What Have We Learned From The Indiana HIV Outbreak?

Oct 2, 2015

When an outbreak of HIV among injection drug users was declared in rural Scott County, Indiana, in February, it made national headlines. HIV was supposed to be an urban problem, and AIDS had been in steady decline among IV drug users since the early 90s. 

Daniel Raymond, policy director at the national Harm Reduction Coalition, says the Scott County outbreak, which infected 181 people, was a “wake up call” for communities around the country who are dealing with rising rates of hepatitis C, ongoing prescription opioid addiction, and increasing abuse of heroin.

The outbreak brought renewed attention to an old idea: helping IV drug users access sterile syringes to reduce the sharing that spreads the disease, also known as needle exchange, or syringe exchange. Needle exchange programs originated during the HIV epidemic of the 1980s, as an alternative to abstinence-promoting strategies that were popular at the time.

Reporter Andrea Muraskin spoke with Raymond to learn more about the Scott County outbreak’s national impact.

Andrea Muraskin: When the HIV outbreak started in Scott County we were surprised to learn that there was no syringe exchange in the state of Indiana, and that it wasn't even legal at the time. Was Indiana unique in this regard?

Daniel Raymond: When the [1980s] HIV epidemic hit, most states had very restrictive drug paraphernalia laws dating back, usually, to the 70s, where the idea was that it would be illegal to possess, sell distribute syringes. And so a lot of states had to modify their laws in order to permit syringe exchange programs to operate effectively. That's been a slow process. We still have probably over 20 states that haven't taken that step. And as we've seen with rising hepatitis C rates, we're certainly paying a price for that lag in action. 

I think the Scott County HIV outbreak was a wake-up call. A lot of communities had looked around and said we have more hepatitis C cases, we have more overdoses, we have more heroin use - we could be next.

AM: Do you think that needle exchanges were suffering under the perception that HIV was under control -- and then they got a boost in visibility and maybe funding as a result of what happened in Scott County? 

DR: I would agree with that up to a point. What we've seen is the peak of the HIV epidemic in the United States amongst people who inject drugs specifically was probably the late 80s, early 90s, and the rates of infections have been steadily declining over the last 20 years by about 70 percent. In the mean time we were still seeing a lot of sexual transmission. And so over the last few years there's been a trend in HIV funding- and HIV funding has been the primary source for needle exchange- to shift HIV funding to the areas where we still have a lot of new cases due to sexual transmission. And that shift has definitely hurt needle exchange programs. 

So I think the Scott County HIV outbreak was a wake-up call. A lot of communities had looked around and said "we have more hepatitis C cases, we have more overdoses, we have more heroin use - we could be next." I think that's really put syringe exchanges back on the radar screen for public health policy makers. I'm not sure that it's resulted in an increase of new funding, but it's definitely resulted in new attention. It’s definitely aided the move to establish programs in states that had historically not taken up syringe exchange like Kentucky, like Indiana, like West Virginia. And I think in the long run it's going to be a useful way for to think through how communities can respond to the broader opioid and heroin issues. 

AM: Other than this general wakeup call, are there any lessons people in the drug policy community can take from Scott County?

DR: I think what came out of Scott County is we can no longer afford to dismiss the role of needle exchange in rural areas. That this isn't just a big city problem. That this isn't just about heroin use. It's also about injection of prescription opioids, painkillers. 

I hear this on a regular basis from health officials in other parts of the country as well as policy makers: If we do not learn from the Scott County HIV outbreak we'll see this repeated over and over again.