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Effects of Addiction

In Addiction’s Wake, HIV Now Popping Up in Appalachia

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Cabell-Huntington Health Department workers demonstrate how the INSTI finger-print HIV test and the Ora-Quick Advance oral HIV test are conducted on Monday, May 13, 2019, at the Cabell-Huntington Health Department in Huntington. Photo: Ryan Fischer, the Herald-Dispatch

For all of Appalachia’s much-profiled health concerns, HIV/AIDS has historically not been one of them.

In 2017, when West Virginia flashed in national headlines detailing the carnage of the opioid epidemic, the Mountain State still had one of the nation’s lowest rates of HIV diagnoses (4.3 cases per 100,000 residents), according to the Centers for Disease Control and Prevention. Neighboring Kentucky (7.9 per 100,000) and Ohio (8.8 per 100,000) have fared similarly.

But a recent HIV cluster in Cabell County, West Virginia, along with a scattering of others beginning to crop up across the region, reflects that more cases of HIV are being transmitted among intravenous drug users – potentially devastating for communities already ravaged by the opioid epidemic.

Cabell County’s current cluster – the only one currently known in West Virginia – is now up to 49 confirmed cases, according to the West Virginia Department of Health and Human Resources. All of those were contracted by intravenous drug use through the sharing of contaminated syringes.

The cluster, tracked from January 2018 to the present, represents a sharp uptick from the baseline average of eight cases annually over the past five years.

It’s particularly troubling considering Cabell County has an estimated 1,800 active IV drug users, creating an ample at-risk population for the virus to spread.

HIV is difficult to track and impossible to predict, but introducing the virus in the region’s drug-using population is an obvious cause for concern for West Virginia’s state health officials.

“We expect the case count to increase just because we know there’s people out there that have not yet been tested,” said Shannon McBee, senior epidemiologist at DHHR, in a joint interview alongside Dr. Cathy Slemp, West Virginia State Health Officer, at the state office in Charleston.

“Until we can get a handle on how many people have been tested in Cabell County, it’s likely we’ll continue to see cases,” McBee said.

HIV cases are still comparatively sparse in West Virginia. The dynamics for addressing it have changed, however, as the chief at-risk population shifts, and it’s created new challenges for those in public health.

Unlike typically close-knit and stable LGBTQ communities, reaching intravenous drug users can feel like chasing shadows. More than half of those in the current Cabell County outbreak are homeless; they’re typically transient and often from out of town, and aren’t likely to seek assistance on their own.

That means meeting them where they’re being housed, where they get their meals and where they encounter the medical system, McBee said – and that’s been the major new challenge from a public health perspective.

While the diseases themselves aren’t comparable, much of the lessons and community partnerships built during last year’s hepatitis A outbreak can be applied to HIV outreach. As in HIV, hepatitis A spread primarily among the homeless and transient.

“This is not something that public health can just step in and fix,” Slemp said. “This is about how we work together as a community to come together. We can guide, support and lead in public health, but it really is about how a community and providers come together to help diagnose and link people to care for HIV.

“It’s very hard to take your medication for HIV if you’re living on the street,” she added.

Where could the next cluster be?

HIV isn’t as easy to track as other diseases because of how difficult it is to transmit. Unlike hepatitis A, which is passed through the fecal-oral route, HIV is bloodborne and not shared through casual contact.

Because of that, HIV doesn’t “spread” in a predictable fashion, but rather “pops up” independently.

Some counties are at greater risk than others. According to a national CDC study in 2015, 220 counties in the United States were vulnerable to HIV, and 28 were in West Virginia. McDowell and Mingo counties were ranked second and seventh, respectively, in the nation for being at risk. The list also included Cabell (122nd), Kanawha (209th), Logan (20th), Wyoming (16th), Wayne (62nd), Mason (85th), Boone (22nd) and Raleigh (18th).

The disease could migrate within West Virginia from Cabell County, though Slemp said that’s not necessary. As it stands, West Virginia’s counties are at different levels of preparedness to respond to their own potential cluster should it occur.

“We’ve got counties at risk in their own ways, and this is a good time to bolster those services available,” Slemp said.

Cabell County is well equipped to handle its own HIV cluster, Slemp and McBee agreed, both through the services it provides and the partnerships built in response to the opioid epidemic, which can easily adapt to HIV prevention.

That includes the Cabell-Huntington Health Department’s syringe exchange program – which offers clean syringes to IV drug users in exchange for used ones to curtail the spread of bloodborne illnesses. Syringe exchange clients, who must physically come pick up and drop off their needles, are five times more likely to seek treatment for their addiction, McBee added.

But neither could speculate what might happen if an HIV cluster developed 50 miles away in Charleston, which scrapped its syringe exchange program in 2018 under public and political pressure. Both, however, expressed their support for it as a valuable asset to stopping the spread of devastating diseases.

“(Syringe exchanges) need to be one part of a comprehensive approach, but they are one of the most effective components of that approach,” Slemp said.

A study published last week by Johns Hopkins University concluded Charleston is more at risk for an HIV outbreak now since the syringe exchange was killed. Researchers found Charleston’s IV drug users are now far more likely to share used syringes to inject drugs and much less likely to be tested for HIV now that they’re no longer coming into a regular clinical setting for their syringes.

“An HIV outbreak doesn’t have to happen,” said Dr. Sean Allen of the Johns Hopkins Bloomberg School of Public Health and leader of the research. “But we need policymakers to really begin to take those steps to prevent another HIV epidemic.

“Any program that’s keeping people alive and reducing the risk of HIV and overdoses, I think it’s hard to argue against that.”

But the fact that Cabell County’s current HIV cluster occurred more than three years after the program was well-rooted could be hoisted as an indictment that the program is failing, particularly by those who oppose the program – chiefly arguing that the free syringes it provides may find themselves littered in the public.

Dr. Michael Kilkenny, physician director of the Cabell-Huntington Health Department, stands by the syringe exchange. It’s rooted in hard science, he said, while the arguments of naysayers contribute nothing to solving the problem.

“We certainly have a climate of misinformation in our country, and that misinformation tends to drive us to failure,” Kilkenny said from his office in Huntington. “We can’t go that direction.”

The HIV efforts at home

Cabell County heeded advice by the state Bureau for Public Health to increase HIV surveillance as early as 2017 – which Kilkenny noted would only have worked in counties with the capacity to do so like Cabell.

The county has since worked closely with the state and the CDC to beef up and fine-tune existing tracking methods. In April, the department ratified the prescription of pre-exposure prophylaxis from its clinic – a drug given to those not infected but at risk for HIV to decrease their chances of contracting it.

Locally, the health department is still tapped into a large network of outside community partnerships, particularly those who serve the homeless, which are still fresh from the hepatitis A outbreak and the ongoing opioid epidemic.

Those ties can easily pivot to HIV efforts, and Kilkenny said it’s part of what’s made Huntington able to respond so well to its past problems.

“Huntington works really well together; we always have. From that standpoint, we are a great community to attack a problem,” Kilkenny said.

But reaching the IV drug use population is still the major challenge, even for more nimble, grassroots groups.

The gay community has long known about the Tri-State AIDS Task Force – founded 30 years ago when the then-mysterious AIDS virus killed by the thousands. The donor-fueled local nonprofit distributes 100% of its funding to HIV patients in need, and those traditionally at risk have always seemed to know where to find help.

Like in public health, connecting the new at-risk population to the readily available help is the main problem.

“A lot of them aren’t from here and they don’t know folks who can help, and they don’t know how to reach out to us,” said Lisa Cremeans, Tri-State AIDS Task Force executive director, in an interview last weekend.

“That’s the big difference: They’re spread out throughout our community, and they don’t know each other a lot of the time.”

They’ve started campaigning at places where IV drug users frequent, primarily Huntington’s homeless outreaches, offering incentives like food packages and gift cards to enter care.

But too often they come to care the first time, get tested and don’t follow through on treatment. That’s another new dynamic, Cremeans added.

“Those IV drug users are lost in their addiction,” Cremeans said. “Men who have sex with men or other folks infected don’t have that addiction personality, so they want to stay healthy and get better.”

In West Virginia, most if not all HIV treatment is covered through Medicaid, though Cremeans noted it’s more difficult for Ohio or Kentucky residents. The majority of those locally at risk for HIV are presumably Medicaid eligible, meaning those likely to contract the disease have the resources to be treated if they’re reached.

Without insurance, HIV medication costs about $6,000 per month, she added.

The medication to treat it, while still brutal, has changed dramatically over the past 30 years. What was once a four to five times a day regimen can often be taken with a single daily pill, and survivors are now living healthy lives decades after contracting it.

Living to the fullest with HIV

Convincing someone to talk about his or her HIV isn’t easy, even in the openness of 2019 and the medical science dispelling the long-held taboos. But a 58-year-old Huntington man did. A jovial, well-liked and active community member, he’s long been open with friends and acquaintances about being HIV-positive, but chose anonymity when speaking to The Herald-Dispatch.

He’s also been open about being gay, but that didn’t contribute to being diagnosed with HIV in 1995. A hemophiliac, he was given tainted blood, likely as early as the 1970s, only to spot it later in life.

His white blood cell count was at 32 (normal is well over 100), and news came at a time when the virus was extremely lethal.

“I prepared to die,” he said flatly. “Life was pretty miserable back then.”

But it was at a time when new medications made living with HIV a real possibility, and he was fortunate enough to have the insurance to cover it.

“It’s a shock when you realize that you’re going to live again,” he quipped. “And then it’s a shock to know you’re going to live again with this disease.”

It became a part of his life, but it didn’t control his life. His weakened immune system means there’s almost always some ailment to worry about, like random tumors on his body or thrush infection in his mouth. There are some days when he simply wakes up feeling exhausted – his “HIV days” – that hit like a bout with the flu.

He got sick every time his infant children were. When he began a job working with young children, his doctor didn’t worry at all about him passing HIV to them, but rather their germs coming to him.

The antiretrovirals he’s taking are brutal, and he’s grown resistant to several types of available regimens over time. He compared it to chemotherapy. They make you sick, they can make a man sterile and all his foods taste like metal.

“The medications are hell, but they have to be because they’re killing a virus that’s difficult to control,” he said.

But given all that, HIV survivors are given two paths, he continued – give up and die, or get up and keep moving. He’s chosen the latter.

“It really depends on how hard you want to live,” he said. “And you need to just throw yourself at life.”

There is currently no cure for HIV.

Where to get help

The Tri-State AIDS Task Force provides help and financial assistance to those living with HIV. They can be reached at 304-522-4357 or through Facebook by searching “Tri-State AIDS Task Force.”

This article was originally published by the Herald-Dispatch.

 
 

Effects of Addiction

After Obamacare: Ending Affordable Care Act could cut addiction treatment

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On a recent gray winter morning Tomas Green drove the rain slick streets of Ranson in West Virginia’s Eastern Panhandle. No matter the weather, Green helps transport clients working through addiction at the Jefferson Day Report Center get to their treatment sessions and meetings.

“If they need rides, I use my own personal transportation sometimes,” he said.

Statistics show how many fall into addiction. This woman’s story shows what it takes to get out. Click the photo above to learn more. (Photo: Rebecca Kiger)

As a Peer Coach for the center, he strives to go above and beyond for the clients. Green can relate to his passengers: He’s in recovery himself.

His experience taught him recovery can be difficult. And now he wants to help others stay on the right path.

“For me, I share with everybody it’s good to have a good support system.”

But the support offered by the day report center faces an uncertain future as Congress considers repeal of the Affordable Care Act. Pending changes could have major consequences for the availability of substance abuse treatment in a region that has become the epicenter of the nation’s opioid addiction crisis.

Care Tied to the ACA

A lot of the funding tied to services offered by the day report center is tied to the ACA. And a repeal without replacement would be damaging.

“It would impact us negatively to the point where we would have to make tough decisions about the level of care that we could provide, even to the point where we might not be able to exist,” Executive Director Ronda Eddy said.

On the road to the Day Report Center. Transportation to regular treatment sessions is important to addiction recovery. (Photo: Rebecca Kiger)

Day report centers work with non-violent drug offenders referred by the court system. They offer medication assisted treatment, counseling and other resources aimed at rehabilitation.

Local law enforcement has embraced this approach to dealing with addiction.

Charles Town Police Detective Ronald Kernes said the center is a valuable tool in the system, as they can’t arrest their way out of the epidemic.

“We understand that people have problems and addiction is a disease,” he said. “It’s nice to have an outlet where people at least have a chance to try to better themselves, and kick the habit and become a productive member of society.”

Jefferson Day Report Center Executive Director Ronda Eddy would face tough choices without the ACA. (Photo: Rebecca Kiger)

 

The day report center is in the infancy of offering services. They established the current facility just a few years ago.

Medicaid expansion under the ACA helped the center build on its early success.

“It certainly has expanded access to care, more behavioral health care, all of those things that support recovery,” Eddy said.

Expanding Treatment

Treatment centers across the Ohio Valley have used the additional resources in hopes of reducing the highest opioid addiction and overdose rates in the country.

And that may be a low estimate. A report from Ohio’s Department of Medicaid claims their number is 50 percent higher than what researchers in the study found.

Republican Congressional leaders are working to repeal the ACA but have yet to agree on its replacement. This is especially true for the ACA’s Medicaid expansion provisions; reform, reduction and elimination have all been proposed.

Cautionary Tales

In Portsmouth, Ohio, Lisa Roberts works with people struggling with addiction as a Public Health Nurse for the city’s Health Department. Scioto County –where Portsmouth is located– has one of the highest rates of opioid addiction in the state.

The department offers Vivitrol shots to treat addiction and counseling to help with recovery. They refer individuals to other treatment programs if it is a better fit.

This program and others would be gone with a full repeal of the ACA, according to Roberts

“There would be people who lose access to their Vivitrol injections, a lot of people that would lose access to their addiction treatment,” she said. “It could just be catastrophic.”

Portsmouth, Ohio, public health nurse Lisa Roberts saw what happens when addiction treatment abruptly ends. “It could just be catastrophic.” (Photo: Aaron Payne / Ohio Valley ReSource)

 

Roberts has two examples of what happens when treatment is suddenly lost: one professional and one personal.

Federal and state authorities shut down Community Counseling and Treatment Services, an opiate treatment practice operating in Scioto and Lawrence Counties on September 25, 2014, during an investigation into Medicaid fraud and other allegations. No charges have been filed and no arrests made in the investigation, but Community Counseling and Treatment Services was never again permitted to accept Medicaid, and remains closed.

That forced Roberts and the Portsmouth Health Department to scramble to quickly find clinics that would accept Medicaid for around 1,200 people who suddenly lost treatment.

“We had to triage. We had to prioritize people,” Roberts said.

Other local facilities were overwhelmed and some people had to travel up to 100 miles for treatment. Long trips proved difficult for those who lacked the transportation or the time.

Some relapsed and had to resume treatment later. Others didn’t make it.

“We did experience a spike in overdoses and we also experienced a lot of fatal overdoses,” Roberts said. “It was actually the most lethal month that we’ve seen in Scioto County.”

Scioto County had no more than three accidental fatal overdoses in a month until October, right after the clinic closed, when they had six.

Close to Home

Roberts’ personal experience with the loss of coverage for addiction treatment came as part of her daughter’s struggle with addiction.

Vivitrol injections were what helped Roberts’ daughter sustain recovery. And she was covered under the Medicaid expansion.

But when her daughter moved to Tennessee –a state that did not expand Medicaid– she suddenly lost access to the shots.

Roberts stepped in.

“I would have to drive 400 miles to give her that injection,” she said. “And eventually she was able to get it there through the Affordable Care Act.”

Her daughter later returned to Ohio and continues recovery.

But Roberts understands that others may not be as fortunate.

She says the lessons for the ACA debate remain the same even if the circumstances of her experiences are different.

She and others fear repealing the ACA without a replacement could trigger a wave of similar events across the Ohio Valley.

Waiting and Working

As Congress continues its health care debate, the people Tomas Green drives to the West Virginia treatment center wait to see what will happen to their coverage.

To Green and others on the road to recovery, the journey is already a difficult one. But he says it comes with rewards.

”First comes the lessons and then the blessin’s.”

This story was originally produced by Ohio Valley ReSource. Rebecca Kiger contributed reporting for this story as part of her work with 100 Days in Appalachia.

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Effects of Addiction

Born Addicted: The Race To Treat The Ohio Valley’s Drug-Affected Babies

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She asked to not be identified. And it’s understandable given the stigma attached to addiction. For this story, we’ll call her “Mary.”

Mary lives in eastern Kentucky and has struggled with an addiction that began with painkillers and progressed to heroin.

“As soon as I opened my eyes, I had to get it,” Mary said. “And even when I did get it, then I had to think of the next way that I was going to get.”

Mary was using when she learned she was pregnant with her first child. She sought treatment but the disease had a tight grip on her.

The child was born dependent on opioids and went through the pains of withdrawal shortly after delivery.

“To see that little boy go through that stuff, you’d think that I would, like, change my life around immediately but I didn’t,” Mary said. “I didn’t want to believe it. I was in complete denial that because of my choices, it was my fault that he was going through that.”

Mary sought treatment but relapsed. Then she learned she was going to have a second child.

Startling Statistics

The number of babies born suffering from neonatal abstinence syndrome — the medical term for being born dependent on a drug — is on the rise.

A study published in the Journal of the American Medical Association-Pediatrics found “incidence rates for neonatal abstinence syndrome and maternal opioid use increased nearly 5-fold in the United States between 2000 and 2012,” and appears to be most pronounced in rural areas.

Credit: Alexandria Kanik / Ohio Valley ReSource

In the Ohio Valley the statistics are startling. Ohio and Kentucky both have rates well above the national average. In West Virginia the most recent data show that for every thousand live births there are fifty drug-affected newborns, the highest such rate in the nation.

Health care workers across the region are responding, finding new ways to treat both babies and mothers.

‘Get Addicted to Motherhood’

Nationwide Children’s Hospital in Columbus treats babies transferred from other hospitals when the symptoms are at their most severe…excessive crying, unable to self-console, unable to eat appropriately, all the way up to seizure activity.

“Based on each symptom and the severity of it, that baby is assessed a number,” Neonatal Intensive Care Unit’s Administrative Clinical Leader Amy Thomas said. “If that number reaches a certain level, then that tells us we have to treat that baby.”

Some drug-affected babies are treated here at the Neonatal Intensive Care Unit at Nationwide Children’s Hospital. (Photo: Courtesy, Nationwide Children’s Hospital)

The staff has been developing the treatment plan since 2013. This was around the time when staff noticed a correlation between increasing length of stay and drug-affected babies.

Treatment begins with non-pharmacological methods like cuddling and music therapy.

But if the withdrawal cannot be managed, morphine is administered. As the baby shows signs of improvement, the dosage is decreased until they are no longer dependent.

Educating the parents on how to care for the baby through methods like skin-to-skin comforting and breastfeeding is also important. And Thomas said treating mothers and fathers as parents, rather than as addicts, can have an impact on the baby’s life.

“I have that window of opportunity there to get her to fall in love with her baby, get her addicted to motherhood,” Thomas said.

Amy Thomas, R.N., is the NICU administrative clinical leader at Nationwide Children’s Hospital in Columbus, Ohio. (Photo: Aaron Payne / Ohio Valley ReSource)

The hospital has seen its admission numbers for drug-affected babies go down as birth hospitals have improved their ability to provide care.

Improved quality of care has also decreased the length of stay for the young patients, which can also help cut costs. The Ohio Mental Health and Addiction Services found in a 2014 study that each drug-dependent newborn can cost the healthcare system $56,000 or more, and most of the patients were on Medicaid.

Lily’s Place in West Virginia

A unique facility in Huntington, West Virginia, aims to reduce the burden on hospitals.

At Lily’s Place, babies are cared for in individual nurseries where the lights are low and noise is kept to a minimum.

“These babies are born very easily overstimulated,” said Rhonda Edmunds, the director of nursing. “We feel a quieter, more homelike environment is the environment that they need.”

Rhonda Edmunds directs nursing at Lily’s Place in Huntington, West Virginia. (Aaron Payne / Ohio Valley ReSource)

A staff of registered nurses provides another option of care for drug-affected babies outside of hospitals.

The facility is one of only two of its kind currently operating in the U.S. and it wasn’t easy to get started.

“The state allowed us to be part of a pilot program but all the babies had to be in state custody for that, which was a hinderance to getting babies over here,” Edmunds said. “But we don’t have to do that anymore.”

Since it opened in 2014, Lily’s place has been working to help other facilities get started and get through the red tape.

A nursery where drug-affected babies are treated at Lily’s Place in Huntington, West Virginia. (Photo: Aaron Payne / Ohio Valley ReSource)

The group published a book in 2015 on how to start a neonatal withdrawal clinic and is updating it to reflect changes in federal regulations that came with the passage of the Comprehensive Addiction Recovery Act last year.

M.O.M.S. in Ohio

Treatment for pregnant women, meanwhile, can be difficult to come by in the Ohio Valley. The ReSource analyzed data from the Substance Abuse and Mental Health Services Administration on treatment centers across all three states and found only a quarter of those centers accepts pregnant women.

A group of organizations in Athens County, Ohio, took a collaborative approach in addressing this issue.

Several years ago the OB-GYN at OhioHealth O’Bleness Athens Medical Associatesnoticed an increase in the number of pregnant women coming in with addiction issues.

“I could see there was some burnout in my providers because these patients had so many other issues, social issues that we didn’t even know how to address,” Practice Manager Pam Born said.

So she reached out to the nearby Health Recovery Services organization in hopes of getting these mothers treatment.

The collaboration was so successful, they looked for other resources.

“As we identified a new problem, we would identify who in the community could meet that problem,” Born said.

Soon they were offering housing, childcare, and other services for the whole family.

Credit: Alexandria Kanik / Ohio Valley ReSource

Interest from lawmakers led to the creation of the Maternal Opiate Medical Support (M.O.M.S.) project. Athens County and three other areas are provided funding to assist the programs in the hopes that others would follow.

Born said collaborations can form in any community and take many forms depending on a community’s unique needs.

In Athens County, Born would like to work toward offering residential treatment for pregnant women and mothers in their program, which is difficult to find throughout the region.

Karen’s Place in Kentucky

Karen’s Place Maternity Center is filling this role for residential treatment in Louisa, Kentucky.

Addiction Recovery Care –with treatment centers throughout mostly rural Kentucky– operates the new facility offering a balance of medical treatment, counseling, and a faith-based element.

“There are no centers doing what we’re doing in this part of Central Appalachia,” CEO Tim Robinson said. “And we felt we had the infrastructure and resources to do it.”

One of the bedrooms for clients who stay at Karen’s Place Maternity Center in Louisa, Kentucky. (Photo: Aaron Payne / Ohio Valley ReSource)

The 16-bed facility at Karen’s Place is a refurbished home in a secluded area, with 24/7 staff support and amenities for both mother and baby.

By focusing on the moms, Robinson said they are investing in the family as a whole.

“We’re not going to have true compassion for the babies until we have true compassion for the moms,” he said.

Mary’s Recovery

Karen’s Place in Louisa is where I met “Mary,” the mother of two whose first child was born drug-dependent. Mary is now in recovery. She was the first woman to come live at Karen’s Place before it was opened to the public in late January.

She sought treatment again after the birth of her first child and was able to get clean for a while. However, she relapsed around the time she found out she was pregnant again.

Mary was determined to give this baby a healthy start. She reached sobriety in October and her second child was born about a month ago with no signs of being affected by opioids.

“It’s been amazing,” she said. “He’s healthy, happy. He’s a calm little guy.”

Living at the maternity center has allowed Mary to focus on her continued recovery, motherhood and her faith. She aspires to further her education and someday help other mothers suffering with addiction.

“I’ve always encouraged people, if they’re still breathing, there’s still hope,” she said.

This story was originally produced and published by Ohio Valley ReSource.

 

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