Controversial Indiana needle exchange program that quelled massive HIV outbreak voted down

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AUSTIN, Ind. — An Indiana county once home to America’s worst drug-fueled HIV outbreak voted Wednesday to scrap the syringe exchange program credited with halting the epidemic.

The Scott County Commission vote, with two of three members arguing the exchange could be contributing to drug use and overdose deaths, drew howls of protest from health advocates who predicted it would lead to a resurgence of HIV cases.

“I know people who are alcoholics, and I don’t buy them a bottle of whiskey," said commissioner Mike Jones, who voted to end the program by Jan. 1. "And I know people who want to kill themselves, and I don't buy them a bullet for their gun.”

The move comes amid a nationwide increase in drug overdoses attributed to the COVID-19 pandemic, leading supporters to argue there could scarcely be a worse time to abandon the harm-reduction program serving a onetime epicenter of the U.S. opioid crisis.

Commissioners rejected pleas from local law enforcement, state officials and former Trump administration Surgeon General Jerome Adams in voting to shutter the exchange, opened to fight a 2015 HIV outbreak fueled by injected opioids that saw cases skyrocket from a small handful to 237 in a county of just 24,000.

The rural nature of the outbreak made global headlines, drawing reporters from as far as Asia, as it came to symbolize the explosive dangers of an opioid crisis in rural areas with inadequate health care and treatment.

Randy Julian, one of the commissioners who voted against the program in a packed meeting room Wednesday night, said he believes it does more harm than good, fueling overdoses despite a track record of reducing HIV and hepatitis C.

He and other critics have argued the exchange facilitates drug use when more treatment efforts are needed.

“With proper care, people can live with HIV and hepatitis," he said in a message before the vote. "(They) can’t come back from death. If they would (have) overdosed anyway, then I didn’t help them to do it.”

The syringe exchange, opened over the initial opposition of then-Gov. Mike Pence, works by offering clients clean needles they must return to limit sharing of infected needles. In addition, clients get access to treatment and overdose reversal drugs.

Dr. William Cooke, who opened the town’s only primary care doctor’s office in 2004 and worked to help curtail the outbreak, said the exchange has proven successful and become a national model.

In 2018, researchers with the federal Centers for Disease Control and Prevention found the proportion who shared syringes in Scott County dropped from 74% to 22% from 2015 to 2018.

Last year, the county had just one HIV case, officials said, from a high of more than 150 in a year.

In a hearing last month, advocates cited decades of research showing syringe exchanges prevent disease and reduce health care costs without increasing crime. And it serves as a critical “touchpoint” with drug users for treatment and overdose-reversing naloxone, Cooke said.

Several residents spoke at Wednesday’s meeting, saying they had been addicted and got treatment through the exchange as they got needles.

“It kept me clean,” Rick Williams said. “And it directed me to recovery.”

Scott County’s drug poisoning deaths fell for most of the time the exchange was in operation, from 21 in 2016 to eight in 2019, the latest statewide figures available. But last year they jumped to 24, according to Scott County Coroner Lonnie Noble.

It’s likely a reflection of drug death rates that soared nationally amid the pandemic. Officials attributed that to poor access to treatment.

Last year, the U.S. saw more than 80,000 drug overdose deaths beginning in May 2020, the highest number ever, according to the CDC.

Advocates said exchanges are more needed than ever as part of a one-stop shop set up by the state that offers not just syringes but HIV testing, immunizations and referrals for substance abuse and counseling.

An influx of new drug treatment centers and community and nonprofit addiction support also came to the area after the outbreak.

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The needle program had 350 participants in 2020 and cost $190,000 a year, all funded by grants with no local tax contribution.

While some complained about finding needles on the streets, clients return 92% of the free syringes they receive.

Exchanges are not meant by themselves to reduce drug abuse, supporters argued, but rather reduce life-threatening illnesses that stem from reusing contaminated needles.

Without it, a surge in HIV and other drug-related infections such as hepatitis C is nearly inevitable, Cooke and others argued.

Dr. William Cooke, a medical practitioner on the frontlines in Austin, Indiana during, and since, the HIV outbreak in 2015, listens in on a hearing where Scott County commissioners consider disbanding the syringe services program that offers clean needles intravenous drug users. May 5, 2021
Dr. William Cooke, a medical practitioner on the frontlines in Austin, Indiana during, and since, the HIV outbreak in 2015, listens in on a hearing where Scott County commissioners consider disbanding the syringe services program that offers clean needles intravenous drug users. May 5, 2021

That’s what happened in West Virginia, where access to needle exchanges has been curtailed in recent years, prompting HIV rates to rise.

The CDC deemed 220 U.S. counties vulnerable to similar outbreaks because of overdose death rates, the volume of prescription opioid sales and other statistics tied to injecting drugs.

Yet a Kaiser Health News analysis shows fewer than a third of those counties have working syringe exchanges.

While Scott County's 2015 outbreak was fueled by Opana, then the injected drug of choice, that has faded as fentanyl-laced heroin and meth have become most popular.

In addition, county doctors still write opioid prescriptions at a rate higher than the state average, state health officials said.

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Jones said he worries county-supplied needles could be involved in overdose deaths, which Julian echoed, saying one research paper he read had suggested a connection. The health department said health-privacy restrictions mean that is not tracked.

Julian argued it wasn’t certain that the exchange, rather than public awareness, led to a sharp drop in new HIV cases. Jones also said he doubted state figures on the numbers of reported HIV cases.

While they argued all the other aspects of drug treatment would remain in place, exchange officials said many access them only because they get needles – and likely wouldn't otherwise.

And while people who use intravenous drugs can order syringes online, one man in recovery said many would simply "pick one up off the street, use it."

Only a few opponents of the program turned out for the meeting, but declined to give their names or outline their opposition to a reporter.

Supporters in the area’s drug treatment community – who filled the meeting room – said the move was a dispiriting rollback after hard-won efforts to turn around the health fallout of the area’s addiction crisis.

The local health director said he fears for the county’s health. Scott County has the most drug users with HIV in the state, state health officials said Wednesday night.

One health official argued private groups might come to the county and hand out needles, since that is legal.

Commissioners decided the program would end by Jan. 1. They said they wanted to consider a community center and additional mental health resources for residents, and said the end date could be delayed if more time was needed.

“We need to come up with something different than, ‘here’s a needle,’” Jones said.

Cooke welcomed new resources but said a community center is not a substitute for a needle exchange in reducing rates of disease. He said there will be continued efforts to change the commission’s minds ahead of the Jan. 1 closure date.

"Scott County experienced the worst drug-related HIV outbreaks in U.S. history in 2015 because elected officials ignored medical and public health experts," Cooke said. "Without access to sterile syringes, cases of HIV, hepatitis C, endocarditis and other infections will begin to rise again – reversing our six years of successes."

Follow Chris Kenning on Twitter @chris_kenning

This article originally appeared on Louisville Courier Journal: Indiana needle exchange that quelled massive HIV outbreak voted down