Last week, Governor Mike Pence of Indiana declared the state’s current HIV outbreak a public health emergency . As of March 27th, 2015, there was a total of 81 new positive HIV tests – most of which stem from Scott County. Out of those 81, 74 were confirmed and seven considered to be preliminary – and experts expect those numbers to rise [2,3]. Considered to be the worst in state history, this outbreak comes as a bit of a surprise, given Indiana’s declining HIV rates in recent years . In 2002, Indiana reported 463 cases of HIV, but only 205 in 2012 .
At the epicenter of the outbreak is Austin, a rural city of 4,200 residents, located seventy miles south of Indianapolis .
What happened in Scott County that led to HIV rates exploding so quickly? According to media outlets, it is the product of a deadly combination of factors – the nature of HIV transmission, drug addiction, poverty, and a weak local healthcare system.
HIV and IDUs
In the late 1990s, rates of opiate abuse rose in Austin including heroin, Oxycontin, and now, Opana . Opana, also known as Oxymorphone, is a prescription painkiller that can be ground up with water and injected intravenously [3,4]. Those who inject themselves are often categorized as Injection Drug Users (IDUs) and for Austin, users gather in “shooting galleries” – usually abandoned buildings – to use drugs like Opana [3, 5]. More often than not, they will also share or re-use needles amongst themselves, which is an effective means of transmitting HIV . While HIV may not be able to survive for long outside of the human body, it has been shown to survive inside a hermetically sealed syringe for up to 28 days .
However, not every injection will lead to infection – according to the National AIDS Manual, there are two risk factors that can determine whether transmission is successful. One factor is the viral load of HIV in the blood that is injected – higher levels indicate a higher probability, and lower levels having a lower probability . The second factor is the quantity of infected blood injected . Research has shown that HIV is ‘dose-related’ – that is, the higher the quantity of blood injected, the more likely seroconversion of HIV will happen .
The National and Global Scale
According to the World Health Organization (WHO), there are approximately 16 million IDUs worldwide, with about 3 million of them currently living with HIV . Additionally, ten percent of new HIV infections globally are caused by injection drug use. In some parts of the world such as Central Asia and Eastern Europe, injection drug use can be attributed to over 80% of all HIV cases . In the United States, IDUs also account for ten percent of new HIV infections and nearly half of those who tested positive did not previously know they were infected . An IDU’s lack of awareness as to their HIV status may contribute to needle sharing behavior.
The Poverty Factor
Exacerbating the situation is the city’s poverty. The median household income in Austin is estimated to be $33,000, which lies below Indiana’s overall median household income of $48,000 . There is also a striking 26% of the city living at the poverty level, with 19% of families living at the poverty line across Scott County . These figures are higher than the statewide estimate of 15.9% .
According to Austin’s chief of police, Donald Spicer, local poverty has contributed to increased drug use. In an article published by the Los Angeles Times about the outbreak, Spicer notes the city’s ‘lack of opportunity, too few jobs, few resources, and few things to do’ as some of Austin’s deep-rooted issues that need to be addressed .
The Doctor Is In
Scott County closed its remaining HIV testing clinic in early 2013 and Dr. William Cooke is Austin’s only doctor [3,7]. For him, this outbreak has not come as a surprise. In an interview with the Chicago Tribune, Dr. Cooke states, “We saw this coming a long time ago. There’s a lot of poverty and very few resources for the community. We’ve been asking for help for some time.”
While Dr. Cooke may be Austin’s only doctor – he says that the nearest hospital with the HIV testing capability and additional social services stands only five miles away . The problem? Most of Austin’s drug users also lack transportation to get to the services they need – including the necessary testing to prevent outbreaks like this one . Additionally, the average HIV patient that enters these clinics tends to be between the ages of 20-30 and often does not have insurance .
In response to the outbreak, collaborating agencies, including local officials, have opened pop-up HIV clinics across the county, including one in Dr. Cooke’s office . The Executive Order issued by the governor included a targeted, short-term, emergency needle exchange program – this is notable because needle exchange programs have been illegal in Indiana . On Tuesday, the Scott County Board of Health approved the emergency needle exchange program to combat the epidemic. It is outbreaks like this one in Austin that shine light on larger issues and finally get communities the help they need.