At the height of the COVID-19 outbreak, Charleston, West Virginia was sideswiped by a second deadly epidemic: what the Centers for Disease Control (CDC) called the most concerning outbreak of HIV in the entire country. It came on the heels of a similar outbreak in Huntington, West Virginia, both driven by shared needle use among injection drug users. There was a bitter tug-of-war over how to respond, but it led to an intensive effort to reach the people most at risk.
Every Tuesday, a team from Charleston Area Medical Center drives two brightly painted minibuses to the west side of Charleston and set up shop in an empty parking lot on Washington Street. The operation is overseen by Christine Teague, director of the Ryan White program for HIV care.
“We provide comprehensive HIV early intervention services, which includes testing, linkage to care and medical and support services for people who are diagnosed with HIV,” said Teague.
By lunchtime, they have seen about two dozen patients, which makes this a typical Tuesday. With the smell of barbecue floating across the street, and storm clouds threatening, they linger and talk around a folding table and a few chairs, under a small white tent.
Cameron, a 38-year-old with a scraggly beard and a big grin, is there to pick up his HIV medication, and a little something for his dog Bailey. She’s whimpering for a treat. Cameron was diagnosed with HIV a few years ago, in the early days of the outbreak that swept through Charleston, back when he was still injecting drugs. He started treatment at the hospital clinic, but a lack of transportation made it challenging to make appointments.
“It’s more of a hassle,” Cameron said, who lives about two blocks from the parking lot where he’s just picked up his medication. “I don’t drive. I don’t have a license. I don’t have the transportation, and it’s just easier for me to walk here.”
Continuity of care is critical. Effective HIV treatment requires regular lab work to ensure that medication is keeping the virus in check. Sticking to a daily medication routine is a particular challenge for patients who are homeless or facing other tough circumstances. While a typical package of antiviral medication might include 30 days’ worth of pills, Teague’s team offers seven-day packets, which patients can renew each week when they stop by for a checkup.
Teague estimated that 80 percent of the patients at the minibuses are HIV-positive. They’re regulars. Along with medication, they are offered hygiene products, snacks and $10 gift cards, while greeting friends or just taking time to rest.
Like most people there, Megan assumed she caught the virus from a shared needle. Her initial diagnosis, in May 2021, came as a shock. “I’m a germaphobe,” she says with an embarrassed smile. “Now I’m a germaphobe with HIV.”
Now, she’s seven months pregnant. On the rare Tuesday when Megan doesn’t show up, someone else on the medical team walks to Megan’s apartment to deliver meds and check in.
“Cassie brought her breakfast the other day, because she didn’t have anything to eat,” nurse Shawna Walker said. “We’re just trying to support her in whatever little way an HIV program can, I mean, that’s not literally what we do, but we don’t want that baby to be positive, so we go to extraordinary lengths to help people.”
Megan’s diagnosis was part of an alarming wave of new cases in Charleston. Just a few months earlier, in October 2020, Dr. Teague had volunteered to test people at a get-together organized by SOAR, a local harm-reduction group. Of 40 people who underwent the tests, seven tested positive for HIV.
“With each one, my eyes just got bigger and bigger,” she said. “It’s a crisis [because] if there’s seven here, there’s going to be a hundred out there because the average contacts are three or four per person.”
National experts from the CDC came to help the investigation, and issued recommendations in August, 2021. Topping the list was a proposal to expand access to clean needles, the very type of program that the county health department had ended back in 2018.
Rather than follow this guidance, the state and then the city of Charleston passed new laws making it even harder for needle exchanges to operate.
But here the story takes a surprising turn. In 2021, Kanawha County saw 46 new cases in IV drug users. The following year, that number fell by half, and fell by half again, in 2023.
Dr. Steven Eshenaur, health officer and executive director of the Kanawha-Charleston Health Department, said this year is on track to be even lower.
“I think we’ve definitely turned the corner,” Eshenaur said. “For the past six or seven quarters, we’ve only had one new case per quarter in Kanawha County. That’s a remarkable turn.”
Some experts are cautious. They say the lower case count could just be a result of there being less HIV testing. But Eshenaur is confident that the decrease is real, and Teague agrees.
“People will often say, well, are your numbers down just because you’re not looking for it as much,” said Teague. “And I would say, in the community, there’s probably not as much [testing], but in the hospital, probably more, and we’re not seeing the same rate of positivity that we were three years ago.”
When it comes to addressing the outbreak, Eshenaur said, needle exchanges are just one piece of the pie.
“Identifying and treating the patients that have HIV was the single most important part of that. Those are the big pieces of the pie that really brought down our number of cases.”
Antiviral medication is central to the effort. For people at high risk, medication can actually prevent HIV infection in the first place. The regimen is called pre-exposure prophylaxis, or PrEP.
Medication also serves as prevention around a person who is infected. If the level of virus in their blood is low enough, controlled by medication, they will not pass the virus to others. When the virus is controlled, HIV patients can go on to live long, healthy lives.
Back at the minibuses, Cameron said that getting diagnosed and staying on medication, actually helped him to stop using drugs.
“I was able to get clean. I was able to find housing,” Cameron said. “It made me stop and realize that I could do those things, for some reason.”
Teague says she’s learned to be creative and flexible in how her team delivers care. This brand of care is labor intensive and intensely personal. For patients like Cameron and Megan, that’s what it takes.
If not for the minibuses, says Megan, “I don’t think a lot of people would get care. I really don’t.” She pauses to wipe away a tear. “I’m pregnant and emotional. Sorry!” She said she’s scared to miss a dose of her medicine, and is doing everything she can to make sure her baby is born healthy. So far, it’s working. Doctors tell her that the level of virus in her blood is now so low, her baby should be fine.
Editor’s Note: That 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.