How Injecting Drug Use Drives HIV Rates

Indiana HIV outbreak highlight dangers of inaction

pile of syringes
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On March 27, 2015, then-Indiana Governor Mike Pence declared a state of emergency after public health officials there confirmed a total of 81 new cases of HIV among injecting drug users (IDUs) in Scott County. Most of the cases were isolated in and around the town of Austin (pop. 4,295), where infections were primarily caused by the sharing of needles while injecting the opioid painkiller, Opana (oxymorphone).​

By early April, the number of confirmed cases had risen to 190.

Upon release of the news, Pence instated emergency health measures, including a temporary needle exchange program which conservative politicians in the state had long resisted. The year-long program provided users in Scott County with harm reduction counseling and a week's supply of free syringes. In addition, on-site registration to the state's new Health in Indiana (HIP) plan affords low-income residents immediate healthcare coverage.

Indiana is among two dozen U.S. states which criminalize the distribution and possession of syringes without a prescription, due to the conceit that it encourages drug use. Following the Indiana outbreak, state lawmakers approved a bill allowing needle exchange programs to operate in certain counties but only if a local health authority "declares an epidemic of HIV of hepatitis C among injecting drug users" and the state health commissioner agrees with the request.

Efforts to pass permanent, state-wide needle exchange legislation have long been thwarted, with Pence himself declaring his vehement opposition to the measure based on "moral grounds."

It was not only instance when Pence took a punitive stance against HIV prevention measures he considered amoral. During his successful run for Congress in 2000, Pence proposed that federal HIV funds provided under the Ryan White Care Act be diverted from organizations that "celebrate and encourage" homosexuality to "those institutions which provide assistance to those seeking to change their sexual behavior."

While the outbreak has rightly drawn world attention to both Indiana and the small, impoverished town bordering northern Kentucky—with many declaring the incident "unprecedented"—others warn that it shouldn't necessarily be seen as being either isolated or unique.

How the Indiana Outbreak Reflects Trends in Russia and Central Europe

While sex is often considered to be the primary mode of HIV transmission worldwide, epidemiological research has shown that this is not always the case. In recent years, global health officials have seen an alarming spike in new HIV infections in Central Asia, Eastern Europe, and Russia, with increases of more than 250 percent since 2001.

Within many of these regions, injecting drug use is today considered the primary mode of HIV transmission—including Estonia where 50 percent of all new infections are among IDUs and St. Petersburg, Russia where IDUs represent 59 percent of all HIV infections. All told, an astounding 40 percent of all new infections within the region are due, directly or indirectly, to the sharing of HIV-contaminated needles.

While the similarities between Austin, Indiana, and Central Asia may not seem all that apparent at first, the drivers for infections are almost textbook in their expression.

Deeply entrenched poverty, a lack of preventative services, and a known drug trafficking corridor can often come together, as they did in Austin, to create the "perfect storm" for an outbreak.

In Indiana, for example, Highway 65, which slices directly through Austin, is well known as a major drug route between the cities of Indianapolis and Louisville, Kentucky. High levels of poverty in Austin (37%) are known to be linked to increased rates of injecting drug use, with established social networks fueling the shared consumption of drugs such as Opana (ranked as among the top three abused prescription drugs in the U.S. today).

With only one doctor in town and the deep-seeded rejection of needle exchange programs driving the abuse even further underground, most agree that there was little to actually prevent an outbreak from occurring.

By comparison, the rise in IDU infections in Central Asia, Eastern Europe, and Russia can be traced back to the mid-1990s following the break-up of the Soviet Union. The socioeconomic collapse that ensued provided drug traffickers the opportunity to increase heroin trade from Afghanistan, the world's largest opium producer, to the rest of the region. With little in the way of government response and next to no prevention and/or addiction treatment services, the epidemic among IDUs was allowed to grow to what it is today: over a million HIV infections in these three regions alone.

Injecting Drug Use Trends in the U.S.

Similar trends are being seen not only in North Africa and the Middle East, but in pockets throughout North America. In fact, in 2007, injecting drug use was reported to be the third most frequently reported risk factor in the U.S, after male-to-male sexual contact and high-risk heterosexual contact.

Since the early- to mid-1990s, efforts have made to increase legal, confidential needle exchange programs to better reduce the incidence of HIV and other communicable diseases among IDUs. Today, there are over 200 such programs in the U.S., distributing over 36 million syringes annually.​

In New York State, public health officials reported that the HIV incidence among IDUs had dropped from 52 percent in 1992, when the state's needle exchange program was first established, to 3 percent by 2012. Increased use of antiretroviral therapy among IDUs is also seen to contribute to the lower rates.

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