Opioid epidemic could spark HIV outbreak, health experts fear
Pennsylvania's widespread opioid epidemic, combined with controversial drug paraphernalia laws and the lack of needle exchange programs in rural areas, could spark a devastating and costly HIV outbreak, health experts fear.
HIV outbreaks have hit several parts of the country, including rural Scott County, Indiana, which could cost the state more than $100 million.
"I expect it," said Dr. Donald Burke, an infectious disease specialist and dean of the University of Pittsburgh's Graduate School of Public Health.
On Wednesday, Burke and other state public health leaders urged Gov. Tom Wolf to decriminalize syringe and needle exchanges. The leaders, representing Pennsylvania schools in the Association of Schools & Programs of Public Health, want to head off what they believe could be a looming HIV outbreak.
In Pennsylvania, it is against state law to run a needle-exchange program, despite evidence in the 1990s that showed it staunched the rapid rise of HIV cases in Philadelphia and Pittsburgh. Syringes are covered by the state's law against possessing drug paraphernalia.
"We write now to strongly support the use of this declaration to immediately expand Syringe Service Programs … in Pennsylvania. Such programs are community-based programs that provide access to sterile needles and syringes free of cost and facilitate safe disposal of used needles and syringes," read the letter signed by Burke and public health representatives from the University of Pittsburgh, Drexel, Penn State, Temple, Thomas Jefferson University and the University of Pennsylvania.
Burke said Wolf has the power to prevent widespread outbreaks of viruses such as HIV, the precursor to AIDS, and hepatitis C — by making clean needles readily available.
"If he doesn't, I can guarantee an HIV epidemic in the state of Pennsylvania," Burke said.
It has likely already started, he said, and the numbers haven't yet come to light.
He estimates there are anywhere from 50,000 to 100,000 people injecting illicit drugs across the state.
Some Pennsylvania cities still run needle-exchange programs, despite the illegality. The Allegheny County Health Department has embraced the local program, Prevention Point Pittsburgh.
Alice Bell, director of Prevention Point, said Pennsylvania's syringe laws help create a climate in which such an outbreak is likely. Legalizing needle exchange programs isn't enough, she said. Decriminalizing syringes — currently considered drug paraphernalia and thus illegal — will help.
Rural areas without health departments won't have the resources to develop exchange programs, Bell said. Decriminalization would mean that anyone can buy needles and syringes.
"In cities where we have needle exchanges, we've kept new HIV cases low," she said.
In rural counties, however, clean needles aren't readily available.
Those opposed to needle exchanges work under the assumption that giving people access to needles and syringes will encourage drug use; rather, those suffering from substance abuse disorder often will continue to use drugs regardless — they'll just use dirty needles and risk infection.
It's what happened in Scott County, Indiana, in early 2015. Funding cuts forced the county's Planned Parenthood to close its doors, leaving the county — situated in the southeast part of the state — with no HIV testing site.
The outbreak began with about a dozen new cases in early 2015. A flurry of testing began, and then-Gov. Mike Pence eventually allowed a 30-day emergency needle exchange to set up within the county. Within a year, 180 cases had been diagnosed, with that number reaching about 190 today.
The fear is that the cluster in Indiana will not be an isolated incident. Earlier this year, officials in Cincinnati and northern Kentucky reported an uptick in drug use-related HIV cases.
Allegheny County showed a slight increase in new HIV cases in 2014, the most recent year for which data were available. There were about 132 new cases reported in 2014, and the health department reported 123 new cases the year prior.
Centers for Disease Control and Prevention data released this year showed that 1 in 4 injection drug users reuse needles, and many have not had an HIV test in the past year.
Bridget Calhoun, a Duquesne University professor specializing in infectious diseases, said she fears that because data lag behind — and because those data rely on individuals voluntarily getting tested — the opioid-driven outbreak could already be in motion.
"My fear is that there's going to be this huge upswing in cases that are not diagnosed initially, as we all know (intravenous drug) users are a population that's very hard to reach, very hard to permeate and very hard to educate," Calhoun said. "They're not the ones coming in the door to get tested."
In Indiana, researchers found that individuals who traded sex for things like drugs or a place to stay turned out to be a large factor in that outbreak.
An explosion in cases of hepatitis C — a sometimes fatal liver disease spread via blood — has already happened across the region. A Tribune-Review report in late 2016 found that cases increased more than eight-fold in the 10-county region between 2003 and 2014, from 335 to 2,818.
A 2015 investigation by WTHR in Indianapolis into the cost of the epidemic in southeastern Indiana reported a cost of about $400,000 to $500,000 in lifetime costs to each patient, citing an average life expectancy of 25 years living with the disease.
Some officials estimate the cost of Scott County's outbreak will be near $200 million when all is said and done.
With life expectancy now nearly normal for those with HIV — assuming they begin antiretroviral treatment soon after they contract the virus — those costs could realistically be even higher. And, experts say, those costs could have been avoided had the state invested in better public health care earlier.
The CDC in late 2016 released a list of 220 counties across the country at the highest risk of an HIV outbreak related to opioid drug use. In Pennsylvania, the CDC identified Cambria, Crawford and Luzerne counties. A majority of the counties are in southeastern Ohio, West Virginia, Kentucky and parts of northern Tennessee — Appalachia.
The factors that allowed the epidemic to flourish in Indiana can be found in Pennsylvania, as well as rural areas across the country: social stigma, economic depression, rampant injection drug use, poverty and a lack of medical resources.
In Luzerne County, there are four locations where people can go for HIV testing. Crawford and Cambria counties have one apiece, according to a state directory of testing locations.
Closer to home, Beaver and Fayette counties each have two testing centers, and Washington, Butler and Armstrong each have one. Greene County has nowhere offering HIV testing, according to the directory.
The lack of resources is so stark in some areas that it was cited in the 2017 Southwestern Pennsylvania's Regional HIV Needs Assessment, put together by the Jewish Healthcare Foundation, which oversees federal HIV/AIDS funding in the region.
"While individuals living close to Pittsburgh have access through needle exchange programs like Prevention Point Pittsburgh, a lack of access in rural areas may pose a risk of HIV outbreak," according to report. It continued: "Opioid use is particularly prevalent in Southwestern Pennsylvania rural areas, and access to harm reduction services is low; as a result, rural areas of Southwestern Pennsylvania may be at risk for HIV outbreaks."
Megan Guza is a Tribune-Review staff writer. Reach her at 412-380-8519, firstname.lastname@example.org or via Twitter @meganguzaTrib.