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The Centers for Disease Control and Prevention spent one month in Kanawha County this summer to investigate the local HIV outbreak. The federal agency released its findings this week.
The CDC called the outbreak the “most concerning” in the nation earlier this year. With an initial push from Charleston Mayor Amy Goodwin, the state requested a team of disease intervention specialists from the CDC to study the outbreak on-site. This Epi-Aid provides short-term, but highly involved, assessment and assistance. Cabell County went through the same process in 2019 for its HIV outbreak.
Over four weeks, the CDC analyzed medical records and spoke with local health and social service providers at the frontlines of the outbreak. It also interviewed 26 people who have HIV or are at risk of contracting the virus. This includes people who use IV drugs and are often homeless, which represent most new HIV diagnoses.
“It’s clear from this report, we do not have the services in place to prevent these infections, diagnose them, and treat them,” said Robin Pollini, an infectious disease expert at WVU specializing in IV drug use.
The report outlines missed opportunities for testing and barriers to HIV treatment and clean needles.
“We were not surprised by the problems noted in the report. We knew they existed,” said Mayor Goodwin.
Local officials and medical and social service providers at the frontlines of the outbreak continue to meet monthly to form solutions. They meet next Tuesday at noon at Charleston’s health department.
“The state needs to take a leadership role,” Goodwin said. “We need their expertise and resources if we are going to get a handle on this serious issue affecting our entire state.”
Nearby counties are not seeing case numbers like Kanawha County, but health workers say some transient patients could spread the virus elsewhere.
State Epidemiologist Shannon McBee says her team is ready to assist the county in implementing some of the CDC’s recommendations. The CDC says it is also on standby for additional assistance as it’s requested.
“We can’t speculate on how many HIV cases will ultimately be a part of the outbreak among people who inject drugs in Kanawha County, but given the evidence of ongoing rapid HIV transmission, response activities should be approached with urgency,” the CDC said.
Before the Epi-Aid began, state and federal health agencies knew HIV cases had spiked in recent years among IV drug users.
Since the beginning of 2019, 75 people who inject drugs have been diagnosed with HIV in Kanawha County. The CDC sounded the alarm because it marks an uptick from previous years.
“We know that the opioid misuse epidemic has substantially increased the transmission… especially during the pandemic, when people have been faced with new challenges such as isolation, and depression,” said McBee.
The CDC found through its investigation that the virus is spreading rapidly among a small but connected group of people in Charleston, at a rate 12 times the national average. The outbreak is separate from Cabell County’s outbreak, which the CDC also studied in 2019.
The median age of those diagnosed is 34 and most don’t have secure housing.
Opportunities for more testing
The CDC analyzed medical records for 65 people diagnosed with HIV who at some point had visited Charleston Area Medical Center or Health Right. CAMC is home to the Ryan White Foundation, which is the largest comprehensive HIV medical provider. Health Right is a free clinic and the only operator of a syringe service program in Charleston.
While most diagnoses were recorded in medical settings, the CDC says there’s more opportunities to test people who come into emergency departments. Many of those using IV drugs visited emergency departments for wound infections. Only five percent received their diagnoses in an emergency department.
“I personally would like to see opt-out testing in emergency departments across the state,” McBee said. “This will allow us to identify those cases sooner and get those individuals into care to prevent further transmission into the community.”
Christine Teague with the Ryan White Program out of CAMC works directly with HIV patients within a much larger hospital setting. She said testing people who visit an emergency room at a hospital would be proactive, but she expects growing pains.
“[Emergency staff] are tasked with treating emergent health care concerns, testing for HIV and prevention, and all these things. They don’t believe it’s on top of their priority list,” Teague said.
The CDC also recommends more testing in correctional facilities and in targeted locations in Charleston’s West Side. The local health department does mobile testing in targeted areas twice a week, but often only a handful of people are tested.
With gaps in testing, social service providers told the CDC they believe there could be many more people with the disease.
Treatment and barriers
The report shows many people who have HIV are not receiving routine treatment for the virus. Most had received initial treatment, but only 19 percent had received treatment in the past 90 days.
Teague has treated HIV patients for more than 20 years. She says many of her homeless clients with substance abuse disorder are intimidated in large hospitals.
“They’re ashamed,” Teague said. “And it’s an everyday struggle to come into a clinic or hospital where there’s all kinds of people there that might be nicer dressed and are clean.”
Interviewees also reported negative interactions with medical providers due to their drug habits.
“That’s probably another reason why I wouldn’t go to the hospital unless I was dying, because they don’t care about you,” one interview participant said.
When clients do opt into treatment, they often face compounding barriers to care.
Without reliable transportation, keeping appointments can be difficult. Asking patients to sit through lengthy visits can be scary for someone who fears going through withdrawal.
Interviewees also reported that any medications they receive could easily be stolen because they have no stable shelter or storage. The CDC found that of those that currently receive routine HIV care, all have stable housing.
The CDC recommends medical providers rethink how to administer care to make it more convenient.
Teague imagines this as a one-stop-shop to provide a host of services in one visit. It could be centrally located or even a mobile clinic. Patients could access clean needles, overdose reversal medication, and medicated assisted treatment. They could also sign up for Medicaid, IDs and housing services.
“If I could just go into a small mobile unit where there’s just a handful of people that I’m already kind of familiar with, and have always been friendly to me, then I think that would be a much more comfortable environment for them,” Teague said.
Clean Needles and Prevention
To prevent further transmission, the CDC recommends more ways to get clean needles out to IV drug users.
Two syringe service programs have closed in the capital city in the past three years. The local health department no longer gives out clean needles. The grassroots group SOAR shut down its health fairs due to public pressure earlier this year.
One needle exchange remains at Health Right. But the CDC’s medical records analysis shows that of the 65 people recently diagnosed, only four people ever got syringes, and they didn’t come back to pick up more.
Health Right opened another location in the city’s West Side, a hot-spot for those most likely to contract HIV. The clinic has said at community meetings it would not distribute needles out of that location without support from neighboring residents.
The city recently adopted an ordinance that restricts who can give out clean syringes. HIV and recovery advocates have blasted the city for this law.
“We shouldn’t arrest the helpers, right? In Charleston right now, if a nurse gave her sterile syringe to someone who uses drugs, she could be arrested and charged with a misdemeanor.” said Joe Solomon, who operated Solutions Oriented Addiction Response, or SOAR. “We’re asking the mayor and city council to show real courage to say, ‘Hey, we made a mistake, and we’d like to amend that mistake.’”
Goodwin said the city has no interest in overturning or working outside state and city law.
The local ordinance makes some health workers question how serious the city is about confronting the current outbreak.
“You should care about what it says about Charleston and trying to bring people to Charleston, West Virginia,” Pollini said. “People want to live in communities where people care about each other, and that promote good health, and adhere to science.”