Christine Teague works to find clients “under the bridge and by the dumpster”. Typically, they are people who inject drugs. Often, they are unhoused. All have HIV.
Once she finds them, Teague, who is the director of the Ryan White HIV program in Charleston, the state capital of West Virginia, might deliver the results of an HIV test, or the medication to reduce a patient’s viral load. What she cannot provide them with, however, is a powerful tool to prevent the spread of HIV: sterile syringes.
“I was really trying to be proactive in getting out into the community, and [to] educate people about the importance of using clean syringes,” said Teague, who along with local public health authorities was able to keep HIV numbers lower by distributing clean needles. “Hundreds” of people showed up for sterile syringes each week.
But in 2018, the city imposed severe restrictions on syringe service programs. Soon, cases were rising. Now, amid an HIV outbreak in her city, Teague says her program can only work “with our hands tied behind our back”.
The outbreak has been severe. Kanawha county, where Charleston is the seat, diagnosed 40 people who inject drugs with HIV in 2020, about as many as New York City, a place 47 times more populous than the rural county of 178,000. Last year, the head of HIV prevention at the Centers for Disease Control and Prevention (CDC) warned Kanawha had the nation’s “most concerning” outbreak of HIV among injection drug users.
Last month, the Biden administration pushed to expand access to clean needles for people who inject drugs. Its National Drug Control Strategy outlined a plan to expand syringe service programs by 85% in high-overdose counties.
But there is little chance of that happening here, where the same syringe restrictions pioneered in Charleston and the nearby city of Huntington were later adopted statewide by West Virginia lawmakers. A Guardian analysis has found that between 2018 and early 2022, nearly half of all syringe service programs registered with health authorities in West Virginia shuttered – and the local fight against clean needles even drew in the Democratic US senator Joe Manchin.
In an investigation, the CDC pinpointed the moment the outbreak picked up steam. After the restrictions on syringes, a county-run program that once served “hundreds” of people was forced to shut down, and access to clean syringes was decimated.
Teague was suddenly left to search for those at high risk for HIV, rather than proactively test people who showed up. The outbreak began by December 2018.
Lack of clean syringes “directly led to the HIV outbreak going on”, said Robin Pollini, an infectious disease epidemiologist and expert in a substance use at West Virginia University.
“We have people getting completely preventable infectious diseases. We have people dying of completely preventable overdoses. The suffering is almost immeasurable.”
There is ample data that clean syringes prevent transmission of blood-borne diseases. What’s more, they can also provide a venue to teach people who inject drugs how to use naloxone, an antidote to opioid overdoses.
“We have reams upon reams of studies showing the efficacy of preventing HIV, preventing overdose deaths” by distributing clean syringes, said Drew Gibson, the director of advocacy for Aids United.
“They are amazing interventions,” he said of the syringes. “And if they were about anything but people using drugs, they would be all over the place.”
The restrictions mean that almost 1 million people in West Virginia, the state with the highest drug overdose rate in the US for nine years running, now live between 20 and 75 miles of the nearest needle exchange.
Meanwhile, experts worry HIV is spreading undetected in rural West Virginia, where testing and treatment is limited.
“The situation in West Virginia is particularly dire” because of the state law, said Pollini. “The way to prevent HIV in this population is to expand access to sterile syringes, and we do not have the ability to do that here.”
Syringe service programs first came under attack in Charleston during a mayoral race. In 2018, Charleston’s mayor and police chief imposed severe restrictions on needle exchanges, in the name of a crackdown on crime and syringe litter.
He required clients to show government-issued photo identification and proof of residency, and to return a syringe for every one they collected. For many people deep in the throes of addiction, these were impossible barriers.
Already, the county had seen years of “rises in hepatitis B infection”, said Teague. “We were just kind of waiting for issues with HIV to emerge”.
By 2021, less than two months after the CDC’s warning that Kanawha’s outbreak was among the nation’s worst, and fully aware of the situation, West Virginia lawmakers passed the most restrictive syringe program requirements in the nation.
It happened amid an acceleration of the American drug overdose epidemic. More than 100,000 people in the US died of drug overdoses in 2021, worsened by the Covid-19 pandemic.
The disaster is now, in 2022, driving the most interest in syringe service programs and other harm reduction policies in “recent memory”, according Gibson. For the first time in decades, a $30m fund in the Covid-19 stimulus bill allowed for government purchase of sterile syringes.
But it also stoked conservative outrage, sucking in lawmakers including Manchin. When the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a grant for organizations to buy and distribute clean syringes in February, the Biden administration was pilloried. A conservative news outlet described it as “distribution of crack pipes to drug addicts”; the Republican senator Ted Cruz tweeted the Biden administration’s “crime policy” was “crack pipes for all”.
In response, Manchin joined two Republican colleagues to express concern about the plan. The following day, he introduced a bill to expand a decades-old, government-wide ban on the purchase of sterile syringes for drug use. He co-sponsored the bill with the Republican Florida senator Marco Rubio, whose home state has the second worst rate of new HIV diagnoses in the country.
Although Manchin’s bill did not pass, it showed the political perils of trying to help people who inject drugs, even as the horror of death and disease ravage communities.
Even the $30m in stimulus funding provides nowhere near the support needed, said Pollini, who described it as “searching under the couch cushions and looking for spare change”.
“We need a massive, sustained infusion of funding for harm reduction,” she said. “Otherwise, we’re rearranging deck chairs on the Titanic.”