The past few years have seen major HIV outbreaks in two of West Virginia’s biggest cities – Huntington and Charleston – which at times put state officials in conflict with guidance from national experts on HIV and public health. At the center of the controversy is the question of whether it’s a good idea to distribute clean syringes to people who inject drugs.
It’s a sweltering night in the gymnasium of the Kanawha United Presbyterian Church, in Charleston. It’s the monthly “mutual aid meeting” organized by a non-profit group called Solutions Oriented Addiction Response, or SOAR. It’s a health fair with a focus on harm reduction: making drug use less deadly.
Iris Sidikman, the harm reduction coordinator at the Women’s Health Center of West Virginia, is a regular at these events.
“A big part of what I do at the harm reduction program is providing clean supplies for people,” said Sidikman. “Clean supplies can help people reduce their risk of HIV transmission. I give out supplies to clean needles and to use drugs in other ways more safely.”
Many people stopping by are homeless, or close to it. Tammy, who recently started injecting drugs again after years of sobriety, said she comes to pick up alcohol swabs and other cleaning equipment. She knows that HIV is a big risk, and says she’s careful to protect herself and her friends.
“I’m sort of a clean freak,” she said. “I have a couple of friends I’ve had to say ‘no’ to. I’m not going to sit back and watch somebody share a needle.”
HIV is still spread largely through sex. Nationally, injection drug use accounts for less than 10 percent of new infections, according to the CDC. But injection drug users are 22 times more likely to contract HIV, and in West Virginia since 2019, they make up nearly two thirds of new cases.
“That is how these outbreaks in Cabell and Kanawha [counties] started,” said Robin Pollini, an epidemiologist at West Virginia University. “HIV got into some groups of people who were sharing syringes and then more or less, everybody in that community that was sharing got HIV.”
Starting in 2015, health departments in both counties ran programs where drug users could pick up clean syringes. But in the face of public complaints, in 2018 Cabell County restricted its program to county residents, which sharply reduced its scope. While the county’s HIV outbreak wasn’t identified until the following January, Dr. Michael Kilkenny, Health Officer of the county health department, said that in hindsight, the change led directly to more infections.
“The CDC (Centers For Disease Control and Prevention) staff authored a really good analysis, and that was their conclusion, that scaling back was contributory to the size of the outbreak,” said Kilkenny.
Facing similar complaints about syringes left on the ground and large crowds of homeless people, the Kanawha-Charleston Health Department ended its needle exchange altogether in 2018. Christine Teague, who heads up HIV care through the Ryan White Program at Charleston Area Medical Center, says the benefits had gone beyond clean needles.
“Obviously they were getting safer syringe products, but it was also an opportunity to engage with folks to do testing, to link them to other services and to get them into SUD services if they were ready to do it,” said Teague. “When the program was cut, there was no touch point for this high risk population.”
Asked if that contributed to Charleston’s HIV outbreak, which was recognized in late 2020, Teague gives a deep sigh.
“I don’t know if the horse was already out of the barn, but it certainly didn’t help,” she said.
At the health fair in the church gym, visitors can pick up alcohol swabs, vials of the overdose-reversal drug naloxone and other items. There are tables offering bike repairs, sewing supplies and free legal advice, too. SOAR co-director Joe Solomon is handing out popsicles. He’d like to give out clean needles as well, but the city won’t allow it. SOAR has been in the fray since it formed in 2018, after the closure of the Kanawha-Charleston Health Department syringe program. For a time, SOAR volunteers handed out needles, but that landed them in a legal gray area and they quit after a police investigation, although the group was cleared of any wrongdoing.
“Sometimes I feel like the colors of the sky haven’t changed since then,” Solomon said .
Today the only syringe program in Charleston is run by West Virginia Health Right, which has three clinics in the city, including its flagship on the east side, which just underwent a $12 million renovation and expansion.
Angie Settle, the CEO, said that West Virginia Health Right services more than 44,000 people from 34 south-central counties. The patients are uninsured or underinsured, and all services are free of charge to patients, made possible by doctors and other medical providers who volunteer their services.
It’s a big operation. But when it comes to harm reduction, the footprint is small. Official filings show that Health Right handed out around two-thousand clean syringes last year. By comparison, the harm reduction program in Fayette County, with less than a quarter of Kanawha’s population, gave out 120,000.
Robin Pollini says it’s like fighting an epidemic with one hand tied behind your back.
“You have sort of a perfect storm of people with undiagnosed HIV in settings where they have no access to syringes,” she said “I go and talk to people in the community who know what’s happening, and what they have told me is that syringe sharing is rampant.”
And yet, even as needle exchanges were cut back, HIV cases in Charleston and Huntington have declined. To fight their epidemics, both Kanawha and Cabell counties rely on other strategies. They have expanded testing efforts to identify cases early. They’ve gotten more patients into treatment and they try to convince IV drug users to take antiviral medication, a regimen which can actually block HIV infection.
Settle said there’s been too much emphasis on syringe programs.
“Handing out syringes is easy,” said Settle. “The hard work is connecting with people, getting people into recovery. Because all this ties together: the HIV problem, recovery, trying to get people back on their feet. Because at the end of the day, if you get people to stop injecting, that ends the risk altogether.”
Kilkenny says that harm reduction programs are still needed.
“Syringe services are a wonderful tool,” Kilkenny said. “If you do offer syringe services, you’re going to have a more effective response. I think that’s settled science. On the other hand, while our knowledge of the impact of harm reduction and syringe service programs has increased, and even as our programs in West Virginia have influenced national strategies to end the HIV epidemic and injection-related HIV cases, our politicians have not grasped that very well.”
That shows little sign of changing. When the CDC investigated Charleston’s outbreak in 2021, it recommended “expanding and improving access to sterile syringes, testing, and treatment.” Instead, in 2022 a new state law put stricter limits on needle exchanges. Since then, nearly half the programs in the state have shut down. In Charleston, which has even stricter rules, the city council voted, last summer, to block a new needle program from opening. And this past January, some state lawmakers introduced a bill that would ban syringe exchanges altogether.
Editor’s Note: This story is part of a series we’re calling “Public Health, Public Trust,” running through August. It is a collaboration with the Global Health Reporting Center and is supported by the Pulitzer Center.