As a Centers for Disease Control and Prevention team landed in Kanawha County last week to bolster the region’s response to the HIV crisis, doctors across West Virginia and beyond watched and worried.
The options are limited, and so is time. While the Kanawha-Charleston Health Department and other local health agencies work to increase testing, some providers wonder what real tools are on the table for prevention.
“I don’t know how you respond to an HIV outbreak among people who inject drugs without expanding access to clean syringes” said Dr. Robin Pollini, an associate professor at the West Virginia University School of Medicine. “Cabell County did that. It controlled the outbreak. In Scott County, Indiana, that’s how they quelled it. Every response I’ve seen to outbreaks of this nature relies on expanding syringe services.”
A recently passed state law and a Charleston ordinance severely limit options for those programs.
The CDC has called Kanawha County’s HIV crisis “the most concerning” in the country. Twenty-eight of the state’s 55 counties are among the 220 most vulnerable in the nation for rapid spread of HIV and other bloodborne diseases among people who use drugs, according to the CDC.
Kanawha County, the epicenter of the current crisis, is ranked on that list. Forty-four new HIV cases were recorded last year, 39 tied to intravenous drug use, according to the state. Health officials say that was a year with record-low testing with resources sapped by pandemic response.
Before 2018, the county recorded an average of 14 new HIV cases a year, fewer than four tied to IV drug use. The number of cases swelled to 29 in 2019, with 15 involving IV drug use. So far in 2021, 16 new cases of HIV have been detected in Kanawha County, all but four involving injected drugs.
“That’s alarming. It’s a really significant increase over a relatively short amount of time,” said Dr. Brandon Marshall, an associate professor of epidemiology and a researcher at Brown University’s School of Public Health.
Marshall studies the effect of syringe service programs on disease spread in rural areas. He’s watched situations similar to the one in Charleston unfold.
“It’s most useful to be proactive, but if syringe service programs are off the table, there are other tools we can rely on that we’d call more biomedical interventions,” Marshall said. “I would hope to see a greatly expanded testing effort, contact tracing and treatment programs for people who are positive.”
The testing piece is already underway, but as a CDC team works to better understand the outbreak and suggest ways to tailor response, some observers worry the effort will come too late.
A study by Marshall and others in Clinical Infectious Diseases, a peer reviewed medical journal, shows that if proactive interventions — specifically syringe programs — are available before diseases start to spread, incident rates for infections can drop by as much as 90% among at-risk populations. Separate modeling in the same journal suggests that shutting down syringe programs in places that have seen high rates of bloodborne disease transmission — like HIV, hepatitis and endocarditis — could lead to more outbreaks.
Last week, local leaders in Scott County, Indiana, voted to close a syringe service program there despite its success in tamping down a 2015 outbreak. Marshall said this is evidence of how widespread the challenges are in operating sustainable harm reduction programs that include syringe services.
“We are seeing this everywhere, and a lot of the time it’s due to misperceptions of what syringe programs do and don’t do,” Marshall said. “We need to be clear about what they don’t do: they reduce crime, decrease injection litter and much more. We need to address these misconceptions. At the end of the day, this is an issue that carries a ton of stigma. That’s the real elephant in the room, often.”
The struggle is greater in West Virginia’s Southern Coalfields, where limited resources make consistent HIV testing difficult and expanded testing nearly impossible. That means HIV could be spreading undetected.
“I haven’t diagnosed anyone with HIV in the six, almost seven years, I’ve practiced here, but I know it’s coming and I expect it to happen soon. It’s happening now, we just aren’t seeing it,” said Dr. Joanna Bailey, who works at Tug River Health Association, a clinic with locations in Wyoming and McDowell counties, rated by the CDC among the country’s most vulnerable. “I test all of my patients for HIV at least once, and I do it usually with their initial visits. I wouldn’t be surprised to have one come up positive on a new patient who is actively using, or someone who moved to the area.”
HIV, or human immunodeficiency virus, attacks the body’s immune system and can lead to AIDS. There is no cure. AIDS-related illnesses killed roughly 690,000 people worldwide last year. Some 1.2 million people in the U.S. are living with HIV, according to the CDC. HIV can be controlled, but testing and early detection are critical.
Southern West Virginia largely relies on a loose system of health clinics to treat people in the region. The clinics are often under-resourced, and the needs outweigh the services — or expertise — available.
“We don’t have any doctors in Wyoming or McDowell counties treating HIV, and very few in Southern West Virginia, period, who treat HIV,” Bailey said.
Doctors and nurse practitioners are more than capable of treating HIV, Bailey said, but they need resources and training. On top of that, there has to be a system to help keep vulnerable people in care once they’re connected to it.
“Having a doctor who knows how to treat it is only part of the solution,” Bailey said. “We need case managers who know how to prescribe the medications, and keep people involved in their own treatment.”
That’s not as simple as it might sound.
“They might not have a car, and we don’t have a real public transportation system here. As a doctor knowing there is more that needs to be done, it’s frustrating sometimes to know that you’re out of your comfort zone as far as treating someone, but you don’t have any other choices,” Bailey said. “It’s difficult to know that if you tell them there’s not much you can do, and they don’t have transportation to Beckley or Princeton or Virginia, then a lot of people probably aren’t going to get care.”
That opens the possibility of greater disease spread. Once an outbreak starts, it’s difficult to stop.
“If you have outbreaks down here, where people can’t get to care, it could look like outbreaks in Africa, in the developing world, where people can’t get to care,” Bailey said. “That sounds scary, but it’s true.”
While a majority of documented spread so far is among people who inject drugs in more populated areas, that’s also where testing is targeted.
“No one operates in a vacuum,” Marshall said. “It’s not an option, from a public health point of view, to ignore the problem and hope it will go away. We know that doesn’t work.”