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Addiction Fuels HIV and Hepatitis C Outbreak in Indiana, across Rural South

When news of the rural Indiana HIV outbreak broke in March, experts warned it may only be the tip of the iceberg.

Boy was it ever.

As of late March, 81 people in the tiny Indiana county of Scott had been infected with HIV, most of them opiate addicts who shared needles to inject the drug Opana. As of June 10, the number had ballooned to 169, according to the state’s health department.

The good news is, the number of confirmed new cases finally appears to be slowing down. The bad news is, Indiana’s HIV nightmare likely is being replicated in other places.

A report issued last month by the U.S. Centers for Disease Control and Prevention (CDC) showed that infection rates of Hepatitis C tripled between 2006 and 2012 among people under the age of 30 in four Appalachian states. Out of almost 1,400 cases reported, three-fourths of them were injection drug users under the age of 30 living in Virginia, West Virginia, Kentucky and Tennessee.

While the report focused on Hepatitis C, it is likely at least some of them also are infected with HIV. In an Associated Press story datelined Hazard, Ky., a town made famous by sexy 1970s outlaws Bo and Luke Duke of the hit television series “The Dukes of Hazzard,” a public health official warned, “One person could be the Typhoid Mary of HIV.”

HIV, Hepatitis C Travel Together on Injector Needles

That official, Dr. Jennifer Havens, an epidemiologist at the University of Kentucky’s Center on Drug and Alcohol Research, explained how a Hepatitis C outbreak can be a precursor to an HIV outbreak. That’s because both diseases are highly transmittable through injection drug use and unprotected sex.

The reverse also is true. HIV outbreaks can signal a coming Hepatitis C outbreak, a scenario already unfolding in Indiana.

What’s making these outbreaks a near doomsday-like scenario for these rural Southern communities is the fact they were not prepared for them. That’s true even though a report issued one year ago by the National Rural Health Association sounded an alarm that this day was coming.

“HIV is of particular concern to rural America because lack of resources can lead to gaps in detection of the infection and in treatment maintenance,” the report stated. ”Further, traditional norms and conservative values in rural areas often translate into high prevalence of HIV-related stigma and low rates of disclosure resulting in reluctance to come forward for HIV screening and treatment among rural individuals.”

Cost of Treating Indiana’s Newly Infected: $64 Million   

Conservative states such as Indiana and Kentucky have been fairly quick to set up needle exchange programs in the face of the growing epidemic. However, Indiana’s legislation only allows the exchanges to last for one year, and Kentucky’s leaves the decision up to individual counties. Virginia, West Virginia and Tennessee do not have needle exchanges.

When it comes to needle exchanges for preventing HIV and Hepatitis C, a paradox exists. The federal government refuses to fund needle exchanges, which have proven over decades to be remarkably effective at stopping HIV transmission. However, many of the newly infected in these poor, rural areas rely on state or federally funded health programs to get care. The Affordable Care Act now mandates health coverage for everyone. While Indiana, West Virginia and Kentucky have expanded their Medicaid programs, Virginia and Tennessee have not.

Using figures provided by the CDC, the lifetime cost of treating someone with HIV is $379,668. That’s going to add up to more than $64 million to treat just those newly infected in Indiana alone.

National Rural Health Association: We Told You So

“It is heartbreaking that a preventable disease like HIV has to become epidemic before it highlights what the National Rural Health Association has been saying for decades: Investment in both the economic and public health of rural communities is essential,” wrote Michael Meit and Brock Slabach in the current edition of Rural Roads magazine, the magazine of the National Rural Health Association. Meit is a board member of the organization; Slabach is senior vice president of membership services.

Instead, they argue, the health infrastructure in such communities have faced cuts in funding. Among the recommendations made in last year’s policy brief:

  • Identify the needs and available resources of each rural community to plan an effective strategy for the community in focus since strategies that address HIV in rural areas are not a one-size-fits-all solution.
  • Distribute educational materials to key places such as beauty shops, barber shops, bowling allies, restaurants, grain elevators, community centers, etc. to help raise HIV/AIDS awareness in rural communities.
  • Enhance efforts to screen for HIV in the rural South by establishing and maintaining screening facilities to encourage individuals who would be otherwise reluctant to or would not be able to travel to urban sites for HIV screening.
  • Train rural health care workforce including physicians on HIV specific issues and their management as well as cultural competency, especially for those who work with multicultural or multiracial patient populations.
  • Increase the number of Ryan White medical providers in rural counties or offer incentives for HIV specialists who deliver their services to rural communities.

“Yes, the chickens have come home to roost due to years of neglect,” Meit and Slabach wrote in Rural Roads. “Let’s use this tragedy to change policy and ensure this is the last epidemic we will have to endure.”