The Lancet has published a study by Gregg Gonsalves and Forrest Crawford finding that earlier implementation of a public health response could have reduced the scale of the HIV outbreak in Scott County. According to the study, the upper bound of undiagnosed HIV infections in Scott County peaked at 126 on January 10, 2015, about two months before Governor Pence declared a public health emergency. The total number of HIV infections was estimated to be 183-184 by August 11, 2015.
Initiation of a response on Jan 1, 2013, could have suppressed the number of infections to 56 or fewer, averting at least 127 infections; whereas an intervention on April 1, 2011, could have reduced the number of infections to ten or fewer, averting at least 173 infections.
Dr. Crawford in a news release summarizing the study said:
Our findings suggest that with earlier action the actual number of infections recorded in Scott County — 215 — might have been brought down to fewer than 56, if the state had acted in 2013, or to fewer than 10 infections, if they had responded to the HCV outbreak in 2010-2011. Instead they cut funding for the last HIV testing provider in the county.
According to a New England Journal of Medicine study, “free HIV testing had not been available in this community since a Planned Parenthood clinic closed in 2013.” Detection could have taken place earlier if there was a better health system in place. Even after the problem was detected, there was resistance to intervention because of moral concerns. Doctors Josiah Rich and Eli Adashi do a good job of explaining the competing policy views:
The tug-of-war in and around NSEPs and syringe access laws is an ideological one. To some, NSEPs condone and encourage drug use, dissuade injection drug users from seeking help, signal governmental acceptance of illegal behavior, perpetuate the cycle of drug crime, contradict law enforcement efforts, and threaten public health and safety. According to Robert Martinez, director of the Office of National Drug Control Policy from March 1991 through January 1993, NSEPs “undercut the credibility of society’s message that drug use is illegal and morally wrong.”4 Framed in this fashion, injection drug use represents a voluntary lifestyle choice by individuals free of behavioral disease. Viewed in this light, NSEPs undermine the “war on drugs” and its attendant drug-control policies. To others, NSEPs constitute patient-centered constructs designed to assist those whom the International Classification of Diseases defines as having “mental and behavioral disorders due to psychoactive substance use.” These patients have a chronic relapsing disease that is amenable to intervention were they not stigmatized, incarcerated, deprived of employment, or kept at arm’s length from medical care. They have been ostracized and marginalized for want of effective outreach.
Ultimately, I think the evidence is on the side of needle exchange programs. Despite what one’s gut reaction might be to the programs, they do more to prevent harm than they do to increase harm. And, ultimately, that’s the moral calculus that policymakers should look at.