A dangerous HIV outbreak gripping Charleston, West Virginia, comes just as the state is trying to dismantle one of the most effective ways to stop it: needle exchanges.
Undercover police officers have run stings on a volunteer group that distributes clean needles from parking lots in the city’s neglected west side. And lawmakers are moving not just to outlaw the program, but to criminalize it.
“I’ve been here 25 years, and this is the biggest problem like this I’ve seen here,” said clinical pharmacist Christine Teague. She helped spot the city’s HIV outbreak while volunteering with Solutions Oriented Addiction Response (or SOAR), the needle exchange group now at the center of the state’s legal fight.
The outbreak has spread to 50 people, most of whom are intravenous drug users. The stunningly high HIV rate is now alarming public health experts nationwide.
“The outbreak is the most concerning HIV outbreak in the United States at this time,” Demetre Daskalakis, the HIV prevention chief at the CDC, said in an email to BuzzFeed News. “It is possible the current case count represents the tip of the iceberg.”
Last month, Daskalakis spoke to the Charleston City Council about the outbreak, explaining that the textbook public health response would be to increase needle exchanges.
Instead, the West Virginia state legislature has moved to block such programs. Last week, the state senate passed a bill, now under consideration in the state’s House of Delegates, that would give local sheriffs final say over needle exchanges, require the tracking and returning of every needle, and impose criminal penalties for operating without a license — a restriction aimed directly at shutting down SOAR. Public health experts say the bill is extremely dangerous and comes at a time when needle exchanges are needed most.
“Two of the four largest HIV outbreaks in the country are here in West Virginia, and that is the background in which they are trying to shut these programs down — ongoing rapid transmission of HIV,” said epidemiologist Robin Pollini of West Virginia University, pointing to another recent outbreak in nearby Cabell County. The state has had a decadeslong problem with illicit drug use that started with overprescription of pain pills, leading people addicted to opioids to start injecting heroin, fentanyl, and methamphetamine.
Long controversial as an intervention that “enabled” drug use, needle exchanges gained acceptance amid an overdose epidemic that killed more than half a million people nationwide in the last decade. The Trump administration endorsed the programs as a public health measure in 2019.
The Charleston health department shut down its own needle exchange in 2018, spurring SOAR to take its place. The West Virginia health commissioner who called for its certification to be suspended, Rahul Gupta, is reportedly under consideration to become the Biden administration’s “drug czar,” drawing fire from public health experts critical of his approach to the opioid epidemic.
Home to 178,000 people, Charleston and its surrounding county now have a higher rate of new HIV cases among people who inject drugs than New York City, according to the CDC. The outbreak is another sign of the US’s ongoing problem with opioid-related diseases, made worse by a pandemic that’s led to record overdose deaths and hobbled public health departments.
“It’s a public health disaster,” said epidemiologist Gregg Gonsalves of the Yale School of Public Health. Closing needle exchanges, like Charleston did in 2018, likely contributed to the new HIV outbreak, he suggested. “Epidemics like this don’t come out of nowhere.”
As the pandemic started, SOAR volunteers quietly distributed needles and the overdose-reversing drug, naloxone, said the group’s co-leader Joe Solomon. On the city’s west side, where nearly 30% of properties are abandoned, they gave out clean needles from their cars, then moved to grocery store parking lots until they were chased off by police. Finally, the program turned to its current location, a Unitarian church parking lot. “This is all driven by the pandemic. We had to find a way to help people,” Solomon said.
The group also tested people for HIV, spotting some of the first signs of the current outbreak. From August to October, eight of the 120 HIV tests they administered came back positive. “For a city this size, that’s huge,” said Christine Teague, who administered the tests for SOAR and serves as the medical director of the Charleston Area Medical Center’s HIV center. Teague quickly notified the city and state about the cases.
But in October, the group became the subject of local TV news reports that portrayed its efforts as suspicious, Solomon said. At the same time, the city police department began an investigation, dispatching informants and undercover officers to request needles.
"Epidemics like this don’t come out of nowhere."
A Jan. 12 police report investigating SOAR’s efforts called its motives “unknown” and concluded that it giving each participant 30 clean needles, along with naloxone and disposal containers, “condones the use of illegal substances” and “increased the probability of used needles being discarded rather than disposed of properly.” The report also noted that the group had given an HIV test to an undercover cop at one of its weekend needle exchanges. In an almost comic ending, the police report concluded that the group could not be prosecuted because it was not selling needles and because a city law requiring that needle exchanges be state-licensed was unenforceable since the state did not offer licenses.
The police did not reach out to the group for their investigation. Charleston’s chief of police did not respond to a request for comment from BuzzFeed News.
Nationwide, there are more than 300 needle exchange programs, which typically provide clean needles and naloxone to people who use intravenous drugs. Decades of public health research show that needle exchanges limit outbreaks of HIV, hepatitis, and other illnesses among IV drug users, cutting the risk of these diseases by an estimated 50%.
Nevertheless, their legal status in many states is still contentious. West Virginia is one of many states where politicians have tried to restrict them, often citing complaints about needle litter where they operate.
Sherri Young, executive director of the Charleston health department, told BuzzFeed News that the city’s now-shuttered needle exchange program was “very damaging to the community, damaging to the health department.” She added, “I don’t feel like the community feels like they want us to be part of the needle service.”
Young cited a city survey of fire, police, and public works personnel released on Monday, which showed that 17% of respondents reported being stuck by needles at some point on the job. More than 80% said they felt that exchanges should require a one-for-one needle return and disagreed that there was a need to expand syringe services. The survey only drew responses from about 33% of those asked to complete it, the Charleston Gazette-Mail reported on Tuesday.
Instead, in response to the HIV outbreak, Young last week announced that the health department would expand testing, including a mobile van intended to reach people “living in abandoned houses and under bridges.” People who test positive for HIV will have housing assistance offered to them, she said, but the health department will not offer needle exchange services, despite what the CDC’s HIV prevention chief, Daskalakis, recommended. “I’m concerned about that, but I do have to follow the direction of my board and I do have to remain within the law,” Young said.
The new bill’s sponsor, Republican state Sen. Eric Tarr, a physical therapist, read aloud from the police investigation into SOAR in his testimony about the bill, using it to argue for more law enforcement oversight of needle exchanges.
Tarr claimed drug use in the state was attributable to shoddy recovery homes that “import IV drug users into West Virginia.” He argued that rather than reducing disease, needle exchanges promote crime, though studies have shown this is false. Last year, Tarr pushed a bill attempting to outlaw needle exchanges altogether. Now, he said, he supports creating licenses for exchanges overseen by the police, offering an amendment to his bill to give sheriffs veto power over programs and requiring patients to enroll in recovery programs to receive bar-coded needles.
The bill looks likely to pass in some form since Republican lawmakers hold a supermajority in the state legislature.
Public health experts who spoke with BuzzFeed News fiercely opposed the bill, arguing it would effectively block needle exchanges from operating and could lead to a bigger HIV outbreak, as initially happened in Indiana in 2014. In that state, then-governor Mike Pence resisted allowing needle exchanges for months as a dangerous HIV outbreak spread in a southern county.
The basic biology of drug addiction means that people who are physically dependent on opioids will inject them to avoid withdrawal symptoms whether there are needle exchanges or not. Providing people with clean needles is a cheap intervention when compared with the $510,000 per person it takes to treat patients with HIV. And it stops outbreaks: When Indiana started offering people clean needles and access to recovery programs in 2015, HIV cases in the affected counties dropped by 75%.
“We are not pleased with the direction this bill is taking,” said Laura Jones, executive director of the Milan Puskar Health Right clinic in Morgantown, West Virginia, which runs a needle exchange in that city, one of more than a dozen in the state.
“The whole idea is meeting people where they are at, so they learn they can trust you, and seeing a substance use disorder as a health problem — not something for the county sheriff to oversee,” Jones added. “It’s like making every diabetic account for every needle they use.”
“The foundation for the opposition is just a very poor understanding of the science, or resistance to the science altogether."
Multiple components of the West Virginia Senate bill go against the CDC’s best practices for needle exchanges, said West Virginia University’s Pollini, such as the one-for-one needle return (impractical for people experiencing homelessness, whose possessions are regularly lost, stolen, or impounded), the requirement that participants sign contracts to receive needles (a high hurdle for people who are scared of being arrested), and law enforcement’s authority over the programs.
“The foundation for the opposition is just a very poor understanding of the science, or resistance to the science altogether,” Pollini said.
The West Virginia Department of Health and Human Resources did not respond to BuzzFeed News’ request for comment on the HIV outbreak.
As SOAR continues to distribute needles and conduct HIV tests, the group’s volunteers are now taking civil disobedience training in anticipation of the state outlawing their efforts.
In a letter to the Charleston City Council in February, the head of the other needle exchange on the city’s east side supported requirements for a one-for-one needle return policy. It adopted the policy after the city’s own program closed, but more people use SOAR’s needle exchange program on the west side. The east side program was “a model that was started out of necessity, and I think it is time to revisit,” said Teague, who is affiliated with both sites. “It’s clear we are not meeting the needs of the community, or we wouldn’t have the outbreak.”
Meanwhile, as needle exchanges grow nationwide, similar disputes have flared up in California and Washington state. “It’s easy to beat up on West Virginia, but this is a nationwide problem, and these kinds of disputes are happening all over the country,” Leo Beletsky, a public health law expert at Northeastern University, told BuzzFeed News.
"This is a nationwide problem, and these kinds of disputes are happening all over the country."
The complaints about needle litter in these places and in Charleston are very real, Beletsky said, but fixing that problem by outlawing needle exchanges is misguided. The HIV outbreak and the needle litter problem both point to a need for wider needle exchange services, Beletsky said. Exchanges should be open all week and after working hours, which can help reduce crowds, with more places to dispose of used syringes. Lawmakers should also stop criminalizing needle possession, he added.
“If I’m going to be arrested or hassled for having needles, of course I’m going to get rid of them everywhere,” Beletsky said. “It’s not rocket science to find a way to make it easy and safe to dispose of syringes.”
Public health studies have suggested that there are other ways to help address community concerns about needle litter: increasing numbers of public syringe disposal boxes, giving workers needle-proof gloves, and having businesses put out sharps bins collected regularly by public health workers.
For Teague, the most troubling thing seen in the uproar is that some people in Charleston are discounting the lives of the people living with HIV and struggling with drug use. “These people are really terribly sick in lots of ways,” she said.
“There's just a kind of head-in-the-sand approach that we’ve seen in the pandemic that if we pretend it’s not happening, it will go away,” Beletsky said. Getting rid of needle exchanges to stop needle litter — a byproduct of bad laws and an epidemic of substance use disorders — makes the same mistake.
“It’s the same thing with intravenous drug users — ‘If we just make life as difficult as possible for people we don’t like, they’ll go away,’” he said. “That’s magical thinking, and it never works.” ●
This story has been updated to clarify that former West Virginia health commissioner Rahul Gupta called for the Charleston health department's needle exchange site to have its certification suspended.
This story has been updated to include that a city survey assessing fire, police, and public works personnel's attitudes towards syringe exchanges only drew responses from about 33% of such workers.