The tenets of public health are to provide strong programs that protect the community as a whole. These efforts should be unbiased and applicable to the health and safety of the population in total, regardless of special interests or political constituency. In earlier times, this belief was central to health care, with interventions like quarantine for influenza and tuberculosis being widely used and accepted to prevent countless deaths. Today, the intrusion of politics and personal choice is much greater. Does this put public health as a whole at risk?
While there have been many examples of this dilemma in the last century, perhaps none is as stark an illustration as the HIV and AIDS epidemic. Ever since the first case was reported in the summer of 1981, controversy has swirled over the best ways to contain the spread of the disease. The closing of bathhouses, exclusion of HIV-positive immigrants, limitation of activities of HIV-positive health care workers, universal screening of pregnant women and harm-reduction efforts were all put to the test. For each attempt at intervention, ripples went through political arenas for miles. Constituencies protested out of fear and other groups made assumptions based on the presumed moral imperative. The result: slow movement in the war on AIDS both in initiation of interventions and also on withdrawal of failed efforts. As such, tens of millions have been infected worldwide; millions have died.
The HIV epidemic has been a fascinating journey. In a short time, we have made many scientific discoveries with regard to diagnosis, transmission and treatment. But in 30 years, we have failed to control the spread of this disease without a cure despite knowing all the ways it is passed from person to person. Efforts to implement the National HIV/AIDS Strategy, initiated nearly five years ago, have stalled, mainly due to the same tug of war between public health, politics and personal choice.
Take for example the most recent outbreak in Indiana. Located in a rural area, the county affected has a population of approximately 4,000 people. Not many resources have been deployed there in the realm of HIV prevention. Until this year, fewer than five local residents were diagnosed annually with HIV. The one clinician who has served this area for years attributes the outbreak largely to a phenomenon of addiction, first to painkillers, which erupted into IV drug abuse in 2010 and 2011. So far, in the first six months of 2015, more than 148 cases have been identified in this county alone, the great majority (approximately 95 percent) in IV drug users.
Unfortunately, how far and wide this epidemic might reach is unknown since this town sits along a major Interstate highway and is struggling with poverty, poor access to health care and a significant sex-based economy. This scenario could be lived out over and over in the U.S., as many rural counties suffer from the same social challenges and because approximately 24.6 million Americans use illegal drugs.
Rural areas have often been overlooked in outreach and resource deployment during the war on AIDS. Why? Because people believe that urban areas are the most likely centers for disease spread. One has to wonder in the face of the current outbreak if that has been true to date or is simply how we have justified our efforts. Are rural outbreaks the next geographic phase of the HIV epidemic?
Those who have dedicated their careers to protecting public health have immediately recommended the institution of harm-reduction measures. These are activities that can help curb if not stop an outbreak. Historically, needle-exchange programs, or NEPs, have been among the most controversial approaches. While the concept of NEPs isn’t new, these programs have remained controversial for decades. The first NEP was started in Amsterdam in 1984, followed by the first U.S.-based program in Tacoma, Washington, in 1988.
In the U.S., there are about 130 NEPs in existence. About half are thought to be run illegally or are under the radar and purposefully ignored. Many states, such as Indiana, have a ban on these programs. The stated reason: fear that such programs give the impression that illicit drug use is OK. For many, this represents a moral dilemma. For others, it represents a political hot potato.
The goal of these programs is to stop drug users from sharing dirty needles. Multiple illnesses are spread from needle sharing including HIV, and hepatitis B and C. Providing clean needles potentially decreases the sharing of needles by as much as 80 percent, according to some studies, with an attendant reduction in HIV spread of 30 percent.
In addition, there is collateral benefit to these programs. When patients arrive to get clean needles, there is opportunity to educate them on HIV and refer them for health care services. The National Institutes of Health, Centers for Disease Control and Prevention and World Health Organization have all come out in support of NEPs as a viable strategy in curbing the spread of the HIV epidemic, and have been supporting this harm-reduction approach since the late 90s. However, there has been a ban on using federal funds for NEPs, which despite being lifted by executive order, has failed to generate funding from Congress. And, as mentioned, many states ban these programs altogether. The result: minimal backdoor efforts at harm reduction.
So back to southern Indiana. The outcry from public health advocates resulted in an emergency order by Gov. Mike Pence to start a NEP. And now, there are some signs that the rate of spread may be slowing. The order has been extended for an additional 30 days. Questions still abound over the longevity of the program and the balance between tacitly legitimizing drug use and stopping an epidemic. Some patrons of the program have given personal accounts of using needles more than a 100 times and borrowing them from others or using dirty ones found on the streets. Many of these same patrons have been referred for testing and counseling. Caregivers have begun to chip away at the elephant in the room. Is it the magic answer? A resounding no.
For people to truly minimize their risk of infection or to be successful in managing HIV once contracted, it’s critical to get them off drugs and whip their addictions. Rehab programs and support efforts are crucial to the long-term health of this community and so many others like it. But in the meantime, maybe NEPs can slow the spread and advocate for other necessary resources. Still, quandaries remain: Can political leaders survive either decision? If they stop the program and many more are infected, they have failed. If they continue the program at the price of their own position due to the moral compass of their constituency, can any of the positive outcomes be sustained?
Whether it is HIV, resistant germs, weapons of mass destruction or the next great unknown, there will always be a threat to public health and safety. As a nation, will we put the public good before politics? If not, we might not be left standing as one nation — or at all.
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As HIV Proliferates, Will the Public Good Be Placed Before Politics? originally appeared on usnews.com
