Preventing an HIV outbreak before it occurs

Why we cannot end the HIV epidemic without syringe service programs

We have a once-in-a-generation opportunity to end the HIV epidemic in the United States. With recent federal commitments to the Ending the HIV Epidemic initiative, unprecedented amounts of resources have been mobilized to increase the reach and impact of proven effective strategies for HIV prevention and treatment.

A core pillar of this initiative involves responding quickly to potential HIV outbreaks to deploy prevention and treatment services to people who need them. Despite this, we still face obstacles in tackling outbreaks, particularly in rural areas. These areas are heavily impacted by opioid use and its infectious consequences, including HIV and hepatitis C, but often lack the appropriate healthcare and social service infrastructure to handle these public health problems. Most often, people who inject drugs in rural areas of the United States lack access to syringe services programs. Syringe service programs provide crucial and lifesaving services for their clients, including overdose education and naloxone (an opioid overdose antidote), testing for HIV and hepatitis C, and other health and social resources. With regard to HIV prevention, perhaps their most vital service involves the provision of sterile injection equipment, including needles, syringes, cotton, and cookers, so that people who inject drugs do not need to reuse equipment after they or someone else has used it. Without access to sterile injection equipment, people who inject drugs are made unnecessarily vulnerable to HIV, hepatitis C, and other blood-borne infections.

Banning the operation of syringe services programs has massive implications for the health and well-being of communities of people who use drugs.

However, these programs often face strong political opposition and outright bans. To some, syringe services programs are believed to encourage drug use, signal governmental acceptance of illegal behavior, and threaten public health and safety. However, decades of scientific research have shown that these concerns are unfounded. Currently in the United States, operating a syringe service program is illegal in 15 states and in areas where they are allowed, some operations have been forced to close due to funding constraints and lack of local support. Banning their operation has massive implications for the health and well-being of communities of people who use drugs.

In 2015, Scott County, a rural county of about 25,000 people in Indiana, was the site of the largest HIV outbreak in a non-urban area of the United States, where nearly 200 people were newly diagnosed with HIV infection over the span of two years. At the time, syringe services programs were not permitted under state law and people found to be in possession of a syringe without a prescription were subject to arrest and faced up to three years in jail. After nearly 100 people were diagnosed, the declaration of a public health emergency led to the operation of the first legal syringe services program in Indiana’s history, but some have argued that it was too little too late.

Without such a program, over 175 people were newly diagnosed with HIV infection over the span of 5 years. When the program was made available before an outbreak occurred, over 90% of these infections were prevented.

What would have happened had a syringe services program been in operation prior to the outbreak cannot be known. When facing an HIV outbreak, what role does the timing of operation play in the effectiveness of such a program? To answer this, we used a mathematical model to understand what could have happened had the syringe services program in Scott County been in operation before the outbreak even began. In a recent publication in Clinical Infectious Diseases, we found that, without such a program, over 175 people were newly diagnosed with HIV infection over the span of 5 years. When the program was made available before an outbreak occurred, over 90% of these infections were prevented.

Because predicting where outbreaks will occur before they happen is nearly impossible, these findings provide strong support for having these programs available regardless of whether an outbreak is currently occurring. Syringe services programs work. We cannot end the HIV epidemic in the United States without making them available and accessible for all who need them.

For more information on our study, please contact William Goedel (william_goedel@brown.edu).

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Public health research that is people centered, place oriented, & data driven. We study drugs, infectious diseases + intersecting epidemics.

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William Goedel

William Goedel

Find me on Twitter @william_goedel. PhD candidate at the Brown University School of Public Health using mathematical models to inform HIV prevention.

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