Only syringe exchange in Lincoln Trail health district is a point of pride for Nelson County, Bardstown newspaper says in editorial

This editorial appeared in The Kentucky Standard, Bardstown, on Oct. 25.

Nelson County should take pride in its syringe exchange.

That might sound strange, at first. After all, a community sets up an exchange when it has a problem with substance abuse.

But the truth of the matter is that Kentucky has a substance abuse problem throughout the state. It can be hard for an idyllic historical town such as Bardstown or as bucolic a county as Nelson to admit that such a modern problem as intravenous drug abuse is just under the surface.

But that is just what Nelson County did when it authorized the needle exchange with the Lincoln Trail Health Department, the only one in the eight-county region.

Photo illustration by The Kentucky Enquirer

Staff from the health department and the exchange visited Nelson County Fiscal Court recently to provide an update following its first annual report.

One number on that report had caught some attention — the return rate of syringes, which was only 36 percent. That means that for every almost three syringes given out, only one was exchanged. At first blush, that does not come off as good.

But, part of that reason is simple math, as Sara Jo Best, the department’s director, explained to the magistrates.

Only a little more than half of the 96 people who sought out services last year ever came back for a second visit. And the vast majority of substance abusers don’t show up the first time with used needles.

The simple fact is that collecting used syringes is not the primary mission of the exchange. Syringe exchanges are about controlling communicable diseases among a population that is highly susceptible to them. And protecting intravenous substance abusers against hepatitis, HIV and other diseases also shields the wider population, because these diseases are not only transmitted through needles. Part of preventing the spread is taking dirty needles off the streets and out of homes, but that is just one part, and arguably not the most important.

One of the biggest advantages of having a syringe exchange is the ability of public health workers to reach a population that can be hard to find.

And these substance abusers are some of the ones where there lies the most potential to make a difference.

“People who come to a syringe exchange program are fundamentally different than those who are not,” Kentucky Commissioner for Public Health Dr. Jeffrey Howard told The Standard recently. “If you are a substance abuser and you say, ‘I’m going to go to a syringe exchange program and get clean syringes,’ then you have acknowledged there’s something negative to what you’re doing and you’re going to take an action about that negative aspect. So in the psychology of that person, they are further along the addiction recovery pathway than someone who is not. We really need to take advantage of that.”

That’s why Howard said he wants to rebrand “syringe exchanges” into “harm reduction” centers, where substance abusers are linked to services such as testing and health screening and addiction recovery programs.

Best told Fiscal Court that is the approach the local exchange is looking to take. She acknowledged they had identified needed areas for improvement, and had already made some changes. One was finding a disease screening that returned faster results. In its first year, 34 percent of clients were tested for Hep C, but staff hope the faster results will improve that rate.

The number of participants could also improve, especially on the returns. Part of that is building trust with the participants, and some of that will involve time. It also means outreach, as Best said, so that those who need the services know where to find them.

Syringe exchanges in this state are new. While exchanges have been around in more densely populated areas for many years, operating one in a smaller and more rural area brings a host of new issues as well as insights.

But too often, fear of failure or the unknown stops organizations or agencies from trying something new. Those fears could be partly to blame for surrounding counties’ refusal to start their own. But if they think turning a blind eye will make the problem go away, they are wrong.

At least here in Nelson, we have acknowledged the problem, and after a year we understand it better. That goes a long way toward dealing with it.

Ky. making great strides in treating patients with hepatitis C, with harm-reduction programs and fewer restrictions on treatment

By Melissa Patrick
Kentucky Health News

Eliminating hepatitis C in Kentucky and the rest of the nation will require universal screening and non-restricted access to treatment, and because new cases of the disease are largely driven by intravenous drug use, states must also commit to increasing harm-reduction programs like syringe exchanges and medication assisted therapies.

Those were the overarching messages to more than 300 people who attended the fifth annual Viral Hepatitis Conference in Lexington on July 31. The good news was that Kentucky has made great strides on all of these fronts since last year's conference, which had a similar message.

Access to harm reduction is one of the areas in which Kentucky has excelled.

Cincinnati Enquirer photo

Dr. Allen Brenzel, medical director for the Department of Behavioral Health and Developmental Disabilities, told the crowd that one of the things he was most proud of was the state's syringe exchanges, which are mainly intended to decrease the spread of infectious diseases, such as hepatitis C and HIV.

Kentucky leads the nation in the number of counties with local syringe exchanges. As of July, 45 of the state's 120 counties have approved such programs at more than 50 sites. That's a lot more than Brenzel expected under a 2015 law that requires approval by the local health board, the county fiscal court and governing body of the city where the exchange is to be located.

"I travel a lot, and the fact that Kentucky has harm-reduction syringe exchange is one of the things I'm most proud of . . . It's an incredible thing," Brenzel said. "We all thought we'd have four or five of them in our urban areas, but what I think is exciting is that our rural counties stood up and said, 'We're tired of this. We're tired of our neighbors dying; we're tired of our friends [dying]. We know this is a health risk.'"

Only about 10 percent of syringe-exchange participants agree to be tested for hepatitis, and critics of the programs claim they enable drug use. On the recent KET program "Disrupting the Opioid Epidemic," host Renee Shaw asked Jennifer Hancock, president and CEO of Volunteers of America Mid-States, about that.

"It is enabling people to take that first courageous step toward a path of recovery," Hancock replied. Earlier, she said, "They are absolutely saving people’s lives."

Hancock, Brenzel and Dr. Ardis Dee Hoven, an infectious disease specialist with the state Department of Public Health, said the exchange specialists strive to build long-term relationships with their clients, making it easier to eventually steer them toward treatment.

"This is not about a supply of needles,” Brenzel said. “This is about the first step in the road to recovery."

At the conference, Brenzel also talked about the state's many different programs that are set up to distribute naloxone, the life-saving drug that can reverse the effects of an opioid overdose. Brenzel added that the U.S. surgeon general has said that having access to naloxone and learning how to use it is "as important as learning CPR."

Jon Zibbell, senior public health scientist at RTI International, an independent nonprofit research institute, told conference attendees that the nation has both a health-care crisis and a public-health crisis.

He said that while it's important to treat the 4 million people who are chronically infected, especially because we know that between 8,000 and 10,000 of them will die annually from a liver-related illness, it is the IV drug users with hepatitis C who are creating the public health crisis.

"The only real way to address the public health crisis for hepatitis C and hepatitis B is to address the people who are still injecting, to protect those downstream transmissions," Zibbell said.

On top of treating people who are actively using drugs, he said, the best way to treat these individuals may be to create a "one-stop-shop" for related services, including hepatitis C treatment, medication-assisted therapies, syringe exchange and access to naloxone.

"We need a way to make it so infected people don't transmit the virus and uninfected people don't acquire the virus, and then naloxone to keep them alive," he said.

Kentucky no longer requires people getting hepatitis C treatment to stay off illicit drugs, only that they be screened and counseled for any illicit drug use. The state has also removed the requirement that only allowed treatment during advanced stages of the disease; now anyone can be treated for it.

The state still requires the disease be treated by or in consultation with a specialist, which is a challenge because there aren't enough specialists to meet Kentuckians' needs.

Dr. Jens Rosenau, an associate professor of medicine at the University of Kentucky and a hepatologist and gastroenterologist at the Kentucky Clinic, said that between July 2014 and December 2016, before the restrictions were removed, only 22 percent of his patients started treatment for the disease, largely because of the restrictions.

But after the majority of the state's managed-care organizations lifted the restrictions in April, allowing Medicaid to pay for treatment, he said his treatment uptake rates have doubled. "This month we actually started 150 patients on treatment," he said. "It is probably our record now."

Rosenau also noted that the UK Healthcare emergency department started doing universal screening for hepatitis C in July and that in just two weeks had identified more than 70 patients with the disease who didn't know they had it: "That is overwhelming." The disease is common, but latent, among the Baby Boom generation.

Kentucky is also the first state in the nation to pass a law that requires all pregnant women to be tested for hepatitis C, and for their babies to be tested at 24 months if the mother tested positive. One in 56 Kentucky births are to mothers who have hepatitis C.

Barbara Cave and Danielle Revert, family nurse practitioners in Louisville, said the state needs universal screening for hepatitis C.

Revert noted a study found that using the current guidelines for screening, 25 percent of people who would test positive for the disease would be missed. "If we're going to talk about eradicating this disease, I really think we're going to have to shift our screening focus more toward this universal screening idea," she said.

Cave added that the prevalence of hepatitis C is likely far greater than the 3.5 million that is normally reported because this number doesn't include any people who are institutionalized, incarcerated, hospitalized, homeless or are military veterans. She said the U.S. estimate should be closer to 5.2 million.

Corinna Dan, viral hepatitis policy adviser for the U.S. Department of Health and Human Services,  said it's challenging to get people to pay attention to a specific health issue like hepatitis, and that it simply doesn't have the kind of support that you see for many other health conditions, like HIV, which has a "huge advocacy base."

"We haven't done that yet effectively for hepatitis," she said. "We do need champions at the ground level, at the local level . . . because that's where people are served, that's where people have the need."

Ashland Middle School students invent device to pick up needles, win $150,000 technology grant for school

A group of middle school students at Ashland Middle School were inspired to create a device to pick up used syringes after learning that first responders had only rubber gloves and tongs to pick them up. The students have been recognized nationally for their invention.

Ashland Middle School was one of three schools to win the 2018 Samsung Solve for Tomorrow Contest for inventing a device to pick up dirty needles, winning the school a $150,000 technology grant. The annual contest challenges sixth through 12th graders to use science, technology, engineering arts and mathematics to address real-world issues and inspire local change.

The device is slightly longer than a syringe and about two inches wide; it looks like a small plastic box with teeth. To pick up the needle, the box is placed over it, teeth side down, then squeezed to pick up then needle, without anyone touching it. The device can then be placed in an evidence cylinder.

"This doesn't solve the drug crisis; it just helps us stay safe while we are trying to solve the drug crisis," Aubree Hay, a student who worked on the project, said on a recent Kentucky Educational Television program, "Disrupting the Opioid Epidemic: A KET Forum."

The students created the device after their school resource officer, Troy Patrick, pitched the idea to their science and technology teacher and explained to them the dangers first responders face when they come upon dirty needles left behind by intravenous drug users, including exposure to HIV/AIDS, hepatitis C and leftover drug residue.

"This is something that could be nationwide," Patrick said. "It could be used in every ambulance and every police department in the nation."

Ashland Middle School is in Boyd County, which has been particularly hard hit by the opioid epidemic. The state's 2017 Overdose Fatality Report found that the county ranked fourth for overdose deaths per person, at 64.6 per 100,000 residents.

Will Wright of the Lexington Herald-Leader reports that staff at the local elementary schools in Boyd County scan playgrounds every day for discarded needles.

The students started working on the project last fall and won the state level competition in December, an honor that came with a $50,000 technology award. In March, they became one of 10 national finalists and after presenting their projects to a panel of judges in New York in April, they were chosen as one of three 2018 national grand prize winners, according to the news release.

The New York Post reports that Ashland Middle School was also named the Community Choice Award winner, based on the public's votes, which will bring a further $20,000 of technology to the school.

The students have also created an online database where people can report where they find used needles, as a way to map the areas most likely to encounter drug paraphernalia.

Ann Woo, senior director of corporate citizenship for Samsung, told Wright that the Ashland project stood out because it could be utilized in communities across the world that are impacted by the drug epidemic. “We loved the creativity and ingenuity,” Woo said, adding that the invention “can actually have impact in other communities across the nation.”

The other two grand-prize winners were Cavallini Middle School in Upper Saddle River, N.J., which developed a helmet concussion sensor, and Thomas Jefferson Middle School in Winston-Salem, N.C., which built a smart water-sensor system that automatically deploys water barriers during floods.

National HIV Testing Day is Wednesday, June 27, a reminder for everyone between the ages of 13 and 64 to get tested

By Melissa Patrick
Kentucky Health News

The only way to know for sure if you have the human immunodeficiency virus is to get tested, and here's a reminder to do so: National HIV Testing Day, which is Wednesday, June 27.

This year's theme is #DoingItMyWay, which delivers the message that HIV testing should be part of everyone's regular health routine and encourages people to share on social media what motivated them to get tested.

Every county health department in Kentucky and many community-based organizations offer free anonymous or confidential HIV testing, according to the stae  Cabinet for Health and Family Services. Click here to find a test site near you. The state also offers a new HIV confidential hotline that is open 24 hours a day: 1-844-294-2448.

In 2015, 339 new cases of HIV were diagnosed in Kentucky, according to the the state's 2017 HIV/AIDS Surveillance Report. More than 1 million Americans are living with HIV, and one in seven don't know it, according to the federal Centers for Disease Control and Prevention. 

The CDC recommends that everyone between the ages of 13 and 64 should get tested for HIV at least once, and that people who are in high-risk groups should get tested at least once a year.

A person is considered to be in a high risk if he or she answers yes to any of these questions:

• Are you a man who has had sex with another man?
• Have you had sex—vaginal or anal—with an HIV-positive partner?
• Have you had more than one sex partner since your last HIV test?
• Have you injected drugs and shared needles or other works (for example, water or cotton) with others?
• Have you exchanged sex for drugs or money?
• Have you been diagnosed with, or sought treatment for, any sexually transmitted disease?
• Have you been diagnosed with or treated for hepatitis or tuberculosis?
• Have you had sex with someone who could answer yes to any of the above questions or someone whose sexual history you don’t know?

HIV is spread only through direct contact with another person's body fluids and is most commonly transmitted through anal or vaginal sex without a condom, or by sharing needles or syringes with a person who is infected with the virus.

HIV attacks and destroys a certain kind of infection-fighting cells in the body, which then makes it difficult for the body to fight infections and certain cancers. Without treatment, HIV can eventually destroy the immune system and advance to AIDS, acquired immunodeficiency syndrome.

The best ways to reduce your risk of getting HIV is to use condoms correctly every time you have sex, limit your number of sexual partners, and never share drug injection equipment, according to the U.S. Department of Health and Human Services.

Kentucky has about 40 syringe exchanges that allow intravenous drug users to trade dirty needles for clean ones as a way to prevent the spread of HIV and hepatitis C.

There is also medication available called pre-exposure prophylaxis, or PrEP, for those who are HIV-negative but at high risk for HIV.

Two churches in Richmond become sites for syringe exchanges

Kentucky Health News; video from WBON-TV, Richmond

Two churches in Richmond have become sites for the Madison County Health Department's syringe exchange, a program designed to prevent an outbreak of HIV or hepatitis C among intravenous drug users.

Elizabeth Missionary Baptist Church and Revival Tabernacle joined the program in late January. The health department also provides clean needles at its offices in Berea and Richmond.

“Both churches reported a very active drug scene in the area they are located and they thought it would be a good idea, and we did too, to be where the potential participants are,” Jim Thacker, public information officer for the health department, told Jonathan Greene of The Richmond Register.

"With the expansion to the two churches, the program hopes to become more diverse," Greene writes. "The overwhelming majority of participants have been white."

Thacker told Greene, “We want to serve everyone. We always wanted to get in the neighborhoods where we knew there was an issue. All it takes is someone willing to host us. We wanted to get in the community and we were pleased that the faith community reached out to us.”

Elizabeth Deacon Andre Patterson told Greene, “We decided as a congregation that whatever we can do, we will do to help. A lot of the church members have friends or family who have been involved in drugs. It is hard to get them off drugs until they are ready. We’re just trying to help somebody out and give them a second chance.”

"Revival Tabernacle Pastor David Lamb said that, while he has mixed emotions about the exchange, the church is willing to try to help," Greene reports, quoting him: “Although I have reservations, statistics state that those involved in the exchange program are five times more likely to join a recovery program.”

The Register used the news as a way to update readers on the syringe exchange.

Greene reports, "Thacker said participation has been about expected as many in the substance-use community still have a perception the exchange program is a set-up."

Thacker told him, “Potential participants believe they’re going to come in and there will be law enforcement. And that’s not the case at all.” He said the exchange has helped several participants get into recovery programs.

"According to information provided by the health department, participants in the program have been about split between male and female, with heroin being the drug of choice for most," Greene reports. "The age range of participants is 22 to 59. . . . Thacker said nearly three out of five participants are actively employed and most learn about the program from family and friends."

Exchange participants can get tested for hepatitis and HIV without charge. "The testing is just a finger prick and results are typically back in 15 minutes," Greene reports.

HIV cases among N.Ky. drug users jump, sparking fear of an outbreak; health officials renew calls for syringe exchanges

Health officials in Northern Kentucky have renewed their cry for syringe exchanges following a huge surge in cases of the human immunodeficiency virus among intravenous drug users in Kenton and Campbell counties.

"HIV cases were up nearly 50 percent to 37 in 2017; the HIV cases among drug users rose 260 percent to 18," reports Terry DeMio, who covers drug abuse for the Cincinnati Enquirer.

The 50 percent increase in the two counties was mirrored across the Ohio River, where Hamilton County, which includes Cincinnati, reported a 50 percent jump in HIV cases.

Local health officials asked the federal Centers for Disease Control and Prevention to determine whether the increase amounted to an outbreak of HIV, like those they and the CDC have predicted. One expert says an outbreak in Appalachian Kentucky is only a matter of time.

Dr. Jeffrey Howard, Kentucky's acting health commissioner, told Terry DeMio of the Cincinnati Enquirer, "We do not want to give the impression of widespread community risk for HIV in Northern Kentucky." However, local officials and advocates were not so sanguine.

Dr. Lynne Saddler, director of the Northern Kentucky Health Department, "cautioned that 2017's rise in reported cases may only be the tip of the iceberg, since many people aren't tested for HIV and injection drug users generally don't the proper health care," the Enquirer reports. "Kimberly Wright, leader of the private Facebook group Kentucky Parents Against Heroin, said the threat isn't just to injection drug users or health and safety workers."

"We're all at risk now," Wright told DeMio. "Here's the thing I think people don't get about users: We have males and females who are prostituting out here. …You know, we have strip clubs where these girls are going to dance to earn their money. We have married men going into these places that are leaving with them."

Advocates and health officials redoubled their calls for syringe exchanges where IV drug users can get clean needles, preventing the spread of infection and providing an opportunities to recruit them into treatment. Local officials, feeling political pressure from both sides, have dithered.

"Kenton County commissioners have approved an exchange there, but Covington has resisted unless a neighboring county gets an exchange, too," DeMio notes. "Campbell County gave a thumbs up, but Newport hasn't acted on the issue."

Approval is required from the county government and the city where an exchange is placed. At a news conference, advocates and heath officials turned up the heat on politicians.

"We must act immediately," Garren Colvin, president and CEO of St. Elizabeth Hospital, said at a news conference with other health officials. "More than ever, Northern Kentucky now needs comprehensive syringe access-exchange programs."

Brent Cooper, president and CEO of the Northern Kentucky Chamber of Commerce, said "It's about lowering our collective health-care costs, improving the health of our community and attracting and retaining workers and business." The chamber "has been at the forefront of fighting the heroin epidemic for more than five years," DeMio notes.

Opponents of syringe exchanges say they enable drug use, but research has debunked that notion.

HIV outbreak in Appalachian Ky. 'just a matter of time;' majority of counties CDC calls most vulnerable have no syringe exchange

An outbreak of the human immunodeficiency virus, which leads to AIDS, is “just a matter of time” in Appalachian Kentucky because of conditions in the region and the lack of syringe exchanges for intravenous drug users in most vulnerable counties.

Dr. Jennifer Havens

That's what Dr. Jennifer Havens, an epidemiologist at the University of Kentucky, told the Courier Journal's Laura Ungar for a story updating the county-by-county threat first identified by the federal Centers for Disease Control and Prevention in 2016.

Using "statistics tied to injecting drugs, such as overdose deaths, prescription-opioid sales, low income and unemployment," Ungar notes, the CDC identified 220 counties in the U.S. that were most vulnerable to outbreaks of HIV or hepatitis C, a liver infection that can also be spread by needle sharing.

Kentucky has 54 of those counties, mostly in Eastern and Southern Kentucky, but 30 of them "haven’t given the go-ahead for needle exchanges," Ungar reports. "And programs approved in the vulnerable counties of Wolfe, Perry and Letcher have yet to open." Ungar's story has a national, interactive map with the ranking of each county.

Ungar adds, "Elizabeth Turner, director of the district health department covering those counties, said they’ve managed to partly fund Wolfe’s exchange but are having trouble buying needles because some of the grant money can’t be used for them. She explained the situation to a state health official this week, she said, and was told Kentucky just received harm reduction funds that will be sent out to counties, including Wolfe. Although this money also can't be used for needles, Turner is hopeful it could offset other expenses," freeing up money to buy syringes.

"HIV has been found across Appalachia, though known rates so far are lower than in urban Kentucky, where testing is more common," Ungar reports. "April Young, a University of Kentucky assistant professor of epidemiology, said less HIV testing in Eastern Kentucky means the disease could be spreading silently."

As evidence of that, "Researchers point to an explosion of HIV’s widely-accepted harbinger: the potentially deadly liver disease hepatitis C," Ungar notes. "Like HIV, 'hep C' can be spread by sharing needles. And it’s easier to contract, so it’s not uncommon to have both diseases. . . . Havens’ long-term study of Eastern Kentucky drug users found that once they start shooting up, most get hep C within a year. . . . From 2008 to 2015, Kentucky had the nation's highest rate of new, acute hep C infections, with 1,089 cases. Another 38,000 Kentuckians live with chronic hep C. "

Meanwhile, “People have forgotten about HIV. … But it’s becoming clear you have the stage set for a major increase in these infections (in places) we’ve basically ignored,” Dr. Paul Volberding, director of the AIDS Research Institute at the University of California-San Francisco, told Ungar. “Whenever we have an infectious disease and we turn our back, it bites us.”

Ungar writes, “Many believe the solution begins with fighting addiction in each family, school and community. But the sheer scope of the drug scourge dwarfs grassroots efforts."

Bardstown newspaper's editorial criticizes one-for-one mandate for state-funded syringe exchanges

New syringes with clean needles

State and local officials need to get politics out of public health when it comes to establishing and funding syringe exchanges for intravenous drug users, The Kentucky Standard of Bardstown said in an editorial Sunday.

"Once again, politics has ruled over expert recommendations," the thrice-weekly paper said in an editorial about the state's rule for syringe exchanges it funds: after the first visit, one clean needed for every used one turned in. Nelson County officials starting an exchange told the Standard that they favored the rule.

"According to health experts, these conditions are not optimal for the intended purpose of the program, which is to reduce needle sharing and slow the spread of disease," the editorial notes. "But in Frankfort, many times, politics trumps the experts, and this is one of those cases. Politicians fear the perception that they will be supporting legislation that enables drug users and is morally wrong."

Another sort of public perception, the stigma of drug use, figures into the issue. "Health officials caution that not all addicts will visit the needle-exchange facility for fear of being recognized, so they warn that if you only allow a one-for-one exchange, the addicts who come in aren't going to share dirty needles," the newspaper says. "It really is defeating the true intent of the program, which is reducing the spread of disease. And that comes not only from needle sharing, but from discarded needles, the editorial notes, before defending syringe exchanges in general.

"Research shows that these types of programs, when allowed to operate effectively, don't increase drug activity but do keep diseases from spreading. They also allow for free and confidential testing for hepatitis C and HIV, which can, in turn, help addicts obtain earlier treatment for the diseases and help build awareness." (Read more)

Nelson County starting syringe exchange on one-for-one basis

Requiring "a clean needle for every dirty one . . . isn't the best practice to reduce the spread of blood-borne pathogens such as HIV and hepatitis C" through a syringe exchange, "but it's the one the Nelson County Health Department will adopt for its exchange, which will begin in July," Randy Patrick writes for The Kentucky Standard in Bardstown.

"When addicts first come in, they won't have to bring dirty needles, but for subsequent visits, they will," because that's what the administration of Gov. Matt Bevin requires in return for funding of a syringe exchange, and County Judge-Executive Dean Watts said that was the intent of the county Fiscal Court when it approved the exchange, Patrick reports.

Health officials in Louisville and Lexington do not follow the one-for-one rule and recommend against it. "All it does is encourage the use of sharing dirty needles," Kevin Hall, communicaitons director for the Lexington-Fayette County Health Department, told Patrick.

The exchange will be the first in the six-county Lincoln Trail District Health Department, which also includes Meade, Hardin, LaRue, Marion and Washington counties. None of the district's counties are among the 54 that the federal Centers for Disease Control and Prevention considers most at risk for an HIV or hepatitis outbreak among intravenous drug users. Breckinridge and Grayson counties, which were once part of the district department, are on that list.

Ky. is a national leader in hepatitis C, but many counties at risk shun syringe exchanges that could prevent disease outbreaks

"Growing intravenous drug use by people sharing syringes to inject heroin and other substances" has helped make Kentucky a national hotbed for cases of hepatitis C, "which ultimately could mean a staggering cost to taxpayers to treat people with the disease," Bill Estep reports for the Lexington Herald-Leader.

"Giving addicts clean needles can help stem the spread of the disease, but many Kentucky counties considered at greatest risk for an outbreak have not approved such programs," Estep notes. His story has a map of syringe exchanges and the Kentucky counties that the federal Centers for Disease Control and Prevention considers most at risk for an outbreak of HIV or hepatitis C due to IV drug use. Of the 220 counties identified, Kentucky has 54, almost half its total number of counties.

Lexington Herald-Leader map

"The programs have only been legal in Kentucky since 2015, when the legislature authorized them in the face of mounting IV drug use," Estep notes. Now there are 33, nine of which are not in operation yet. They are run by local health departments with approval of the county fiscal court and the city where the exchange is located.

"Despite the documented problems, more than 30 of the counties the CDC identified as being at high risk for a disease outbreak have not set up needle-exchange programs," Estep reports. "Some local officials said they’ve faced concerns from residents of their culturally and politically conservative counties that giving needles to drug users condones or perpetuates drug abuse."

Russell County Judge-Executive Gary Robertson "said he had much the same reaction when the idea first came up but changed his mind after learning more," Estep writes. "Drug addicts will find needles and use drugs with or without a local needle-exchange program, but the program can help reduce the spread of expensive diseases, Robertson said."

Studies show that people who use exchanges are much more likely to get drug treatment, Estep notes. "Other studies have shown that exchange programs don’t encourage people to start taking drugs or increase how often users inject drugs; that they don’t increase crime; and that they help reduce the problem of drug users disposing of dirty needles improperly."

Read more here: http://www.kentucky.com/news/state/article151550027.html#storylink=cpy

Read more here: http://www.kentucky.com/news/state/article151550027.html#storylink=cpy

Read more here: http://www.kentucky.com/news/state/article151550027.html#storylink=cpy

Read more here: http://www.kentucky.com/news/state/article151550027.html#storylink=cpy

The CDC said recently "that in 2015, Kentucky was among seven states where the incidence of new hepatitis C cases was more than twice the national rate," Estep reports. "Kentucky, West Virginia and Massachusetts had the highest rates, the May 12 report said. The problem has been building for years, according to the 2017 update to the Kentucky Department for Public Health’s state health assessment. The update, released in March, said Kentucky had the highest rate of new hepatitis C infections in the nation from 2008 through 2015, the last year with available data." Kentucky also has the second highest rate of babies born to mothers with the disease, trailing only West Virginia.

Those mothers need to be identified and treated before delivery, said Dr. Ardis Hoven, an infectious disease specialist with the state health department.“We have an epidemic, and we need to continue to deal with it,” she told Estep.

Treating hepatitis C is expensive, Estep notes: "In the last full fiscal year, Kentucky’s Medicaid program spent $69.7 million on pharmacy claims to treat 833 beneficiaries, or $83,735 apiece, according to the Cabinet for Health and Family Services."

Boyd, Clark counties approve needle exchanges; Boyd's is a limited, one-for one; Covington's proposed limits draw objections

By Melissa Patrick
Kentucky Health News

Clark and Boyd counties are the ninth and 10th Kentucky counties to approve a needle-exchange program, and Madison and Anderson counties are talking about it. Meanwhile, the city of Covington has approved an exchange with conditions that don't match its health department's plan, and one of the conditions might not even be legal.

Needle exchanges were approved under the state's anti-heroin law passed in 2015, and require both local approval and funding. They are meant to slow the spread of HIV and the hepatitis C virus (HCV), which are commonly spread by the sharing of needles among intravenous drug users.

Clark County Health Director Scott Lockard noted that the federal Centers for Disease Control and Prevention has "identified 54 counties in Kentucky as being vulnerable to rapid dissemination of HIV or HCV infection among persons who inject drugs. Of the top 25 most vulnerable counties in the nation 16 of them are in our state."

Clark County

On March 23, the Clark County Fiscal Court approved on a 4-2 vote a needle exchange that will start on or before June 1, but the program will need re-authorization in January, Greg Kocher reports for the Lexington Herald-Leader.

"Both the Fiscal Court and the [Winchester] City Commission inserted a sunset clause in the orders requiring the health department to present data on our program in January 2017 in order to get re-authorization for a longer time period," Lockard told Kentucky Health News in an e-mail.

He noted that the CDC identified nearby Wolfe County as the most vulnerable county in the nation to rapid dissemination of HIV and HCV among drug users, with adjoining Powell and Estill counties 15th and 25th, respectively.

"Residents from all three of these counties frequently come to Clark County for medical services from our provider community and the health department," he said. "More must be done in the area of prevention if we are to avoid a situation similar to what Scott County, Indiana, encountered."

That county, about 30 miles north of Louisville, has drawn national attention for its high rates of HIV and hepatitis C, mostly caused by intravenous drug users who share needles. According to published reports, "from November 2014 to mid-June 2015, the Indiana county of 24,200 reported 170 HIV cases. It reported 130 new cases of hepatitis C in 2014," noted Bill Robinson of The Richmond Register.

According to Lockard, Clark County's program will use a patient negotiation model, which does not require a one-to-one needle exchange, during the initial visit, but will try to get close to a one-for-one model on subsequent visits.

"We will educate participants that they need to return needles to get needles," he said.

Boyd County

The Boyd County Fiscal Court voted 4-1 March 15 to approve a one-to-one needle exchange for one year, Lana Bellamy reports for The Daily Independent. 

The Ashland City Commission had already given its approval for the exchange, which may begin as early as July. Bellamy reports that the program will be paid for by special taxing districts, and all of the fiscal court members voiced concerns about the sustainability of the funding.

Ashland-Boyd County Health Department Director Maria Hardy told the court that syringes typically cost about 97 cents each, but the health department will be able to buy needles from a distributor for 9 cents each, Bellamy writes.

The Boyd County program will assign tracking numbers to its participants to protect their identities and allow a maximum of 40 needles to be exchanged each week.

County Commissioner John Greer, the only member to vote against the resolution, said he was concerned the program would encourage drug abuse and Sheriff Bobby Jack Woods agreed, Bellamy reports. This is a common concern among opponents of needle exchange programs, though evidence-based studies have proven otherwise.

Covington

During the same week, the City of Covington approved a needle-exchange program, but with conditions that could kill the program, Terry DeMio reports for The Cincinnati Enquirer.

The conditions are that all participants be tested for hepatitis C, hepatitis B, HIV, and, where applicable, pregnancy. That could be illegal, DeMio reports.

A Northern Kentucky Health Board spokeswoman told DeMio that they believe that they cannot require anyone to undergo any medical procedures, but said they were checking with legal counsel. Other health and harm-reduction officials told DeMio that this requirement is not legal, and that such a condition would likely prevent a program from getting off the ground.

"The Covington commission's resolution includes other conditions that differ from the health board's model program, too, and would require passage from the Kenton County Fiscal Court and the Board of Health before it's approved," DeMio writes.

These conditions include a requirement that two other counties in the Northern Kentucky Health District also adopt a needle-exchange program (only Grant County has); restrict use of the program residents of the district's four counties; and moving the exchange to St. Elizabeth Healthcare hospital.

The city also wants a one-for-one exchange, Michael Monks reports for The River City News.

The health department says its plan is "need-based," not one-for-one, because studies show that is the best way to reduce the risk of community exposure and spread of HIV and HCV. This is the main goal of the program, although needle-exchange programs also provide HIV and HCV testing and access to drug treatment.

The health department's plan is to initially provide clients with the number of syringes they would use in a week, along with a safe container for their return with instruction to return the used needles for new ones. Participants who don't return dirty needles after three trips would not receive new syringes, DeMio reports.

The department has been trying to establish needle-exchange programs in the district since the law passed one year ago. The Kenton County Fiscal Court is expected to discuss a needle exchange plan March 29, DeMio reports.

Dr. Lynne Saddler, the health department's director, told the Enquirer "that the Covington resolution was a start and that more discussion is planned by the health department."

Other counties

Madison County Health Department officials are also worried about becoming another Scott County, Indiana, as they face an epidemic of heroin use in their county, Bill Robinson reports for The Richmond Register.

Thus they have begun the process of educating their public officials, Robinson writes. Public Health Director Nancy Crewe presented her detailed findings to support a needle exchange at a quarterly joint meeting of the county Fiscal Court, Richmond City Commission and Berea City Council, noting that they were just beginning the long process of educating the public.

A needle exchange program was also brought up at the March meeting of the Anderson County Fiscal Court meeting, and was met with some disparaging remarks, Ben Carson reports for The Anderson News.

"What jackass thought of that idea?" asked Magistrate David Montgomery. "We might as well give them the dope, too."

Despite these comments, Montgomery did volunteer to be on a committee to explore a needle exchange program along with members of the health board, Lawrenceburg City Council, law enforcement, EMS and county jailer.

Robinson also reports that the Bourbon County Fiscal Court has voted to reject an exchange.

The other needle exchanges in the state that are either operating or have been approved are in Louisville and Lexington and in the counties of Pendleton, Carter, Elliott, Franklin, Grant, and Jessamine.

Grant is eighth county to approve needle exchange; op-ed calls for N. Ky. to take a vote; and Louisville opens its third site

By Melissa Patrick
Kentucky Health News

Grant County is the eighth county in the state to approve a needle-exchange program, nearly 11 months after the legislature paved the way to do so, while much of Northern Kentucky is still talking about it. Meanwhile, Louisville has opened its third site amid controversy.

The Grant County Fiscal Court agreed to the needle exchange Feb. 15, almost six months after the Williamstown City Council had unanimously approved the exchange Aug. 18, Terry DeMio reports for the Cincinnati Enquirer.

"I am grateful to the elected officials who took the time to educate themselves and their constituents on the necessity of not only helping to stop the transmission of disease but also to provide assistance to a vulnerable population," Jim Thaxton, coordinator for the Northern Kentucky Heroin Impact Response Task Force, said at the meeting.

The Northern Kentucky Health Department will operate the program,which will be located in the department's Williamstown Health Center. The opening date has yet to be decided.

Needle exchanges were approved under the state's anti-heroin law passed in 2015, and require both local approval and funding. They are meant to slow the spread of HIV and hepatitis C, diseases that are commonly spread by intravenous drug use and to provide testing and treatment for those who are ready to seek it.

Kentucky leads the nation in hepatitis C, which is especially prevalent in Northern Kentucky with a rate that is 19.5 times higher than the rest of the nation, DeMio reports.

The other needle exchanges in the state that are either operating or have been approved are in Louisville and Lexington and the counties of Pendleton, Carter, Elliott, Franklin and Jessamine.

Northern Kentucky

Meanwhile, several Northern Kentucky counties continue to debate the issue with no action, prompting Mark Hansel, the NKyTribune's managing editor, to write a detailed op-ed that says it is time for Northern Kentucky to make a decision on a regional needle exchange program.

"It’s becoming pretty clear that if there is to be needle exchange in Northern Kentucky, it is going to have to be region-wide," he writes.

He says that the local-decision part of the law has allowed local elected officials in the region to "dodge the issue by not bringing it up for a vote" and that it's time for them to take a vote on this issue so voters know where they stand, noting that "elected officials in several Northern Kentucky municipalities are up for reelection in November."

Hansel explains, "At this point, it appears Covington, Kenton County, Newport and Campbell County are ready to support needle exchange," but "have indicated they will not move forward without assurances that Boone County and Florence will participate as well." He notes that Florence also has "increasing support," but requires Boone County's Fiscal Court to make a decision first. He says that it is unclear if Boone County has enough votes for it to pass, "but most observers believe it does not."

Hansel suggest these counties "could move the needle forward" by approving their needle exchanges "contingent on implementations by all cities and counties eligible to participate."

Louisville

Meanwhile, Louisville is opening its third site for a needle exchange, and reaction to the new site has been mixed, Danielle Lama reports for WDRB-TV.

Rev. Owen Sheroan, who is with nearby Churchman Chapel Ministries, told Lama he was concerned that it would create more drug activity in the area, while other neighbors said they weren't concerned with it being there.

"About 20 percent of our participants right now that are driving all the way up here to our main site are coming from that ZIP code and surrounding areas," Public Health and Wellness Interim Director Dr. Sarah Moyer told Lama.

Allison Martin, spokeswoman for Jefferson County Public Schools, told WDRB that the district has expressed concerns to the city that the site is so close to Hazelwood Elementary School.

Lama reports, "When asked about the school's proximity, Moyer said the needle exchange will help get dirty needles off the street and that could in turn make the neighborhood safer. She also says the department hasn't had any problems at their other sites."

The exchange will be in an empty lot along Bicknell Avenue and will be open on Wednesdays from 11 a.m. to 2 p.m. Health officials told Lama that so far, more than 2,000 people have used the city's needle-exchange program.

Louisville opens first needle exchange in state; officials predict rural counties will be slow to follow

Photo by Scott Utterback, The Courier-Journal

Louisville Metro Public Health & Wellness opened its mobile needle-exchange program Wednesday, June 10, making Louisville the first place in Kentucky to implement such a program.

Lexington and Northern Kentucky are expected to follow soon, but officials say that establishing needle exchanges in much of Kentucky will be "more politically complex," Mike Wynn reports for The Courier-Journal.

"We're going to see some parts of our state where this is available and others where it is not," Scott Lockard, president of the Kentucky Health Departments Association, told Wynn. "Rural areas are opting for a slow and deliberate approach, heavy on education and dialogue," he said, and some communities won't even consider a exchange because of "seemingly endless hoops to jump through."

Bullitt County, south of Louisville, is a prime example. There, officials told Wynn that they plan to do a needs assessment and host a community forum with input from law enforcement and mental health experts.

"It's a work in progress," Public Health Director Andrea Renfrow told Wynn. "We are not able to go as quickly as Louisville Metro."

One critic, Magistrate Joe Laswell, told Wynn that he had talked to many voters who are against the exchanges and want to know why police wouldn't arrest addicts when they show up to swap out dirty needles. "I believe in charging and incarcerating," he said, apparently unaware that the addicts would need to have drugs in their possession to be charged.

Lockard, who heads the Clark County Health Department, told Wynn that he won't ask his board to take a vote until August and that he can't predict the political outcome when it goes to city and county officials.

In three other Bluegrass counties, Scott, Harrison and Nicholas, the board of the Wedco District Health Department wants to start a needle exchange, reports The Cynthiana Democrat, but can't proceed in any of the counties without approval of the fiscal court.

So, despite the two-year debate that just ended in Frankfort over the law, it's not really over.

Democratic state Rep. John Tilley of Hopkinsville, the legislature's biggest proponent for needle exchanges, told Wynn that giving city councils and fiscal courts final authority over the programs was necessary to sooth critics and pass a comprehensive heroin bill this year.

Opponents of the law say the exchanges promote drug use, while proponents cite evidence that doesn't support those claims, but instead "help prevent the spread of deadly and expensive diseases and pull addicts into treatment programs while keeping dirty needles out of parks and off the streets," Wynn writes.

A Lexington Herald-Leader editorial wrote about needle exchanges: "Congressional critics rely on a gut feeling that providing needles endorses drug use, but 20 years of research argues otherwise." Listing that where there are syringe exchange programs:

• Participants are five times more likely to get treatment.
• HIV and hepatitis C declines among drug users.
• Participants can get referrals to substance abuse treatment, disease prevention education, vaccinations, condoms, counseling and testing for communicable diseases.
• Costs are more than recaptured. A 2011 European study found that $1 spent on needle-exchange programs yielded $27 in health-care cost savings, prompting an international report to call needle exchanges "one of the most cost-effective public health interventions ever funded."

The federal Centers for Disease Control and Prevention recently reported that new cases of hepatitis C more than tripled in Kentucky, Tennessee, Virginia and West Virginia between 2006 and 2012, mainly from the use of dirty needles. Officials fear an outbreak of HIV and AIDS will follow.

HIV and AIDS cases are on the rise in Kentucky; officials blame lack of education and increase of heroin use

Despite readily available information and awareness about practicing safe sex, and avoiding sharing needles, HIV and AIDS cases are on the rise in Kentucky. And the reason, say officials, is ignorance and an increase in heroin use, Mary Meehan reports for the Lexington Herald-Leader. Mark Royse, executive director of AVOL, which serves clients with HIV and AIDS in 72 Kentucky counties, said "his nonprofit routinely offers support services, including housing assistance, to about 400 families affected by HIV and AIDS."

Lauren Kirk, HIV and AIDS outreach specialist for the Lexington-Fayette County Health Department, "said a lot of the people they see are young and were born after the AIDS epidemic was at its lethal peak," Meehan writes. Another specialist, John Moses, told hr that the health department is seeing more young people with HIV. Part of that surge, he said, is from the use of shared needles as heroin use in Kentucky is on the rise." Heroin drug deaths in Kentucky increased by 550 percent in 2012, John Cheves reports for the Herald-Leader.

Another problem is that many people refuse to get tested, because discussion of HIV and AIDS includes talk of sexuality, homosexuality and drug abuse, Meehan writes. Royse told her, "It is a perfect storm of things we don't like to talk about." Royse said "a 'silence-is-better' policy is especially prevalent among Latinos and blacks, who account for the majority of new infections in Kentucky. He's concerned that if people stop talking about HIV and AIDS and become complacent, the infection will continue to spread." (Read more)

The state Cabinet for Health and Family Services, in its annual report from June, 2012, said 8,513 Kentuckians are diagnosed with HIV, with 7031 men and 1,482 women. Most of the cases are in urban areas, with 3,849 in Jefferson County and 1,099 in Fayette County. Of those cases, 4544 are classified as from men having sex with men (MSM), 917 as injection drug users (IDU) and 425 as people who reported to having engaged in both MSM and IDU.

The overall total of HIV and AIDS cases includes 21 boys under 13 years old, 107 between ages 13-19, and 1,269 between ages 20-29. For women, it includes 13 girls under 13 years old, 39 between ages 13-19, and 203 between ages 20-29. (Cabinet graphic: Newly diagnosed HIV cases in 2010 for Kentuckians ages 20-29 years old accounted for 32 percent of all new cases, even though that age group only makes up 13 percent of the total population)

Kentucky ranks 25th in HIV infections. In 2010, the state had 85 new HIV cases for people ages 13-24, accounting for 25 percent of all new cases in the state, which is higher than the national average for that age group of 21 percent. The average age of Kentuckians diagnosed with HIV went down from 37.1 years of age in 2006 to 35 years of age in 2010. To read the full report click here.

Poll shows Kentucky health-care providers often fail to discuss HIV testing with patients

A new poll suggests that most Kentucky health-care providers follow guidelines for discussing HIV screening with their patients, despite the the importance of early treatment to prevent its progression to AIDS.

Although the Centers for Disease Control and Prevention recommends routine HIV screenings for most patients, just 32 percent of Kentucky adults aged 18 to 64 report discussing HIV testing with their medical provider, according to the Kentucky Health Issues Poll.

About 40 percent of Kentucky adults reported they had never been tested for HIV. It’s estimated that 4,500 Kentuckians are living with HIV infection and it is estimated nationally that one in five people who have HIV do not know they do.

“It made headlines earlier this month when a little girl - the second person in history - was cured of HIV. As exciting as this development was, for most people, HIV remains a life-long condition that must be managed through medication to keep it from progressing to AIDS. The CDC’s recommendations are meant to improve the overall population health by detecting HIV so treatment can begin,” said Dr. Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsored the poll.

“It appears that Kentucky providers are either not adhering to the routine screening recommendations or not communicating this message clearly to patients,” she said.

The poll, co-sponsored by the Health Foundation of Greater Cincinnati, was taken Sept. 20 through Oct. 14 by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults throughout Kentucky was interviewed by landline and cell telephones. The poll's margin of error is plus or minus 2.5 percentage points

More breakthroughs lately in fight against HIV/AIDS

It has been an inspiring season of breakthroughs in the fight to prevent the spread of HIV and AIDS. Earlier this week, the Food and Drug Administration approved the pill Truvada, "a preventive measure for healthy people who are at high risk of acquiring HIV through sexual activity, such as those who have HIV-infected partners," reports Matthew Perrone for The Associated Press.

Just two weeks ago, the agency also approved the first over-the-counter HIV test that can be used at home. "I think the combination of self-testing and a medicine that you can take at home to prevent infection could mean a whole new approach to HIV prevention that is a bit more realistic," said Dr. Demetre Daskalakis of New York University's Langone Medical Center.

In the meantime, a research team at the University of Nebraska Medical Center is making progress to develop a weekly or twice-monthly injection that would help manage patients with HIV. The long-acting injection "would be a substantive improvement over daily and sometimes more complex regimen of pills," lead investigator Dr. Howard Gendelman told research-reporting service Newswise.

"We actually followed the process exactly as we would with a person — and it worked," he said. "This is all very exciting. Although there are clear pitfalls ahead and the medicines are not yet ready for human use, the progress is undeniable." (Read more)

FDA approves fast, take-home test that detects HIV

A model demonstrates how to use the OraQuick test, which
detects the presence of HIV in saliva.
AP photo by Chuck Zovko.

Soon, taking an HIV test will be no more complicated than swabbing one's mouth and waiting for the results. The Federal Food and Drug Administration last week approved the OraQuick test, which detects HIV antibodies and gives a result in 20 to 40 minutes. 

Orasure plans to start selling the test in October at local pharmacies and online, reports Matthew Perrone for The Associated Press. It is expected to cost less than $60 but more than the one used by health professionals, which costs $17.50.

About 240,000 of the 1.2 million people who are suspected of carrying the HIV virus don't know they are infected. 

The FDA says the test is not 100 percent accurate, but a trial conducted by Orasure showed it only detected HIV in people who have the virus 92 percent of the time. It was 99.9 accurate ruling out HIV in people not carrying the virus. People who test negative should re-test after three months because it can take time for the HIV antibodies to appear. (Read more)

Pharmacies to offer free HIV tests as part of pilot program; no Ky. locations chosen yet

Getting tested for HIV may soon be as easy as going to the pharmacy to get a flu shot or blood pressure check. Pharmacies in 24 cities and rural communities will offer rapid HIV tests free of charge as part of a $1.2 million program. Testing is already available in Washington, D.C., Oakland, Calif., and an Indian health service clinic in Montana. The remaining 17 locations will soon be chosen by the Centers for Disease Control and Prevention.

The test involves swabbing the inside of a person's mouth and preliminary results take about 20 minutes. Makers of the test say it is accurate 99 percent of the time. "If the test is positive for the AIDS virus, pharmacy employees will refer customers to a local health department or other health care providers for a lab blood test to confirm results, counseling and treatment," The Associated Press reports. "The workers are expected to deliver the news face-to-face and give customers privacy."

According to the CDC, there are about 1.1 million Americans who are infected with HIV, but up to 20 percent of them don't know they have it. Since 2006, the CDC has recommended all Americans ages 13 to 64 get tested at least once, but fewer than half of adults under the age of 65 have done so. (Read more)

More Americans dying from hepatitis C than from AIDS

More people are dying in the U.S. from hepatitis C than from AIDS, a new report from the Centers for Disease Control and Prevention says. More than 3.2 million Americans have the hepatitis virus, which can cause chronic infection of the liver and eventually lead to liver failure.

Hepatitis C death rates climbed to almost 5 per 100,000 in 2007, from fewer than 3 per 100,000 in 1999. In the same time period, the HIV-AIDS death rate dropped to slightly more than 4 per 100,000 from more than 6 per 100,000.

"The declines in HIV reflect the accomplishments in building a public health response to the epidemic that improved screening and provided means of access to effective treatment," said Dr. John W. Ward, director of the Division of Viral Hepatitis at the CDC and author of the study. A similar program for hepatitis C would be similarly helpful, he said.

The disease is most commonly spread by exposure to infected blood. Intravenous drug abuse is the most common method of transmission, reports MedicineNet.com.

Ward said there is now a treatment "that was about 70 effective at clearing the virus from the body, but, he said, most infected people are unaware of their condition and do not receive treatment," reports Nicholas Bakalar for The New York Times. (Read more)

Get tested, get treatment, Bluegrass HIV Coalition encourages

Today is World AIDS Day and health advocates are asking Kentuckians to get tested and get treatment.

Hundreds of Kentuckians are diagnosed with AIDS each year, reports Mary Meehan of the Lexington Herald-Leader. Minority populations are hit particularly hard, with black men nearly 10 times more likely to die of AIDS than non-Hispanic white men. Black women are almost 23 more times more likely to die from the infections, compared to non-Hispanic white women.

Though people are still dying, AIDS is not a widely-discussed disease, in part because of its past association with homosexual activity. Mark Johnson, member of the Bluegrass HIV Coalition, said AIDS can be hard for people to talk about.

In addition, the infection is often seen as treatable, in part because of people like Magic Johnson, who has had the infection more than 20 years but is still in good health. What people don't see "is the often expensive regimen of drugs that is needed to keep the worst of the disease at bay, the side effects of those medicines or the ultimate end of what is still an incurable disease," Meehan reports. (Read more)