When Injecting Drug Use Drives HIV Rates

Alarming Rise in U.S. Echoes Trends in Russia, Central Asia

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Photo Credit: Spencer Platt/Getty Images

On March 27, 2015, Governor Mike Pence of Indiana declared a state of emergency after public health officials there confirmed a total of 81 new cases of HIV among injecting drug users (IDUs) in Scott County. Most of the cases were isolated in and around the town of Austin (pop. 4,295), where infections were primarily caused by the sharing of needles while injecting the opioid painkiller, Opana (oxymorphone).

By early April, the number of confirmed cases had risen to well over 100.

Upon release of the news, Governor Pence instated emergency health measures, including a temporary needle exchange program which conservative politicians in the state had long resisted. The 30-day program, deemed insufficient by activists, provides users in Scott County with harm reduction counseling and a week's supply of free syringes. In addition, on-site registration to the state's new Health in Indiana (HIP) plan affords low-income residents immediate healthcare coverage.

Efforts to pass permanent, state-wide needle exchange legislation have long been thwarted, with Pence himself declaring his vehement opposition to the measure.

While the outbreak has rightly drawn world attention to both Indiana and the small, impoverished town bordering northern Kentucky—with many declaring the incident "unprecedented"—others warn that it shouldn't necessarily be seen as being either isolated or unique.

 

From Indiana to Russia: Injecting Drug Use as the Driver of Infection

While sex is often considered to be the primary mode of HIV transmission worldwide, epidemiological research has shown that this is not always the case. In recent years, global health officials have seen an alarming spike in new HIV infections in Central Asia, Eastern Europe and Russia, with increases of more than 250% since 2001.

Within many of these regions, injecting drug use is today considered the primary mode of HIV transmission—including Estonia where 50% of all new infections are among IDUs and St. Petersburg, Russia where IDUs represent 59% of all HIV infections. All told, an astounding 40% of all new infections within the region are due, directly or indirectly, to the sharing of HIV-contaminated needles.

While the similarities between Austin, Indiana and Central Asia may not seem all that apparent at first, the drivers for infections are almost textbook in their expression. Deeply entrenched poverty, a lack of preventative services, and a known drug trafficking corridor can often come together, as they did in Austin, to create the "perfect storm" for an outbreak.

In Indiana, for example, Highway 65, which slices directly through Austin, is well known as a major drug route between the cities of Indianapolis and Louisville, Kentucky. High levels of poverty in Austin (37%) are known to be linked to increased rates of injecting drug use, with established social networks fueling the shared consumption of drugs such as Opana (ranked as among the top three abused prescription drugs in the U.S. today).

With only one doctor in town and the deep-seeded rejection of needle exchange programs driving the abuse even further underground, most agree that there was little to actually prevent an outbreak from occurring.

By comparison, the rise in IDU infections in Central Asia, Eastern Europe and Russia can be traced back to the mid-1990s following the break-up of the Soviet Union. The socioeconomic collapse that ensued provided drug traffickers the opportunity to increase heroin trade from Afghanistan, the world's largest opium producer, to the rest of the region. With little in the way of government response and next to no prevention and/or addiction treatment services, the epidemic among IDUs was allowed to grow to what it is today: over a million HIV infections in these three regions alone.

Injecting Drug Use Trends in the U.S.

Similar trends are being seen not only in North Africa and the Middle East, but in pockets throughout North America. In fact, in 2007, injecting drug use was reported to be the third most frequently reported risk factor in the U.S, after male-to-male sexual contact and high-risk heterosexual contact.

Since the early- to mid-1990s, efforts have made to increase legal, confidential needle exchange programs to better reduce the incidence of HIV and other communicable diseases among IDUs. Today, there are over 200 such programs in the U.S., distributing over 36 million syringes annually.

In New York State, public health officials reported that the HIV incidence among IDUs had dropped from 52% in 1992, when the state's needle exchange program was first established, to 3% by 2012. Increased use of antiretroviral therapy among IDUs is also seen to contribute to the lower rates.

Sources:

Indiana State Department of Health. "State, Local and Federal Health Officials Respond to HIV Outbreak." Indiana, Indianapolis; press release issued March 27, 2015.

United Nations Programme on HIV/AIDS (UNAIDS). "2012 UNAIDS World AIDS Day Report." Geneva, Switzerland; issued December 1, 2012.

Strathdee, S. and Stockman, J. "Epidemiology of HIV Among Injecting and Non-Injecting Drug Users: Current Trends and Implications for Interventions." Current HIV/AIDS Report. May 2010; 7(2):99-106.

Green, T.; Martin, E.; Bowman, S.; et al. "Life After the Ban: An Assessment of US Syringe Exchange." American Journal of Public Health. May 2012; 102(5):e9-e16.

New York Department of Health AIDS Institute. "Comprehensive Harm Reduction Reverse the Trend in New HIV Infections." Albany, New York; issued March 4, 2014.

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