Events, trends, issues, ideas and independent journalism about health care and health in Kentucky, from the Institute for Rural Journalism at the University of Kentucky
Showing posts with label needle exchanges. Show all posts
Showing posts with label needle exchanges. Show all posts
Screenshot of health portion of Cabinet for Health and Family Services report on Clay County
By Al Cross
Kentucky Health News
Most Kentuckians probably don't know much about Medicaid, but for more than one in three people in the state, it is a lifeline. In some counties, more than half the residents are Medicaid beneficiaries. But Medicaid runs somewhat under the radar, because many Kentuckians frown on the receipt of public assistance -- even though Medicaid benefits come only with demonstrated medical need.
Medicaid is a combined federal-and-state program, created in 1965 by the law that created Medicare. Originally it was for the very poor, the disabled and the pregnant, but in 2014 expanded to households with incomes up to 138 percent of the federal poverty level because then-Gov. Steve Beshear embraced the 2010 Patient Protection and Affordable Care Act, better known as Obamacare.
The federal government pays 90 percent of the cost for people covered by the expansion, and about 72 percent of others' costs. The state pays the rest, which means Kentucky taxpayers put billions of dollars a year into it. It's not the sort of program that needs to run under the radar; if we are paying the freight, we need to know what's in the haul, and it helps to know it at the local level.
That's easier now that the state Cabinet for Health and Family Services, which runs Medicaid in Kentucky, has posted monthly Medicaid enrollment reports on its website.
These county-by-county reports are more useful than the annual reports that the cabinet circulates more more to show the local impact of its programs. The Medicaid figure on those reports is the number of people in the county who received Medicaid benefits at any time during the program's fiscal year (April to March). That number overstates the rolls at any particular time, because many people go on and off Medicaid each month.
For example, the Fiscal 2022 report for Clay County, one of the nation's poorest, shows 15,922 total beneficiaries in the year, but only 12,815 in the month of June. That is still 62.6 percent of the county's estimated population of 20,484.
That said, the annual reports provide much more information about Medicaid than the monthly reports; among other things, they:
Break down Medicaid enrollment into types of enrollees: traditional, expansion, children in foster care, and "presumptive eligibility," people who have been enrolled during the pandemic without all the usual checks for eligibility, under legislation passed by Congress. Starting April 1, states will have to start running all the usual checks, and many people will no longer be eligible. In Clay County, for example, 2,842 presumptive eligibles were on the rolls in fiscal 2022, or 18% of the total enrollment.
Give the number of children who were beneficiaries at any time during the year; in Clay County, 4,612 kids were helped by Medicaid in fiscal 2022.
Give the top five diagnoses for adults and children on Medicaid, which can vary widely from year to year. In another poor county, Clinton, the top five diagnoses for adults in fiscal 2021 were chronic obstructive pulmonary disease, hypertension, unspecified illness, opioid dependence and diabetes, in that order. In fiscal 2022, they were hypertension, Covid-19, contact with and suspected exposure to Covid, myopia (nearsightedness) and "other fatigue."
Give the top five procedures performed on beneficiaries and the top five medications prescribed for beneficiaries. In both Clay and Clinton counties in the last two fiscal years, the most-prescribed drug was naloxone, which reverses the effect of a drug overdose.
Show the number of health-care providers who served residents of the county and the total they were paid. For example, in Clinton County in fiscal 2022, residents were served by 48 providers who were paid $33 million; $14.3 million of that went to local providers.
Show the number of newborn screenings and other figures on programs for children, including the percentages of foster children who had an official goal of adoption, and the number with other official goals, such as reunification with their birth families.
The annual reports give much information on programs other than Medicaid, such as the Supplemental Nutrition Assistance Program (once known as food stamps), behavioral-health services (including syringe exchanges), other services by local health departments, health-insurance assistance, child-care assistance, child-support enforcement, social services (such as meals, home care and other services to seniors), and funding of Family Resource and Youth Service Centers, which serve public-school students and their families. The reports also list the number of cabinet employees working in each county.
Kentucky is lauded nationwide for its embrace of syringe exchanges to thwart the spread of HIV and hepatitis C among intravenous drug users, but getting them approved locally continues to be a challenge and generally only happens after months, or even years, of educating the public.
Van Ingram, executive director of the Kentucky Office of Drug Control Policy, attributed the success of Kentucky's syringe exchanges to the ongoing efforts of the state's public health workers, who promote the exchanges as "harm reduction programs."
"It's just great public health advocacy at the local level, who just wouldn't give up," Ingram said July 11 at a health-related forum in Covington.
He was speaking broadly about the state's many efforts to battle the opioid epidemic, including a 2015 law that allows syringe exchanges with approval of the county health board and fiscal court and the legislative body of the city where the exchange is to be located.
Kentucky has 59 operating syringe exchange locations in 52 of its 120 counties, with six more approved but not operational. Since mid-February, when Kentucky Health News did its last syringe exchange roundup, 11 additional counties have been marked on the state health cabinet's map of exchanges.
Since February, Henderson, Hopkins, Taylor and Owen counties have been added to the map and are identified as operational locations. Magoffin County was also recently added, even though it opened last June, Hazard's WYMT-TV reports.
Among the 54 Kentucky counties the federal Centers for Disease Control and Prevention has identified as being the most vulnerable to outbreaks of HIV and hepatitis C among IV drug users, 33 have approved an exchange, with 29 of them operational.
The vulnerable counties that have not approved an exchange are Allen, Bell, Breckinridge, Carroll, Casey, Clinton, Cumberland, Edmonson, Gallatin, Grayson, Green, Harlan, Hickman, Johnson, Lawrence, Lewis, Martin, Menifee, Monroe, Rockcastle and Wayne.
Bath, Estill, Knott, and Leslie counties, which are included on the list of 54, were recently added to the exchange map, as have Todd County in Western Kentucky and Scott County in the Bluegrass region. These exchanges are marked as not yet operational.
State Sen. Whitney Westerfield of Hopkinsville "still thinks some of his colleagues are uneasy" about syringe exchanges, Max Blau reports for Stateline. "But he’s still hopeful that the results will mirror that of the CDC’s research, which shows that injection drug users who have access to syringe exchanges are five times more likely to get treatment than those who don’t.
“There’s not universal support, but we’ve moved in that direction,” Westerfield said. “I don’t see the people who hated [syringe exchanges] filing bills to reverse it. With harm reduction, there’s more general acceptance of it.”
Western Kentucky
Western Kentucky has been slow to adopt such programs, but that could be changing; three of the eight syringe exchanges west of Louisville are among the newest.
Henderson County's exchange offers an example of the importance of persistent public health advocacy and education when it comes to getting these exchanges approved.
Douglas White details in his article for The Gleaner the many evidence-based arguments that Green River Health District Health Department officials presented at a January meeting of the Henderson City Commission meeting in support of a syringe exchange. He noted that the issue had been discussed on and off for several years and the exchange had been approved by the Fiscal Court, but needed the approval of the city, which finally happened in February.
Clayton Horton, the health department's director, told Charles Taylor of the National Association of Counties about the importance of getting buy-in from the community.
“That required us to do a lot of education and do some advocacy with local governmental bodies,” he said. “We weren’t asking for resources; we’re weren’t asking them to pay for it. But we were asking them to consent and agree and to trust us and to trust the evidence-based practice to set these up and run them.”
Todd County's exchange was approved June 14, Adam May reports for WHOP in Hopkinsville, and his story also spoke to the importance of public health' leaders' role in educating the community.
Magistrate Brent Spurlin said "he was initially skeptical and heard from people who believe the needle exchange is only a way to enable addicts, but he changed his opinion as he learned more," May reports.
When Graves County opened its exchange in April, Mayfield Police Chief Nathan Kent told Chris Yu and Randall Barnes of Paducah's WPSD-TV that he applauded the health department for opening the program, and that he believed it would not enable drug users -- which is a common misperception.
“From our perspective, if folks come in here and take advantage of this opportunity, and they get the resources that convince them to make a change in their life, and they are able to overcome their addiction, then that’s just one more productive citizen,” Kent said.
Lauren Carr, the Graves County Health Department's harm-reduction coordinator, told WPSD that the first person who came to the exchange for clean needles told her, "No one has treated me like a person before."
“The whole goal of this program is to meet individuals where they’re at, but you can’t leave them there," she said. "You have to give them the resources, the education, and the things that they need to make better choices for themselves."
Hopkins County approved its exchange in April, Doreen Dennis reports for Surf KY News.
Cave City in Barren County was considering an exchange, but the city council voted unanimously against it, Gina Kinslow reported for the Glasgow Daily Times on Feb. 11. Barren County already has an exchange, in the county seat of Glasgow.
The middle of the state
The first sentence in Steve McClain's Georgetown News-Graphicarticle about Scott County finally passing its syringe exchange sums up the challenges involved in getting many of these programs passed: "After months and months of tense debate and votes, Scott County’s syringe exchange program launches Monday, July 1, from noon to 4:30 p.m."
And while there's not much posted online about Owen County's newly approved exchange, a December 2016 article in the Owenton News-Herald indicated that the Three Rivers District Health Department has been working on getting one there for years.
In another example of public-health persistence, the Anderson County Health Department proposed a syringe exchange three years ago and couldn't gain the support from either the city or county -- but in June of this year, the health board approved one, which now allows it to go before the city council and fiscal court, Ben Carlson reports for The Anderson News.
Taylor County approved its exchange in April. The Lake Cumberland District Health Departmentoffers two educational videos about syringe exchanges to educate its community, one that addresses how syringe exchanges help with the cost of Hepatitis C and the other titled, "Why in the World Would You Give a Needle to a Drug Addict?", shown below.
Exchange models vary
Ingram told the forum attendees, "When you've seen one syringe exchange program in Kentucky, you've seen one syringe exchange program in Kentucky." While they all work toward what is commonly called "harm reduction," they vary in their hours, locations and services offered.
One of the more unique set-ups is the use of mobile exchanges, which Laurel, Knox, Clay and Jackson counties will share. Whitley County, which has a stationary exchange, was supposed to join the program, but has decided to not participate, according the county health department.
WKYT-TVreported in April that Lexington's program was expanding to two days a week, and since September 2015 has served more than 2,700 people, with an average of 175 coming in every Friday.
"The thing we are most proud of is 128 people have entered rehab through this service," health department spokesman Kevin Hall told WKYT. "We have on-site counselors available to offer referrals into programs and so that is 128 people who get a second chance."
Another evolution of these programs is that many of them now regularly distribute naloxone, a drug that can reverse an opioid overdose.
Terry DiMio reports for the Cincinnati Enquirer that at least 92 lives have been saved with naloxone that was handed out at two Northern Kentucky syringe exchanges. Since opening the two exchanges have handed out 1,358 naloxone kits, she reports.
Click here to get a list of all the exchanges and their hours of operation, as well as a list of facts about syringe exchange programs.
A mobile syringe exchange will go to five Eastern Kentucky
counties: Knox, Laurel, Whitley, Clay and Jackson.(WYMT-TV)
Five Eastern Kentucky counties will soon have a mobile syringe exchange to minimize the spread of infectious diseases and to help get people who are addicted to drugs into treatment, Justin Kase reports for WYMT-TV in Hazard. It is expected to be running in two months.
A specially outfitted van, called a Mobile Harm Reduction Unit, is funded by a grant from the state Department for Public Health and will serve adjoining Knox, Laurel, Whitley, Clay and Jackson counties. All but Jackson are among the top 54 counties in the nation with an increased risk of outbreaks of hepatitis C and HIV due to intravenous drug use.
Mark Hensley, the executive director of the Laurel County Health Department, told Kase that the mobile exchange will offer many of the same services as stationary ones, including HIV and hepatitis C testing, hepatitis A vaccines, information about addiction treatment, and a peer counselor aboard.
Each of the counties in the program has an established syringe exchange in place. Hensley said Laurel County opened its syringe exchange about two months ago, and participation has been a bit slow. He told Kase that he expected better participation with the mobile van because it might help to break down some of the barriers associated with syringe exchange programs, such as "reliable transportation or just fear of the program itself."
The plan is for the unit to spend one day in each county before moving on to the next. Locations have not been determined. "We might establish four different locations within the county, you know, maybe try to hit the four corners of those rural areas," Hensley told Kase.
Forty-nine percent of Kentucky adults continue to favor programs that allow people who use intravenous drugs to exchange used needles or syringes for sterile ones, while about 40 percent oppose such programs, according to the latest Kentucky Health Issues Poll.
The poll asked, “Some people favor needle exchange programs because they feel these programs help reduce the spread of AIDS. Others oppose needle exchange programs because they feel these programs send the message that it’s okay to use illegal drugs. What about you? Do you favor or oppose needle exchange programs?”
Kentuckians with more education, those who live in urban areas, and those aged 18 to 29 are most likely to favor needle or syringe exchanges. Generally, the more familiar they are with the exchanges, the more likely they are to support them as a strategy to reduce the transmission of HIV, hepatitis C and other viruses.
Among Kentuckians who said they were not very familiar, or not at all familiar, with the exchanges, support for them has increased since 2016, to the point that they are about evenly divided on the issue. Support may have decreased slightly among those with more familiarity, but the shift in those numbers was within the poll's margin of error for each number, 2.5 percentage points.
The Foundation for a Healthy Kentucky, which co-sponsors the poll, said in a press release that the stigma of drug use and addiction generates opposition to needle or syringe exchanges. That has occurred most often among county fiscal courts, whose approval is required for an exchange to open in a county. Approval is also required by the county health board and the council or commission of the city where the exchange is located.
"Needle exchange programs are about community safety and connecting people to treatment," said Ben Chandler, the foundation's president and CEO. "They don't lead to higher drug use, and they don't lead to more crime in the communities where they're located. We can't let false perceptions stand in the way of a proven strategy to help deal with Kentucky's opioid and meth crises."
The federal Centers for Disease Control and Prevention has identified 54 Kentucky counties most at risk from an outbreak of HIV or hepatitis C from intravenous drug use and dirty needles. Only 27 of those counties have syringe exchanges.
State Department for Public Health graphic; click on it for a slightly larger version
The state Department for Public Healthwebsite has information about the exchange programs.
"More than 50 needle exchange programs are operating in Kentucky, helping to reduce the chances of hepatitis C or HIV outbreaks that can put everyone in a community at risk," said Dr. Brent Wright, associate dean for rural health innovation at the University of Louisville. "These programs also remove dangerous used needles from the community, and can give participants access to vaccinations, substance-use-disorder treatment, overdose-prevention information and disease screening."
Wright was quoted in a press release from the foundation, which co-sponsors the poll with Interact for Health, a Cincinnati-area foundation. He is treasurer of the Kentucky foundation's board of directors.
Kentucky leads the nation in the number of syringe exchange programs, but passing such programs continues to require great amounts of public education and perseverance.
Daviess County, home of Owensboro, the state's fourth-largest city, is the latest to launch a syringe exchange. That brings the number of exchange locations to more than 50, in 47 of the state's 120 counties. Graves County has approved a program, but it's not yet operational.
Western Kentucky has been slow to adopt such programs, which were approved by the state legislature in the 2015 anti-heroin bill as part of an effort to decrease the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles by intravenous drug users.
Daviess County's program, which will serve residents of the seven counties in the Green River health district, is the fourth syringe exchange to open west of Louisville. The others are in Muhlenberg, Warren and Barren counties.
Daviess County Judge-Executive Al Mattingly said the slow embrace of exchanges in Western Kentucky is because there has been less need for the programs in that part of the state, Katie Pickens reports for The Owensboro Times, an online newspaper.
The latest Kentucky Health Issues Poll found that the percentage of adults in Western Kentucky who knew someone who used heroin was 12 percent, compared to 36 percent in Northern Kentucky, 24 percent in Lexington and Louisville and 21 percent in Eastern Kentucky.
Daviess County is not one of the 54 Kentucky counties listed by the federal Centers for Disease Control and Prevention to be most at risk to outbreaks of HIV or hepatitis C as a result of IV drug use, but it is near three counties that are on that list that haven't approved syringe exchange programs: Breckinridge, Grayson and Edmonson. None are in the Green River health district.
Of those, Grayson County has come closest to getting one. The county health board and the Leitchfield City Council have already approved it, but the county Fiscal Court failed to get a second to a motion for it on Jan. 15, Matt Lasley reports for the Grayson County News-Gazette. (The health board, fiscal court and the legislative body of the city where the exchange is to be located must approve it.) UPDATE: The fiscal court unanimously rejected the idea on Feb. 8.
The first failed vote followed two hours of testimony, both for and against the program, Lasley reports.
And it seems the course of these discussions are similar across the state.
Proponents, largely from the medical community, line up to present evidence-based research about syringe exchange programs that shows how they do not encourage people to start using IV drugs,or increase the frequency of use among current users; how they reduce the spread of infections like HIV and hepatitis C; how they do not increase community crime; how they do increase community safety by taking dirty syringes off the street; and how they are known to help connect people to treatment, with one study finding that syringe-exchange participants are five times more likely to enter a drug treatment program than non-participants.
Opponents say they believe that the programs enable addiction, increase drug use or would bring drug users from neighboring counties into their communities, which could lead to more crime. Others struggle with providing an addict with a tool to feed their addiction. And many simply say they don't believe the research.
"Commonwealth's Attorney Rick Hardin said he was hesitant to believe statistics that say needle exchange programs actually increase an individual's likelihood to attend rehabilitation, as well as whether they cut down the spread of diseases such as hepatitis and HIV," Lasley reported for the Leitchfield newspaper. Hardin also prosecutes felony cases in Breckinridge and Meade counties.
Dr. Joe M. Lee
On Jan. 22, the News-Gazette published a guest editorial by Dr. Joe M. Lee, medical director of the local health department, that tried to overcome the opposition by giving the paper's readers more information. "Part of the magistrates’ concern was that the people they represent don’t understand the program and were generally opposed to it," Lee wrote. He said there had been "huge increase in Hepatitis C and HIV/AIDS" in the county, mainly as a result of intravenous drug use.
"This is a public health emergency," he wrote in bold letters."Please encourage your magistrate to vote YES and let's help our county begin recovery from this epidemic. You may be saving the life of a child, a loved one, a neighbor or a friend." Grayson County Judge-Executive Kevin Henderson said he may call up the issue again, Lasley reports.
Meanwhile, the Twin Lakes Regional Medical Center in Leitchfield will soon offer an opioid medical stabilization program for expectant mothers. CEO Wayne Meriwether said he started the program because one of the hospital's OB-GYNs said he cares for a large number of mothers who are addicted to drugs, Amy Lindsey reports for the News-Gazette.
Farther east, in the Bluegrass region, Scott County is one step closer to adopting a syringe exchange. After the fiscal court voted it down in December, with two magistrates absent, it was called back up for a vote in January and passed 5-3. The program already has the approval of the county's board of health and now must be approved by the Georgetown City Council, Paul Watson reports for the Georgetown News-Graphic. Scott County has been debating the issue for about two years.
Other localities that are actively considering a syringe exchange program are Henderson and Todd counties and Cave City in Barren County.
State Rep. Kim Moser
The chair of the House Health and Family Services Committee, Rep. Kim Moser, R-Taylor Mill, told Kentucky Health News that she would like to see the law changed to let the local health board and health department start syringe exchange programs on their own.
"This is the only issue that the legislature gets involved with in telling the health department what to do," said Moser, who once ran the Northern Kentucky branch of the state Office of Drug Control Policy.
Needs-based vs. one-for-one syringe exchanges
Another point of contention is whether these programs should be based on the weekly injection needs of the client – called needs-based – or whether they should require a one-for-one exchange of syringes.
Health officials say that if the goal of the program is to stop the spread of infectious diseases such as HIV and hepatitis C, Kentucky must allow intravenous drug users to have as many needles as they need in order to have a clean one for every injection, and that a one-for-one requirement defeats that purpose.
A one-for-one model is also listed on the Cabinet for Health and Family Services' website as one of the "practices to avoid" because it "results in sharing of needles."
Senate Majority Floor Leader Damon Thayer, R-Georgetown, a critic of the program since its inception, has filed Senate Bill 69 that would require syringe exchanges to dispense only one clean needle for each used needle.
Sen. Damon Thayer
"I would love to get rid of the needle exchange altogether," Thayer told Lawrence Smith at WDRB, "but I don't think I could get that passed." He added, "I respect the public health argument. I just am philosophically opposed to taxpayers paying for a needle for someone to do an act that is illegal."
Moser said she doesn't support Thayer's bill and hopes it doesn't get out of the Senate Health and Welfare Committee. "I oppose it," she said. "I do not think that removing programs that are working, that are getting people into treatment is the way to go."
Moser pointed out that health departments are statutorily required to reduce communicable diseases, and that's what a syringe exchange program does. Further, she said Kentucky can't afford to pay $80,000 per hepatitis C treatment for its Medicaid patients, when a "very simple, cost effective" solution to prevent hepatitis C is a six-cent needle.
Dr. Lynne Saddler, Northern Kentucky Health Department's district director, also opposes Thayer's bill. She told Terry DeMio of the Cincinnati Enquirer, "The science is clear that a 1:1 [one-for-one syringe] policy is not effective in stopping the spread of HIV through injection drug use."
The Louisville and Fayette County programs use a needs-based model, as do some others. But many of them start off by giving out a set number of needles on an as-needed basis, and then move to a one-for-one model. Counties that use any grant money from the Kentucky Agency for Substance Abuse for their syringe exchange programs are required to use a one-for-one model.
The demand for syringe exchanges crosses county lines; if local governments haven't allowed one in a county where intravenous drug users live, some of them go to a county that does have one. For example, most clients of the exchange in Adair County (population 19,485) are from Taylor County (population 25,472).
Sharon Burton of the Adair County Community Voicereported those figures after getting them from the Lake Cumberland District Health Department, which operates exchanges in Adair, Russell, Pulaski and McCreary counties, where local officials have authorized them.
The headline on her story said "Syringe program shows dire drug epidemic," and a front-page graphic from the health department showed how often IV drug users say they inject. Almost half said they do nine or more times a day.
Pulaski County, with an estimated population of 65,000, currently has 447 participants, or 0.69 percent of its residents. McCreary has 191, or 1.1 percent of its population of 17,465. Taylor has 181, or 0.71 percent. Russell with 151, or 0.85 percent of its population of 17,775. Only 76 are from Adair, 0.39 percent of its population. "Others come from Casey, Green and other counties not listed," Burton reports.
"Of the people participating in the program in Adair County, 178 are from Taylor County (58.6 percent) while only 64 (21.1 percent) are from Adair," Burton reports. In Adair, "294 different people have participated in the program a total of 985 times since the program began in September 2017. . . . A total of 43,040 syringes have been dispensed and 29,065 collected. Participants are not required to bring in syringes on their first visit but are expected to bring them in during subsequent visits."
Tracy Aaron, the district's director of health education, "said the program has been very effective for several reasons," Burton reports. "It is reducing the spread of disease and people are reporting fewer needles in parks and on the streets, she noted. The program also connects participants to volunteer peer counselors, people who have successfully completed treatment themselves. In addition, the health district’s staff provides participants with information about treatment and counseling programs."
Aaron told the Community Voice, “To see those individuals, and to know they have trust and that someone cares about them, this is really an opportunity for those individuals.”
Health dept. chart shows exchange participants by month in Adair County
"Since its inception starting first in Russell County in June 2017, a total of 1,037 participants have visited 4,311 times," Burton reports. "A total of 173,383 syringes have been dispensed and 129,286 collected. The most highly used drug is methamphetamine, with 751 participants reporting they used it. The second most highly used was suboxone, used by 394 clients. A total of 315 participants reported using heroin."
Burton adds, "Of 1,135 clients in the district who self-reported, a total of 420 participants (37 percent) reported injecting drugs at least nine times a daily. Another 339 reported using six to eight times daily and 270 reported using at least three to five times daily. A total of 317 clients reported testing positive for Hepatitis C," which is prevalent among IV drug users.
Monthly reports on the district's syringe exchanges are available online.
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.
It took two years, but Campbell and Kenton counties will finally launch their syringe exchange programs the week of July 23.
The new mobile exchanges will be run by the Northern Kentucky Health Department at locations of St. Elizabeth Healthcare. The Newport location will begin July 24 and the Covington location will start July 26, reportsThe River City News.
It took perseverance for the counties to establish the exchanges, overcoming social and political obstacles, like many other Kentucky counties that are still trying to create their own exchanges.
Campbell County approved an exchange in 2016, but state law requires approval from the city in which the exchange will operate, as well as the board of health and the county government, and Newport did not approve the exchange until February of this year.
Newport's decision came after a cluster of HIV cases were identified in the region, as well as a high number of hepatitis C cases. From Jan. 1, 2017, to March 16 of this year, the NKHD had diagnosed 45 cases of HIV, 21 of them intravenous drug users. From 2009 to 2016, zero to five such cases were reported each year, department spokeswoman Emily Gresham-Wherle told Terry DeMio of the Cincinnati Enquirer. The region also has a high rate of hepatitis C infections, typically carried by sharing of needles.
Kenton County and Covington had also approved a syringe exchange in 2016, but with a requirement that it could not start until two other Northern Kentucky counties in the NKHD district had operational exchanges. Campbell County's exchange allows the Kenton County program to go forward; NKHD has operated one in Grant County for three years.
The new mobile units will provide clean needles, Naloxone overdose-reversal kits, offer HIV tests, and provide referrals for other health services, including addiction treatment. What they won't do is provide condoms -- which are also known to fight infectious diseases and commonly distributed in these programs -- because the mobile exchanges will be located on the grounds of Catholic hospitals, DeMio reports.
Nevertheless, it appears that health officials in the area are grateful to St. Elizabeth for providing a site for the exchanges. Hospital spokesman Guy Karrick told DeMio that while the hospital couldn't countenance the distribution of contraceptives, it wanted to get the exchange going as quickly as possible. He added that the exchange might be better situated on health department property.
Despite the many challenges that face largely rural, conservative Kentucky counties to support opening these programs, Kentucky leads the nation in the number of counties with local syringe exchange programs (perhaps in part because it ranks third in the number of counties). As of June, 4745 of Kentucky's 120 counties have approved syringe-exchange programs at more than 50 sites.
However, the federal Centers for Disease Control and Prevention says 54 Kentucky counties are among 220 in the nation with the highest risk of an HIV or hepatitis C outbreak among IV drug users, and half of those 54 counties still haven't approved exchanges.
One of the 27 high-risk holdouts, Clinton County, narrowly approved an exchange in March but backed out eight days later after complaints that it would encourage drug use. In the Republican primary election in May, the Fiscal Court magistrate most vocally opposed to the exchange defeated the county judge-executive, who favored it. The CDC says the county has the 11th greatest risk of any county in the nation for an HIV or hep-C outbreak among drug users.
Lawrence County, ranked 39th on the list, has also struggled with the issue. The county health board approved the proposal in September 2016, and the Louisa City Council followed suit in July 2017, the Fiscal Court unanimously rejected the proposal in March, WYMT-TVreported.
County Judge-Executive John Osborne told a packed house at the meeting that while he worries about HIV and hepatitis C, he worries about needles more, WYMT reported. "If you give out 40 needles at a time, you're probably are going to see a lot more needles on the ground," Osborne said. “It does bring a lot of people not from this area and that could cause a lot more problems.”
Public Health Director Debbie Miller told WYMT that she was disappointed but not surprised with the result. “I feel like the Fiscal Court is telling us that they’re not concerned with the fact that Lawrence County has been deemed one of the most vulnerable counties in the U.S. for an HIV or hepatitis C outbreak," she said. "The bottom line is, no matter how uncomfortable these syringe exchange programs make us all feel, and they do all make us somewhat uncomfortable, they are proven to save lives."
On the other hand, five Eastern Kentucky counties on the CDC list have started syringe exchanges in the last few months.
Perry, Letcher and Wolfe counties added exchanges in April "thanks to the expanded initiative by the Kentucky River District Heath Department," Will Puckett reported for WYMT in April. That came a few months after after Lee and Owsley counties approved theirs.
Scott Lockard, the department's public health director, told Puckett that the price of bringing in used needles and exchanging them for clean ones is small compared to the cost of treating diseases: $80,000 for a case of hepatitis C, "and the cost for someone who contracts HIV can cost over half a million dollars."
Getting county officials to accept a syringe exchange program often depends on public education and perseverance, as evidence by another county that took two and one half years to get its exchange.
In March, Mary Meehan reported for Ohio Valley ReSource that it took Bourbon County two and a half years, and two failed votes, to get an exchange. It finally passed on a 6-2 Fiscal Court vote, and opened its doors in May.
Bourbon County is not on the CDC list, but the concerns there reflect those voiced across the state. People worry that the drug users will just take the needles and sell them; some say drug users are just looking for a handout; others say it is enabling their misbehavior, and others worry that it will draw addicts from surrounding counties that don't have exchanges.
Research shows that syringe-exchange programs do not encourage the initiation of drug use, nor do they increase crime or the frequency of drug use among current users. They do reduce the spread of infectious diseases like HIV and hepatitis C; increase community safety; and connect people to treatment, according to the state Cabinet for Health and Family Services.
Meehan writes, "The health facts run up against deeply help opinions about the moral aspects of drug use and the notion that a needle exchange enables drug addicts to continue harmful behavior." She reported that Bourbon County Judge-Executive Mike Williams encouraged other community leaders to persevere. "It took us three times," he said. "Don't give up, and keep presenting the facts."
The State Journal in Frankfort recently said in an editorial that syringe exchanges are part of a holistic approach to fight the opioid epidemic, noting that the Franklin County's exchange had provided more than 115,000 clean syringes to users, and collected more than 82,000 used ones.
The newspaper said there are still many in Franklin County who object to the exchange, but "We’d ask whether it’s better for a user to share needles and potentially infect others or be infected or to use clean needles and reduce or eliminate the chance of infection."
Clinton County, which has a serious drug-abuse problem, took a big step toward becoming the fifth county in the 10-county Lake Cumberland Health District to approve a syringe exchange. Then it backed off.
The county Fiscal Court voted 4-3 in favor of the exchange March 15, with Judge-Executive Richard Armstrong casting the tie-breaking vote. "Armstrong noted that he was at first skeptical about the program himself, but the more he has learned about it, the more he was in favor of it," the Clinton County Newsreports. "He noted that if the program saved just one life it would be worth it. 'At least it’s an improvement,' he said."
Ricky Craig, one of the three magistrates who voted no, and one of Armstrong's five opponents in the May primary election, disagreed. “It’s like promoting drug use,” he said. He also noted that diabetics "are not eligible for free syringes in most cases," the News reports. "Craig also noted that the addict chooses to use the drug, while people who have illnesses like diabetes do not choose it."
Dr. William Powell of the county Board of Health "said the point of the exchange program was not to promote drug use but rather prevent disease," the News reports. Tracy Aaron of the Lake Cumberland District Health Department said drug users will exchange needles whether they are clean or dirty, and dirty needles are a health hazard.
The hazard is not just to users. Health board member Christy Guffey "noted that there had been syringes found at the park and other places, that are a danger to children and others, such as people who clean up roadways."
The health board has approved the exchange; the last hurdle was to be the Albany City Council, which next meets April 3. But on March 23, the fiscal court held a special meeting at which all the magistrates voted against the exchange and Armstrong did not vote, according to Alan Gibson, editor and publisher of the News.
Clinton County has one of the highest annual rates of drug-overdose deaths (9.62 per 10,000 people aged 15 to 64) in Kentucky, and the federal Centers for Disease Control and Prevention has ranked it 11th among U.S. counties most vulnerable to outbreaks of HIV or hepatitis C as a result of intravenous drug use.
Adjoining Russell County, with an overdose-death rate of 7.3, has adopted a syringe exchange. Others in the Lake Cumberland district that have done so are Adair, McCreary and Pulaski.
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.
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."
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)
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.
The administration of Republican Gov. Matt Bevin is requiring syringe exchanges funded by state grants to be limited to one-for-one trading of clean needles for dirty ones, raising the chance that all such programs might have to do likewise.
Republicans said in the last legislative session that the 2015 law allowing syringe exchanges was intended to only allow a one-to-one trades. Their effort to impose such a limit died in the House, notesThe Floyd County Times in Prestonsburg. The county recently approved an exchange.
If the Democratic-majority House goes Republican in November, both the legislature and the administration would be Republican, and in a position to impose a one-syringe limit. That would reduce the protection provided by syringe exchanges, say health officials running them.
The exchanges are meant to slow the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles among intravenous drug users. They are not required to have a one-for-one exchange because of an opinion by then-Attorney General Jack Conway.
Clark County Health Director Scott Lockard said in a telephone interview that most Kentucky syringe-exchange programs use a "patient negotiation model," which provides the user with as many needles as they need for one week to assure they use a clean needle each time, often up to a capped amount.
"The goal is that they use a clean needle for each time they inject," he said. "We want to stop the spread of HIV. We want to stop the spread of hepatitis C and any of these other blood-borne pathogens that can be spread through the sharing of contaminated needles."
Lockard noted that while a one-for-one exchange is the goal, sometimes it is impossible to adhere to such strict requirements. For example, he said users don't always keep up with their syringes or sometimes will tell you they are sharing them.
So, with a strict one-for-one exchange you aren't able to provide them with enough needles to prevent sharing, "which means you are not doing anything to prevent the spread of disease. And the purpose of these exchanges is to prevent disease," he said.
Dr. Sarah Moyer, then interim director of the Louisville Metro Department of Public Health and Wellness, told Kentucky Health News in March that it is widely accepted that not requiring one-for-one is considered a best practice.
The state grant program requires applicants who plan to use the money for a syringe exchange program to promise that it would be a strict one-for-one exchange after an initial transaction with a client.
Asked why the requirement was added, Van Ingram, executive director of the state Office of Drug Control Policy, said only, "That was an administration decision." The governor's office and the Cabinet for Health and Family Services did not respond to requests for an explanation. Neither did Thayer.
The grant program is funded by the Agency for Substance Abuse Policy. The deadline for application was Sept. 23 and grant amounts will be considered up to $20,000. The grants can also be used for Narcan (naloxone) programs, community education and other harm-reduction efforts. The agency received 38 applications and expects to announce the recipients near the end of October, Ingram's office said.
Boyle and Floyd counties are the most recent counties to approve syringe exchange programs, bringing the total in the state to 20.
Both counties will offer a one-for-one exchanges and have applied for an ASAP grant to help fund their programs. Both say their decision to implement a one-for-one exchange was largely driven by the requirements of the grant.
Boyle County Health Director Brent Blevins said, "The grant we are applying for is very important to help us get this off the ground."
Floyd County Health Director Thursa Sloan said, "It was just a better fit for our area, for the board and for the people. We don't know that that couldn't change down the road, but the funding we are seeking to help support it is contingent on an equal exchange program."
Both Blevins and Sloan noted that the original version of the 2015 legislation called for one-to-one exchanges. Boyle and Floyd, respectively, are considered the 35th and 10th most vulnerable counties in the nation for HIV and hepatitis C outbreaks among those who inject drugs, according to estimates by the federal Centers for Disease Control and Prevention.
Lockard said syringe exchanges are a "very political issue," and while one-for-one exchanges are not the ideal solution, they may be what is "politically palatable."
Ingram stressed the importance of such programs: "We have the fastest growing rate of hepatitis C in the country in large part due to the sharing of needles." He added, "More than 100 people have been guided into treatment as a result of their participation in a needle exchange program.
Partly because it's much cheaper than pain pills, heroin is "quickly making inroads in Southern and Eastern Kentucky," the head of an anti-drug organization told Laura Ungar of The Courier-Journal.
Numbers show rank on Centers for Disease Control's national list of counties at risk for outbreak of HIV or hepatitis C from needles.
Nancy Hale is president and CEO of Operation UNITE (Unlawful Narcotics Investigations, Treatment and Education), which serves 32 Appalachian Kentucky counties and has law-enforcement powers. "Hale said they are arresting more people for small-time heroin offenses and hearing from ERs treating overdose victims," Ungar reports. "One reason, she said, is that the drug provides a relatively cheap high. A hit of heroin in Appalachia costs about $5, compared with around $30 for one pain pill."
Meanwhile, treatment centers in the region "are serving more people seeking to kick heroin and break the cycle of addiction," Ungar reports. "At Hope in the Mountains, a women’s recovery facility in Prestonsburg, 22 of 36 clients are heroin addicts."
Heroin started becoming more common in Kentucky's major metropolitan areas after the legislature cracked down on pain pills in 2012, but took a while to reach rural areas because the supply chain from Mexico runs through major cities, then smaller ones, officials said. Now, in Hazard, "I’m definitely scared about heroin," Police Chief Minor Allen told Ungar. "We already have syringes laying
around in playgrounds and neighborhoods. Anything that deals with shooting up is
scary."
The federal Centers for Disease Control and Prevention considers the region the most vulnerable in the nation to outbreaks of HIV and hepatitis C from sharing of needles by intravenous drug users, but only four counties in the area, Pike, Carter, Elliott and Knox, have syringe exchanges where users can get clean needles. The exchanges require city and county approval.
Amanda Holpuch of The Guardian took a trip to Wolfe County, perhaps the U.S. county most vulnerable to an outbreak of HIV or hepatitis C from needle sharing by intravenous drug users, a report noted here June 16.
"A man was lying sedate after injecting drugs. His fellow users, to amuse themselves, threw needles at him like a human dartboard to see if they would stick, according to a recent police report in Wolfe County," Holpuch reports, quoting special deputy sheriff Gary Smith: “Back in the day, all we had to worry about was people drinking or smoking weed.” An unnamed captain says, “Everybody is using drugs here – end of story.”
The federal Centers for Disease Control and Prevention, in determining the 220 counties most vulnerable, used "a sobering recipe: high rates of drug overdose deaths and prescription opioid sales, a high white population, astounding rates of hepatitis C and searing poverty," Holpuch writes. "The CDC said the top 20 most vulnerable counties identified in its report are effectively equal in vulnerability because of the analysis’s margin of error, but Wolfe County is ranked first and serves as a model for the places at most risk, 13 of which are in Kentucky." Of the 220, 54 are in Kentucky.
Smith likened the sharing of syringes "to a more dangerous version of a group of men getting together to share a bottle of whiskey. Instead of swapping saliva on a bottle cap, users are exchanging all types of body fluids and pushing a needle coated with those fluids into their bodies."
Kentucky was the first state in the South to authorize syringe-exchange programs, in 2015, but local officials have yet to establish one in Wolfe County or in many of the other 54 Kentucky counties on the national list of 220, the Lexington Herald-Leaderreported in July.
Why, if 54 of Kentucky's 120 counties are among the nation's most vulnerable to outbreaks of HIV and hepatitis C among intravenous drug users, do only a few of them allow users to exchange used syringes for clean one to avoid spreading the diseases?
That question was asked, implicitly, by a national expert who spoke at the 2016 Viral Hepatitis Conference in Lexington July 26.
"I think it is very interesting to compare the counties we believe are at risk, based on our modeling, and then where are prevention services, such as syringe-service programs," said Dr. John Ward, director of the Division of Viral Hepatitis at the federal Centers for Disease Control and Prevention. "You can see there is a big disconnect, that there is a big gap in syringe service availability and other powerful prevention interventions, such as medication-assisted therapy."
Syringe exchanges were authorized in Kentucky under a 2015 anti-heroin law and require local approval and funding. They are meant to slow the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles among intravenous drug users.
So far, 14 counties have approved syringe exchanges, according to the Cabinet for Health and Family Services, with 11 of them operating. But only six (Carter, Boyd, Pike, Knox, Mercer and Grant) are in the most-vulnerable group.
A spokeswoman for the state Department of Public Health said the agency supports the exchanges and is available to provide support, share best practices, offer technical guidance, and provide information on their effectiveness and benefits.
"In addition, DPH has hosted several statewide conference calls with local health department directors to discuss setting up syringe exchange programs," spokeswoman Beth Fisher said. "We have also coordinated several trainings for syringe-exchange staff members as well as administrators. We also work to provide education and training regarding harm reduction related to syringe use to communities."
Dr. John T. Brooks, senior medical adviser for CDC's Division of HIV/AIDS Prevention, pointed out the HIV outbreak that occurred in Scott County, Indiana last year, which drew national attention because of its high rates of HIV and hepatitis C.
He said Scott County isn't that different from many rural Kentucky counties because of its high poverty and unemployment rates, low education and life expectation, lack of HIV and hepatitis C care, insufficient addiction services and no needle exchange when the outbreak began. The CDC found that 18 Kentucky counties were more vulnerable to a hepatitis C and HIV outbreak among IV drug users.
"If we don't pay attention to history, we are doomed to repeat it at some point in the future," Brooks said. "You want to prevent this from getting introduced and recognize it the moment it is introduced so that you can do what you can to prevent it from continuing to spread."
Ward said multiple approaches are needed to stop the spread of hepatitis C. Using the Scott County outbreak as a model, he said a syringe-exchange program would decrease hepatitis C by 27 percent; adding medication-assisted therapy would make the decrease 41 percent; and adding a robust testing and treatment program would get it to 71 percent.
Brooks said syringe exchanges and medication-assisted therapies would reduce the potential spread of new HIV infections by 64 percent and 56 percent, respectively.
He encouraged Kentucky counties to gather their own data to determine the prevalence of IV drug use in their communities; to test people with substance-use disorders in jails and prisons, and those who frequent emergency rooms, for HIV and hepatitis C; and to create a countywide plan for a potential HIV or hepatitis C outbreak.
Referring to resistance to syringe exchanges, Wayne Crabtree of the Louisville exchange asked, "When has judgement, stigma or shaming ever made a difference in someone's life? When did it ever change behavior? I would say never. And we in public health know it is the hand reaching out to someone in need lifting them up and making them realize their self-worth that elicits change."
Dr. Ardis Hoven, a state infectious-disease expert, said "Stigma continues to exist everywhere around many of the issues we are discussing today and I think it is our responsibility and our challenge to begin to open up the dialogue in a way that goes to minimizing it. Because as stigma is sitting out there, we are not going to be able to get the job accomplished as well as we should."
Hoven said establishing a syringe exchange requires local data and local allies, especially local police, who can "make or break a syringe-exchange program."
