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106 Cases and Counting

HIV is a preventable disease, which makes the epidemic in rural Indiana all the more frustrating.
Scott County Courthouse in Scottsburg, Indiana. (Photo: Bedford/Wikimedia Commons)

Scott County Courthouse in Scottsburg, Indiana. (Photo: Bedford/Wikimedia Commons)

Thirty years to the month after a 13-year-old boy named Ryan White, born in Kokomo, Indiana, was diagnosed with HIV in December 1984, an outbreak of HIV was reported in White’s home state. White, infected with the HIV virus through transfusion with contaminated blood, became a symbol in the 1980s of how everyone was vulnerable to this virus and how a society can respond to such challenges.

Approximately 140 miles down Route 65, south of where White lived at the time of his diagnosis, you’ll find southeastern Indiana’s Scott County. In the past three months, 95 new cases of HIV have been reported in Scott County, with 11 preliminary positive cases waiting to be confirmed, as of Sunday afternoon. This in a county with, according to state statistics, less than five new HIV cases in an average year, and just 21 residents living with HIV in 2014. The vast majority of these recent cases involve individuals sharing needles when they injected the prescription painkiller Opana; others have been linked to unprotected sex with individuals who had been injecting.

In the United States there were 1.5 million initiators of non-medical use of opioid pain relievers in 2013, and 4.5 million current users, according to the National Survey on Drug Use and Health.

Nationally, the epidemic of prescription drug abuse, particularly the non-medical use of prescription opioid pain relievers, has grown exponentially—though recent data demonstrate some slowdown or decline. In the United States there were 1.5 million initiators of non-medical use of opioid pain relievers in 2013, and 4.5 million current users, according to the National Survey on Drug Use and Health. The sequelae are tragic. Public health officials report that someone dies of a prescription drug overdose every 25 minutes. And drug overdose was the leading cause of injury death in 2012, causing more deaths among 25- to 64-year-olds than motor vehicle crashes, according to the Centers for Disease Control and Prevention. Prescription drugs—and specifically prescription opioid pain relievers such as Opana and, historically, Oxycontin—play a major role in this phenomenon.

While injecting drug practices, historically with heroin and traditionally in larger urban settings, have been tightly linked to new cases of HIV, this new, rapidly emerging epidemic in rural Indiana highlights vulnerabilities to both the burgeoning problem of prescription opioid injection as well as its serious consequence—in addition to overdose—of new HIV infections. While the governor of Indiana has authorized a “short-term” needle exchange program, he also indicated at the time he declared a state of emergency that “This is all hands on deck,” which means that all possible measures should be considered to stem what has been reported to be a likely ongoing epidemic.

These other measures include well-established effective interventions such as opioid agonist treatments with methadone or buprenorphine. These medications act at the site of the brain’s opioid receptors, blocking the symptoms of withdrawal, in many cases significantly decreasing the likelihood that the individual will continue to use opioids, including prescription painkillers. These medications have been shown to be effective in reducing the risk of HIV related to injection drug use.

Methadone and buprenorphine, approved by the Food and Drug Administration in 1972 and 2002 respectively, have demonstrated widespread success in treating opioid dependence, including that with prescription opioids, in individuals who have the access to these medications. Unfortunately, access to treatment is limited with less than half of those diagnosed with opioid dependence receiving one of these effective medications. This finding is particularly true in rural settings such as southeastern Indiana.

Of the two, buprenorphine holds the most immediate promise due to fewer restrictions on its provision. Physicians with training may prescribe it and patients may pick it up at a local pharmacy, while methadone dispensing is limited to federally regulated opioid treatment programs that can take years to open. Since its introduction in 2003, buprenorphine has allowed rural physicians in places such as Virginia and Maine to effectively address local ravages of opioid dependence including HIV transmission and overdose.

A newer measure in the armamentarium for HIV prevention is PrEP, or Pre-Exposure Prophylaxis. With PrEP someone who does not have HIV but is at a substantial risk of being exposed to the virus takes a pill called Truvada on a daily basis. Truvada is comprised of two medications that are routinely used in combination with other medicines to treat HIV. In the case of PrEP, Truvada, which was approved by the FDA in 2012 for this use, prevents the virus from becoming a permanent infection. When taken daily, PrEP can reduce the risk of HIV acquisition by up to 92 percent.

While a “short-term” needle exchange program is a first step in combatting this epidemic, there is so much more that can be done. We as a medical community are in a much better position, not only in terms of treatment of HIV infection—in great part because of the legacy of young Ryan White and the creation of the Ryan White HIV/AIDS Program, which provides primary medical care and support services for those with HIV—but also in terms of prevention. All hands really do need to be on deck in Indiana and elsewhere so that we can stop counting the cases of this preventable disease.