Lessons From Indiana HIV Outbreak Aren’t What You’ve Been Told

Joey Fox

As the legislative director for the Indiana State Department of Health during the HIV outbreak in Austin, Indiana, I saw firsthand the heroic, effective, and sustainable response of the community, with the support of the state.

Sign in front of Community Outreach Center (the “One-Stop-Shop”) in Austin, Indiana, 2015. Tyler Stewart/AP

This week, Molly Martin, the Indiana director of the New America think tank in Indianapolis, penned a column for her native Charleston, West Virginia, newspaper, on increasing rates of HIV and Hepatitis-C that followed the closure of a local syringe exchange program.

She points to the alleged failures of Indiana in addressing similar issues, specifically and gratuitously taking aim at former Governor Mike Pence.

As the legislative director for the Indiana State Department of Health during the HIV outbreak in Austin, Indiana, I spent most of my time working on policy in Indianapolis, but I saw Austin firsthand and the heroic response of the community, with the support of the state. I’m writing on my own behalf and not as a spokesperson for the response or my former employer.

While I have many objections to her piece and the thinking behind it — factually, historically, culturally, ideologically, and logically — I have five primary objections.

1. The author doesn’t tell the rest of the story.

The facts simply don’t align with the author’s description of a response that didn’t provide “greater access to care.”

Consider the timeline. The cluster of HIV cases was identified in late January of 2015. By April 4, the community, with the support of the state, had deployed disease intervention specialists and multiplied testing efforts, established an incident command system, requested and received federal assistance from the Centers for Disease Control and Prevention, began testing the regional jail population, declared a public health emergency (in accordance with an executive order signed by Governor Pence), opened a local HIV treatment clinic, and launched the first legal syringe exchange program in Indiana history. State law was changed later that April to allow other local communities to establish syringe programs.

The author conveniently left out a description of the comprehensive response the state supported in Austin. The Governor directed state agencies to join a “one-stop-shop” in the community, to allow for people to get birth certificates and ID cards, sign up for health insurance (made possible thanks to Governor Pence and his implementation of the Healthy Indiana Plan Medicaid waiver), get tested, get vaccinated, begin pre-exposure prophylaxis, see a mental health counselor, get a referral for substance abuse disorder treatment, begin HIV treatment, and more.

The author also left out mention of the local community and its heroes. Moms, dads, and family members who were heartbroken by their loved ones’ addiction and subsequent diagnoses, but who supported them nonetheless. The people diagnosed with HIV who bravely started treatment and brought their friends and families to get tested. The kids at the local schools who rallied around one another as their parents and families faced this crisis. The civic organizations that organized a cleanup of syringes littering the parks and streets (which, despite the author’s assertions otherwise, actually do worry parents and citizens — and for good reason). The doctors who had served Austin before the outbreak (identifying it, actually) and would continue to do so after the news crews left. The public safety officials who put aside grave concerns for their constituents and community to allow for public health intervention when it was needed most.

Perhaps most importantly: today, Austin, Indiana, has a rate of viral suppression far exceeding the national average. This is the measure by which the virus count in the blood is so low it is virtually impossible to pass along. Hepatitis C is being cured in Scott County. The state has pioneered Project ECHO, which teaches providers how to treat and cure Hep-C. Not for nothing, the research stemming from this outbreak was given the CDC’s highest honor, the Charles C. Shepherd Science Award.

2. Mike Pence made syringe exchange legal in Indiana.

Say what you will about him, but the fact is that when Mike Pence took office, syringe exchange was illegal in Indiana. When Mike Pence left office, syringe exchange was not only legal, but was being established in communities throughout the state. Acting as if the community refused to use a proven public health tool is disingenuous at best. The tool was illegal. Law had to be changed. The Governor intervened by executive order. The legislature passed a bill changing the law on the final night of the session, and Governor Pence signed it shortly thereafter.

3. Indiana’s syringe exchange program is unique, because it was born of unique circumstances.

One can certainly disagree with the structure of Indiana’s syringe exchange law. But it worked.

To the best of my knowledge, the outbreak in Scott County was the country’s largest (and one of the earliest) rural HIV outbreak. To some degree, this was new territory. It will surprise no one that urban and rural areas are different. All the research and practice on syringe exchange was related to urban areas. It is the height of condescension to believe you could just impose an urban solution on a rural area.

Further, for a syringe exchange program to be effective, it must have community buy-in and trust among its customers. In a town of 4200 people, if you had the “experts” from Indianapolis or Washington, D.C., come in, take over the locally controlled county health department, and set up a place to hand out needles on Main Street, you would have been run out of town. Community stakeholders from public health, public safety, civic institutions, and the general public, communicated real concerns about these programs. Those couldn’t be dismissed off hand if the community was to build an effective and sustainable response. The process that was designed by executive order of the Governor and later refined and ratified in state law allowed the local community to determine the path forward.

4. The author clearly has “values,” but she defines the word “values” as a negative trait of those on the other side of the ideological spectrum from her.

The author belies her own ideological underpinnings by insinuating that only conservatives could be driven by “values,” but more enlightened (read: liberal) leaders just want to do “what works.” But that’s ridiculous. Everyone has values. This turn of phrase allows for condescension, rather than disagreement. For example, the author clearly values the right to have an abortion, evidenced by her multiple mentions of the importance of Planned Parenthood in communities, even though there are many healthcare access points that don’t have the destruction of innocent human life as part of its profit model. Here, the author and I have different values, but she just wants “what works.”

5. Planned Parenthood and the HIV outbreak in Scott County are unrelated.

This trope must die that the closing of a Planned Parenthood clinic in Scottsburg, Indiana, somehow caused or foretold an HIV outbreak in Austin, Indiana.

Not to let facts get too far in the way, the Scottsburg Planned Parenthood closed in early 2013. Scientific testing indicates that 90% of the infections identified in the outbreak (2015) were less than 221 days old. In addition, the original cluster of infections was identified through care provided by a local medical doctor, supported by the county and state public health infrastructure to trace contacts. It’s not an honest argument to suggest that Planned Parenthood (or any one organization, frankly) could have or would have prevented this outbreak. But, for sake of argument, let’s play it out.

First, Planned Parenthood has plenty of money. If they had wanted to keep that particular clinic open, they could have done so.

Second, Scottsburg and Austin are completely different communities in many senses, and if you spent any time there, you would know the parochial nature of the relationship. As a generality, people in Austin don’t go to Scottsburg unless they must; Scottsburg tends to act as if Austin doesn’t exist.

Third, the group of people using injection drugs in Austin was in the height of active addiction. And Planned Parenthood certainly wasn’t out on the streets of Austin going house to house looking for people who use injection drugs. That’s what state and local health officials did. Instead of heralding the local medical professionals who worked so hard to identify and fight the outbreak, the author chose to repeat a nonsensical claim that only served to further her ideological “values.”

The author and I agree that much can be learned from Indiana’s experience with an HIV outbreak. And we may also agree that those lessons are at least partially political. In America, and within individual states and communities, you have to build coalitions and support. You can’t just impose solutions.

This outbreak was heartbreaking. We can all share the hope that the lessons of this outbreak and its locally-driven, heroic, effective, and sustainable response, can be used to prevent and respond in the future.

Joey Fox

Written by

Joey Fox

Dad/husband. Republican. #LoveIndy. Love life and music. Principal at Joey Fox Consulting: lobbying/comms. Former legislative director, Indiana Dept of Health.

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