In late January, Indiana state health officials began investigating an HIV outbreak among syringe-sharing members of a rural community in Scott County. The outbreak was traced primarily to IV drug use of Opana (oxymorphone, Endo Pharmaceuticals). According to the investigators, injection drug use in this community of 4,200 people is a “multigenerational activity, with as many as three generations of a family and multiple community members injecting together.”

To date, there have been 181 cases of HIV associated with the outbreak, Patel said. Researchers estimate there are more than 500 syringe-sharing partners in Scott County.

On March 26, Indiana Gov. Mike Pence declared a public health disaster emergency in Scott County, which allowed the temporary provision of a needle exchange program (NEP). Prior to the outbreak, NEPs were illegal in the state.

Patel and colleagues assessed the impact of the NEP in Scott County, comparing injection-related risk behaviors reported over time by 148 (62%) of its clients. Each participant made at least two visits, where they received sterile syringes, a wound kit, harm reduction education and referrals to health and substance use treatment services, and completed surveys about current risk behaviors.

The proportion of injection drug users (IDUs) who shared syringes decreased from 18% at the first recorded visit to 5% at the last visit (P < .001). The median frequency of IDUs reusing the same syringe also significantly decreased — from two times at the first visit to one time at the last visit (P < .001) — as did the median number of syringes returned (0 to 57; P < .001) and new syringes distributed (35 to 63; P < .001). The researchers also saw a decrease in the percentage of IDUs sharing syringes to divide drugs (19% to 4%; P < .01) and the sharing other injection equipment (24% to 5%; P< .001).

However, results suggest the frequency of reported injections per day increased over time (5 to 9; P < .001).

“It is noteworthy that some clients returned syringes after their first visit, indicating that information about the program reached the community, and clients may have learned about the opportunity to bring new syringes for disposal in advance of enrolling in the program,” Patel said.

NEPs across the country and worldwide have met with similar success. For example, Washington, D.C., saw a 70% drop in newly diagnosed HIV cases in just 2 years. New Haven, Connecticut; New York; San Francisco; Amsterdam; Vancouver; Australia; France; and Taiwan also have benefited from NEPs.

Some health experts have advocated for the permanent implementation of the NEP program in Indiana, arguing that HIV, HCV and addiction “will continue to challenge this community and others like it for decades unless a very aggressive, multipronged public health prevention strategy is implemented.”

Patel recommended that the NEP should be integrated with other services “as part of a comprehensive approach to HIV prevention.” – by John Schoen

References:

Conrad C, et al. MMWR. 2015;64:1-2.

Patel MR, et al. Abstract 638a. Presented at: IDWeek; Oct. 7-11, 2015; San Diego.

Ruiz MS, et al. AIDS Behav. 2015;doi:10.1007/s10461-015-1143-6.

Strathdee SA, et al. N Engl J Med. 2015;doi:10.1056/NEJMp1507252.

Disclosure: The researchers report no relevant financial disclosures.

The positive outcomes in terms of reduction in risk behaviors with needle exchange is something we have known for a long time, and the success of these programs as one of the critical tools in prevention of HIV transmission is really something that should become part of the permanent fabric our prevention efforts, not something that is offered during an emergency and then taken away. Whether the program becomes permanent in Indiana is greatly dependent on the political climate. The biomedical evidence is extremely strong — that these programs are an important tool in prevention of transmission for any bloodborne pathogen. The fact that we do not have more integrated syringe exchange programs as part of our public health approach to prevention of HIV transmission and hepatitis C transmission is really a political issue, not a biomedical one.