HIV Intravenous Drug Use-Related Outbreak in Southern Indiana

On May 26, 2015 Indiana Governor Mike Pence called a public-health emergency about the rising rate of HIV infections in southern Indiana. On March 30, 2015 the Indiana House Committee on Public Health passed an amendment allowing for syringe exchange programs in 23 counties with the highest numbers of Hepatitis C virus (HCV). HIV is by far not the only substance use problem, HCV cases have increased, endocarditis cases have increased, and overdoses have increased as well over the past years. The situation is so bad that the U.S. Department of Health and Human Services (HHS) Center for Disease Control and Prevention (CDC) officials went to Indiana to help. The counties mostly affected by the epidemic are Scott, Clark, Jackson, Perry, and Washington counties. The executive order issued is short-term, lasting only 30-days in Scott County. Governor Pence is very late enacting common sense policy, costing Indiana taxpayers millions of dollars.

Eighty-one confirmed cases of HIV infections derive from injection drug use (IDU) since the beginning of 2015, and there is a good possibility that there will be more cases in the near future. Some are speculating there could be over 100 cases.  It would be interesting to see the number of cases over the past several months to find out the exact day or week of the increase. From what I have found, the number kept increasing from 26 IDU HIV related cases on February 25th, 27 cases on February 27th, 44 cases on March 11th, 55 cases on March 20th, 72 cases on March 25th, 79 cases on March 26th, and 81 cases on March 27th. (I am not sure if the data is only HIV or HIV and AIDS IDU-related cases, because if the number does not includes AIDS cases then the number could be much higher.) This is very shocking due to the fact that over a seven year period there have been 39 IDU HIV related cases at first diagnosis: 12 cases in 2008, 5 cases in 2009, 7 cases in 2010, 5 cases in 2011, 5 cases in 2012, 4 cases in 2013, 1 case in 2014. Adding IDU AIDS related cases the number is between 20-27 cases: 9 cases in 2008, 6 cases in 2009, 0-4 cases in 2010, 0-3 cases in 2011, 2 cases in 2012, 2 cases in 2013, 1 case in 2014. (The numbers of cases in 2010 and 2011 do not have clear definitive numbers, but the minimum is 20 cases while the maximum is 27 cases.) Pence should have acted much earlier since the number of HIV IDU cases rose from 39 in seven years to 81 cases in three months – nearly a 110% increase – but it is an inaccurate percentage because of time frames in which cases occurred. To get a more accurate picture would need to get an annual month by month data of HIV transmissions or wait until the first semi-annual report or annual report is released.

HIV/AIDS Transmission of Injection Drug Use

Year HIV AIDS Total
2008 12 9 21
2009 5 6 11
2010 7 0-4 7-11
2011 5 0-3 5-8
2012 5 2 7
2013 4 2 6
2014 1 1 2
2015 81*

Many drugs can be injected; a list of the injectable drugs includes psychotherapeutics – opioid pain relievers, heroin, cocaine, methampethamine, ampethamine, methylenedioxymethampetamine (MDMA), ketamine, PCP, and anabolic steroids. In the United States, the drugs causing the most concern in terms of abuse, dependency, and overdose are pharmaceuticals opioids and heroin. In 2010, fifty percent of overdoses in the U.S. derived from heroin and pharmaceutical pain killers. In 2012, Indiana reported that opioid pain relievers contributed to 20.6 percent drug overdose deaths. According to reports, the drug causing most of the outbreak in southern Indiana is Opana – a pharmaceutical painkiller (oxymorphone).

Syringe Exchange Programs (SEPs)

Syringe Exchange Programs is a service that exchanges used hypodermic syringes for sterile syringes. There are different names for these programs such as needle exchange programs (NEP), needle-syringe programs (NSP), syringe exchange programs (SEP), and syringe services programs (SSP).

As the number of AIDS cases rose in the 1980s, countries – the Netherlands was one of the first –  implemented SEPs. The United States banned federal funds to be used for SEPs. Now, over forty countries have some form of SEP, which includes “Australia, Belgium, Brazil, Bulgaria, Canada, China, Croatia, Czech Republic, Denmark, Estonia, Finland, Germany, Greece, Hungary, India, Kazakhstan, Latvia, Luxembourg, Nepal, Netherlands, Norway, Philippines, Poland, Portugal, Slovak Republic, Salvador, Slovenia, Thailand, Ukraine, United Kingdom and the United States of America.”

Since 1988, the federal government banned syringe exchange programs as part of the war on drugs. As countries were implementing SEPs to reduce the number of intravenous drug use HIV-related transmissions, the U.S. banned federal funding of SEPs. The ban was not lifted, until the Democratic-controlled Senate and House in 2009 passed a bill lifting the ban, but unfortunately the ban was reinstated on December 16, 2011 by the Republicans. On December 12, 2013, seventy Maryland scientists sent a letter to Senator Mikulski about removing the federal ban and funding federal exchange programs. On June 26, 2014, over 140 organizations sent a letter to leaders of the Senate Appropriations Committees and Subcommittees Barbara Mikulski, Tom Harkin, Jack Kingston, and Hal Rogers on lifting the federal syringe exchange ban.

Looking at the United States, according to the The Henry J. Kaiser Family Foundation (KFF), in 2013 thirty States have some form of syringe exchange program: Alaska, Arlzona, California, Colorado, Connecticut, Delaware, Georgia, Hawaii, Illinois, Indiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Vermont, Washington, and Wisconsin as well as District of Colombia. Within those thirty States, there are 223 SEPs. In 2014, KFF found there are thirty-three States along with D.C. mandating some form of HIV education policy. Indiana has only one SEP, and Indiana mandates absence as part of their HIV education policy.

Ms. Pelosi: In those studies, is there any evidence that the needle exchange program has led to increased drug use  by exchange clients or in the wider community?

Dr. Ammann: The weight of the evidence is that there is no increase in drug use following a needle exchange progresm. Many of the people who enter those programs also enter counseling programs in terms of drug abut itself.

Ms. Pelosi: So there is a link between, an effective

SEPs and HIV/AIDS and HCV

Costs of Treatment

The temporary 30-day syringe exchange program put into place essentially allows for people to obtain a sterile syringe. It is estimated the cost of a syringe range from less than fifty cents to about one dollar. The cost of HIV/AIDS depends on the advancement of the disease. HIV/AIDS treatment costs as high as $618,000 per person in a lifetime. Dr. Kevin Burke stated HIV treatment could cost people about $20,000 per person per year, so taxpayers of Indiana will have to pay about $1,620,000 for the current 81 people per year. Currently, the 11 in jail who tested positive are not receiving treatment due to costs issues; the longer treatment is forgo the more it will cost. Hepatitis C treatment costs approximately $100,000 to $300,000 per person in a lifetime.  Studies illustrate “for every dollar spent on SSPs, an estimated $3-$7 are saved in HIV treatment costs.”

An Australian study of SEPs between 1991-2001 found:

Australia spent a total of $150 million on syringe exchange programs. This included $130 million by the government, the remainder by consumers. During that time, the government estimated that 25,000 cases of HIV were prevented, at a savings of $7 billion for lifetime treatment. For hepatitis C, the government estimated that 21,000 cases were prevented and that it saved about $783 million in total treatment costs over the lifetime of cases. Overall, total treatment costs saved by preventing cases of HIV and HCV totaled approximately $7.8 billion.

HIV/AIDS and HCV Prevalence of Injection Drug Users

SEPs do not increase the number of HIV-positive injecting drug users. A JAMA article found that there has been a major decrease in the number of people who became exposed to HIV from injecting drugs. The report stated: “Overall, HIV incidence among individuals exposed through IDU has decreased approximately 80% in the United States. Over that time, those exposed through IDU have reduced needle sharing by using sterile syringes available through needle exchange programs or pharmacies and have reduced the number of individuals with whom they share needles.” Looking specifically at Maryland, there has been a significant reduction in the percentage of cases in Maryland. The letter stated, “the proportion of HIV diagnoses attributable to injection drug use in Maryland has dropped from 53.3% to an all-time low of 15.9% in 2010.”

Drug Use and Syringe Exchange Programs

First, we have to understand simple basic facts of drug use. People use drugs for social, medical, and religious reasons. People gather at social events such as tailgating at a football game to socialize and use alcohol or gather at a hookah bar to smoke and socialize; people use pharmaceutical medicals to relive anxiety (Klonopin, Xanax, Valium) or to reduce pain (Oxycontin, Oxycodone); and Christians use wine religious ceremonies, Hindus and Rastafarians use marijuana in some form for religious practices, and various Native American tribes use tobacco and psychedelics for religious purposes. We have been using drugs for thousands of years, and we will use drugs another thousand years. We have to learn to live with drugs and create the best possible solutions to reduce drug use, increase public safety, and reduce the harm associated with drug use.

Simply handing out sterile syringes will not encourage (increase or decrease) drug use. But the SEPs can help the individual find a primary care doctor and/or a drug treatment facility and officials and to educate them about drug abuse, health risks, and addiction, potentially leading to a decrease in drug use and abuse and a decrease in the sharing of syringes. According to the Center for Disease Control, “[s]ince the epidemic began, injection drug use has directly and indirectly accounted for more than one- third (36%) of AIDS cases in the United States. About 8 – 11 percent of HIV transmissions annually can be attributed to IDU.

The primary reason why syringe exchange programs are underdeveloped on the Federal level and the State level is because of conservative ideology and the war on drugs. They seem to not care about harm reduction strategies. Even though there is unquestionable evidence across thirty States and over forty Nations that SEPs reduce the number of disease and infection transmissions from IDU, reduce taxpayer and healthcare costs associated with HIV/AIDS, HCV, endocarditis, and other diseases and infections, gains in cost per quality-adjusted life year, enhances public safety and health, does not encourage drug use, conserves valuable medical resources, and saves lives. Congressman Waxman (D-CA) is correct:

“Needle exchange is preventing AIDS and saving lives in dozens of American cities in over 20 States. The Surgeon General, the National Academy of Sciences, the National Institutes for Health, the American Medical Association all concluded that needle exchanges save lives, prevent AIDS and do not encourage drug use. But do not confuse the Republican leadership with the facts; they are not interested. They want Americans to believe that the government was going to install needle vending machines next to coke machines across the country.”

Various well-known organizations and U.S. agencies agree that SEPs do not increase drug use. A World Health Organization (WHO) report on intravenous drug use concluded, “The studies reviewed in this report present a compelling case that NSPs substantially and cost effectively reduce the spread of HIV among IDUs and do so without evidence of exacerbating injecting drug use at either the individual or societal level.” Felice Levine of the American Sociological Association testified at the April 16, 1997 U.S. House Appropriations Subcommittee on the Department of Labor, Health and Human Services, Education, and Related Agencies. She stated, “sociological research demonstrates that when drug users educate other drug users about how AIDS is spread, they share equipment less, use shooting galleries less often, decrease their injections and are more likely to use new needles or sterilized needles.” Anthony S. Fauci, Director, National Institute of Allergy and Infectious Disease, National Institutes of Health, stated at a September 16, 2008 hearing “the scientific data are really rather firm and totally convincing that injection drug use and the transmission of HIV through injection drug use can be decreased significantly by needle exchange programs.”

But unfortunately you have widely inaccurate statements from former and current politicians and former administration officials, mainly from the Republican Party, who believe syringe exchange programs increase drug use. This political division continues today, but it is not expressed as much by the conservatives as before during the latter part of the 1990s. Many of the conservatives believe SEPs will increase and encourage drug use. Here are several quotes:

“The reason I am up here talking about it is we know a whole lot about how to help people succeed. Our Government is getting ready to spend our tax dollars to help people fail by enabling drug addicts to have needles available to them, to violate the law, to use our tax dollars to have clean needles.”

“Harm Reduciton” is an ideological position that assumes certain individuals are incapable of making healthy decisions. Advoates of this position hold that dangerous behaviors, such as drug abuse, therefore simply must be accepted by society and those who choose such lifestyles — or become trapped in them — should be enabled to continue these behaviors in less “harmful” manner. Often, however, these lifestyles are the result of addiction, mental illness oaf other condicitons that should and can be trateed trashier than accepted as normative, healthy behaviors.”

  • Former Senator of Missouri and former Attorney General John Ashcroft stated on February 9, 1998:

“the ban to be lifted if the Secretary of Health and Human Services determines that needle exchange programs reduce HIV among intravenous drug users and does not encourage drug use. Well, I think it would be a very difficult finding to be able to make.”

“Mr. Speaker, what is it about 1960s liberals and their absolute incapacity to distinguish between good science and bad? Again and again we see the same pattern where left-wing politics trumps science when it comes to regulation, environmental policy, secondhand smoke, safety and risk studies, global warming and, now, free needles for illegal drug users. It is always the same story: bogus science and new government programs.”

  • Former Congressman Bob Schaffer (R-CO) stated on April 22, 1998:

“studies have shown that such programs increase the spread of HIV, AIDS. In addition, needle exchange programs encourage drug use and pose a serious threat to the health and safety of innocent people.”

“Mr. Speaker, many people remember the President’s Surgeon General claiming that the answer to youth violence was safer guns and safer bullets; that the answer to sexual promiscuity among America’s youth is condoms in schools. Now we have the answer to the escalating drug problem in America coming out of the White House, free needles to heroin addicts. Imagine that, Mr. Speaker, government-subsidized free needles to heroin addicts.

I submit the following: Any President who supports and would promote the subsidization of free needles to heroin addicts is just as guilty as any drug pusher or any drug user who causes death and destruction among America’s communities today.”

  • Senator Chuck Grassley (R-IA) believes that federal SEPs, and SEPs, in general, increase drug use and satirically suggests the government to hand out drugs. He said on May 9, 1998:

“Indeed, on 20 April, Donna Shalala, the HHS Secretary, issued a statement saying that needle exchange programs were a good thing. That they stopped the spread of AIDS and did not encourage drug use. She encouraged communities to embark on programs giving needles to drug addicts. She did not go so far as to say that the Administration would back up this determination with federal dollars—a small blessing. But she has now put the authority of the Administration behind this idea. Exactly what is this idea? It is startling simple: The Administration has announced that it will now facilitate and promote others to facilitate making drug paraphernalia available to drug addicts in our communities.”

It will now use the voice of the Federal Government to facilitate drug use. What next, handing out the drugs themselves to addicts?

This is voodoo science backing up Cheech and Chong drug policy. It is making the federal government a Head Shop.

They are worried because they believe addicts will easier access to keep their addiction. Personal failures are most of the time attributed to those who have a substance abuse addiction. But if they understood addiction and why it occurs and how the addict trys to cure himself, then they might view it different.

Addiction Specialist Dr. Gabor Mate discusses addiction in the documentary The Culture High.

It is interesting to see or to ask who becomes addicted. People can have sex without being addicted to it, they can go shopping, but some people become severely addicted to all these pursuits. Is a pack of cards addictive? Well, no or yes, depending on the individual. So it is the same process, no matter what the addiction is. The only difference is really is that the substance addict is getting the dopamine from an outside substance, whereas the behavior addict is having it triggered from the particular behavior.

If I speak to a group of a 100 people or a 1000 people and I ask: well, how many of you have addiction issues to any substance, a number of you will take their hand up and I say: “What did it do for you? Not what was bad about it, we already know that, but what did it do for you? What was positive in your experience of it? Well, it gave me a sense of peace, it gave me a pain relief, it made me feel more connected, it made me more confident, I could speak now and interact with other people. In other words, the addict is just after wanting to be a normal human being, and the real question is what keeps them from having those qualities in their life and what happened to them? And so that the addiction should be seen not as the problem, although it is a problem, but it is not the problem, it is the addicts attempt to solve a problem in the first place.

The adverse childhood experience studies, done in California, looked at conditions such as physical, sexual, emotional abuse in the child’s life, the loss of a parent through death or rancorous divorce, or a parent being jailed, or a mental illness in a parent, or addiction in a parent, or violence in the family, and for each of the adverse childhood experiences, the risk of addiction goes up exponentially. By the time a male child has had six of these adverse experiences, his risk of having become a substance dependent, injection-using addict is 4600% greater than that of a male child with no such experiences.

Why is that?

It’s because that trauma shapes the brain in such ways as to make the addictive substances more appealing to the individual. That trauma also gives that person the pain that they will try to then escape from or to soothe through the addictive behaviors. It is the social and emotional environment that shapes the actual biology of the brain. So if you want to understand somebody’s addictions you have to look at what created pain in their lives.

The person occasionally has a beer, occasionally smokes marijuana, but generally has no negative consequences, does not impair their health, does not endanger their lives, does not impair their personal relationships, you can’t call those people addicts and you can’t call those behaviors addictive. So that we have to make a real distinction between the use of substances and the addiction to substances. Which then brings us to the war on drugs. Basically the war on drugs is being waged against people that were abused and traumatized in children and have mental health problems. There is enough punishment in there, in the negative consequences of the addiction that we don’t have to add punishment onto that.

There is unquestionable evidence that SEPs reduces the number of HIV/AIDS, HCV and other diseases and infections, reduces drug use and abuse, saves taxpayers in the long run, and enhances public safety. Indiana had a tragic outbreak of HIV and HCV intravenous drug use-related cases. This could have been avoided if syringe exchange programs were more widely available in every county and if politicians use evidence-based practices to implement effective harm-reduction based drug policy reforms.

Incomplete list of Organizations Supporting Syringe Exchange Programs

  1. AME Church Conference of Bishops
  2. American Academy of HIV Medicine
  3. American Academy of Pediatrics
  4. American Bar Association
  5. American Civil Liberties Union
  6. American Foundation for AIDS Research
  7. American Medical Association
  8. American Public Health Association
  9. National Academy of Sciences
  10. CDC
  11. Episcopal Church
  12. Human Rights Watch
  13. International Red Cross-Red Crescent Society.
  14. Johns Hopkins School of Public Health
  15. Latino Commission On AIDS
  16. NAACP
  17. National Alliance of Methadone Advocates
  18. National Alliance of State AIDS Directors
  19. National Association of People with AIDS
  20. National Minority AIDS Council
  21. New York Academy of Medicine
  22. Physicians for Human Right
  23. The Presbyterian Church (USA)
  24. UNICEF
  25. U.S. Conference of Mayors
  26. United Church of Christ
  27. University of Alabama
  28. University of Colorado at Denver
  29. University of Hawaii
  30. University of Kansas
  31. University of Washington
  32. World Health Organization
  33. Yale University School of Medicine
  34. World Bank
  35. amfAR
  36. AIDS Project Los Angeles
  37. Bristol-Myers Squibb
  38. Campaign to End AIDS
  39. CommunityEducationGroup.org
  40. fhi360
  41. Human Rights Campaign Foundation
  42. International Association of Providers of AIDS Care
  43. Legacy Community Health Services
  44. Pozitively Healthy
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