Dangerous infections are surging in Richmond and throughout Virginia as a wave of hepatitis C continues to spread alongside the opioid epidemic, and an HIV outbreak could be around the corner.
But state officials are hoping to curb the rise in the deadly infections by swapping out injection drug users’ dirty needles for clean ones.
On July 1, a new law legalizing syringe services programs — also known as needle exchanges — went into effect, but none has yet been started. The state Department of Health is awaiting applications from eligible jurisdictions before implementing the programs.
The story of Scott County, Ind., serves as a haunting case study of the side effects of the growing number of people injecting heroin and other opioids. Typically, the rural county reported fewer than five HIV infections every year, according to the Centers for Disease Control and Prevention. But in April 2015, that jumped to 135 infections, and it was preceded by a sharp increase in hepatitis C.
“We really want to use the lesson learned so we don’t have a repeat of what happened in Indiana,” said Elaine Martin, director of Virginia’s HIV prevention services. “We really want to prevent something before it takes hold. While we have a big increase in hepatitis C already, it will only take one person getting into a network that could cause a potential outbreak of (HIV) cases.”
Last year, 1,133 people in Virginia died due to overdoses of opioids — a class of drugs that includes illicit drugs such as heroin as well as prescription painkillers. That increase represented a 40 percent spike over the previous year.
But the sharp rise in hepatitis C — caused largely by an increased number of people sharing needles for injection drug use — is just one example that the opioid epidemic’s deadly impact on Virginia is even further-reaching than the already steadily increasing death toll.
Needle exchanges are considered harm-reduction programs in the public health sphere and have been gaining more national attention in recent years as the opioid epidemic continues to rage.
The programs provide clean injection equipment to drug users and give them a place to deposit dirty needles. Some criticize them as encouraging users to continue abusing drugs, but much public health research has backed them up as lowering the chances a drug user will pass along bloodborne diseases like hepatitis C and HIV.
The Health Department identified 55 jurisdictions eligible for the programs based on figures that show they are at higher risk for infections related to injection drug use. Richmond was on the list, along with Chesterfield and Henrico counties.
Martin said the programs will not only serve as places for patients to get clean needles, but a growing body of research shows that they encourage users to seek treatment, as well.
“People who go to syringe service sites are five times more likely than other users to get into treatment,” she said. “It’s really a gateway into other treatment that not only protects them, but also their family members and their community.”
Last year, the rate of hepatitis C in Richmond was 395.8 per 100,000 people, more than three times the rate in Chesterfield and Henrico. Chesterfield’s and Henrico’s were 129.5 and 119.3 per 100,000, respectively. In 2015, Richmond’s rate was 213.9.
There has been a similar increase statewide. Last year, more than 11,352 cases of hepatitis C were reported to the Health Department, nearly twice as many as in 2014.
While those numbers are alarming, health officials are especially concerned that the increase in hepatitis C could be foreshadowing a spike in HIV, which was the case in Scott County, Ind.
Early last year, the CDC released a list of the counties most likely to see an HIV outbreak just like Scott did. Eight Virginia counties were on the list: Buchanan, Dickenson, Lee, Patrick, Russell, Tazewell, Wise and Wythe.
Needle exchanges are considered a critical component of preventing an HIV outbreak, which, along with hepatitis C, can be transmitted by sharing needles. Hepatitis C spreads more rapidly than HIV, which is why it could indicate that a rise in HIV cases could be on the horizon.
Local health districts and community-based organizations can apply to start programs in their jurisdictions. So far, the Department of Health has yet to receive any applications, Martin said, though she expects to receive several by the end of the month.
“Two of the requirements (for the programs) are that sites have to provide a letter of support from local law enforcement and also one from their local government, so it might take a little bit of time for folks to put together the documents they need,” she said.
Law enforcement’s cooperation is critical because the patients visiting the sites must be protected, Martin said.
“The law provides protections for people who are operating a harm-reduction site, but it doesn’t provide any protection for the participants,” Martin said. “They would still be vulnerable to the same paraphernalia laws that currently exist. If you don’t have law enforcement support, then you risk that your participants could be arrested when they walk away from the site.”
Generally, she expects law enforcement agencies to support the programs. Most understand that the state cannot arrest its way out of the opioid epidemic, she said, and the programs would be an important means through which users can access treatment programs.
The Richmond Police Department’s potential support for the programs is unclear. In a statement, public affairs director Gene Lepley said the department is willing to support efforts to address the opioid epidemic, “but as far as a needle exchange program, we’d need to first review any proposed plan.”
Likely the first to submit such a proposed plan to Richmond police is Health Brigade, formerly the Fan Free Clinic. The free clinic serves the city’s low-income population, including those with hepatitis C and HIV.
Karen Legato, Health Brigade’s executive director, said in an email that the organization is reaching out to local agencies, including the city government and law enforcement.
Chesterfield and Henrico officials said the counties are in the planning process.
Dr. Alex Samuel, the incoming director of the Chesterfield County Health District, said the county is in the early stages of investigating the application.
“There has to be a lot of conversations with community and local government before any decisions are made,” said Samuel, adding that the health district is also still determining if it, versus a community organization, would be the best choice to run the program.
It will also offer overdose prevention education and kits that include the overdose-reversing drug naloxone, mental health services, and health insurance enrollment assistance, among other services. It will also provide testing for hepatitis C and HIV, along with hepatitis A and B vaccinations.
Laura Young, the Henrico County Health District’s epidemiologist, said she presented the idea of applying for a needle exchange to the Henrico Heroin Task Force — which includes law enforcement officials — and the members expressed interest and support, but the county is still in the planning stages.
“With the framework of the Henrico Heroin Task Force already in place, there is significant opportunity for collaboration across county agencies as we move forward with planning,” Young said in an email.
Martin said that once the department receives applications, it will respond within 45 days.
“We would like to get these up and running as soon as possible, because the law does sunset in June of 2020, so we will need as much good data to show the efficacy of these programs as possible,” she said.
To see a list of the 55 municipalities approved for a needle exchange program, go to www.vdh.virginia.gov/disease-prevention/chr.