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Gov Declares Emergency-HIV & HCV Outbreaks in Southeastern Indiana Due
to IV Drug Use of Prescription Medication
 
 
  First HIV Clinic Set to Open in Indiana Town Beset by Epidemic...."The first HIV clinic in a rural, midwestern community grappling with an abrupt HIV epidemic is set to open on Tuesday in Austin, Indiana - the outbreak's apparent epicenter".
 
......http://www.nbcnews.com/health/health-news/indiana-governor-declares-public-health-disaster-amid-hiv-epidemic-n330546......In Scott County, nearly 20 percent of the 24,000 residents live below the poverty line......That's why he's determined, he said, to help them acquire low-cost health insurance - along with any anti-HIV drugs......A medical team from the CDC arrived in Scott County Monday to help with following up on contacts of HIV-positive individuals.
 
HIV & HCV Outbreaks in Southeastern Indiana Due to IV Drug Use of Prescription Medication Opana, Gov Oks Needle Exchange Reluctantly Indiana is battling the worst HIV outbreak in its history....."This could explode everywhere in Indiana," he told the Star. "It just started in Scott County."....
 
http://www.washingtonpost.com/news/morning-mix/wp/2015/03/26/indiana-is-battling-the-worst-hiv-epidemic-in-state-history/
 
The HIV epidemic that now grips Austin, Ind., seemed to come out of nowhere. Since the first diagnosis in mid-December, the number of infected there and in the surrounding region has skyrocketed - 26 by the beginning of March, 72 as of this Wednesday. It's the worst HIV outbreak in state history, and has local and federal officials scrambling to stem the spread of the disease.
 
But to William Cooke, who runs the only doctor's office in this city of about 4,300, this epidemic has been years in the making.
 
"We identified long ago there was an undercurrent there that was very unhealthy," he told NBC. Poverty and drug addiction in Austin created "a recipe for disaster."
 
Long before the first HIV diagnosis, the city has been coping with another epidemic: intravenous drug use. Used needles can be found strewn across yards and roadsides, but just as often wind up in the hands of other users, contributing to the spread of infection.
 
In the 10 years since he established his family practice here, Cooke has watched drugs and disease take hold - first the opiate addiction, driven by the trafficking of painkillers up nearby Interstate 65, then the increased rate of overdoses, then the spread of hepatitis C, another blood-borne disease. "We knew it was only a matter of time until HIV set in," he told NBC.
 
On Monday, investigators from the Centers for Disease Control and Prevention were dispatched to Scott County, where Austin is located, to investigate the outbreak and determine whether the virus is a new strain or one that has been circulating for a while. They agreed with Cooke's assessment that this epidemic is driven by drug use, epidemiologist Pam Pontones told the Associated Press. Intravenous drug use has been identified as the mode of infection in nearly all of the 72 confirmed cases, she added - the vast majority of those infected shared a syringe with someone else while injecting a liquid form of a prescription painkiller called Opana. All of those infected either live in Scott County or have ties to the area. Austin is considered the epicenter of the epidemic, but the disease could easily spread.
 
"With the amount of drug use that's happening and the intravenous needle-sharing that's going on, if someone who's highly infectious becomes part of that sharing network, that infection can transmit very rapidly," Pontones said.
 
Indiana Gov. Mike Pence (R), who is set to announce a public health emergency in the community Thursday, said he would consider implementing a targeted needle exchange program to combat the disease's spread. Such programs, which allow people to trade-in used hypodermic needles for clean ones, are currently illegal in Indiana. Pence, a Republican, has previously opposed them as anti-drug policy.
 
The plan Pence is expected to announce would last 30 days, according to the Indianapolis Star, and would legalize needle exchanges only in Scott County. "What we're considering is a surgical strike for the areas affected," Jennifer Walthall, deputy state health commissioner, told the Star. Pence "is opposed to it as a systematic 92-county solution."
 
But many local doctors said such a limited plan falls short of what's needed. Scottsburg doctor Shane Avery pointed out that hepatitis C cases, which often precede HIV, are already on the rise regionally.
 
"This could explode everywhere in Indiana," he told the Star. "It just started in Scott County."
 
Cooke, the Austin doctor, spoke at a hearing of the Indiana legislature's public health committee Wednesday, advocating for a law that would legalize needle distribution and collection programs statewide.
 
Republican Rep. Ed Clere of New Albany, who proposed the legislation, said a similar law was considered last year but never made it out of the House.
 
"Unfortunately we're back here, not just with needle exchange as a hypothetical theory, but with a real situation where a needle exchange [program] could make a difference," he told the AP.
 
But a needle exchange isn't the only program Scott County needs, Cooke said. He is petitioning for an addiction treatment center - right now, the nearest such facility is in the next county over, and many residents lack the means to get there - and for more infectious-disease experts, addiction councilors, cardiologists and pulmonary doctors. He also wants more funds and training for his staff to serve the growing number of HIV patients.
 
"We need help. But that costs money," he told NBC. "My clinic serves the poorest people in Indiana, potentially the poorest in the country. ... It's overwhelming how much pain and suffering is going on here."
 
Ultimately, he added, officials will need to address Austin's poverty as well. The city's drug addiction - and the resulting epidemic - are really about "hopelessness," he said.
 
Residents "think there's nothing to live for tomorrow. And the drugs are so available. This is what happens - here and in other towns in America. It's not unique to Austin," Cooke said. "As far as this HIV outbreak, we are the canary in the coal mine."
 
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HIV & HCV Outbreaks in Southeastern Indiana Due to IV Drug Use of Prescription Medication Opana, Gov Oks Needle Exchange Reluctantly......"Indiana Gov. Mike Pence (R), who is set to announce a public health emergency in the community Thursday, said he would consider implementing a targeted needle exchange program to combat the disease's spread......But a needle exchange isn't the only program Scott County needs, Cooke said. He is petitioning for an addiction treatment center - right now, the nearest such facility is in the next county over, and many residents lack the means to get there - and for more infectious-disease experts, addiction councilors, cardiologists and pulmonary doctors. He also wants more funds and training for his staff to serve the growing number of HIV patients."
 
"Meyerson said that there had been clear warning signs over the past several years that the state was at risk of an HIV outbreak like the one being seen in Scott County, including a significant rise in the incidence of hepatitis C infections and a growing proportion of people seeking drug treatment for heroin use, which rose from 2.9% to 9% of all those entering treatment for drug use between 2007 and 2011......Mr. Pence's order, which is in effect for 30 days, would allow for a needle-exchange program within Scott County if one is requested by local officials.....Intravenous drug use has been identified as the mode of infection in nearly all of the 72 confirmed cases, she added - the vast majority of those infected shared a syringe with someone else while injecting a liquid form of a prescription painkiller called Opana."
 
"On Monday, investigators from the Centers for Disease Control and Prevention were dispatched to Scott County, where Austin is located, to investigate the outbreak and determine whether the virus is a new strain or one that has been circulating for a while. They agreed with Cooke's assessment that this epidemic is driven by drug use, epidemiologist Pam Pontones told the Associated Press."
 
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Needle Exchange Is Allowed After H.I.V. Outbreak in an Indiana County
 
NY Times
By ALAN SCHWARZ and MITCH SMITHMARCH 26, 2015
 
http://www.nytimes.com/2015/03/27/us/indiana-declares-health-emergency-after-hiv-outbreak.html
 
An outbreak of H.I.V. in southeastern Indiana prompted the governor on Thursday to declare a public health emergency as officials worked to stop the spread of the virus that causes AIDS.
 
Officials said that 71 cases of H.I.V. identified since mid-December have been traced to intravenous use of a prescription painkiller in Scott County north of Louisville, Ky. Nine more cases are still under investigation, and state health officials predicted that more would appear in coming weeks. The governor authorized a short-term exchange program that would provide drug users with access to sterile needles so that contaminated needles were less likely to be shared.
 
Gov. Mike Pence, a Republican, has long opposed such programs. But he said that the outbreak, which was first identified in late January, had reached epidemic proportions, justifying the action. "This is all hands on deck," Mr. Pence said. "This is a very serious situation."
 
Mr. Pence's order, which is in effect for 30 days, would allow for a needle-exchange program within Scott County if one is requested by local officials.
 
Scott County has about 24,000 residents, 19 percent of whom live below the poverty line, a rate higher than the state average. Mr. Pence said that Scott County typically sees about five new cases of H.I.V. a year.
 
The governor said the cluster of cases diagnosed so far had been traced to intravenous drug use, with the virus most likely spreading as people shared infected needles. He said those infected had illegally used Opana, a powerful prescription pain medication prescribed only in pill form. Opana is marketed by Endo Pharmaceuticals as a long-acting formulation of oxymorphone. It is prescribed less frequently than oxycodone and hydrocodone because of its strength. When used illicitly, it can provide a potent high.
 
"Once you alter it and inject it, it's no longer extended-release," said Dr. Melinda Campopiano, a medical officer at the federal Substance Abuse and Mental Health Services Administration. "It is much quicker."
 
Allowing clinics and other entities to dispense sterile syringes in exchange for used ones has long been debated. Proponents, including the White House Office of National Drug Control Policy and the federal Centers for Disease Control and Prevention, say such programs can impede the spread of infectious diseases like H.I.V. and hepatitis C. Opponents say they may encourage illegal drug use.
 
United States law prohibits federal funding of needle-exchange programs. About half of states, generally those that are politically conservative, have banned the practice, according to the North American Syringe Exchange Network, which tracks state policies.
 
Mr. Pence has supported Indiana's ban, but after meeting with federal advisers he said he decided to "make an exception" and allow a temporary program in Scott County.
 
"I'm going to put the lives of the people of Indiana first," Mr. Pence said. He later added: "It's a commitment to law and order, but it's a commitment to compassion."
 
The state will establish a command center in Scott County, with a task force of state agencies and a mobile enrollment facility for Indiana's Medicaid program, which covers H.I.V. testing and treatment.
 
"The sooner we get people who may have been exposed, by whatever means, in this region, in for testing, in for treatment, the sooner that we will also suppress the spread of this virus," Mr. Pence said.
 
Dr. Jerome M. Adams, the state health commissioner, said his department had been working in Scott County after H.I.V. diagnoses began to surge in January. He said public health workers have had limited success locating and testing those at risk of infection.
 
"Scott County is a rural area," Dr. Adams said. "It's also a very close-knit area. When you're identified, the whole town knows. There's a feeling of hopelessness within this community. They're addicted, and they're getting H.I.V. because they're addicted."
 
Misuse of prescription opioids has become a national concern, with more than 16,000 deaths attributed to it in 2013, according to the C.D.C. The Scott County coroner, Jerry Buchanan, said in a telephone interview on Thursday that his office had handled 11 fatal drug overdoses since 2013, one caused by Opana.
 
Mr. Pence said: "I have deep compassion for people who have been trapped by this addiction, and we want to make sure people know they're not alone. There is help, there is treatment and we're surging into the county now to make that available."
 
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Indiana declares health emergency in response to HIV outbreak
 
BMJ
Published 27 March 2015
 
Michael McCarthy
 
Indiana's governor, Mike Pence, declared a public health emergency on Wednesday 25 March in response to an outbreak of new HIV infections in the southeast of the state.
 
Since the outbreak was first detected, in January, state officials have confirmed 79 cases of new HIV infection. Most have occurred in Scott County, a rural county with a population of 24 000, which would typically see fewer than five cases a year.
 
All the confirmed cases have been linked to injected drug use, particularly of a prescription form of oxymorphone (marketed in the United States as Opana), which has become widely misused in rural areas of the US.
 
Under the governor's executive order Indiana's State Department of Health will set up an incident command center to coordinate HIV testing and treatment for substance misuse in the county and a mobile "one stop shop" where people can be helped to enroll in the state's Medicaid program, the state run health insurance plan for residents on low incomes.
 
The order also allows county officials to implement a needle exchange program, which Pence said would be short term and be limited to the "sole purpose of suppressing the HIV epidemic in Scott County." Pence, a conservative Republican, has said that he would oppose a state-wide needle exchange program. "I do not support needle exchange as antidrug policy, but this is a public health emergency," Pence said.
 
Some doctors and public health experts have criticized the governor's actions, arguing that the measures are not enough to tackle the growing problem of injection drug use in rural Indiana. Beth Meyerson, co-director of the Rural Center for AIDS/STD Prevention and an associate professor at the University of Indiana Bloomington School of Public Health, said that there was little chance that a short term needle exchange program limited to one county would curb the epidemic.
 
Meyerson said that there had been clear warning signs over the past several years that the state was at risk of an HIV outbreak like the one being seen in Scott County, including a significant rise in the incidence of hepatitis C infections and a growing proportion of people seeking drug treatment for heroin use, which rose from 2.9% to 9% of all those entering treatment for drug use between 2007 and 2011.
 
The arrival of oxymorphone seemed to have been the spark that set "the tinder on fire," Meyerson said. Needle exchange programs are effective, Meyerson said, but to succeed they need to be "tightly tied" to a well developed system that provides HIV testing and treatment and access to substance abuse treatment programs. There is no evidence that a limited "band aid" approach such as that proposed by the governor would work, she added. "It's a political decision" that would not seriously tackle the state's public health problem, she said.
 
 
 
 
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