‘No justification:’ Senate bill will end syringe services in WV, experts say

Senate Bill 334, passed by the Senate on March 9, establishes a licensing program within the state Department of Health and Human Resources for harm reduction programs operating syringe exchange programs.

All new and existing programs will need to apply to the Office for Health Facility Licensure and Certification. Programs will need to have the support of the county commission and, as amended on the floor Tuesday, the county sheriff. They will be required to pay an application fee and have a 30-day comment period.

Programs will be required to offer a full array of harm reduction services, such as HIV testing — not just syringe exchanges. Any current program offering only syringe services must cease and desist operation six months after passage of the bill.

Exchanges will have to operate toward a 1-to-1 exchange rate and be able to track syringes. A person must be designated to track and collect any needle litter. Participants must have a valid West Virginia I.D. and cannot receive needles for another person.

Licenses will need to be renewed yearly, and there are criminal punishments for failure to comply with the license requirements.

Kilkenny said three key things make the bill unfeasible: the criminal penalties, the required tracking of syringes and, first and foremost, it’s a model proven not to work.

“It’s not a recommended model,” he said. “It’s a model that’s been invented outside of expertise. It is a model that’s been tested, and it’s a model that will fail to prevent and control the spread of communicable disease. The health department is mandated by law to prevent and control the spread of disease. A model that will not achieve that should not be used.”

The science

The Cabell-Huntington Health Department started its syringe exchange program in 2015. The first in the state, it was added to the department’s harm reduction program in response to growing HIV and hepatitis C cases as a result of the booming opioid epidemic. The city still had relatively low numbers of the communicable diseases, but Kilkenny and others knew it wouldn’t be long before case numbers grew if nothing was done.

The program operated for a few years with support of the police department and the community. Reports of hepatitis C dropped 60% from 2016 to 2017.

In 2018, after a Huntington Police officer was stuck with a needle while searching a suspect, the police department approached the health department about changing some protocols in the exchange program. Then-police chief Hank Dial said crime had increased since the program started and said there was an increase in needle litter.

Dial and Kilkenny worked together to reach a compromise for the program, implementing many of the things listed in SB 334, such as a goal of 1-to-1 exchange rate and requiring a Cabell County I.D.

That year, the health department had a syringe return rate of 100%.

“[Sen. Eric] Tarr seems to want to discount that as it doesn’t fit his narrative,” Kilkenny said.

But, as Kilkenny had feared from the start, the changes also led to an outbreak of HIV. In fact, Cabell County had the second-highest increase of the disease in the intravenous drug-using population, just behind Scott County, Indiana.

The outbreak was reported in March 2019, with the first cases identified at the end of 2018. From January 2018 to January 2019, 28 cases of HIV were diagnosed in Cabell County. Most were Cabell County residents who were intravenous drug users.

This was an uptick from an average of eight cases over five years prior to 2018.

As of Dec. 15, 2020, Cabell County had 113 HIV cases reported since 2018.

The U.S. Centers for Disease Control and Prevention worked with the health department to combat the outbreak, and subsequently published several pieces of research on the event.

The research found Cabell County could be a model for expanding HIV pre-exposure prophylaxis (PrEP), the HIV preventative drug, in drug-injecting populations during and before an outbreak. There was research on collecting data on individuals who inject drugs.

Most importantly, officials agree, the county was included in research about the once-again growing HIV epidemic. One study specifically on Cabell found the 2018 restrictions were a contributing factor in the outbreak.

In a Journal of Infectious Disease published paper studying the worst outbreaks in the country since 2016, Cabell’s outbreak was studied.

That report concluded the “tipping point” for outbreaks varies and could be related to changes to things such as access to syringe exchange programs.

On the floor last Tuesday, Tarr, R-Putnam, said the research into syringe exchanges was “tunnel visioned.” He said of course restrictions to programs cause spikes in HIV because there is more testing being done. But that was not the case for Huntington’s program.

Kilkenny said to discount the research of the CDC and others is a serious error of judgment.

“When we talk about concepts like, ‘Maybe we should see how this works,’ we have already done that,” he said. “We know that inadequate surveillance is a factor in HIV outbreaks. We know that restricting syringe service programs contributes to HIV outbreaks, especially when the outbreak is established. We know that with reasonable certainty restricting access to sterile syringes in 2018 contributed to the expansion of the HIV outbreak. Our only defense for that strategy is we did not know we had an outbreak when we restricted services.

“Today, we know that we have ongoing transmission at about half the rate during the outbreak. The contributing factor for that is reduction in services related to the pandemic. Some of those are beyond our control, but to know that there is this ongoing transmission in Cabell County and to know there is evidence of another outbreak of even greater concern in Kanawha County — to purposely restrict harm reduction service with that knowledge is irresponsible. There is no justification.”

The cost

An HIV diagnosis is not the death sentence it once was, thanks to medication that can reduce a person’s viral load to the point they are undetectable for the virus and unable to transmit it. But those medications come at a cost. The CDC estimates lifetime cost of treating one person living with HIV is more than $450,000.

HIV is also not the only concern for those injecting drugs. Other issues are viral hepatitis and infections like endocarditis. The CDC estimates hospitalizations in the U.S. for substance use-related infections cost over $700 million each year.

“These alarming statistics are from persons who inject drugs not having regular visits to health care providers,” said Danny Scalise, executive director of the West Virginia State Medical Association, member of the board of Thomas Health System and the Kanawha-Charleston Board of Health, in an op-ed sent to The Herald-Dispatch about SB 334. “Too often these patients are diagnosed with HIV in the emergency room when it is much too late. All of this creates a rapid transmission that makes the epidemiology of this disease difficult to control in the absence of robust harm reduction programs.”

At 6 cents a syringe, syringe exchange programs are a good return on investment, he said.

“We need to find a way to practice sound public health in West Virginia that is led by public health experts, not politicians,” Scalise said. “Harm reduction programs do exactly what their title says — they reduce harm. Our public health system was taxed before COVID-19 hit, yet bills like SB 334 wish to tax it further. It puts more hurdles in place and takes health care out of the hands of experts and makes it a political issue.”

In separate statements, both Mountain Health Network in Huntington and Charleston Area Medical Center, Cabin Creek Health Systems, Family Care and Thomas System said they support responsible harm reduction, including syringe exchanges.

In the statement, Mike Mullins, president and CEO of Mountain Health Network, said the hospital system has partnered with Marshall University and the Cabell-Huntington Health Department to provide access to support and comprehensive programming for vulnerable populations. These programs include the harm reduction program, which he points out has community support.

“Harm reduction programs serve as critical contact points where people with substance use disorder can enter drug treatment programs and access health and safety services,” Mullins said. “According to the CDC, ‘Research shows new users of syringe services programs are five times more likely to stop using drugs than those who don’t.’ We support our community and the Cabell-Huntington Health Department’s position on the harm reduction program and access to comprehensive care and treatment.”

The hope

Since Huntington’s exchange was started in 2016, more have cropped up around the state. According to DHHR, there are 15 certified harm reduction programs.

Programs do not need to be certified by DHHR to operate, but they do need it to receive any state funding.

The Wyoming County Health Department started its program in 2018. Now-Sen. David Stover, R-Wyoming, was on the board of health at the time and said when it was first proposed, he was against it. Like others, he believed it was enabling.

Today, though, while he still believes it may enable some, Stover said he realizes there are greater benefits to programs that outweigh any negatives.

“One, if you are coming to the program, you know that at least someone cares about you,” Stover said. “And maybe there is infrastructure to get you off of drugs.”

Stover, one of two Republicans to vote against SB 334 along with Upshur County Sen. Bill Hamilton, said the other thing that trumps the possible negatives is the disease prevention.

He said he believes Wyoming County was spared an outbreak because of the program.

Stover said he doesn’t think SB 334 will shutter the Wyoming County Health Department’s exchange, but doctors he knows and trusts have reached out about their concerns about the bill.

“They said, ‘Do not let this program go away,’” he said. “’We will face a horrible disaster in addition to the drug problem if you do.’ These are students I taught and are now on the front lines treating the problems. They believe this program saves lives.”

In Charleston, the Kanawha-Charleston Health Department no longer operates a syringe exchange after the program was shuttered in 2018 following backlash from the city government. Health Right still operates in the city’s East End, and Dr. Sherri Young, health officer at the health department, said the health department would like to see that expanded to the West Side, but that is up in the air with this legislation.

“This bill as it stands will make administration of harm reduction programs onerous and prevent the help many West Virginians need that are struggling with addiction,” Scalise said. “Further, there will be unnecessary state funds spent on investigating and treatment of preventable diseases like HIV, HBV or HCV. Senate Bill 334 will be the most stringent regulation of this necessary public health intervention in the nation. I hope the House of Delegates doesn’t even take it up.”

SB 334 has been double-referenced to the House Health and Human Resources Committee, then the Judiciary Committee.