1 in 10 new HIV cases in the United States are attributable to injecting drug use due to the transmission of bloodborne pathogens via reused and unsafe needles. Sharing needles is the second riskiest behavior for contracting HIV right after unprotected sex, with the chance of contracting HIV from a dirty needle being 1 in 60 (CDC, 2021). And even though access to HIV treatment has expanded, injectable drug users generally face other social or economic barriers to healthcare which would make them more likely to postpone care – increasing the risk of transmission to others in the period before treatment – and are compounded by the social stigma around both HIV and using injectable drugs. 10% of new HIV diagnoses in the U.S are attributed to people who inject drugs (CDC, 2022). And between 2007 and 2011, the total direct expenditure of HIV and AIDs treatment was 10.7 billions dollars annually (National Institute of Health, 2023)
Though historically HIV is seen as an issue in urban areas, it is becoming increasingly prevalent in rural ones as well. As recently as 2015 in Austin, Indiana 235 people were diagnosed with HIV in a community of only 4,1000 (Ungar, 2020). This outbreak was caused almost exclusively via injectable drug use. The only physician in Austin, Dr. Willian Cooke, said that the community already had an existing drug use problem with a high prevalence of those with opioid use disorder, but it worsened in 2010 to 2011 when users started turning to other, more extreme options like injectable drugs. He believes that the HIV outbreak was inadvertently caused by the opioid epidemic (Varney, 2015). This was later proven true in a 2016 study which found that 87% of HIV patients in Scott County Indiana reported injecting the prescription opioid, oxymorphone (Peters, P. J., Pontones, P., et al. 2016).
In 2017, among 15 counties with the highest opioid prescribing rates, 14 were rural (García, M. C., Heilig, C. M., et al. 2019), which likely explains why the incidence of overdose death is significantly higher in rural communities than in urban ones. With this in mind, we can assume that rural areas are at a uniquely high risk of an HIV outbreak due to the incidence of injecting opioids.
Following the 2015 outbreak in Scott County, the CDC conducted a national assessment to determine what counties with similar characteristics – Hepatitis C incidence, opioid use data, etc. – would be at risk of a severe HIV outbreak. This totaled to 220 counties in the U.S (CDC, 2021). The Indiana HIV outbreak can be used as a model for how a well-informed and scientifically- backed federal response can significantly determine the resolution of an outbreak. In 2015, the then governor of Indiana, Mike Pence, announced a public health emergency two full months after the first surge of cases were reported, and then reluctantly authorized the implementation of a targeted needle exchange program where he stated that he opposes such programs for combating drug use but had to make an exception for Scott County (Harper, J. 2015). A Brown University study using model predictions on the spread of HIV in Scott County Indiana estimated that an earlier implementation of needle exchange programs could have reduced the incidence of HIV in rural Indiana by 90% (Goedel, W. C., King, M. R., et al. 2019).
But the sentiment from Mike Pence is a common one. In 2012 former president Obama signed the FY2012 omnibus spending bill which reinstated the ban on the use of federal funding for needle exchange programs, reversing the 2009 decision allowing it, despite the evidence proving their efficacy in preventing HIV. This decision was largely due to conservative constituents believing that needle exchange programs promote and encourage drug use by making it safer, contradict the efforts of law enforcement, and worsen public health in general, despite strong evidence demonstrating that this is not the case; Individuals who participate in needle exchange programs are five times as likely as those who do not to enter drug treatment programs (CDC, 2019). But political opposition wouldn’t be the only barrier to the implementation of needle exchange programs, and would require coordination with the justice system as well. Most state drug paraphernalia laws mean that an injecting drug user who takes advantage of needle exchange programs could be charged with a misdemeanor and, in the state of Georgia, could face up to one year in prison (Kohn, 2020). In order to implement needle exchange programs, state legislators would have to be willing to cooperate with public health officials to make it so that those carrying drug paraphernalia are not criminally charged, something which completely alters how most state laws perceive the handling of drug abuse.
The method in which a needle exchange program is implemented is just as critical for its efficacy as the legislation surrounding it. Some states such as Nevada and New York implemented a needle vending machine program in 2017 and 2022 respectively. This allows the individual to remain anonymous, encouraging utilization in the absence of social stigma. However, though beneficial, sterile needle vending machines haven’t been proven yet to have the same long term benefits as intervention programs with provider-to-user interaction such as those run in clinics or mobile health units (Stewart, R. E., Cardamone, N. C., et al. 2023). Intervention programs can provide a way to connect users to other relevant resources while they participate in the needle exchange, such as referral to substance use disorder treatment programs, screenings for Hepatitis C and HIV, wound care, and Naloxone distribution supplemented by education on how to respond to an overdose (CDC, 2019). These supplemental interventions are most common in needle exchange programs operating out of clinics, however, given the prevalence of healthcare deserts in rural America, this may only exacerbate existing health disparities.
One alternative solution which allows for face-to-face contact while still expanding access to healthcare to rural areas, which are already at a greater risk of HIV outbreaks, would be through the mobile clinic model. The mobile clinic model was popularized during the COVID-19 pandemic for similar reasons related to rural healthcare accessibility. With this method, medically underserved regions can easily get in touch with healthcare providers regardless of the availability of standing clinics. In 2020, the Substance Abuse and Mental Health Services Administration offered the Colorado Department of Human Services, Office of Behavioral Health a federal State Opioid Response grant to expand access to treatment for opioid use disorder (Rural Health Information Hub, 2021). These mobile health units were RVs converted into clinics, which had on-board a nurse, a licensed addiction counselor, and a peer support specialist. These units traveled to 32 counties in Colorado where they supplied services like counseling, drug testing, naloxone, and syringe disposal where they served hundreds of residents.
Providing similar grants to mobile health unit companies such as The Health Wagon or Remote Area Medical could help smaller organizations to expand their client base to more cities in rural America, and provide them with the resources to offer a greater variety of services so that they could include needle exchange and overdose prevention. This method allows needle exchange and other drug related programs to provide users face-to-face contact which is associated with a greater chance of quitting drug abuse, while also reaching areas which otherwise would have had little to no access to a physician.
References
Centers for Disease Control and Prevention. (2021, April 21). HIV and injection drug use. cdc. Retrieved April 27, 2023, from https://www.cdc.gov/hiv/basics/hiv-transmission/injection-drug-use.html#:~:text=Risk%20of%20HIV,and%20blood%20can%20carry%20HIV.
Varney, S. (2015, May 7). Rural Indiana struggles with drug-fueled HIV epidemic. KFF Health News. Retrieved April 27, 2023, from https://kffhealthnews.org/news/rural-indiana-struggles-with-drug-fueled-hiv-epidemic/
Ungar, L. (2020, February 16). 5 years after Indiana’s historic HIV outbreak, many rural places remain at risk. NPR. Retrieved April 27, 2023, from https://www.npr.org/sections/health-shots/2020/02/16/801720966/5-years-after-indianas-historic-hiv-outbreak-many-rural-places-remain-at-risk
Goedel, W. C., King, M. R., Lurie, M. N., Galea, S., Townsend, J. P., Galvani, A. P., Friedman, S. R., & Marshall, B. D. (2019). Implementation of syringe services programs to prevent rapid human immunodeficiency virus transmission in rural counties in the United States: A modeling study. Clinical Infectious Diseases, 70(6), 1096–1102. https://doi.org/10.1093/cid/ciz321
Centers for Disease Control and Prevention. (2021, August 31). Vulnerable counties and jurisdictions experiencing or at-risk of outbreaks. cdc. Retrieved April 27, 2023, from https://www.cdc.gov/pwid/vulnerable-counties-data.html
Peters, P. J., Pontones, P., Hoover, K. W., Patel, M. R., Galang, R. R., Shields, J., Blosser, S. J., Spiller, M. W., Combs, B., Switzer, W. M., Conrad, C., Gentry, J., Khudyakov, Y., Waterhouse, D., Owen, S. M., Chapman, E., Roseberry, J. C., McCants, V., Weidle, P. J., … Duwve, J. M. (2016). HIV infection linked to injection use of oxymorphone in Indiana, 2014–2015. New England Journal of Medicine, 375(3), 229–239. https://doi.org/10.1056/nejmoa1515195
García, M. C., Heilig, C. M., Lee, S. H., Faul, M., Guy, G., Iademarco, M. F., Hempstead, K., Raymond, D., & Gray, J. (2019). Opioid prescribing rates in nonmetropolitan and metropolitan counties among primary care providers using an electronic health record system — United States, 2014–2017. MMWR. Morbidity and Mortality Weekly Report, 68(2), 25–30. https://doi.org/10.15585/mmwr.mm6802a1
Harper, J. (2015, March 26). Governor declares public health emergency as HIV outbreak spreads. WFYI Public Media. Retrieved April 27, 2023, from https://www.wfyi.org/news/articles/governor-declares-public-health-emergency-as-hiv-outbreak-spreads
Centers for Disease Control and Prevention. (2019, May 23). Syringe Services Programs (ssps) faqs. cdc. Retrieved May 1, 2023, from https://www.cdc.gov/ssp/syringe-services-programs-faq.html
Kohn, L. (2020, March 28). Georgia drug laws on Paraphernalia: Drug Objects Charges. Criminal Defense Matters. Retrieved May 1, 2023, from https://criminaldefensematters.com/georgia-drug-laws-on-paraphernalia-drug-objects/
Stewart, R. E., Cardamone, N. C., Loscalzo, E., French, R., Lovelace, C., Mowenn, W. K., Tarhini, A., Lalley-Chareczko, L., Brady, K. A., & Mandell, D. S. (2023). “there’s absolutely no downside to this, I mean, except community opposition:” a qualitative study of the acceptability of vending machines for harm reduction. Harm Reduction Journal, 20(1). https://doi.org/10.1186/s12954-023-00747-4
Rural Health Information Hub. (2021, April 8). Rural Health Information Hub. Rural Project Summary: Mobile Health Units for Opioid Use Disorder Treatment. Retrieved May 1, 2023, from https://www.ruralhealthinfo.org/project-examples/1089
Centers for Disease Control and Prevention. (2022, June 28). HIV among people who inject drugs. Centers for Disease Control and Prevention. Retrieved May 2, 2023, from https://www.cdc.gov/hiv/group/hiv-idu.html
National Institute of Health. (2023, March 23). Cost considerations and antiretroviral therapy: NIH. clinicalinfo. Retrieved May 2, 2023, from https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/antiretroviral-therapy-cost-considerations
