When local health officials around the country speak about Scott County, Indiana, they do so in the hushed, fearful tones these men and women reserve for disasters they pray will never befall their own municipalities. This small county close to the Kentucky border has become a symbol for the ways in which the opioid epidemic can tear a community apart.
Starting in December 2014, Scott County grabbed national attention when an HIV outbreak linked to intravenous opioid abuse ripped through its population at a remarkable pace.
In the time since that outbreak, it has become clear that one of the factors that brought the spread of the virus under control was an executive order from Indiana Gov. and Vice President-elect Mike Pence—that many have argued came too late—which legalized needle exchanges on a temporary, ad hoc, top-down basis.
In the outbreak’s wake, more and more local government officials—even those who may have previously balked at the idea—are recognizing just how vital a public health service needle exchanges provide.
But, even as more legislative roadblocks to syringe programs fall away the money isn’t following. Across the country, funding remains limited for these harm reduction services, and counties are wondering just how much they can do with the little money they have—and if it will be enough to keep a situation like the one in Scott County from repeating itself.
It Could Happen Elsewhere
Public health officials have identified a number of factors that made the population of Scott County particularly vulnerable to HIV transmission.
According to reporting by the Courier-Journal, Dr. William Cooke, the lone physician in Austin, the small Scott County city that was the epicenter of the outbreak, believes the tell-tale risk markers were clear—poverty, unemployment, hepatitis C rates that were already high, along with a steady flow of opioid drugs into the region.
Sadly, in these ways, Scott County is not altogether unique.
One study carried out by the U.S. Centers for Disease Control and Prevention in 2016 has identified as many as 220 other counties around the nation with those same risk markers present.
Kanawha County, West Virginia, is one such place. Dr. Michael Brumage, the executive director and health officer of the Kanawha-Charleston Health Department told Route Fifty in an interview that the Scott County scenario is never far from his mind.
“A situation like Scott County, Indiana, was my worst nightmare, and I want to do everything in my power to keep that from happening in my community,” he said.
Brumage, whose department operates a needle exchange program in the city of Charleston, sees harm reduction programs like this one as a no-brainer, particularly in a state like West Virginia.
West Virginia has the dubious distinction of being first in the nation when it comes to hepatitis B cases—the figure is 10 times higher than the national average—and second in the nation with regard to hepatitis C. 28 of the at-risk counties the CDC identified in its study are in West Virginia.
In Brumage’s mind, his state has an important choice to make, either it invests in harm reduction programs on the front end, or as he says, “we’re going to be on the back side of this problem with either an HIV outbreak or increased levels of hepatitis C and B that are financially unsustainable for a state like ours, which is already strapped.”
It’s an important calculus to keep in mind. After all, they say an ounce of prevention is worth a pound of cure. That’s likely a phrase that rings true in Scott County where, according to the CDC, the lifetime cost of treating it’s HIV and hepatitis C patients could approach $100 million.
But, as it currently stands, West Virginia’s state budget includes no line item for harm reduction programs—meaning no state funding for needle exchanges. And strapped is certainly a good way to describe their fiscal situation—the Mountain State is currently in the midst of dealing with a $353 million budget deficit.
As for federal funds, Congress voted a year ago to lift the three decades-old ban on federal funding for needle exchanges. It was an effort led by U.S. Rep. Hal Rogers, a Kentucky Republican who wanted to make money available to state and local agencies devoted to harm-reduction programs.
But, according to Brumage, that funding has been slow to trickle down, and when it does, it comes through in the form of grants to carry out research, rather than money that can be spent in support of facilities that do this type of work.
Doing the Best With What They Have
So for now, the needle exchange program in Charleston—which opened in December 2015 just three months after the start of a syringe program in Huntington, West Virginia—is almost exclusively on private donations to operate. Those that run the exchange are grateful for the donations they’ve been given, but Brumage acknowledges that “that’s no way to have a sustainable program especially when we know how big this problem is.”
Given the limited funding available to them, the needle exchanges in Charleston and Huntington are each only able to operate one day per week.
But, even with that tight mandate, the Charleston syringe exchange program served more than 1,660 people in 2016, with nearly 5,000 total visits. Just last week they set a new record, serving 222 people within a five-hour period. And, it’s important to remember that the syringe exchange facility provides more than just clean needles. It also gives those who suffer from opioid addiction connections to counseling, treatment and testing for HIV and hepatitis.
Both the needle exchange in Charleston and the one in Huntington would like to expand to be able to offer services more than once per week. But, at the moment, any expansion plans are completely dependent on the generosity of donors.
Beyond the Mountain State
West Virginia isn’t the only place where lack of funding is curtailing the efforts of syringe exchange programs.
After 26 years, New Haven, Connecticut, formally ceased its exchange program, which was one of the first in the country in operation, in part because of issues with public funding. The Yale School of Medicine will be taking over the operations of the program.
And, in Indiana, tight legislative restrictions on syringe programs have kept many counties from being able to offer these critical services to their residents in need. Those regulations may be loosened under Pence’s successor, Gov. Eric Holcomb, but until then, even in the wake of Indiana’s HIV outbreak, situations like the one in Clark County—Scott County’s neighbor to the south—remain all too common.
According to the Courier-Journal, over a year ago, Clark County submitted a 200-page application to the state government explaining its dire need for a syringe exchange program—the county has one of the worst rates of hepatitis C in the state.
The state sent the application back, asking for a revisions, and the funder, AIDS Healthcare Foundation backed out. One year later, after reviewing the application, finding new funding options—without financial help from the state—the Clark County needle exchange will finally be opening its doors on Jan. 26.
Many other countyies haven’t been so lucky. Since the outbreak in Scott County, 25 other Indiana counties have taken steps to adopt syringe exchanges, but only three counties (including Scott County) have been able to make that dream a reality.
Data from around the country shows that these programs are working, even in states like Indiana that traditionally oppose needle exchange. But, that same data also shows that there’s much work left to be done. In 2015, only 1 in 4 people who injected drugs got all their syringes from sterile sources.
Looking to the Future
In Kanawha County, West Virginia, Brumage isn’t making any assumptions about where his future funding may be coming from. But he makes one thing abundantly clear: With or without government funding, the needle exchange in Charleston must continue.
“It’s not an option to stop what we’re doing. Because the consequences of stopping means an explosion in risk that will affect not only the people who use [drugs], but also everyone else in our community.”