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Indiana health officials confront rural HIV outbreak related to opioid abuse.

An alarming HIV outbreak linked to injection drug use in southeastern rural Indiana has brought the nation's opioid addiction epidemic to the forefront and highlighted the critical role of public health workers in tracing disease outbreaks, providing health education and implementing prevention programs.

In February, the Indiana State Department of Health announced that an outbreak of HIV was quickly spreading across the southeastern portion of the state, with 26 confirmed cases of HIV and four preliminary HIV cases since December 2014. Health officials linked a large majority of the HIV cases to injection drug abuse and more specifically, injection of the painkiller Opana, a prescription opioid.

Fast-forward a few months later and as of early June, the state health department had documented the HIV outbreak at 169 cases. In the previous four years, the same rural community had just three total cases of HIV. In response to the injection drug-fueled outbreak, Indiana Gov. Mike Pence declared a public health emergency in southeastern Scott County in March and authorized a short-term needle exchange program. The needle exchange program was eventually extended though 2016. According to a June 10 news release from the state health department, the needle exchange effort had provided nearly 26,000 needles to date.

In a May news release, state Health Commissioner Jerome Adams, MD, MPH, said that the small rural community was likely not alone in experiencing a rise in drug-related HIV cases --it was simply that Indiana public health workers were the first to detect such an outbreak.

"I think the reason we see it here is because we found it," Adams said. "It's no secret that intravenous drug use and drug abuse in general is at an all-time high in the United States. And many areas of the country are experiencing, along with drug abuse, especially in smaller, rural towns, high unemployment, lower incomes and a lack of education. Sadly, there are places in this country where the future looks bleak."

To address the HIV outbreak, state and local public health workers began working with the Centers for Disease Control and Prevention, local medical providers and drug treatment centers to provide newly diagnosed HIV patients with treatment and begin contact tracing. Indiana health officials also launched a public awareness campaign known as "You Are Not Alone," which urges residents to get screened for HIV and is advertised in print and digital ads and on TV, radio and billboards. The campaign also educates residents on how to safely dispose of needles and advertises HIV services as well as an addiction services hotline. In May, health officials expanded the awareness campaign to reach travelers and truckers along the interstate, with messages to get tested for HIV and avoid risky sexual activity.

At the federal level, CDC issued a health advisory alerting public health workers and health providers to the outbreak and noting that a majority of the Indiana residents newly diagnosed with HIV also tested positive for hepatitis C.

Also in response, the state health department opened a One-Stop Shop in late March at a community outreach center in Scott County to provide HIV testing, job counseling, vaccinations, substance abuse referrals and other services. As of June, the One-Stop Shop had conducted more than 300 HIV tests.

In May, during testimony before the U.S. House of Representatives Committee on Energy and Commerce Subcommittee on Oversight and Investigations, Adams suggested a number of options to address the country's opioid abuse epidemic, including creating opioid take-back programs, instituting prescription drug monitoring systems, increasing access to addiction services and increasing access to naloxone among first responders and overdose bystanders. Naloxone is an easily administered medicine that can reverse the effects of an opioid overdose.

"Accountability for this epidemic must be systemic and include parents and schools, the pharmaceutical industry, patients, prescribers, pharmacists and payers," Adams testified.

To learn more about the HIV outbreak and the public health response, visit
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Title Annotation:STATE & LOCAL: Issues at the state and community levels
Author:Krisberg, Kim
Publication:The Nation's Health
Date:Aug 1, 2015
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