By Emily Beukema, Aila Hoss, and Nicolas Terry
In November 2014, Scott County, Indiana was the site of a now infamous HIV outbreak linked to intravenous drug use. Syringe service programs (SSP) would not only have curbed that outbreak but also could have prevented it from occurring in the first place. Later analysis found that then Governor Pence of Indiana failed to declare a state of emergency until two months after the peak infection rate and that, even after that declaration, disagreements among stakeholders later delayed the implementation of a temporary SSP. Absent those delays the number of infections could have been dramatically decreased.
Currently, the Scott County outbreak seems to be repeating itself in Cabell County, West Virginia. This county, the state’s third largest, has reported more than 70 cases of new HIV cases since January 2018, primarily among drug users sharing syringes. This new cluster is on trajectory to be the largest outbreak since Scott County which had a cluster of 215 new HIV infections between 2011 and 2014. And, once again, inadequate harm reduction programs seem to be front and center in the developing story.
SSPs are cost effective and considered to be one of the most effective methods to prevent the spread of bloodborne infectious diseases, such as Hepatitis C and HIV. They provide participants with sterile syringes and other supplies and often offer naloxone kits, testing for communicable diseases, links to other social service resources, and referrals to treatment. Research confirms the benefit of proactive implementations of SSPs which are broadly viewed as “essential prevention programs to reduce HIV transmission among” intravenous drug users. The evidence further indicates that SSPs neither increase criminal activity nor threaten public safety and, in practice, offer an excellent return on investment.
Of course, in the five years that separate the Scott County and Cabell County outbreaks our understanding of opioid use and the opioid overdose crisis has been recalibrated as the third wave of drugs, illicit fentanyl and its analogues, have overtaken prescription opioids as the drugs of choice with intravenous injection increasingly being the likely delivery method.
In 2015, and although not explicitly authorized by state law, Cabell County became one of the first West Virginia counties to fund a SSP. In 2016 the largest SSP in the state was opened in the nearby city of Charleston, capital of West Virginia’s most populous county. However, public pressure led to the closure of the Charleston SSP in March 2018, that city’s mayor calling it a “mini-mall for junkies and drug dealers.”
Reportedly Cabell County officials cannot explain the HIV outbreak which occurred despite the county’s public health surveillance system. However, this outbreak should come as no surprise based on the lessons learned in Scott County and elsewhere. Cabell County implements two policies that run counter to the evidence-based best practices for SSPs: oversight by law enforcement and a one-for-one exchange model. The evidence base is clear that SSPs are most effective when law enforcement cooperates with the mission of these programs and the program does not restrict the number of syringes participants receive. Efficacy of a SSP is impaired when its participants fear criminal prosecution or require frequent trips to the programs to obtain the number of sterile syringes they need to inject safely. A person who injects drugs (PWID) is less likely to participate in a SSP when they encounter these barriers, which not only prevents them from receiving sterile syringes but also reduces links to social services and treatment resources. Strikingly, when engaged with a SSP, PWIDs are five times more likely to enter treatment for substance use disorder.
As is almost always the case with “wicked problems” there are likely other factors at work. The public health workforce in Cabell County reportedly is strained and exhausted. The frustration within the public health and health care workforce largely stems from the consistently neglected drivers in the opioid use disorder crisis—social and structural determinants of health. In West Virginia, not only SSPs are scarce but so are basic medical services, especially in rural counties. Inability for first responders to effectively link people to nearby treatment has largely contributed to stigma and “compassion fatigue.”
The lessons of Scott County seem obvious; ongoing public health surveillance and timely evidence-based harm reduction policies can minimize these outbreaks. Yet, stigma and a failure to educate communities about the low risk and high returns of SSPs continue to create barriers while, increasingly, attention needs to be focused on structural determinants negatively impacting the healthcare workforce and access to care.
Emily Beukema is a JD/MPH Candidate 2020, Aila Hoss, JD is a Visiting Assistant Professor and IU Grand Challenge Fellow, and Nicolas Terry, BA (Law), LLM is the Hall Render Professor of Law and Executive Director, William S. and Christine S. Hall Center for Law and Health at Indiana University Robert H. McKinney School of Law at IUPUI. Their work is supported by the Indiana University Addictions Grand Challenge.