Syringe exchange in southern Indiana to respond to an increase in HIV cases: better late than never?

Needle exchanges don’t put more syringes on the streets. In this photo a clean syringes chart is shown at the Aids Center of Queens County needle exchange outreach center in New York in 2006. Shannon Stapleton/Reuters

The recent upsurge in HIV cases linked to injection drug use in southern Indiana has thrust the issue of syringe exchange programs (SEPs) into the headlines. While authorities are linking these cases of HIV infection directly to injecting drugs, it is unknown how many are caused by sexual activity with an infected drug user.

Nearly all states prohibit possession of syringes other than for medical need through their drug paraphernalia laws. Syringe access laws that require ID and proof of medical need to purchase them from pharmacies also exist in the majority of states, including Indiana. Federal funding of syringe exchange programs is banned as well.

To respond to the current outbreak, Indiana Governor Mike Pence signed a 30-day exception to the state’s restriction on needle exchange programs. The governor has extended the exception for another 30 days, as the state’s legislature considers legalizing needle exchanges in some areas. The Centers for Disease Control and Prevention as well as other federal and state personnel are working to contain the outbreak.

This upsurge in HIV cases in Indiana hasn’t exactly come out of nowhere. An increase in Hepatitis C cases (which can also be spread through re-used syringes) began nearly fifteen years ago in Scott County, so officials should not have been surprised that a corresponding rise in HIV cases would eventually follow.

Injection drug use and HIV

Injection drug use (IDU) is a well known risk factor for HIV, as well as Hepatitis B and C infections. The fact is that injection drug use accounts for about one-third of HIV infections in the country since the beginning of the epidemic.

Transmission of HIV occurs through an exchange of bodily fluids. In the case of injection drug use, transmission can occur not only by sharing needles, but by sharing any of the materials used to prepare and inject the drug, such as water or cotton used to filter the solution.

Women are particularly vulnerable, either from injecting drugs themselves, or from having unprotected sex with injection drug users, and women account for about twenty percent of new HIV infections yearly.

Why do people reuse syringes?

In most states, access to syringes is severely restricted. This forces injection drug users to reuse or borrow syringes.

These laws intending to prevent illegal injection drug use, while perhaps well-intentioned, do not prevent it. Drug users do not quit because they don’t have access to new syringes. Not having access to a clean glass doesn’t keep me from being thirsty. Glass or no, I will find a way to get a drink of water.

Being forced to re-use dirty syringes places not only the drug user at risk of greater harm, but the public as well.

Needle exchanges are important for HIV prevention. Used syringes are dropped into a container at a needle exchange in Barcelona in 2002. Gustau Nacarino/Reuters

In my twenty years of work in the HIV field, I have seen patients who borrowed family members’ insulin syringes, migrant workers who shared syringes used to inject liquid vitamins, hospital workers who recovered used syringes from the trash. These syringes are used repeatedly until the needle is too dull to pierce skin. One HIV-positive person places the entire needle-sharing network at risk.

For example, a 73-year-old grandmother was referred to our HIV clinic after her grandson, a 29-year-old addict, had infected her by using and returning her insulin syringes.

We saw groups of migrant workers who had shared needles to inject the liquid vitamins needed to withstand the hard labor, and who were all now HIV positive. We also saw diabetics who shared insulin syringes to save the expense of new ones. The substance being used doesn’t matter – only the syringe.

Injection drugs and poverty: a few hours of escape

Research also shows an association between poverty and both illegal drug use and HIV infection. The stresses of living in poverty are well known, and often people feel the only ways to relieve the stress include escaping through drug use.

In research conducted in 2011, at Indiana University-Purdue University Fort Wayne (IPFW), located in the center of northeast Indiana counties similar to Scott County, the epicenter of the latest outbreak, we interviewed fifty injection drug users about their drug use. Of the people we interviewed, only one was employed and the rest were living in impoverished situations. Some of the women survived by trading sex for drugs, others in the sample sold drugs – either illegal drugs or legal prescription medications.

They all agreed that getting high was one of the only times they felt good, and while they felt guilty about using drugs, they couldn’t give up those few hours of escape that the drugs gave them. Becoming addicted, they then couldn’t quit.

None of the people in our sample used drugs alone; they were accompanied by at least one other person, and everyone shared needles at least “several times.” Frequent unprotected sex was reported, and only one person reported knowing their HIV status.

Frequently, as the CDC has reported for Scott County, families use drugs together, making it a multigenerational issue. In this case some cases also involve pregnant women who, in a resource-poor area, may or may not have access to treatments that would prevent transmission to their unborn child.

That isn’t unusual. Many people with HIV don’t know about their positive status. According to the Centers for Disease Control and Prevention, about 14% of 1.2 million HIV positive persons in the US do not know they are HIV positive.

Syringe exchanges can also provide medical services and drug treatment information

Given the incidence of HIV infection in rural, impoverished areas, plus the transmission routes of shared injection syringes and unprotected sex, the situation in southern Indiana is not surprising, and a syringe exchange program (SEP) is a logical response. These programs have been around nearly as long as we have known how HIV is transmitted.

Syringe exchanges are about more than syringes. Kaytee Riek, CC BY-NC-SA

I worked with one such program. A typical SEP trades one sterile syringe for each used syringe. This approach does not put additional syringes on the street. Many programs also include bleach kits and instructions for properly cleaning syringes when clean ones are not available. They also provide condoms and information about safer sexual practices and includes the opportunity for HIV testing.

Research has consistently shown that SEPs do not increase drug use or the number of used syringes discarded in streets and playgrounds. Further, SEPs provide a point of contact for obtaining HIV testing, substance abuse counseling, screening for tuberculosis (TB), hepatitis B, hepatitis C, and other infections as well as referral for medical services.

When I handed out a sterile syringe, bleach kit, and condoms, I also included information about drug rehabilitation, jobs, housing, and my business card. More than once, I received phone calls months later from drug users I had contacted through the SEP who then wanted help with recovery.

Syringe exchanges should be the rule, not the exception

The response to the Scott County situation seems reasonable. However, given the predictability of this current outbreak based on the Hepatitis C increase beginning 15 years ago,the Scott County response comes late in the game.

Any HIV statistics are likely underestimates of the true numbers, and given the percentage of persons who are positive and do not know it, the incidence of known HIV cases in Scott and other Indiana counties is quite likely to increase.

Officials would have served the population better with preventative services in place. Governor Pence and the Indiana State Legislature would do well to put establishment of syringe exchange programs on a fast-track to-do list so there is a way to stem the tide of new HIV infections.