IDWeek: A talk examines micro-epidemics, and the elusive solutions they require

At a conference dominated by discussion of a coronavirus pandemic that, circling the globe, has led to the infections of more than 41 million people and killed more than a million, Dr. Judith Feinberg this week came to talk about a smaller scale public health challenge in a talk titled "HIV Micro-Epidemics: When HIV Comes to Your Town."

"My town, so to speak, is West Virginia," she said. While not a town, it is the 10th least populated state in the nation, with its largest city the capital, home to fewer than 50,000 residents. The impacts of an epidemic there would seem, from a distance, to be containable.

Until recent years HIV incidence across the state was low and confined largely to men who have sex with men. But unemployment and hopelessness have fueled the opioid epidemic across the state's rural stretches and  the challenges there are vast, she notes.

Dr. Feinberg is the immediate past president of the HIV Medicine Association (which with the Infectious Diseases Society of America, produces this blog), a professor and researcher at West Virginia University of approaches to prevention and treatment of infections associated with injection drug use, and her area of focus includes the state's southern coalfields. That includes, for example Wyoming County, with a population of 21,000 people, two grocery stores and not one traffic light.

The county's last coal mine and remaining largest employer put 300 people out of work when it closed last year. As across the state, where nearly a fifth of the residents live in poverty, and only a little more than half are employed, the county's residents rank high for risks of chronic diseases, and low for access to health care. While the opioid epidemic fuels the spread of infections that include HIV, hepatitis C and B, fewer than 20 infectious diseases specialists are in practice across the state.

These vulnerabilities came into focus in 2017, when the identification of 10 people with HIV led to the discovery of 47 more, "a shocking, shocking development," she said. It represented, she says, "a transition point," in the spread of HIV in West Virginia. While about 9% of infections were attributed to injection drug use, and another 5% were among men who had sex with men and also injected drugs, the mode of transmission remained unknown for about a quarter of those infected. "I take from that it is highly likely that most, if not all of those individuals were likely to have been people who inject drugs."

Across the 15 southern coalfield counties where the infections occurred, only three had services that provided sterile syringes to people who inject drugs. In recent years the largest syringe service program in the state capital had been closed, and another had imposed restrictions, including county residency that limited access to its services greatly, Dr. Feinberg said. In the meantime, access to HIV testing, prevention, including PrEP, knowledge of HIV and treatment for substance use disorder remained scarce.

In the three years since the shift in West Virginia's HIV epidemic was noted, the trends it reflected continued to grow, with both the numbers of HIV infections and the percent attributed to injecting drug use rising each year. "So there are urgent needs to respond to," Dr. Feinberg noted.

They could be met, she says through comprehensive services to screen for, diagnose, and treat substance use as well as accompanying infections -- that could be offered, ideally, through expanded and need-based syringe services programs.

Like the needs raised by the ongoing pandemic, however, those responses would require two critical ingredients -- appropriate funding, and political will.