In January, Indiana Health department officials confirmed 11 HIV cases in a rural county in southeastern Indiana, where historically, less than five cases of HIV infection have been reported annually. It was soon determined that a majority of the new cases were occurring among residents of a small, tight-knit rural community of about 4,200 people, 33 miles north of Louisville, Ky.
Nearly all of the original cases were associated with needle sharing among individuals injecting the prescription opioid Opana (oxymorphone). By late April, the number jumped significantly. Now, the official number of HIV cases in the Indiana outbreak has reached 143, including five cases that appeared in a neighboring county just to the north.
Approximately 80 percent of cases reported IV drug use (Opana, methamphetamine and heroin), including a few pregnant women and 10 commercial sex workers. Comorbid hepatitis C has been seen in about 85 percent of the cases.
In conjunction with the local health department, community-based healthcare providers, the local community mental health center and other regional providers, the Indiana State Department of Health and the Indiana Division of Mental Health and Addictions responded immediately. A federal Centers for Disease Control and Prevention (CDC) team was also deployed to the area to assist.
A public health emergency was declared, and the governor authorized:
- A temporary needle exchange program;
- Extensive testing services;
- A public education campaign;
- An incident command center;
- A community outreach one-stop center;
- Medical care for HIV and hepatitis C;
- Assistance for greater access to Medicaid benefits; and
- Increased access and opportunities for substance abuse counseling and treatment.
A variety of socio-economic-cultural factors are related to this outbreak. This county has high unemployment and low levels of educational attainment with approximately 20 percent of the population living in poverty.
In the last Robert Wood Johnson Foundation County Health Rankings survey, this county ranks last in the state of Indiana for health indicators. Economically depressed with few opportunities and a sense of fatalism, the outbreak epicenter is relatively isolated along the I-95 corridor, and transportation services are limited. In some segments of the county, substance use is part of the group identity and a cohesive factor. The CDC has reported that, “Injection drug use in this community is a multi-generational activity, with as many as three generations of a family and multiple community members injecting together.”
The challenge for behavioral healthcare providers is primarily in developing sufficient trust for engagement, providing credible information regarding realistic options, and developing aftercare services that can mitigate the powerful socio-cultural influences emanating from the community.