In late 2014, health officials belatedly became aware of an HIV outbreak in Scott County, Indiana. With fewer than 24,000 people, this rural county rarely saw a single new case in a year, according to The New York Times. But by the time government agencies tried to stop the transmission of the virus a few months later, some 215 people had tested positive.
One man seemed responsible for needlessly letting the situation get out of control: Indiana’s then-Governor Mike Pence. In 2015, when the virus was seeming to rapidly move through networks of people who use intravenous drugs, even the reluctant local sheriff encouraged the governor to authorize a clean-needle exchange, a proven tool to reduce such an outbreak.
But, as the Times reported when he became Donald Trump’s running mate, “Mr. Pence, a steadfast conservative, was morally opposed to needle exchanges on the grounds that they supported drug abuse.” His opposition was based on an incorrect belief; while research has long shown that needle exchanges do reduce HIV and hepatitis, it has also shown that they do not encourage drug use.
Pence went home to “pray on it” before he decided to approve a limited needle exchange. Many observers believed that the program acted as a kind of public-health Hail Mary pass, staunching a catastrophic wound that would have gotten much worse.
But as new research from the Yale School of Public Health published in the British medical journal The Lancet HIV shows, even that was marred by chaos and disorder, and the program likely had little effect on the outbreak. Indiana’s needle program began “with police officers initially confiscating syringes,” and it went into effect the same day the Pence “signed a bill that upgraded possession of a syringe with intent to commit an offence with a controlled substance from a misdemeanor to a felony charge, subject to imprisonment for up to 2.5 years.” This law began immediately after the 30-day exchange.
The study was co-authored by Yale assistant professor of epidemiology (and one-time ACT UP activist) Gregg S. Gonsalves and associate professor of biostatistics, ecology, and evolutionary biology Forrest W. Crawford. And while it projects that the worst of the HIV outbreak in Indiana was avoidable, this was because of reasons not previously understood. Gonsalves and Crawford write that the needle program began well after the peak of the epidemic: “The number of undiagnosed HIV infections had already fallen substantially by the time a public health emergency was declared and syringe-exchange programmes implemented.” Using mathematical modeling, the researchers estimate that the HIV infections had been rising since 2011 and had actually peaked in January 2015, “over 2 months before the Governor of Indiana declared a public health emergency.”
This is not to say Pence hadn’t erred in preferring prayer over science in 2015, but that he’d been failing to deal with HIV in his state for years. Gonsalves and Crawford’s models estimate that instead of 215 infections in 2015, “a response on Jan 1, 2013, could have suppressed the number of infections to 56 or fewer, averting at least 127 infections” and that “an intervention on April 1, 2011, could have reduced the number of infections to ten or fewer, averting at least 173 infections.”
But those dates are years before Indiana knew there was an HIV epidemic underway. Because of funding cuts, the only HIV testing provider in southeastern Indian had closed in 2013. This, according to the study, “could have delayed the diagnosis of the initial case of HIV infection in Scott County.”
The disaster in Scott County was not just a failure of clean needles or even just Indiana’s long-time “abstinence stressed” sexual education. It was a disaster born of a total abdication of Indiana’s public-health responsibility—and it’s the kind of health disaster we could see nationally. Pence is now vice president in an administration that is gutting HIV/AIDS resources and further criminalizing drug use—two paths that will increase HIV prevalence across the country. Meanwhile, the twin crises of deindustrialization and rising opioid usage mean that the conditions for localized HIV epidemics are not unique to Scott County. Indeed, Gonsalves and Crawford write that the Centers for Disease Control and Prevention believes there are “220 counties across the USA at risk of outbreaks of HIV” and hepatitis C.
As conditions favorable to epidemics spread across the country, the ability for public-health agencies to respond to such crises are being throttled. As NPR reported in 2016, 40 percent of health departments have reduced services, with one CDC official saying, “More than half of state and local STD programs have experienced budget cuts. In 2012, 20 health departments reported having to close their STD clinics.” And, as local governments are turning away from STD and overdose-prevention efforts, they are also incarcerating more people on charges related to drug addiction and sex work—and even prosecuting individuals for harm-reduction work.
Austerity budgets that cut public-health resources are a predictor of certain health disasters, something I’ve seen in my own HIV research. For instance, St. Charles County, Missouri, has spent an enormous amount of money and resources prosecuting Michael Johnson, who is alleged to have exposed others to HIV. In the nearly five years I have been researching his prosecution, St. Charles County has repeatedly said it has pursued that case in the name of protecting public health, even though research has shown that prosecuting people does not reduce HIV rates. Meanwhile, St. Charles County shut down its only STD clinic, which had performed about 1,000 STD exams in 2017.
Lacking any ability to test for STDs, St. Charles County is primed to become another Scott County. I have reported in the St. Charles County courthouse for years, and nearly every case I have witnessed other than the HIV trial has been for drugs. Its opioid crisis is so bad, the county is suing drug manufacturers. The county spends money prosecuting people for using drugs, but not for monitoring or testing for the STDs that inevitably come with the epidemiology of opioid use. That’s a disaster in the making.
With such a retreat from infectious-disease prevention, America could become the next Greece, a country where I am conducting my current research and where the relationship between gutted public-health budgets and rising HIV rates is well documented. “In 2009–10, the first year of austerity, a third of the street work programmes were cut because of scarcity of funding, despite a documented rise in the prevalence of heroin use,” a 2014 study in The Lancet found. As condom and syringe distribution fell and prevention efforts declined In Greece, “the number of new HIV infections among injecting drug users rose from 15 in 2009 to 484 in 2012”—an increase of more than 3,000 percent in four years.
The epidemiology of HIV flourishes amid drug stigma, homophobia, poverty, and racism; in turn, government approaches that allow HIV to thrive also breed homophobia, racism, classism, and drug panic. In both Greece and America, there have been eerie parallels that suggest a worrying, violent future for queer people and people living with HIV. In Athens, on September 21, HIV-positive queer-activist Zak Kostopolous was kicked to death in broad daylight. One of the most horrifying things about the video of it is that many men watching do nothing to intervene. The same weekend, in New York, two gay men were beaten unconscious at my old neighborhood gay bar in Brooklyn.
It should be no surprise that in societies where resources and education regarding marginalized communities are decimated—whether regarding intravenous-drug users, people living with HIV, transgender people, Muslims, or immigrants—hate prospers.
Much of US society often doesn’t care about HIV infections or AIDS deaths—or about hepatitis infections or overdose deaths—when they are perceived to be happening to people who are black, queer, and/or immigrant. Scott County tardily registered as worthy of limited government intervention because it had about one case of HIV for every 110 residents or so in a county which is 97 percent white. At the same time, the CDC projects that if current trends do not change, one in every two black queer men will become HIV positive—and yet, government agencies are not mustering any kind of robust plan for communities in which HIV may become 50 times more prevalent than it ever was in Scott County.
Gonsalves and Crawford’s study of Scott County shows that preventable epidemics can happen anywhere where austerity is combined with theocratic, anti-science policies. As public-health approaches are abandoned throughout the United States, that applies to increasingly large swaths of the country.