At his recent abstract presentation delivered at the Conference on Retroviruses and Opportunistic Infections (CROI), Dr. R. Paul McClung presented a portrait of a successful HIV intervention in Cabell County, West Virginia. By his estimation, the response to what was then the third HIV outbreak in that state, beginning in January 2018, was a fine example of a successful infectious disease responseMedPage Today described it as “A Blueprint for Public Health Response,” and McClung cited a strong public health infrastructure in the county, including “…a large academic medical center, a large network of community health centers, and a ‘growing capacity to treat substance use disorder,’ such as a syringe service program in place since 2015” (Walker, 2020). Given the consistently negative press both the state and the county receive, this glowing review of Cabell County’s response is a welcome change—but it is also, unfortunately, a largely incomplete portrayal of events as they occurred, and of circumstances on the ground as they still stand.
While the staff of the Cabell-Huntington Health Department, their Harm Reduction Program, and the local community-based organizations and healthcare providers did an excellent job of working together to identify new cases of HIV among People Who Inject Drugs (PWIDs) and others in the county, what Dr. McClung fails to mention is that many—a significant percentage—of those cases identified in Cabell County between January 2018 and December 2019 were patients who were not/are not residents of Cabell County.
Huntington sits on the border of both Kentucky and Ohio and is also surrounded by several rural counties. It serves as one of the primary hubs of drug trafficking in the region, a place where people drive hours and hundreds of miles to get their drugs and, unfortunately, often contract infectious diseases in conjunction with the injection of those drugs. As Dr. McClung’s reporting correctly identified, a majority of the new HIV diagnoses were directly related to Injection Drug Use (IDU). According to the West Virginia Office of Epidemiology and Prevention Services (OEPS), of the 69 new cases identified in 2019, 63 (91.3%) reported IDU as a risk factor (OEPS, 2020). It was not, however, until January of this year (2020) that the state redefined how they count reported cases of HIV, allowing for counties to correctly attribute newly identified cases back to the patients’ counties or states of origin.
Dr. McClung’s reporting leaves out the important fact that little to no investigation has been done on the ground in the rural counties that surround Cabell and Kanawha Counties, the site of the fourth HIV outbreak, identified in 2019. This is not because nobody wants to conduct these investigations, but because the resources simply do not exist for them to be done. Even in Cabell County, the Harm Reduction Program operates with only a handful of staff members for a job that requires ten. In these rural counties, entire county health departments operate with similarly small staffs, yet their responsibilities extend beyond just Harm Reduction and HIV testing. They are also tasked with protecting communities from environmental health risks, and with inspecting houses, institutions, recreational facilities, sewage and wastewater facilities, and drinking water facilities.
When we discuss West Virginia’s response to the inaccurately defined “cluster,” we cannot do so without acknowledging that we do not know whether or not the HIV outbreak was
contained to Cabell (nor if the outbreak in Kanawha Count was contained) simply because neither adequate testing, nor case investigation, has been conducted outside of Cabell and Kanawha Counties. To paint a portrait of a successful public health intervention without addressing the existing gaps in public health infrastructure and surveillance outside of urban areas of rural states is misleading.
When it comes to both drug use and infectious disease, two things are certain: (1) neither are contained solely within urban areas, and (2) both have been growing in rural America for more than a decade. We have yet to effectively grasp or contend with these rural health crises, despite the best efforts of county and state health departments.
Despite Dr. McClung’s accurate observation of Cabell County, there is a greater story to be told and greater needs to be met. We need more resources. We need enough funds dedicated to hiring appropriate staff. We need enough funds to adequately provide infectious disease testing and epidemiological reporting. We need enough funds to provide treatment. Right now, West Virginia’s rural counties lack those resources, putting a strain on Cabell to pick up where they cannot.
References
Driesbach, E. (2020, March 16). Treating patients ‘rapidly and effectively’ helped contain HIV outbreak in West Virginia. Thorofare, NJ: SLACK Incorporated: Healio: Infectious Disease: HIV/AIDS: Meeting News. Retrieved from: https://www.healio.com/infectious-disease/hiv-aids/news/online/%7Bd14dcd…
Office of Epidemiology and Prevention Services. (2020, March 01). HIV Diagnoses by County, West Virginia, 2018-2020. Charleston, WV: West Virginia Department of Health and Human Resources: Bureau for Public Health: Office of Epidemiology and Prevention Services. Retrieved from: https://oeps.wv.gov/hiv-aids/documents/data/WV_HIV_2018-2020.pdf
Walker, M. (2020, March 11). West Virginia HIV Outbreak: A Blueprint for Public Health Response – Used four pillars of federal initiative to manage local HIV epidemic. New York, NY: MedPage Today, LLC: Meeting Coverage: CROI. Retrieved from: https://www.medpagetoday.com/meetingcoverage/croi/85378