A small town in rural Indiana had more needle-using drug users infected with HIV this year than New York City, according to the Centers for Disease Control and Prevention.
The same thing could happen in Kentucky.
A drug-fueled HIV outbreak infecting 160 people in Austin, Ind. — population 4,200 — is shocking the nation. But it didn't surprise University of Kentucky researcher Jennifer Havens.
The infection rates in Austin, which continue to rise incrementally, rival those of HIV-ravaged areas of sub-Saharan Africa, according to the CDC.
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"There are a lot of the same ingredients (in Kentucky) that are behind what is going on in Indiana," said Havens, who has followed 500 drug abusers in Eastern Kentucky since 2008 for UK's Center on Drug and Alcohol Research.
The appearance of a drug-using HIV patient in Eastern Kentucky, a "patient zero," is what Havens dreads.
HIV rates have traditionally been low in rural parts of the state. But once HIV enters rural drug-using communities, it will spread quickly, she said.
As in Scott County, Ind., where the outbreak was the worst in state history, rural Kentucky has interconnected groups of intravenous drug users sharing needles and having sex, and often trading sex for money or drugs.
"There are often dense networks of people" existing in areas with limited treatment options and the lingering stigma of HIV as a disease of homosexuals, Havens said.
Havens' research has centered on drug abusers in Perry County, but the situation echoes what is happening in many communities across the state, she said.
Kentucky's urban areas — Louisville, Lexington and Northern Kentucky — have long had higher rates of HIV than most rural parts of the commonwealth. Intravenous drug users have steadily accounted for about 14 percent of all HIV cases in Kentucky over the years, said Dr. Kraig Humbaugh, the state's epidemiologist.
But even in Kentucky cities used to battling HIV, health officials are on alert as needle use soars, in part because of the well-documented increased use of heroin. As a blood-borne disease, HIV can be passed through sexual activity but also as needles are shared or dirty needles are reused.
"We are one or two people away from infecting the entire community," said John Moses, HIV outreach specialist with the Lexington-Fayette County Health Department. Many people associate drug use, particularly heroin or the injection of painkillers, with the stereotype of what Moses calls "people using behind the dumpster."
In reality, he said, addicts come from all walks of life. Some have sexual partners who aren't aware of the needle use. Some users, he said, "are like the functional alcoholic who drinks all night and still gets up and goes to work and has a productive life," he said. If they become infected with HIV, they can pass it to their partners.
A nation-leading problem
Health officials worry about an explosion of HIV cases, but a jump in hepatitis C infections is already here.
Kentucky, West Virginia, Virginia and Tennessee lead the nation in the increase of hepatitis C among people under 30, according to a recent report from the CDC.
In Kentucky, the rate of infection of hepatitis C has risen 300 percent since 2007, according to the CDC. Among the 500 drug abusers Havens has been researching, 400 now have hepatitis C, she said.
The increased availability of health insurance through the Affordable Care Act — Kentucky is among national leaders for new enrollment in Medicaid — provides a way to encourage prevention and stem the spread of blood-bourne illnesses such as HIV and hepatitis C, said Public Health Commissioner Dr. Stephanie Mayfield.
But, she said, drug users are a notoriously difficult group to engage. In Massachusetts, which is a model for the national Affordable Care Act, about 95 percent of the population signed up for health insurance, she said. The uninsured 5 percent, she said, were mostly drug users.
Moses, who has built a rapport with drug users in Lexington over the years, said it's a group that's often leery of government involvement and therefore reluctant to divulge the true extent of their drug use.
Free or low-cost HIV tests are available in all 120 Kentucky counties, mostly through local health departments. In recent years, the state has expanded the use of a rapid test that can provide a diagnosis within minutes.
But people in Havens' study are reluctant to be tested at their local health departments because of the stigma related to HIV as a disease prevalent among gay men, she said. Even with federal health laws protecting private health information, they worry that their test results will be shared in small towns.
To compound the problem, the drug users feel no sense of urgency to be tested.
HIV and hepatitis C can be life-threatening, but there are no immediate symptoms except in the case of HIV, when it sometimes seems like a terrible case of flu.
Most drug users aren't known for being attentive to their health, and a disease that won't affect them for years might not seem to them to be much of a threat. Statistics show that addicts from rural areas put off testing for HIV, which can be effectively treated with drugs, Humbaugh said. They are often first diagnosed with full-blown AIDS.
According to AIDS.gov, a clearinghouse for AIDS information, it takes about 10 years for untreated HIV to turn into AIDS. Without treatment, the survival rate for untreated AIDS is about three years.
In March, Kentucky approved legislation allowing health departments to offer needle-exchange programs. Louisville and Lexington are among the first in the state to pursue such a plan. In Central Kentucky, Scott County also is looking at a program. The Lexington-Fayette County Health Department plans to have a program in place by the end of the summer.
For Moses, the Fayette County HIV outreach specialist, the ability of departments to provide a needle exchange is "great news."
Indiana Gov. Mike Pence issued an emergency order allowing for a needle exchange program in Scott County, Ind., in April to stem the spread of HIV there. The exchange program has been extended by county health officials for a year.
There is a demand for clean needles in Kentucky, Havens said, and diabetics are selling their needles at a profit.
There are syringe dealers in Eastern Kentucky offering clean needles at a price that can exceed the cost of the drugs addicts seek.
Perhaps the biggest challenge for needle-exchange programs is funding. Kentucky's legislature allowed for the programs but didn't provide funding for them. That leaves local health departments, many of which are stretched financially, scrambling to find resources, Havens said.
Mayfield suggested that just as many communities have formed partnerships to fight substance abuse, those partnerships could cooperate in making syringe-exchange programs a reality.
Another solution is lifting a federal ban that prohibits the use of federal money in support of needle exchanges, Havens said, and there is pending federal legislation that would lift the ban. It's part of the annual health spending bill, which will be addressed by the House Appropriations Committee this summer. U.S. Rep. Hal Rogers, R-Somerset, is chairman of that committee. In 2003, Rogers founded Operation UNITE, which offers many prevention and education programs but also has a strong law enforcement component. Since it began, UNITE, which stands for Unlawful Narcotics Investigations, Treatment and Education, has helped arrest 4,216 people and has received more than 20,700 calls.
Havens said many federal lawmakers are reluctant to lift the ban on funding for needle-exchange programs. Some view it as a federal endorsement of illegal activity and have the unfounded fear that it could encourage people to try shooting up, she said.
But there is a growing chorus asking for a change at the federal level.
Connecticut Gov. Dannel P. Malloy's was the latest voice raised when he wrote to Rogers and three other house leaders on May 19. He urged them to overturn the ban, calling it a "federal policy that is failing our public health system."
According to a statement from Rogers' office, the congressman "continues to support the ban."