Map of life expectancy at birth from Global Education Project.

Monday, July 25, 2016

When ideology trumps reality

(I took a few days off to rest my brain. Results are mixed, but I'm back.)

You may have heard about the HIV outbreak in Scott County, Indiana. (Not sure how much of this the grand poobahs at New England Journal of Medicine will let you read, but I'll run it down for you.)

This is a rural area, almost entirely white, with high unemployment and poverty. The governor of Indiana, Mike Pence, is now the Vice Presidential candidate of the Republican party. Prior to 2015, with Pence's backing, Indiana outlawed needle exchange programs. Needle exchange has been shown to substantially reduce the risk of transmission of HIV and Hepatitis C virus (HCV); and it does not increase the prevalence of injection drug use. On the contrary, by bringing users into contact with service providers, it increases the chance that people will enter treatment. However, conservatives have succeeded in banning the practice in many states using the argument that it "enables" illicit drug use. Of course, addicts will inject any way they have to, and if they can't get clean needles, they'll share.

One more thing -- free HIV testing had not been available in Scott County since the Planned Parenthood clinic closed in 2013.

Early in 2015, a disease intervention specialist (DIS) discovered a cluster of 11 HIV infections in Scott County. A DIS is a public health worker who interviews people diagnosed with an infectious disease such as HIV and tracks down people they have potentially infected, or who potentially infected them, in order to diagnose additional cases and gain an understanding of transmission networks. Previously, there had only been 5 HIV infections identified in Scott County since 2004. All of the infected persons had crushed, dissolved and injected extended release oxymorphone.

As a result, the CDC and Indiana state government declared a public health emergency, and began intensive contact tracing and population screening. Ultimately they found 181 people with HIV in the county, nearly all of whom reported injection drug use. As a result, Pence relented and allowed needle exchange in April, 2015, after which the cumulative diagnoses leveled off and finally stabilized. As the authors also write:

A lack of health insurance could have been a barrier to the response to this outbreak, but fortuitously, in January 2015, Indiana received a waiver to provide Medicaid insurance [which] helped to ensure health care coverage in the largely underinsured and impoverished community . . . and facilitated the immediate enrollment, coverage and access to critical health care services.

I might note that people who are effectively treated for HIV are essentially non-infectious, meaning that treatment for all can stop the epidemic in its tracks.

Is there a lesson here? Yes. We were right and Mike Pence was wrong. But who do you think the good citizens of Scott County are going to vote for?

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