By delaying the state government’s response to the2014 to 2015 HIV outbreak among people who inject drugs (PWID) in Scott County, Indiana, then-Governor Mike Pence missed the opportunity to prevent a considerable proportion of the 215 new cases of the virus.

Publishing their findings in The Lancet HIV, researchers created a mathematical model to estimate how an earlier public-health response on the part of the Indiana government might have affected the trajectory of the Scott County outbreak. The study authors included in their model weekly case data about the outbreak as well as data on the uptake of HIV testing, treatment and prevention services, deriving this information from Centers for Disease Control and Prevention (CDC) reports and from researchers in Indiana.

An HIV infection cluster was first detected among PWID in Scott County in November 2014, and, according to the new paper’s findings, the outbreak actually peaked at about 126 cumulative people on about January 10, 2015. Initially dragging his heels and saying he wanted to “pray on it,” Pence would not declare a public health emergency until March 26, 2015. At that time, he temporarily permitted the establishment of a syringe services program (SSP) and the launch of an HIV testing clinic.

Several years earlier, local public health leaders had warned state officials about signs of expanding opioid use in Indiana and about an emerging hepatitis C virus (HCV) outbreak in Scott County. These experts recommended establishing SSPs and other HIV prevention programs in the area, only to be met bya cold shoulder from Governor Pence’s administration.

CDC research has indicated that the Scott County outbreak originated in 2011.

In 2017, the CDC warned that 220 other counties in the United States were at risk for similar injection-drug-use-driven outbreaks of HIV and HCV. Recently, smaller outbreaks have been reported in Ohio, Kentucky, West Virginia, Massachusetts and Seattle.

The new study estimated that if Pence’s government had initiated a response at the outset of 2013, the outbreak could have been limited to just 56 cases or fewer. Launching a response in April 2011 could have limited the outbreak to 10 cases or fewer.

“A comprehensive response, including access to clean syringes for people who inject drugs, as well as therapies such as buprenorphine and methadone, could avoid new outbreaks of HIV and HCV in at-risk counties in the first place,” Gregg S. Gonsalves, PhD,anassistant professor of epidemiology at the Yale School of Public Health and the study’s first author, said in a press release. “Unfortunately, these interventions are in woefully short supply in the places that need them most. Unless we act, it’s not a question of whether we’ll see a repeat of what happened in Scott County, but when and where.”

Gregg GonsalvesChristopher Beauchamp

To read the study abstract, click here