana was one of the catalysts for the increase in HIV cases, with some residents injecting it as frequently as 10 times a day, and sharing syringes with other members of their community.

HIV is mainly spread either by sexual contact with another person with HIV, or by sharing needles or syringes with someone who has HIV. One way to reduce the spread of the disease is to implement syringe exchange programs (SEPs) that reduce the transmission of blood-borne pathogens like HIV by providing free sterile syringes and collecting used syringes from injection-drug users (IDUs).

In 2013, 10% of new HIV diagnoses were attributed to IDUs and another 4% were attributed to a combination of IDUs and male-to-male sexual contact. Needle exchange programs started in the United States in the late 1980s and have slowly been adopted in some U.S. states. Today, 17 US states explicitly authorize syringe exchange programs. Although a thorough randomized, controlled trial of syringe exchange has not been conducted for practical and ethical reasons, the scientific evidence suggests that SEPS are an important part of preventing HIV transmission among injection drug users. Economic analysis finds that they are a good investment, saving much more money than they cost. Expert health organizations around the world have endorsed SEPs, and for all practical purposes the scientific debate on the efficacy is over.

Indiana Governor Michael Pence signed an executive order in response to the outbreak to implement a syringe exchange program there, which he extended to last until May 24, 2015. Indiana’s legislature passed a bill allowing counties that meet certain conditions to implement syringe exchange programs on Wednesday, April 29, 2015, hours before the legislative session was set to expire. Governor Pence signed the bill into law on May 5, 2015.

The new law is one of the most restrictive SEP authorizations in the country, requiring a county to be placed in the bottom two quartiles among Indiana Counties for average number of newly reported cases of hepatitis C before an exchange can be launched, and providing very limited protection from arrest for users. Time will tell whether this limited measure is sufficient to solve Scott County’s HIV outbreak, but the evidence is that more restrictive SEPs and limited protection for users work against effectiveness.

Temple University Center for Public Health Law Research

Temple University Center for Public Health Law Research

Based at the Temple University Beasley School of Law, the Center for Public Health Law Research supports the widespread adoption of scientific tools and methods for mapping and evaluating the impact of law on health. It works by developing and teaching public health law research and legal epidemiology methods (including legal mapping and policy surveillance); researching laws and policies that improve health, increase access to care, and create or remove barriers to health (e.g., laws or policies that create or remove inequity); and communicating and disseminating evidence to facilitate innovation.

One thought to “A needle in a haystack – finding the elusive solution to Indiana’s HIV Outbreak”

  1. Most states do not regulate the sale or possession of veterinary sterile needles and syringes which are manufactured using identical processes and standards as those for human use. Just sayin’ to my public health friends in the trenches.

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