Decades into the fight against HIV/AIDS, politicians ideally would have learned the costs of allowing stigma and moralism to guide policy response. A recent outbreak of HIV among intravenous drug users in Scott County, Indiana, though, shows that HIV responses are still badly hampered by misguided political posturing. There have been more than 140 reported cases of HIV/AIDS there, and the epidemic—fueled by long- and short-term policy failures—shows little sign of slowing.
The immediate cause of the Indiana crisis is a spike in IV drug use. This spike is part of a nationwide phenomenon, spurred by a decline in heroin cost. In Indiana, IV drug use also increased when the state cracked down on prescription drug abuse, pushing some addicts to use heroin instead. The major interstates that run through Indiana have also facilitated importation of heroin, and the problem has flourished because of "significant poverty," according to Ross D. Silverman, a professor at Indiana University-Purdue University Indianapolis' School of Public Health.
Indiana’s per capita state funding for public health dropped from 37th lowest in the country in 2013 to 44th lowest in 2014.
Indiana, and Scott County in particular, have also seen a dangerous growth in the use of Opana. Opana is a prescription painkiller that can be altered for use as an injectable. Opana is particularly dangerous in terms of HIV/AIDS because, Silverman explains in an email, "the high wears down quickly and is coupled with significant negative side effects, leading users to inject more often, and the drug requires a larger gauge needle to inject (meaning more exposure to blood of others if needles are shared)."
Rises in the use of injectable Opana and heroin created the possibility for an infectious disease outbreak. But government policy has enabled that outbreak to become reality. Beth Meyerson, co-director of the Rural Center for AIDS/STD Prevention at Indiana University-Bloomington’s School of Public Health, says that "Indiana has been historic in its lack of public investment in health." According to Trust for America's Health, Indiana’s per capita state funding for public health dropped from 37th lowest in the country in 2013 to 44th lowest in 2014.
Meyerson added that the state has done "a fine job gutting our resources in reproductive health." Rural Planned Parenthood clinics have been shut down, partly because of ideological opposition to abortion and reproductive health services. As a result, Scott County's Planned Parenthood clinic, the sole free HIV testing center, was closed in 2013. The problem is compounded, Meyerson says, by the fact that primary care physicians and community health clinics in Indiana have not been suggesting routine HIV testing to patients. "We have an investment problem because the public system, writ large, has been starved," she explains, "and we're seeing our primary care colleagues unable, maybe even unwilling, to provide sexual health services to their patients."
Another serious failure in the current outbreak has been the reluctance to provide IV drug users with clean needles. In an email, Dr. Eric Meslin, director of the Indiana University Center for Bioethics, says that the best response to the outbreak would have been "a policy to quickly implement a needle exchange program statewide, supplemented by a public health education initiative. They’ve been shown to be an effective brake on the spread of HIV and other diseases elsewhere."
But at the behest of state prosecutors, and as a supposed anti-drug measure, needle-exchange programs are illegal in Indiana. Governor Mike Pence did put in place a 30-day emergency order at the end of March allowing needle exchange programs in Scott County exclusively, and then extended that for another 30 days, through the end of May. But, Meslin says, this "initial response fell short in two ways: by making it time-limited, and by making it county-limited. We know that people and diseases are rarely constrained by either."
Pence's emergency program could be seen as a partial effort to improve policy, even if it doesn't go far enough. Myerson, however, feels that the limited needle exchange was actually intended to forestall the broader necessary changes. "The governor tried to pre-empt legislative process to move forward with a statewide syringe exchange," she says. She was particularly critical of the effort to frame the needle-exchange as an emergency measure since, she argues, the main benefits of the needle exchange are not just in providing clean needles, but in providing institutional contact with affected populations. "If we can't do anything but temporary, temporary, and temporary for needle exchange," she says, "who will use it in the long run? If I was a user, I'd horde the needles, because you know they're going to be gone." What is needed, she argues, is a "long term relationship builder with a community that's really separated from the care system." IV drug users need testing, education, and ultimately treatment if they are infected, none of which they can get if they're not connected to the health system. If needle exchanges are only temporary, IV users will probably not come to them for fear that, when the exchanges end, they’ll be targeted for possessing paraphernalia by law enforcement.
Myerson emphasized that the local health care system has done the best it can with "two hands tied behind its back." And Silverman says that, despite the long-term failures and continuing policy barriers, the immediate response to the outbreak "has been pretty incredible, with significant federal, regional, state, and local entities collaborating to get on top of the problem." This week, Indiana legislators passed a measure that would allow counties with high rates of Hepatitis C and infectious drug use to apply for permission to set up needle exchanges. That's a step forward—but there's still a reluctance to fully commit to needle exchange as a consistent preventive policy, rather than as an emergency stopgap. Though syringe exchanges have not been shown to increase rates of drug use, prosecutors worry they'll provide a defense for people arrested with drug paraphernalia.
There has been no sign so far that the outbreak is turning around, according to Myerson, and it's likely that the problem will flare up in other Indiana counties as well. This is not necessarily because it will spread from Scott County. Rather, it's because the conditions and policy failures in Scott County are similar to the conditions and policy failures elsewhere in the state.
"The days of blaming and shaming should be historical relics of a time when fear and ignorance were common," Meslin says. But it's clear that they're not. Stigma against IV drug users, political opposition to reproductive health services, and the moral politics of the drug war have combined to create a serious health crisis in Indiana. "It’s hard to say just how much worse [the outbreak] can get," Meslin says, "but we know that without a comprehensive prevention and treatment response it will get worse."