A cluster of HIV cases in a rural West Virginia county represents what public health officials have long feared amid the nationwide opioid epidemic.
Cabell County has reported 74 cases since January 2018, primarily among drug users sharing contaminated needles. The recent surge in infections represents the convergence of two major health epidemics, HIV and opioids, the Trump administration has pledged to fight.
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The fact that the uptick is happening in a rural county with an unusually robust public health system — which already does much of what the Trump administration wants to replicate nationwide as it seeks to eradicate HIV transmission within a decade — may be fortuitous for officials trying to prevent a broader outbreak. But the fact that the cases have occurred despite the county’s surveillance and prevention is also worrisome.
“The ground is fertile,” said Judith Feinberg, a professor of behavioral medicine and infectious diseases at West Virginia University. “This is the nightmare everyone is worried about.”
The latest swell in HIV cases appears to be among the largest since an outbreak in Indiana’s Scott County four years ago, when more than 200 people were infected largely through injecting a powerful prescription opioid using dirty needles. Vice President Mike Pence, then governor of Indiana, was widely criticized for dragging his feet before allowing the distribution of sterile needles to prevent the spread of HIV and hepatitis C among intravenous drug users. Surgeon General Jerome Adams, who at the time was Pence’s top health aide, was credited with bringing the outbreak under control.
West Virginia health experts said Cabell County has been ahead of others in the state on HIV prevention. The same year as the Indiana outbreak, Cabell became the first West Virginia county to fund a needle exchange, considered among the most effective ways to prevent the spread of bloodborne infectious diseases, though the practice is still controversial.
Since then, Cabell has taken other steps to prevent the spread of HIV, including testing, drug treatment programs and expanded access to treatment that significantly reduces the likelihood of HIV infection if taken every day. This treatment, known as pre-exposure prophylaxis (PrEP), is a centerpiece of efforts to stamp out new infections.
About of half Cabell’s at-risk population has been tested for HIV through a concentrated outreach effort, estimates Michael Kilkenny, physician director at Cabell’s health department. Public health experts credit Cabell’s response to the uptick in HIV infections, suggesting the spread of HIV could have otherwise been worse.
They also praised the response of federal officials who have been advising the county. Since the beginning of the year, the CDC has been working with the state health department to expand infectious disease testing in Cabell, linking infected people to care and analyzing data about new cases.
Cabell County’s efforts are also being aided by Marshall University, located in its largest city of Huntington. The medical school has helped expand access to medication-assisted treatment, considered the gold standard for fighting opioid addiction, and it is providing HIV testing in the emergency department and treating HIV-positive patients.
Still, Kilkenny said he can’t explain the jump in HIV infections given the county’s prevention efforts.
“I have no answer for that,” he said. “At night, it’s what you ask when you are screaming at the sky.”
The surge in HIV cases comes as the Trump administration deploys a plan to stop the spread of the virus by 2030. The administration is focusing efforts on 48 counties with the highest infection rates and seven states — a group that doesn’t include Cabell County or any place in West Virginia — as well as Washington, D.C., and San Juan, Puerto Rico.
The federal government knows other problem areas could emerge, though. The CDC in 2016 identified 220 counties at high risk because of the prevalence of intravenous drug use. About half of West Virginia’s 55 counties, including Cabell, were on that list.
“We’re recognizing every day just how big a challenge this is,” said John Wiesman, co-chair the Presidential Advisory Council on HIV/AIDS, who pointed out the president’s plan calls for responding quickly to new, unforeseen outbreaks.
“There are a lot of things making this a really difficult task, and one of those is the opioid epidemic,” said Wiesman, who’s also the health secretary of Washington state. “We’ve got all of these overlapping issues coming together, a lot of which are social factors, which is why it is so important to have both a medical approach and a larger health and human services approach to this epidemic.”
Many West Virginia towns, hollowed out by the loss of coal mining jobs, don’t have the resources to address the social factors such as homelessness and injection drug use that can spur an outbreak, and they “would be in trouble” if one occurred, said Feinberg of WVU. She also said there’s a need for primary care providers familiar with diagnosing and treating HIV. A lack of providers also means less screening.
“It’s a manpower issue and the logistics of going out into the community,” said Greg Puckett, a county commissioner in Mercer, an Appalachian county of about 60,000 people.
Experts fear a much larger problem if HIV infections tied to opioid use begin spreading elsewhere in the state, especially rural parts.
“I don’t think this would have been contained with any degree of success in any other county in the state,” said Jay Adams, an HIV care coordinator at the federal Ryan White HIV/AIDS program.
Other parts of the state have also taken a more combative approach to needle exchange. The exchanges have historically been viewed more skeptically by Republicans, who worry the programs amount to an endorsement of illegal drugs, though research shows the exchanges don’t increase drug use.
West Virginia’s Logan County, about 70 miles south of Cabell, adopted a resolution last month opposing the creation of any needle exchange programs and prohibiting the use of county funds to create one.
In the state capital of Charleston, only an hour’s drive from Cabell, the county-run program was shuttered in 2018 following opposition from then-Mayor Danny Jones, who claimed it caused crime in the city to skyrocket. Charleston has not seen a significant increase in HIV infections since then, and an independent clinic, West Virginia Health Right, continues to operate a smaller needle exchange in the city.
Attitudes are changing in some red states, though. Georgia, which has the highest rate of new HIV diagnoses in the country, and Idaho authorized needle exchanges this year.