In the early 80’s, the medical community was stunned by a growing epidemic of severe complications of immune deficiency which first appeared in gay men but began to be seen in other populations as well. Based on the epidemiology of the disease during these early years of the U.S. AIDS epidemic, the groups identified at highest risk for AIDS were the four H’s; Homosexuals, Haitians, Heroin addicts, and Hemophiliacs.
Intravenous drug use, mainly heroin, may have played a critical role in HIV entering Black communities and of course, people infected with HIV from sharing contaminated needles could also spread the infection sexually.
To me, there has been an Opioid epidemic for decades, decimating poor communities of color and poor white communities as well. Because heroin addiction was so prevalent among HIV-infected individuals, treating the addiction was a required skill for managing these patients.
Indeed, the epidemic is nothing new in our communities. Disturbingly, a strong body of science showed conclusively that needle exchange programs (programs that provide clean needles to drug users to protect them from contracting HIV/Hepatitis through sharing needles withonly
infected persons) could reduce transmission of HIV and viral hepatitis and that this intervention was cost-effective. Yet, legislators would not allow the use of Federal dollars in needle exchange programs. Heroin addicts were heavily stigmatized and considered “bad” people and ultimately, drug usage was criminalized.
Not so long ago, this picture started to change. Addiction to opioids was occurring at increasing frequency among middle-class whites. Many of these addicts were initially taking prescription opioids to control moderate to severe pain resulting from medical problems. Sometimes, it may be difficult to taper patients off the prescription product and some of these patients resort to injecting street opioids, like heroin, to satisfy their cravings. The outcomes can be devastating with opioid overdoses taking a very high toll (nearly 65,000 deaths in 2016).
There is also the high cost of social decay that these communities are now confronted with; problems that communities of color have been combatting for decades. This is the “Opioid Crisis” that is so catastrophic that we hear about nowadays. For these newly impacted communities, drug usage is a medical problem, not a criminal act. In 2016, the use of Federal funds for needle exchange programs was authorized. Here again, we see that we are the “canaries in the coal mine”.
Marginalized communities of color and impoverished communities are highly vulnerable to these types of social ills. These are the people who are first affected and heavily impacted by complex social problems. Our failure to recognize and intervene on these issues in these communities usually results in those problems spreading into the mainstream. At that point, they may be much more difficult and costly to control or eliminate.
Case Presentation
Scott County is ranked at the very bottom of Indiana’s 92 counties for health and social indicators. For example, this county has the lowest average life expectancy in the state. The unemployment rate isonly
around 9%, which is almost twice the national average of 4.8%. About 21% of residents have no high school diploma and 19% live below the poverty line. Incarceration rates are high and many residents lack health insurance.
Sound familiar? I don’t need to tell you that these conditions provide the perfect environment for an HIV explosion. Over the past decade, the HIV infection rate in Scott County was about 1 case/year. But in early 2015, there were 11 new diagnoses. By 2016, there were 188 new diagnoses of HIV infection in the county and over 90% of them were co-infected with hepatitis C. BTW, did I mention that Scott county is 97% white?
The percentage of blacks in this county is 1% at most. This outbreak of HIV and Hepatitis C was fueled by the opioid epidemic. There are some harsh lessons that emerge from this crisis. We see that conditions of poverty adversely affecting employment, housing and access to health care prime a community for the high rate of opioid addiction, irrespective of race. HIV and HCV flourish in this environment. Blacks, Latinos and other peoples of color are not inherently prone to these infections, but disproportionate numbers of these groups live in environments that place them at high risk.
In the next article, we will talk about opioid addiction and how it can be treated.
Dr. Crawford received a B.S degree in Biology from Cornell University and a B.S. in Pharmacy from Temple University. He completed a residency in clinical pharmacy at the National Institutes of Health. He earned a doctorate in Pharmacology from the Uniformed Services University of the Health Sciences in Bethesda, Maryland. He completed a post-doctoral fellowship at the National Institutes of Health, studying microbial biochemistry and genetics.
He is currently with the Division of AIDS at the National Institutes of Health. He has over 25 years of experience in HIV treatment and clinical research. This article reflects his personal views and opinions.
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