Years ago, a syringe exchange helped end a devastating HIV outbreak. Now it might be forced to close

The Indiana county at the center of a devastating HIV crisis in 2015 may soon close the syringe exchange program widely credited with helping to end its outbreak.

For public health advocates in Scott County, home to 24,000, the controversy is all too familiar. Six years ago, the county drew national attention for recording roughly 200 HIV cases in a single year, largely driven by injection drug use. Critics have charged that the state government’s slow response and monthslong refusal to permit needle exchanges only made the crisis worse.

Closing the exchange now, they warn, could lead to a new wave of HIV and hepatitis C cases and increased drug overdoses. Nationally, too, many are worried it could trigger a broader wave of closures. Scott County’s syringe exchange was hailed as a success in 2015 and paved the way for other programs to open across the country. Many fear that shuttering the program, similarly, could inspire activists from coast to coast seeking to close syringe exchanges in their communities.

“We were the model,” said William Cooke, a local physician who was among the most influential supporters of establishing Scott County’s exchange. “I do feel responsible nationally.”

The new debate in Indiana comes amid a wave of anti-syringe-exchange activism across the country, including a controversial new law in West Virginia that critics say could force many local programs there to close. West Virginia is experiencing a worst-in-the-nation HIV outbreak not unlike Indiana’s six years ago.

Nonetheless, the state’s legislature and the city council in Charleston, its largest city, recently voted to impose a number of stiff new restrictions, including requiring that syringes be tagged with individual barcodes and that individuals seeking sterile needles provide a photo ID.

It comes, too, at a moment when syringe exchanges were poised to get a national boost. The Biden administration has made clear it supports syringe exchanges and other services aimed at preventing overdoses and infectious disease spread, like providing fentanyl test strips, and wider availability of HIV and hepatitis C testing.

More broadly, it is clear the national environment on syringe exchange has shifted.

“If you look at what happened in Scott County, you had to drag Mike Pence kicking and screaming to allow a needle exchange to be set up” in 2015, said Gregg Gonsalves, a Yale epidemiology professor and longtime HIV-prevention activist.

Pence, who served as vice president from 2017 to 2021, was intensely criticized for his refusal to immediately permit syringe exchange services while serving as governor of Indiana. Jerome Adams, then the state’s health commissioner and later the U.S. surgeon general, was also strongly criticized for not pushing Pence harder. One study estimated that a functional syringe exchange in Scott County in the years preceding the outbreak could have prevented roughly 90% of HIV cases.

Now, though, Adams is aggressively speaking out against a local official’s proposal to close the exchange, even appearing in person at a county commission meeting to voice his opposition.

“We can’t afford [to] go backwards,” he wrote this week on Twitter. “So many worked so hard to make this syringe service program happen, and to create a template for the rest of rural/middle America to connect people to care. I hope cooler heads prevail.”

Despite the reduced rates of transmission, Scott County is still among those most vulnerable to HIV outbreaks, according to the Centers for Disease Control and Prevention. It sits at the western edge of the country’s largest HIV hotspot: An area spanning several hundred miles that includes parts of Indiana, Kentucky, Ohio, West Virginia, Virginia, and Tennessee, where much of the HIV transmission is thought to be driven by injection drug use.

Still, neighbors and local lawmakers there have sought to close the exchange, citing fears it encourages or facilitates drug use and crime (data shows that such programs do not). They have also charged that syringe exchanges lead to hazardous litter, like stray needles — a problem that, in some cases, harm reduction advocates have acknowledged and pledged to help address.

Closing the syringe exchange service now, though, would be akin to firing a CEO who has successfully transformed a company because the company is now successful, said Cooke, the local doctor.

“We went from having 200 cases in 2015 to one last year,” he said. While he acknowledged that the concept of syringe exchanges can be counterintuitive, he urged the county government not to follow an example set by West Virginia, where the state’s largest county closed its city-run syringe exchange in 2018.

Within a year, fatal overdoses soared, and 1% of the county’s population, or nearly 2,000 people, had been diagnosed with hepatitis C.

Advocates have warned that the new state law in West Virginia, and the proposal to shutter Scott County syringe program, could prove similarly devastating.

“Watching West Virginia do what it did, it was just like: Really?” Gonsalves said. “Are you gonna throw gasoline on the fire?”

Scott County’s decision is “life or death,” said Tony Pastrick, an outreach worker at the Damien Center, an Indianapolis HIV/AIDS services provider. Pastrick, who identified as a person in recovery from addiction, credited the Scott County syringe exchange with slowing the outbreak there. And he pushed back, too, on the common but scientifically disproven argument that syringe exchanges enable drug consumption — and that shutting them down will simply prevent people with addiction from future use.

“People are not going to stop shooting drugs,” he said. “But what can stop is the spread of HIV.”