SOUTHERN INDIANA — In the 1970s and '80s, William "Happy" Cox was heavily into drugs — speed, downers, heroin — anything he could afford to get high on.
At the time, he didn't think about the consequences. Those days eventually caught up with him.
Cox has been in recovery now for 25 years, but a doctor's visit several years ago showed signs of health issues. He was diagnosed with hepatitis C, which his doctor estimated he'd been carrying without knowing for more than 20 years.
The Jeffersonville resident and business owner said it may have been unprotected sex or intravenous drug use that put him at risk for hepatitis.
A recent surge in intravenous drug use throughout Indiana, including Clark and Floyd counties, has sparked the need for solutions. While the state comes to grip with soaring health care expenses associated with fighting diseases tied to addiction, many say investment in harm reduction that syringe exchanges can offer is a good first line of defense.
“This is a dilemma that's not on the surface,” Cox said. “The potential for things to be worse is people don't know and they're continuing with behaviors that could spread it.”
A GROWING NEED FOR HARM REDUCTION
While syringe exchange programs aren't new in the U.S. — some states have had them for decades — the recent surge in intravenous drug use by Hoosiers puts Indiana among states with a growing need for the harm-reduction services.
The Scott County needle exchange, the first program in the state, just hit its two-year mark at the beginning of April and was approved unanimously for a third year by the county commissioners.
As of April, the program had given out 451,371 needles and received 425,244. Scott County has reported no new HIV cases in the past 90 days.
Indiana now has nine programs — operating in Anderson, Bloomington, Fort Wayne, Indianapolis, Jeffersonville, Lafayette and Scottsburg — and the state Legislature is on the brink of making the programs easier for municipalities to initiate.
Indiana House Bill 1438 is awaiting the signature of Gov. Eric Holcomb, who is expected to sign it. The measure would give municipalities the authority to implement needle exchange programs, eliminating the need for state approval.
The programs are designed to prevent the spread of HIV and hepatitis C by providing clean needles and other sterile supplies to intravenous drug users in a nonthreatening environment. Drug users also are provided HIV and hepatitis testing and other medical care and are informed about health insurance and treatment options.
Carrie Lawrence, assistant researcher at the Indiana School of Public Health in Bloomington and associate director of the Rural Center for AIDS/STD Prevention, said the programs are necessary amid the drug epidemics in the state and nation.
“We want to have all the tools available to prevent disease transmission,” she said. “We're trying to prevent not only HIV but hepatitis B and C – on top of education on what to do to prevent an overdose death and prevent overdose in general.”
Lawrence said the drug issue is going to get worse before it gets better and it's important to keep the tools at hand to help battle all the fallout.
“We've attempted to have this war on drugs,” she said. “We’ve lost for decades and this is where we're at today. Hopefully we won’t be there in the future — there won’t be a need for syringe service programs — but this is where we are today.”
TOOLS TO STAY SAFE
Cox has been free from drugs and alcohol for more than 25 years. He's worked on mending his relationships, health, finances and soul. He went back to college. He started a business helping others in recovery.
He said he got tested for HIV soon after getting clean — it was the early 1990s and public messages were strong to take this newfound illness seriously. He got a negative result and considered himself safe. He didn't think about hepatitis C, though, and didn't really even know what it was.
“The awareness that I could have it or it could kill me was not there,” he said.
That's why he says syringe exchange programs are a crucial step in education and disease prevention.
“If everybody had a clean needle, we wouldn't have shared,” he said. “That's just the reality of using what you got to work with as an addict. When we got our drugs, we did whatever we could to get it in us whether it was share a needle or get our own.
“The people I shared needles with, I didn't know I had hepatitis C. I didn't want to give it to my friends but potentially I could have, or did.”
COST OF HEALTH CARE
Lawrence said the benefits far outweigh the costs when it comes to harm-reduction services associated with the programs, estimating that 75 percent of the services are geared toward linking clients with care and 25 percent for the syringe services.
Not only that, but the prevention of infectious diseases linked to intravenous drug use is less costly and more manageable than treatment, she said.
“If we were able to prevent one [HIV] infection through a syringe service program — the cost associated is $4,000 to $12,000 – it's much less than the lifetime cost of treating a person with HIV, which is $400,000,” she said.
Cox's hepatitis C treatment several years ago was Interferon; a newer formula exists today. His cost, if he hadn't received financial assistance, would have been $77,000. Still, he paid for lost time as the treatment left him unable to work or function well.
“I was very nauseous and uncomfortable for three months,” he said. “I didn't trust myself to drive a car.”
Although physicians are reticent to use the word "cured" when it comes to hepatitis C, Cox's viral loads are so low now after treatment that it does not affect his health and can't be transmitted.
He has to go back every year to get checked to make sure it hasn't returned — which is unlikely as long as he stays away from behaviors that could cause it.
“I'm fine today but I feel like I have a responsibility to carry the message to others, to protect them from lack of information,” he said.
Clark County's needle exchange, The Interchange in Jeffersonville, is among the most recent to open in the state, although it took more than a year of the county health department working with the state and funding organizations to get started.
Since it opened in January, the program has had 52 new members with no more than 14 so far in a single day, said Laura Lindley, Clark County Health Department administrator. It operates every Thursday from 9 a.m. to 3 p.m.
The health department reported 313 active cases of HIV in the county as of December 2016, of that 15 new cases were diagnosed in 2016. Cases of hepatitis C, which often coexists with HIV, numbered 258.
Among program members, no HIV cases have yet been determined through testing at the needle exchange and less than five cases of hepatitis C were caught.
Lindley said it's hard to gauge how many people have gone to addiction treatment through the needle exchange — sometimes a person may not report back that they've gone, or they just stop showing up. But currently, there are between eight and 13 in treatment and using the exchange.
“We give referrals to everybody,” she said. “Some refuse it, but we make sure they know we can offer them a place to go.”
ENABLING ILLEGAL DRUG USE
Not everyone in the community agrees that a needle exchange is the best way to help. Paul Fetter, Clarksville Town Council president, said he and some of his constituents have concerns over what the new Clark County program means.
“I think they feel they are going in the correct direction,” he said, of the health department. “But I feel that it is encouraging bad behavior as much or more as it is helping the people that are coming in.
“One thing we have to remember is that the addict is benefiting from the needle exchange while engaging in illegal activity. I know the purpose is to reduce HIV and hepatitis, but we are helping someone improve … their illegal habit.”
He said he'd like to see accountability measures, such as community service and commitment to treatment, required for someone to be able to receive the needles.
"If it is [creating a barrier,] so be it,” he said. “If there's not some type of requirement, then all you're doing is enabling.”
Fetter also takes issue with the number of needles allotted — a member can get up to 140 needles per visit, based on injecting 20 times per day. The first visit, they're not required to bring needles in for exchange. After that, they are encouraged to bring them back, but Fetter is concerned the system is too lax in making sure that happens.
“A needle exchange should truly be a needle exchange,” he said, adding that treatment services should take precedence over supplying the needles.
Lindley said adding those requirements wouldn't work.
“It's a case-by-case basis,” she said, of the one-for-one exchange. “We're trying to stop the spread of HIV and hepatitis C and not supplying … clean needles [means] somebody's going out there and sharing because they've run out or reusing their dull needles and creating larger wounds or more infection.”
ROAD TO REDEMPTION
Cox now works to help people in recovery find spiritual solutions. Before that, though, come the first-responder programs like the needle exchange, that open doors to get healthier and get into recovery.
“First you have to live, then you try to live better,” he said.
He said if the community as a whole was better informed on the risks and causes of hepatitis, he thinks more would accept the needle exchange and what it is trying to do.
"People don't know they are harming others," Cox said. "If they knew better, they would do better, and so I think that information is critical.”