As an opioid crisis drives the spread of HIV, Kentucky plan invests in harm reduction, training, care and community

Using funds generated by Kentucky's HIV drug assistance program, a plan launched this month will support urgent and ongoing responses to the infectious disease impacts of an injecting drug use epidemic

From all the evidence that Dr. Alice Thornton and her colleagues could see in the growing numbers of patients coming through the doors of the Bluegrass Care Clinic at the University of Kentucky, the mounting infectious disease impacts of their state’s opioid epidemic were far outpacing ready responses. In the not-distant past, only a small number of people treated for the virus there had become infected through injecting drug use. Now clinicians were seeing a fast climb that reflected what was happening across northern Kentucky: Injecting drug use suddenly was surpassing sexual transmission as the leading risk factor for HIV. In 2016, five of 25 new HIV infections in northern Kentucky were linked to having shared needles used to inject drugs, followed the next year by 46 new HIV infections — nearly half of which were linked to injecting drug use. By 2018, of 46 patients diagnosed with HIV in northern Kentucky, 29 had become infected from sharing needles. Adding to the growing tragedy was knowledge that measures to stop the surge of infections existed but remained widely out of reach. 

Dr. Alice Thornton

“If people have clean needles, that will break the chain of transmission,” Dr. Thornton observed. The reactions of people newly diagnosed who had not perceived themselves at risk, she said, also showed an urgent need for public health outreach to raise awareness of the infectious disease threats associated with injecting drugs. Fast links to care for infectious diseases related to injecting drug use were needed, and that need highlighted another need — for a sufficient health care workforce trained to recognize and refer patients needing harm reduction, treatment, care and prevention services. The missing piece was money. That piece fell into place with income produced by KADAP (Kentucky’s AIDS Drug Assistance Program), the state program that supports HIV patient access to antiretroviral drugs with funding from the Ryan White HIV/AIDS Program. The program supplies the drugs at no cost for patients who can’t pay for them, and at low cost for patients who can, with the understanding that the income produced by those payments must be invested in efforts to reduce HIV incidence and impacts. Some of the expertise needed to do that was already in place. Dr. Ardis Hoven, a University of Kentucky professor of medicine, and an infectious disease consultant to the Kentucky Department for Public Health was a strong proponent of needle and syringe exchange programs who had overseen the development of such programs across the state. Mark D. Birdwhistell, vice president for University of Kentucky HealthCare had 30 years of healthcare policy experience including around Medicaid, which more than 40 percent people of living with HIV nationwide rely on for medical coverage. Dr. Thornton, chief of UK Division of Infectious Diseases, saw opportunities to improve access to HIV care and prevention on a daily basis as chief medical director of the Bluegrass Care Clinic at UK, one of four federal Ryan White program sites statewide. Clinic program manager Jana Collins brought finance experience and federal program planning expertise, that helped shape responses, while Kentucky Health Commissioner Dr. Jeffery Howard brought statewide needs to the discussion. With other UK, Kentucky Health Department and clinic colleagues, they developed a plan. “Here is our state’s great need. How are we going to solve this together?” Dr. Thornton said. “It was really exciting.” The result, launched in mid-March was KIRP — the KDAP Income Reinvestment Program — an innovative plan to maximize the use of those resources to address the urgent need for harm reduction measures, support for HIV prevention, care and treatment programs, training for healthcare providers addressing HIV, hepatitis C, substance use disorders and mental health issues, and new programs tailored to community challenges. The most immediate need was for responses to reduce the harms stemming from injection drug use, including through the provision of sterile needles and syringes. Five years earlier Kentucky did not have any syringe exchange programs. Now it is home to about 50, a development Dr. Thornton calls sad — for the challenge that necessitated the response -- but also inspiring. KIRP will provide supplies and augment workforces for those efforts, with trained harm reduction experts who also will conduct HIV and hepatitis C screening. In addition, struggling on shoestring budgets to meet growing needs, the programs shared other needs with KIRP planners — including the need to offer services every day or the need for a mobile unit to have better reach in the community. The training component will build on the existing AIDS Education and Training Center, which also is supported by the Ryan White Program, by adding opportunities for medical students, social work students and those in related disciplines to shadow clinicians providing care for lower-income patients with complex medical needs including HIV and substance use disorders. In addition, KIRP will directly re-invest funds into the Ryan White programs across the state, responding to challenges that include meeting patients’ transportation needs in rural areas, supporting mental health services, and training clinicians to provide medically assisted treatment for substance use disorders. And, Thornton said, the program will support community-based interventions. Through all of this, the program will track outcomes and remain a work in progress, including with opportunities to work with justice-involved populations, Dr. Thornton said. “There are ideas out there that are exciting.”