By Mark Hansel
NKyTribune managing editor
Tuesday’s disclosure of a cluster investigation of HIV infections among people who inject drugs in Northern Kentucky was initiated because of a shift in risk factors for the virus in the region.
Local and state health officials discus the recent surge in HIV cases in Northern Kentucky tied to intravenous drug use. Left to right, St. Elizabeth Healthcare CEO Garren Colvin, Stephanie Vogel, director of population health at the NKY Health Department , Dr. Jonathan Ballard, KY public health epidemiologist and Dr. Jeffrey Howard acting commissioner for the KY Department of Public Health (photos by Mark Hansel)
The Northern Kentucky Health Department and the Kentucky Department for Public Health initiated the investigation because data from 2017 shows the virus appears to be spreading among individuals that inject drugs, at rates higher than it has in the past.
“Specifically, we have a cluster of cases identified in Campbell and Kenton counties,” said Dr. Lynne Saddler, district director of health for the Northern Kentucky Health Department. “This change is concerning, although not surprising, given the ongoing issues that we have with injection drug use in our region.”
Dr. Jeffrey Howard acting commissioner for the Department of Public Health said the department has been working diligently in support of the Northern Kentucky Health Department’s efforts to investigate this increase in HIV diagnoses in people who inject drugs.
“Protecting the community’s health is our top priority and will remain so,” Howard said. “The Kentucky Department of Public Health and the Cabinet for Health and Family Services stand ready to assist Northern Kentucky and to provide all of the resources at our disposal to help investigate and address this issue.”
HIV, is a sexually transmitted disease as well as a bloodborne pathogen. It is spread though contact, as well as sharing needles and through injection drug use.
Of the 37 cases of HIV newly diagnosed in 2017 in Boone, Campbell, Grant and Kenton counties, the region covered by the Northern Kentucky Health Department,18 have injection drug use as a risk factor.
Dr. Jonathan Ballard, Kentucky public health epidemiologist, said this represents a three- to four-fold increase over what is typically seen in the region.
“In each of the past nine years, 2008 to 2016, we have seen fewer than five cases of HIV per year (in the region) with a risk factor of injection drug use,” Ballard said. “This also represents a distinct shift from past years, to a majority of cases that have injection drug use as a risk factor for HIV transmission, over what have been previous risk factors including sexual contact and perinatal exposure.”
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Health officials said they do not want to give the impression that the community at large is at risk.
“We (do) want the public to know that the health of the overall citizenry is related to the health of each individual citizen and that awareness is a key component,” Howard said. “We consider this change in transmission risk to be extremely important and something that necessitates community action. It is equally important to emphasize that this change was discovered as part of our regular monitoring service, which is a key component of public health.”
All of the cases have been investigated by the State’s disease intervention specialist and HIV surveillance section to verify the residence at the time of diagnosis. Campbell County and Kenton County have experienced the greatest increases of HIV diagnoses in injection drug use, with eight cases and 10 cases respectively in 2017.
“In the past nine years, Campbell County never had more than case per year with injection drug use as a risk factor,” Ballard said. “Kenton County has never had more than two cases diagnosed per year with injection drug use.”
Cases will continue to be reviewed for several months and the number attributed to injection drug use in 2017 in the region could still rise.
The determination of new cases of HIV involve several steps, including the reporting by health care providers to the Kentucky Department for Public Health and the determination that the case is new and has never been previously diagnosed in Kentucky. A determination that the person is a Kentucky resident at the time of diagnosis involves cross-referencing with all other states to verify that it is indeed a new case.
That has been done for all of the previously diagnosed 2017 cases.
“This cluster investigation will include assisting the Northern Kentucky Health Department with expanded case questionnaires and additional HIV testing a well as testing for Hepatitis C and molecular linkage testing to determine if these case of HIV are linked between each other,” Ballard said. “This work will help us understand what needs to one done to further prevent the spread of HIV and what these changes mean as we examine the broader picture of Kentucky’s health.”
“They are our friends, they are our family members and they are our neighbors. The population impacted here is also one that is particularly vulnerable. This makes the response especially challenging,” Stephanie Vogel, director of population health at the NKY Health Department
In addition to the impact HIV can have on infected individuals, it can also increase the overall cost for health care and create a risk for the larger public, particularly first responders and health care workers.
Stephanie Vogel, director of population health at the Northern Kentucky Health Department said these are not just numbers, they represent members of the community
“They are our friends, they are our family members and they are our neighbors,” Vogel said. “The population impacted here is also one that is particularly vulnerable. This makes the response especially challenging.”
In addition to HIV infection, and a known substance use disorder, Vogel said many of the individuals who are diagnosed with HIV in 2017 are also dealing with a diagnosis of Hepatitis C.
Hepatitis C is a contagious liver disease that ranges in severity from a mild illness lasting a few weeks to a serious, lifelong illness that attacks the liver. It is caused by a virus that is spread when blood from an infected person enters the body of someone who is not infected.
Of the cases diagnosed in the region in 2017, 78 percent are co-infected, according to the Northern Kentucky Health Department.
“Through our review of information, we find that behavioral and mental health issues and other sexually transmitted diseases are also found in the population,” Vogel said. “Accessing medical care for HIV and the other health issues may be a challenge for these individuals.”
Improvements in treatment in recent years allow individuals who are diagnosed to lead productive lives and manage their HIV infection when connected to proper health and social services. Connection to medical care also reduces the risk of further transmission.
Swift action is key in stopping the rise in HIV infection but HIV testing rates are typically low among individuals who inject drugs.
“Just 42 percent get tested once per year,” Vogel said, “and individuals can have HIV for years without having any symptoms.”
Garren Colvin, St. Elizabeth Healthcare president and CEO has been a strong advocate for a regional syringe exchange program as part of a comprehensive effort to reduce the spread of disease among intravenous drug users.
He said the St. Elizabeth Healthcare Board of Directors support that position as well.
“St. Elizabeth Healthcare has been and will continue to take an active leadership role in the treatment and prevention of the spread of these devastating diseases,” Colvin said. “For the last several years, St. Elizabeth and the Health Department have advocated for syringe access exchange programs in our region. Now, more than ever, we need to move from advocacy to action.”
In addition to the toll on human lives, widespread transmission of HIV could have a devastating impact on the region’s economy. The cost for treatment of a person with HIV is estimated at $300,000 over the course of a lifetime.
Colvin said dollars invested in syringe access exchange programs can save in treatment dollars later.
St. Elizabeth CEO Garren Colvin said the need for a comprehensive regional syringe exchange program is even more critical with the disclosure of an HIV cluster in Northern Kentucky.
“Besides reducing the transmission of HIV and other infectious diseases among individuals who inject drugs syringe access exchange programs can reduce the amount of syringes and needles improperly disposed of in the community,” Colvin said. “It can also provide individuals who use IV drug with access to health care services, including referrals to substance abuse treatment programs.”
Despite a full-court press among health care leaders in recent years and data that indicates syringe exchange can greatly reduce health risks, Northern Kentucky still does not have a comprehensive regional program.
While increases in the number of cases of HIV and Hepatitis C are a serious health risk, the health department cannot declare a public health emergency and implement a regional program on its own.
In Kentucky, the health department is the agency that would administer a syringe exchange program, but it requires approval from both the counties and cities where the program would be implemented.
Some elected officials, including the judges/executive in Boone, Campbell and Kenton County have been very vocal in their support for syringe exchange.
Covington, in Kenton County, has approved a mobile exchange unit for three hours a week at a St. Elizabeth Healthcare facility there, but no city in Boone County or Campbell County has agreed to host any type of program.
To date, only Grant County, in the region that the Northern Kentucky Health Department serves, has a syringe exchange program. While results there, and in Kentucky’s Pendleton County and Hamilton County in Ohio, are encouraging, it has not moved the needle enough for implementation of a comprehensive regional program.
Since March of 2016 when Grant County’s program was implemented, more than 275 people have been served. The program has also had success getting IV drug users to seek HIV testing and has referred 120 people for substance abuse treatment.
Contact Mark Hansel at mark.hansel@nkytrib.com
