Growing intravenous drug use by people sharing syringes to inject heroin and other substances continues to drive new hepatitis C infections in Kentucky, which ultimately could mean a staggering cost to taxpayers to treat people with the disease.
Giving addicts clean needles can help stem the spread of the disease, but many Kentucky counties considered at greatest risk for an outbreak have not approved such programs.
Two recent reports illustrate the challenge the state faces.
The Centers for Disease Control and Prevention said that in 2015, Kentucky was among seven states where the incidence of new hepatitis C cases was more than twice the national rate.
Kentucky, West Virginia and Massachusetts had the highest rates, the May 12 report said.
The problem has been building for years, according to the 2017 update to the Kentucky Department for Public Health’s state health assessment.
The update, released in March, said Kentucky had the highest rate of new hepatitis C infections in the nation from 2008 through 2015, the last year with available data.
There were 1,089 new cases recorded in the state in that time. Other states had more total cases, but that was the most per capita in the country.
“We have an epidemic, and we need to continue to deal with it,” said Dr. Ardis Hoven, an infectious disease specialist with the Kentucky Department for Public Health.
Hepatitis C rates rose sharply in the state between 2006 and 2013 as more people used syringes to shoot up prescription drugs and heroin, but the numbers went down in 2014 and again in 2015, according to the state report.
That could reflect efforts to increase knowledge about the disease among health professionals and drug users, including getting addicts to understand sharing needles can spread it.
Hoven said state public health officials have worked to spread the word about the importance of testing people for the hepatitis C virus among agencies that could have contact with drug users, including local health departments, substance abuse treatment providers and jails.
Officials also have stressed the need to get people into care.
Still, Hoven said, it’s too soon to say the decline in new reported cases will hold. And even if it does, there could be thousands of Kentuckians who have been infected but haven’t been tested yet. Many will face deteriorating health at some point.
It can take decades for symptoms to develop. As a result, available data “largely underestimate the prevalence” of hepatitis C, the CDC said.
For every 100 people infected with hepatitis C, as many as 70 will develop chronic liver disease, up to 20 will develop cirrhosis over a period of 20 to 30 years, and as many as five will die as a result of the infection, the agency said.
Kentucky also has seen a troubling number of babies born to mothers infected with hepatitis C, which puts babies at risk to have the disease.
Nationwide from 2009 to 2014, hepatitis C present at the time of delivering a baby increased 89 percent, to 3.4 per 1,000 live births, according to the CDC.
But in Kentucky, the rate was much higher at 15.1, second only to West Virginia at 22.6, the agency said. Not all states report that statistic on birth certificates.
The state’s health establishment needs to focus on identifying mothers with the disease and getting them into treatment before delivery, Hoven said.
Hepatitis C can be cured, but the cost of the treatment is high.
In the last full fiscal year, Kentucky’s Medicaid program spent $69.7 million on pharmacy claims to treat 833 beneficiaries, or $83,735 apiece, according to the Cabinet for Health and Family Services.
Studies have shown that one tool to reduce the spread of hepatitis C and the human immunodeficiency virus (HIV) are programs allowing drug users to trade dirty needles for clean ones.
The availability of such programs continues to grow in Kentucky as local officials grapple with concerns over drug use and disease.
The programs have only been legal in Kentucky since 2015, when the legislature authorized them in the face of mounting IV drug use.
Louisville started the state’s first needle-exchange program in June 2015, followed by Lexington in September.
Since then 31 additional counties have approved needle-exchange programs, bringing the total to 33, according to the Cabinet for Health and Family Services. That number has more than doubled since last summer. Of those 33, 24 are in operation and the others are setting up.
County health departments run the exchanges with the approval of the city and county where the program is located.
Typically, the programs give users clean syringes in exchange for dirty ones, handle disposal of the old needles and provide users a safe container to store and transport dirty needles until they return for more clean ones.
Workers also offer people access to hepatitis C and HIV testing and can refer them for treatment of health problems and substance abuse.
More than 7,300 people took part in needle exchanges from mid-2015 through January, most of them in Louisville and Lexington, according to the Cabinet for Health and Family Services.
More than 650 received testing for HIV, and 609 were referred for substance-abuse treatment, the cabinet said.
Supporters sometimes point to an outbreak of HIV cases in rural Scott County, Ind., as an example of why needle exchanges are needed in Kentucky.
In a county with only 10 new HIV infections in the previous decade, 181 people were diagnosed with the disease between November 2014 and October 2015, according to the CDC.
The disease spread so quickly because of addicts sharing needles to inject a painkiller called Opana. Drug users said they shared needles with up to six people, according to one study.
After then-Gov. Mike Pence approved an emergency program to provide free needles to drug users, the rate of new HIV infections went down sharply.
The outbreak worries Kentucky health officials because of a study the CDC did in the aftermath, which identified the potential for a similar problem in many counties here.
The agency analyzed measures such as overdose deaths, per capita income, unemployment and sales of painkillers to figure out which counties in the nation were most at risk for disease outbreak.
Researchers concluded that of the 220 most vulnerable counties in the nation, 54 were in Kentucky, mostly in the southern and eastern parts of the state.
The study said there were 18 Kentucky counties more vulnerable to a spike in disease among IV drug users than Scott County, Ind., had been.
Wolfe County was cited as having the highest risk in the country.
The Kentucky counties share many of the same problems that contributed to drug abuse in Scott County, Ind., including high unemployment and poverty, relatively low educational attainment and limited access to health care.
And sharing needles is just as common in rural Kentucky, health officials said.
“Their injection drug problem, we have the same thing here,” said Karen Cooper, director of the Kentucky River District Health Department, which includes seven counties in the Hazard area. “If you drop HIV in that mess … it’s gonna go like wildfire.”
A long-running study of hundreds of IV drug users in Perry County has shown high rates of hepatitis C.
The study found that of 392 IV drug users tested, 54.8 percent were infected with hepatitis C, compared to less than 2 percent in the general U.S. population, according to results published in January 2013 in the American Journal of Public Health.
Several researchers from the University of Kentucky are taking part in the study, which continues to follow IV drug users.
Needle-exchange programs and additional substance-abuse treatment should be considered a necessity in Eastern Kentucky “given the alternative of having hundreds, if not thousands” of hepatitis C cases, researchers said in the paper.
“I wish every single county would get on board,” said Jennifer R. Havens, an associate professor in the UK College of Medicine who is one of the researchers on the study.
Dirty needles abound
Despite the documented problems, more than 30 of the counties the CDC identified as being at high risk for a disease outbreak have not set up needle-exchange programs.
Some local officials said they’ve faced concerns from residents of their culturally and politically conservative counties that giving needles to drug users condones or perpetuates drug abuse.
“You’re just stimulating drug use, that’s a lot of people’s thoughts,” said Russell County Judge-Executive Gary D. Robertson.
Robertson said he had much the same reaction when the idea first came up but changed his mind after learning more.
Durg addicts will find needles and use drugs with or without a local needle-exchange program, but the program can help reduce the spread of expensive diseases, Robertson said.
Still, the vote was 3 to 2 in April when the fiscal court approved allowing a needle-exchange program in the county. Two magistrates were getting so much pushback from constituents they couldn’t vote for the program, Robertson said.
Jackson County Judge-Executive Shane Gabbard, a Baptist minister, said he also had concerns about having a local needle exchange but came to support it.
Gabbard said an exchange program doesn’t enable drug use, and creates an opportunity for people to be tested for disease and maybe steered to drug treatment.
“It’s actually a chance to reach out to someone and offer them rehabilitation,” Gabbard said.
One study in Seattle showed that people taking part in syringe-exchange programs were five times more likely to enter drug treatment than non-participants.
Other studies have shown that exchange programs don’t encourage people to start taking drugs or increase how often users inject drugs; that they don’t increase crime; and that they help reduce the problem of drug users disposing of dirty needles improperly.
That improper disposal in ditches, trash cans and public parks creates a risk of getting stuck for children, maintenance and sanitation workers, and police and firefighters.
“It’s amazing what kind of problem it’s getting to be” even in his rural county of 13,000, Gabbard said of improper syringe disposal.
Stories about people getting accidentally stuck by a discarded drug needle are commonplace.
Cooper said a little girl in her area stepped on a needle in her yard. She was tested at the local health department for hepatitis C and HIV and will have to be tested again after six months, Cooper said.
The cost of an exchange program also is a concern for some local officials. It’s hard to know what the cost will be because it’s unclear how many addicts will take part.
“Many of them are strapped anyway,” Cooper said of the seven counties in the district health department.
But health officials argue the programs are cost-effective because of the potential to avoid the much higher cost of treating people with hepatitis C and HIV.
“If you cure their hepatitis C, you’re going to prevent them from infecting others,” Hoven said.