How the Opioid Crisis Is Driving HIV Rates

woman's hand holding heroin needle

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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 health care 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 on the heels of the Indiana outbreak, the Massachusetts Department of Public Health reported a similar outbreak in August 2018 in the industrial towns of Lowell (population 110,000) and Lawrence (population 80,000) wherein 129 injecting drug use were infected as a direct result of a synthetic opioid known as fentanyl.

As with Pence, who had vehemently opposed needle exchange programs based on "moral grounds," legislators in Massachusetts only called for a lifting of the needle exchange ban after the HIV outbreak was reported.

While some pundits have discounted the outbreaks as isolated events, others warn that they foreshadow an explosive increase in HIV infections nationwide driven by the growing opioid crisis and ongoing inaction on the part of U.S. legislators.

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.

Within many of these regions, injecting drug use is today considered the primary mode of HIV transmission—including Estonia where 50% of all new infections are among IDUs and St. Petersburg, Russia where IDUs represent 59% of all HIV infections. All told, an astounding 40% of all new infections within the region is 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 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.

With only one doctor in town and the deep-seated 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 socio-economic 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% in 1992, when the state's needle exchange program was first established, to 3% by 2012. Increased use of antiretroviral therapy among IDUs is also seen to contribute to the lower rates.

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  1. United States Census Bureau. City and town population totals: 2010-2019. Updated May 7, 2020.

  2. Centers for Disease Control. HIV infection among injection-drug users — 34 states, 2004–2007. MMWR Weekly. 2009;58(46):1291-1295.

  3. Des Jarlais DC, Kerr T, Carrieri P, Feelemyer J, Arasteh K. HIV infection among persons who inject drugs: ending old epidemics and addressing new outbreaksAIDS. 2016;30(6):815-826. doi:10.1097/QAD.0000000000001039

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