Syringe exchange programs meant to slow HIV's alarming spread in West Virginia limited by political resistance

Photo by R. Konkathi, Unsplash

Despite federal recommendations and community efforts to stem HIV infections among opioid or methamphetamine users in central Appalachia, the disease continues to spread. Harm-reduction advocates and medical providers cite resistance to syringe exchange programs as the primary obstacle, reports Taylor Sisk of KFF Health News. "The situation likely hasn’t improved, in part because of politicians who contend that such programs encourage illegal drug use."

In 2021, West Virginia's HIV outbreak was particularly concerning to officials from the Centers for Disease Control and Prevention. Sisk writes, "The CDC’s HIV intervention chief called it 'the most concerning HIV outbreak in the United States and warned that the number of reported diagnoses could be just 'the tip of the iceberg.'" 

Rural areas without substance disorder treatment or disease education present a ripe breeding ground where HIV can spread undetected. Ryan White HIV/AIDS Program Director Christine Teague "is concerned for West Virginia’s rural counties, most of which don’t have a syringe service program," Sisk adds. "Tasha Withrow, a harm reduction advocate in rural Putnam County, said her sense is that HIV numbers aren’t alarmingly high there but said that with little testing and heightened stigma in a rural community, it’s difficult to know."

Robin Pollini, a West Virginia University epidemiologist who conducts community-based research on injection drug use, told Sisk, “You would think that in a state that had the worst HIV outbreak in the country, we would have a statewide testing strategy." Sisk reports, "Teague would like every rural county to have a mobile unit. . . offering harm reduction supplies, medication, behavioral health care, counseling, referrals, and more."

While disease prevention through syringe exchange programs is well documented, the CDC's health warnings and recommendations for improved access to syringe exchanges have been largely ignored. Sisk reports, "In April 2021, the state legislature passed a bill limiting the number of syringes people could exchange and made it mandatory to present a West Virginia ID."

Syringe program restrictions led to severe HIV outbreak in rural W.Va.; state often leaves local health depts. in the dark

Most residents of West Virginia now live more than 75 miles from a
sterile-syringe program. (Graphic by The Guardian; click on it to enlarge)

West Virginia is seeing a severe outbreak of the human immunodeficiency virus (HIV) that causes AIDS, spurred by state restrictions on clean-syringe programs for intravenous drug users, The Guardian reports. The problem may be particularly severe in rural areas, which now have even less access to the programs.

"Kanawha County, where Charleston is the seat, diagnosed 40 people who inject drugs with HIV in 2020, about as many as New York City, a place 47 times more populous," Jessica Glenza reports. "Last year, the head of HIV prevention at the Centers for Disease Control and Prevention warned Kanawha had the nation’s 'most concerning' outbreak of HIV among injection drug users." Cases began rising there in 2018 after the city restricted syringe programs. Soon afterward, nearby Huntington, then the state, followed suit. Since 2018, nearly half of such programs in the state shut down.

"The new law requires programs to offer a range of health services in addition to the exchange, only serve people with a West Virginia ID card, and aim to get one used syringe back for each new one they give out," Quenton King reports for Mountain State Spotlight.

Glenza reports, "The restrictions mean that almost 1 million people in West Virginia, the state with the highest drug overdose rate in the U.S. for nine years running, now live between 20 and 75 miles of the nearest needle exchange. Meanwhile, experts worry HIV is spreading undetected in rural West Virginia, where testing and treatment is limited."

However, it's difficult to assess the impact of HIV in rural areas: To preserve patients' privacy, the state's health department only releases ballpark numbers, King reports. That means even county health departments are in the dark about the local extent of the problem, and they are generally left out of the loop on HIV cases.

Robin Pollini, a substance-abuse and infectious-disease epidemiologist at West Virginia University, "says that it should be considered a significant concern when HIV appears in any county that previously had no cases, but especially in rural counties where access to care is limited," King reports. "There are actions that counties can take — from ramping up testing to creating harm reduction programs — by just knowing the number of HIV cases popping up in the county."

But local agencies might have a difficult time responding even if they knew about new cases. "With the current landscape — stressed by Covid, underfunded, and with new laws restricting the types of harm reduction programs they can offer — county health departments have few opportunities to address potential outbreaks, even if they see them coming," King.

High HIV case rate in Miss. blamed on rural stigma, lack of broadband/telehealth and reticence to discuss sexual health

New HIV diagnoses are declining in the U.S., mostly because the preventive drug PrEP (pre-exposure prophylaxis) is being used more widely. But diagnoses have remained high in Mississippi, especially in rural areas, because of stigma and lack of telehealth or broadband, Sarah Fowler reports for The Washington Post.

Those factors contribute to an overall increase in rural HIV cases, according to a May 2020 report by the National Advisory Committee on Rural Health and Human Services. Black and Latino Americans are also at a higher risk of becoming infected. 

Mississippi, which is largely rural and has the largest Black population percentage of any state, finds itself at the crosshairs of both trends. "Despite a recent push to install broadband across the state, many still don’t have reliable Internet access. Without it, telehealth services aren’t an option," Fowler reports.

Another problem is that health-care providers are often uncomfortable having frank conversations about sexual health with patients. As Thomas Dobbs, Mississippi's chief health officer, told Fowler: "People don't want to talk about sex in the South."

National Rural Health Day, Nov. 19, is a chance to spotlight inequalities and local health issues in rural areas

National Rural Health Day, coming up on Nov. 19, is an excellent opportunity to shed a spotlight on rural health inequalities and local health issues in rural areas. Newspapers could take the opportunity to produce special sections, spreads or pages underwritten by local health-care providers -- and insurers, since the observance falls in the open enrollment period for Medicare and Affordable Care Act plans.

It is the 10th annual observance, coordinated by the Health Resources & Services Administration's Office of Rural Health Policy. They say nearly 57 million Americans, or 17 percent of the population, live in rural areas; they frequently face problems getting health care and the best health outcomes, and as a whole they are older and sicker than the general population. That's especially noteworthy as the pandemic burns through rural areas.

The Payson Roundup in central Arizona did a good job of using the observance to focus attention on rural health. For resources and statistics that can help with coverage, visit the National Organization of State Offices of Rural Health website or the National Rural Health Day website.

HRSA will host a variety of events next week to call attention to rural health issues. All are open to the public, though registration is required for some. Click here for a list of webinars, recordings, and virtual workshops on topics such as HIV, coronavirus testing at rural health clinics, death-rate disparities in rural areas, telehealth, Native American health, a virtual job fair, and more.

Tuesday afternoon webinar will discuss the challenges of HIV/AIDS prevention and treatment in rural America

The Rural Health Information Hub will host a free webinar at 3 p.m. ET Tuesday, Oct. 6, to discuss "recent increases in new HIV infections in rural areas, address barriers to HIV prevention and treatment services, and present on the committee's site visit and policy recommendations," according to the website. Click here for more information about speakers or to register for the webinar.

Specifically, the webinar will discuss recent a recent policy brief and recommendations the National Advisory Committee on Rural Health and Human Services wrote for the Department of Health and Human Services.

The NACRHHS paper made three major policy recommendations: 

1. HHS should modernize the Ryan White HIV/AIDS Treatment Extension Act of 2009 to better meet rural needs. That includes increasing funding to grow existing rural programs and encourage pilot programs, earmarking some funding opportunities for rural areas, giving preference to rural applicants in areas with a shortage of health-care professionals, and expanding telehealth to increase access to services and reduce stigma in rural areas.
2. HHS should increase rural access to pre-exposure prophylaxis for rural residents through the Health Resources & Services Administration's Community Health Centers Program and the Rural Health Care Services Outreach Program.
3. HHS should support a streamlined grant application process for cash-strapped rural providers, as well as more virtual grant-writing technical assistance for rural communities so they have a better chance of successfully applying for HHS funding.

HIV patients in rural South get less experienced local care

A newly published study found that HIV patients in the rural South are far less likely to have local access to experienced HIV clinicians.

They examined 14 states (including Oklahoma, Arkansas and Maryland in the broader South) and found 5,012 clinicians who routinely treat HIV. Of those, 28 percent were considered "HIV-experienced," and most of them practiced in metropolitan areas. Over all, 81% of counties—the vast majority of them rural—had no HIV-experienced clinicians, the researchers found.

"Significant urban-rural disparities exist in HIV-experienced workforce capacity for Southern U.S. communities," the researchers conclude. "Policies to improve equity in access to HIV-experienced clinical care for both urban and rural communities are urgently needed."

Rural HIV infection rates are rising in much of rural America, even as rates fall in many large cities. 

Transportation, fear of stigma and lack of confidentiality biggest barriers to use of rural syringe exchanges: Ky. study

Counties in study are in red; click on the image to enlarge it.

Rural residents who inject drugs say they are less likely to access syringe exchange programs because of transportation problems, inability to get to the service at times it's open, and concerns about stigma, lack of confidentiality, and law enforcement. So says a newly published study examining barriers that can prevent people who inject drugs (PWIDs) from accessing syringe service programs (SSPs) in Appalachian Kentucky.

The researchers surveyed 186 PWIDs who used their local health department SSPs in three rural counties in 2018: Clark, Knox and Owsley (though Clark is in a metropolitan area, much of it is rural). Kentucky leads the nation in the number of SSPs, partly because it has 120 counties. As of July 2019, it had 52 SSPs that aim to reduce the spread of HIV and hepatitis C by giving PWIDs clean needles and disposing of dirty ones, and often offer more information about addiction treatment services when the person is ready.

Among the study's participants, 53.2 percent were male, 92.5% were non-Hispanic whites, and 78.5% had Medicaid coverage. About 39% said they injected more than one drug; methamphetamine was the single most popular drug, with 45.2% reporting it as the primary drug they inject. The next most popular was non-prescribed buprenorphine, which is sold legally as Suboxone for drug treatment (25.8%), followed by heroin (16.1%), other non-prescribed opioids (11.3%), and various other drugs (1.6%).

The biggest barrier to SSP use was the lack of transportation, with 18.3% reporting it as the primary barrier. Other barriers were: inability to access the program during operating hours, which are often limited (12.9%); concerns about stigma, privacy, and/or law enforcement (9.1%), not enough syringes (5.4%); and the location of the program (4.8%).

Participants' concerns varied based on the degree of their county's rurality. In Clark and Knox counties, the least rural, transportation was the most frequently cited barrier. But in Owsley, the most rural county, fear of stigma and lack of confidentiality ranked highest.

Rurality also factored into participants' consistency in accessing the SSPs. Participants in Knox and Owsley were more likely to consistently use the program than participants in Clark. The researchers believe the more consistent uptake in rural areas is because people in rural areas tend to have higher residential stability. However, Clark County participants may be less likely to consistently use SSPs because they're more likely to have an alternate means of accessing clean needles.

The study is part of a larger National Institutes of Health-funded effort to learn about SSP uptake in rural areas. This study's authors recently published another study about PWIDs in the same three counties, focused on what kind of interventions are most effective and which drug users are most likely to seek treatment.

Quick hits: Podcast talks about HIV in rural America; coal company that hired laid off Blackjewel miners lays off some

Here's a roundup of stories with rural resonance; if you do or see similar work that should be shared on The Rural Blog, email us at heather.chapman@uky.edu.

The coal company that hired some laid off Blackjewel coal miners has now laid off some of them. Read more here.

Most Americans say they want more oversight of large-scale livestock operations, according to a new poll. Read more here.

A new podcast discusses HIV's threat to rural America. Read more here.

Oil and gas sites release enormous amounts of methane, which contributes to climate change, but it's hard for people to see the phenomenon because the gas is invisible. A crew from The New York Times used an infrared video camera to make methane leaks visible, revealing a troubling amount of pollution. Read more here.

New albums from rural Kentucky artists shed light on the soul of rural America, says Paste Magazine. Read more here.

Because we're not all doom and gloom here at The Rural Blog, here's some fun stuff: a church in southeastern Kentucky created a fake ad for the Amazon Echo: Eastern Kentucky Edition. Does it play on rural stereotypes? Yes. Is it hilarious? Also yes. And, this blogger with Harlan County roots can confirm that a few parts hit pretty close to home. Watch the video here.

Rural HIV infection rates rise as urban rates fall; crisis 'can't be ignored any longer,' journalism professor writes

HIV infection rates are falling in many large U.S. cities, but rates are rising in much of rural America.

"There have of course always been cases of HIV in sparsely populated parts of the country, but in these places far from cities, the conditions that lead to HIV transmission are now intensifying — and rural America is not ready for the coming crisis," Northwestern University journalism professor Steven Thrasher writes for The New York Times. "Unlike large urban areas that have dealt with similar health and substance crises in the past, and that have networks of service providers and consumers in place, small rural health jurisdictions often lack the infrastructure to confront the crisis and have little history of dealing with comparable health issues."

The opioid epidemic is a major factor in the explosion of rural HIV infections, since opioid users are more likely to engage in risky behavior such as having unprotected sex while high or sharing needles. (Prescription opioid abusers often turn to higher-octane intravenous opioids like heroin.) In West Virginia's Cabell County and Huntington, for example, where there is a massive prescription opioid addiction problem, 80 new HIV infections have been diagnosed over the past year. "This avoidable crisis has been exacerbated by unemployment, declining coal mining production and economic pressures on regional press to act as effectively as a watchdog," Thrasher writes.

Most frustratingly, the rise in rural HIV infection rates was predictable, Thrasher writes: "After a hepatitis C and HIV outbreak in Scott County, Ind., in 2014 and 2015 that was fueled by deindustrialization and opioids, the CDC released a list of 220 counties similarly vulnerable to such outbreaks among people who use intravenous drugs. The densest concentration of those counties is along the Appalachian Trail, with 28 of them in West Virginia — more than half of the state’s 55 counties."

However, many rural areas are ill-equipped to prevent or deal with an HIV outbreak because they frequently refuse to effective policies such as needle-exchange programs, more comprehensive sex education, and LGBTQ+ public health efforts, Thrasher writes. Rural HIV patients also may be reluctant to admit they're infected or seek treatment because of the stigma associated with it. That leads to worse health outcomes and more infections. Thrasher says the problem "can't be ignored any longer."

Nov. 7 webinar will look at HIV/AIDS in rural America

The Rural Health Information Hub will host a webinar Nov. 7 to discuss HIV and AIDS in rural America. The free event will begin at 11 a.m. ET and will last about an hour. A recording will be available on the RHI Hub website afterward.

The webinar will review a recent Centers for Disease Control and Prevention report that says the decline in HIV infections has hit a plateau because effective prevention and treatment efforts aren't adequately reaching some populations with the highest need for such services, including rural areas.

Speakers will provide an overview of a federally funded initiative called "Ending the HIV Epidemic: A Plan for America. They will also discuss the rural distribution of medical providers funded by the Health Resources & Services Administration's Ryan White HIV/AIDS Program, and highlight the work of a Ryan White grantee in rural Alabama. Click here to learn more or to register.

Why is medication to prevent HIV so hard to find in rural South? Stigma, poverty, racism, ignorant doctors . . .

Rate of people with HIV per 100,000 in 2017. (Map by AIDSVu)

A prescription medication called Truvada can protect users from HIV infection, but it's difficult to find in the rural South. That's a big part of the reason the South had about 20,000 new HIV diagnoses in 2017, more than the rest of the U.S. combined, Lenny Bernstein reports for The Washington Post. "Stigma, poverty, inadequate access to health care and lingering racial bias" are also reasons the South have a disproportionately large share of HIV infections.

The Trump administration says it wants to reduce HIV transmission by 75 percent within five years and at least 90 percent by 2030, but it's unclear how that will be implemented. President Trump's proposed 2020 budget would fund a program targeting HIV transmission in the rural South, but would also slash funding for Medicaid, which most people in poverty, some of them with HIV, depend on. Beyond that, it's unlikely the budget will pass in Congress as is, Bernstein reports.

Bernstein writes that the most effective way to fight HIV transmission is to increase access to Truvada (to prevent infection), and antiretrovirals to lower the viral load of already infected people so they can't transmit the disease. "Theoretically, you could end the epidemic tomorrow if you did that," Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases and one of the architects of Trump's plan, told Bernstein.

But in 2015, a third of primary-care doctors surveyed said they had not heard of Truvada, according to the federal Centers for Disease Control and Prevention. "Persuading many more people to take the drugs will require more federal money for health clinics as well as for education and outreach to certain groups, especially black men who have sex with other men. At current rates, half that group will be diagnosed with HIV infection," Bernstein reports.

Stigma, limited privacy, lack of sex education, shortage of health insurance hamper rural efforts to fight HIV and AIDS

President Trump said in his State of the Union address that he wants to stop the spread of HIV in the U.S. within 10 years. "In addition to sending extra money to 48 mainly urban counties, Washington, D.C., and San Juan, Puerto Rico, Trump's plan targets seven states where rural transmission of HIV is especially high," Jackie Fortier reports for NPR. Health officials in those states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma and South Carolina) welcome the funding, but told Fortier that ending or slowing rural HIV transmission is a big challenge.

In rural areas,there is still a stigma attached to being gay and/or having HIV or AIDS, says Dr. Michelle Salvaggio, medical director of the Infectious Diseases Institute at the University of Oklahoma Health Sciences Center in Oklahoma City, a federally funded HIV clinic. It employed a case manager to serve a nearby rural area, but eliminated the position because no patients went to see her, Salvaggio told Fortier: "They didn't want to be seen walking into the HIV case manager's office in that tiny town — that can only mean one thing."

That lack of anonymity is not just a problem in small towns. When Native Americans, an at-risk population in Oklahoma, "go into an Indian Health Service clinic, it is possible that they will see their cousin behind the desk, and their cousin's brother-in-law working in medical records, and their niece's boyfriend working in the pharmacy," Salvaggio said.

An HIV-positive Cherokee, Ky Humble, told Fortier that rural Oklahomans with HIV and AIDS need more than medical funding; they also need more access to related services like food pantries, mental health therapy, and transportation assistance.

Another difficulty: Oklahoma, and many other states with large rural populations, don't require comprehensive sex education that could help teens learn about cheap, effective methods of preventing HIV, such as use of condoms. Lack of health insurance will also likely hamper efforts to get rural residents tested and treated, especially in states that did not expand Medicaid, Fortier reports.

Rural residents less likely to get HIV testing; researchers say rural health-care providers should routinely offer it

Rural residents are less likely to have had an HIV test than their urban counterparts, according to a study of responses to a continuous national poll conducted by the federal Centers for Disease Control and Prevention.

The study of the the Behavioral Risk Factor Surveillance System found that HIV tests for rural people were less likely in the past year and over the course of their lives. That's worrisome because rural America is experiencing an increased incidence of HIV, especially in the South and Midwest.

The research used data from 2015. Out of about 250,000 respondents, 24.5 percent of urban residents said they had received an HIV test within the past year, while 20.2 percent of rural residents did. Overall, 26.9 percent of urban residents reported having ever had an HIV test, compared to 21.5 percent of rural residents.

The researchers also dug into where people tend to get HIV tests. In rural areas, people tended to get tested in hospitals, emergency rooms and clinics, and are less likely to get tested in their doctor's office.

The study's authors conclude that rural medical providers should routinely offer HIV testing to patients, and that "targeted interventions are needed to remove structural barriers in rural communities such as long distances to clinics and low availability of free HIV testing at clinics serving the un- or under-insured."

Some rural areas hit by opioid epidemic don't get priority for federal response grants; CDC cites lack of county drug data

"A federal agency recommended steering the $100 million Congress appropriated for rural counties to battle the opioid epidemic to those dealing with high rates of hepatitis C infection and HIV/AIDS instead," leaving out many rural counties hit by the epidemic, Susannah Luthi reports for Modern Healthcare.

In April, the Health Resources and Services Administration said it would award 75 grants to counties to develop plans for opioid-abuse treatment and recovery, selecting counties considered "at risk" by the Centers for Disease Control and Prevention. But the CDC prioritized counties based on confirmed cases of hepatitis C instead of opioid-overdose rates, according to emails obtained by Modern Healthcare. A CDC official wrote in one that the agency's selected counties are not those "most at risk for overdose or with the highest rate of opioid overdose." The emails said the agency chose hepatitis C infection rates as the key indicator because there is no county-level measure of injection drug use.

While there is a great deal of overlap between the counties facing hepatitis C and those with many  overdoses, some counties with high overdose rates and low hepatitis C rates were left out of the CDC's recommendations. "The CDC's metrics excluded some states battling the highest rates of opioid deaths, including New Mexico, New Hampshire and Florida. Other states with equally high rates, such as Nevada and Pennsylvania, have only a few counties flagged even though they are heavily rural," Luthi reports. "Kentucky, Tennessee, West Virginia and Missouri hold the most counties recommended for funding. These states face the same high opioid overdose death rates as excluded states like New Mexico and New Hampshire. But counties in other states with significantly lower death rates, such as Kansas and Georgia, also made CDC's priority list."

Telemedicine app could help address rural opioid addiction

"For President Donald Trump’s national emergency on opioid abuse to get traction in Appalachia and the rural South, the treatment effort will have to overcome some stubborn logistical barriers — and an obscure legal hurdle complicated by the president’s own push to reduce regulatory burden," Tony Pugh reports for McClatchy.

The logistical barriers to treatment in rural areas include fewer available medical care options, transportation problems (no car, too long a distance), and widespread poverty. Trump's limited emergency declaration included a call to expand telemedicine services so specialists can treat rural patients remotely via video conference. The National Institutes of Health is funding a $1.7 million study of an app called "emocha" that could help doctors remotely monitor whether rural patients were taking daily anti-addiction drugs like buprenorphine. The patients would use their phones or tablets to record themselves taking their meds, and send it to their doctor for verification. Patients could also report cravings and side effects in the app. The app can also be used to monitor patients with tuberculosis, HIV and hepatitis C.

"Other emerging technology, such as online digital counseling apps, along with pharmaceutical innovations including longer-lasting doses of buprenorphine could help bridge the geographic and clinical gaps faced by opioid abusers in isolated areas," Pugh reports.

There are some problems with this approach. For one, limited access to broadband internet may limit the feasibility of telemedicine, especially in very rural areas. And a federal law designed to crack down on shady internet pharmacies is stopping doctors from prescribing controlled substances without an in-person consultation first. The American Telemedicine Association has been trying to get a federal waiver for the Ryan Haight Online Pharmacy Consumer Protection Act for nearly a decade, but say the Drug Enforcement Administration has been slow to respond.

"DEA spokesman Rusty Payne said the agency is working on the waiver guidelines, but it’s unclear when the waiver will be ready and what it will entail," Pugh reports. "A senior DOJ official suggested the effort could be delayed by a Trump executive order that discourages creation of new rules by requiring agencies to eliminate two rules for every new one created. The White House did not respond to questions about the matter."

Free webinar on rural HIV and AIDS set for Nov. 7

The Rural Health Information Hub and the the Walsh Center for Rural Health Analysis, part of the research organization Norc at the University of Chicago, will host a free webinar, "Rural HIV/AIDS Prevention and Treatment," Thursday, Nov. 7.

The one-hour webinar will begin at 1 p.m. EDT, and will present a toolkit designed to help rural communities plan, implement and sustain HIV/AIDS programs. The toolkit was developed by Norc for the federal Office of Rural Health Policy. The speakers will discuss examples of successful programs and lessons learned. Featured speakers will be:

• Alycia Bayne, senior research scientist at the NORC Walsh Center for Rural Health Analysis;


• Daniel Wakefield, interim director of the Ursuline Sisters HIV/AIDS Ministry in Youngstown, Ohio; and 


• Lisa McKeithan, director of Positive Life and the North Carolina Rurally Engaging and Assisting Clients who are HIV positive and Homeless (NC REACH) project at CommWell Health. 

 A recording will be available on the Rural Hub website afterward. Click here to register or for more information.

Sharing syringes isn't like sharing a bottle or a joint: it could lead to HIV or hepatitis outbreaks

Map from The Guardian highlights Wolfe County, Kentucky

Amanda Holpuch of The Guardian took a trip to Wolfe County, Kentucky, perhaps the U.S. county most vulnerable to an outbreak of HIV or hepatitis C from needle sharing by intravenous drug users, a report noted here June 16.

"A man was lying sedate after injecting drugs. His fellow users, to amuse themselves, threw needles at him like a human dartboard to see if they would stick, according to a recent police report in Wolfe County," Holpuch reports, quoting special deputy sheriff Gary Smith: “Back in the day, all we had to worry about was people drinking or smoking weed.” An unnamed captain says, “Everybody is using drugs here – end of story.”

The Centers for Disease Control and Prevention, in determining the 220 counties most vulnerable, used "a sobering recipe: high rates of drug overdose deaths and prescription opioid sales, a high white population, astounding rates of hepatitis C and searing poverty," Holpuch writes. "The CDC said the top 20 most vulnerable counties identified in its report are effectively equal in vulnerability because of the analysis’s margin of error, but Wolfe County is ranked first and serves as a model for the places at most risk, 13 of which are in Kentucky."

Smith likened the sharing of syringes "to a more dangerous version of a group of men getting together to share a bottle of whiskey. Instead of swapping saliva on a bottle cap, users are exchanging all types of body fluids and pushing a needle coated with those fluids into their bodies."

Kentucky was the first state in the South to authorize syringe-exchange programs, in 2015, but local officials have yet to establish one in Wolfe County or in many of the other 54 Kentucky counties on the national list of 220, the Lexington Herald-Leader reported in July. Here is The Guardian's version of the national map:

Pennsylvania officials fear a rural HIV outbreak, fueled by a rise in intravenous drug use

Last year's outbreak of HIV in rural Indiana—blamed on a rise in intravenous drug use—has officials in Pennsylvania worried about a similar outbreak in rural areas in the Keystone State. The number of HIV cases in southeastern Indiana, mostly around Austin in Scott County, stands at 190, according to state data. A Centers for Disease Control and Prevention study released in December said that rural areas lack prevention services for opiate addiction and HIV infections.

"Since 1980, IV drug use accounted for 15,000 HIV cases or roughly 26 percent of Pennsylvania's overall total, the second most prevalent cause in the state," Colin Deppen reports for Penn Live. "In 2014, the most recent year for which data is available, IV drug use accounted for 5 percent of Pennsylvania's 1,210 new HIV cases, the third biggest cause that year." The Center for Rural Pennsylvania found that In rural Pennsylvania counties, home to about 3.5 million people, there were 108 new cases of HIV in 2011, 128 in 2012, 113 in 2013 and 112 in 2014. Rural HIV deaths fell from a peak of 140 in 1994 to 15 in 2013.

Officials say a needle exchange program would help reduce HIV cases, Deppen writes. "But under Pennsylvania law, distributing needles is still technically a crime," said Loren Robinson, deputy secretary for health promotion and disease prevention with the Pennsylvania Department of Health." (Read more) (Penn Live map: HIV diagnoses from 2011-14)

HIV outbreak in rural Ind., driven by intravenous drug use, puts other rural areas on notice

Last year's outbreak of HIV in rural Indiana—blamed on a rise in intravenous drug use—has put other rural areas on notice to look for warning signs to prevent a similar epidemic in their necks of the woods. The number of HIV cases in southeastern Indiana, mostly around Austin in Scott County, stands at 188, according to state data. A Centers for Disease Control and Prevention study released in December said that rural areas lack prevention services for opiate addiction and HIV infections.

The Indiana epidemic has put Virginia officials on notice, Becca Pizmoht reports for the Madison County Eagle. While HIV rates remain stable statewide, "concern grows that rural counties are seeing a disproportionate number of new cases. Several factors are cited as possible causes, including lack of available education and testing and increased intravenous drug use in rural populations." Madison County (Family Search map), population of 13,000, has not had any reported HIV diagnoses since 2011, but adjoining Greene County (18,000) has had six and Orange County (34,000) eight.

Ann Rhoades, director of HIV Surveillance in Virginia, told Pizmoht, “After the Indiana outbreak we have been watching rural areas more closely. Urban areas have a lot of available testing and there are needle exchange and education programs in place. We need to have education and testing available to our rural populations because there is a stigma attached to HIV sometimes people in small communities aren’t willing to get tested.” (Read more)

Medicaid rules limit treatment of hepatitis C in rural Indiana town facing HIV epidemic

The lone doctor in the rural Indiana town of Austin (Best Places map) that has faced an HIV outbreak is unable to "prescribe the latest treatments for patients also infected with the deadly Hepatitis C virus," Maureen Hayden reports for Community Newspaper Holdings Inc. While Dr. William Cooke is treating dozens of people with HIV, "state Medicaid rules forbid him from prescribing new treatments to those same patients with Hepatitis C, the blood-borne disease that causes inflammation in the liver and now claims more lives than HIV in the U.S."

"The rules put tight limits on treatments paid for with taxpayer dollars," Hayden writes. "The only doctors who can prescribe the expensive drugs are gastroenterologists and infectious disease specialists. But neither exist in the poor rural communities of Scott County—nor in many other rural areas throughout where cases of Hepatitis C are on the rise."

Even though Cooke said most Hepatitis C treatments can be delivered in a family doctor’s office or clinic, "a gastroenterologist specialist from New Albany, 30 miles away, visits patients at the county’s only hospital, in Scottsburg, twice a month," Hayden writes. Cooke told her, "Some of my patients can’t or won’t go. We had a hard enough time getting people tested for HIV. They don’t trust doctors to begin with, and they don’t trust strangers.”

Medicaid officials "say the rules were written with the input of a state panel of medical experts and are meant to safeguard patients who are chronically ill and need the care of specialists," Hayden writes. "Indiana is one of at least 14 states with Medicaid programs that require Hepatitis C treatment to be overseen by a specialist, according to a study by infectious disease experts that was published in the Annals of Internal Medicine." (Read more)