In 2014, Scott County, Indiana, found itself in the middle of an HIV epidemic.

Opioid addicts shared infected needles with each other, spreading HIV and other infectious diseases like wildfire. Meanwhile, then-Governor of Indiana Mike Pence did nothing to fix it.

There was no way he could have known about the outbreak — he closed down the county’s Planned Parenthood testing clinic in 2013. The first official diagnosis was announced in November 2014, but at that time the outbreak had raged for over three years.

Pence finally acted two years later, declaring a public health emergency. On May 5, 2015, Pence established temporary centers to try to fix the epidemic. That same day, the governor made it a felony to possess a syringe with the intent of injecting drugs.

A new study published by School of Public Health and Law School professor Gregg Gonsalves SPH ’17 in the journal The Lancet HIV on Sept. 13 found that the actions of Pence and Surgeon General Jerome Adams, who served as Health Commissioner of Indiana at the time, were too little, too late.

“Earlier intervention would have drastically blunted the epidemic,” Gonsalves said. “We could have prevented that epidemic in Scott County if we had intervened earlier.”

A team of researchers from the Yale School of Public Health used publicly available data from the Centers for Disease Control and Prevention to model the outbreak of HIV in Scott County, Indiana, over a four-year span and simulate what would have happened if needle exchange programs were opened earlier.

For many in the field of public health, the results were unsurprising. Had governmental responses to the epidemic started in 2013, the number infected would have been greatly reduced, said School of Public Health professor Forrest Crawford. If the state had intervened in 2011, when HIV first started spreading, the outbreak would have never happened.

According to Gonsalves, opposition to needle exchange centers among policymakers is relatively common due to misinformation and misconceptions.

“Many people think syringe exchange programs promote drug use, while many, many studies have shown that it doesn’t promote drug use, and it reduces HIV infection,” Gonsalves said. “There’s the idea that … there’s some sort of moral component to giving drug users needles in that you’re fostering their drug use.”

According to Crawford, Pence was vocal in his opposition to needle exchange for injection drug users, believing these programs would increase drug use rather than improve public health. By the time he finally instituted a needle exchange program, the worst of the outbreak was already over.

“We show in the paper the exact date in which he authorized a needle exchange program, but we show that it occurred very well after the peak in undiagnosed infections,” he said.

Needle exchange programs prevent the spread of HIV among populations who abuse injection drugs by supplying them with fresh needles, according to Gonsalves.

By introducing more needles to at-risk populations, needle exchange programs reduce the proportion of HIV-containing syringes in a given area, which in turn lowers the probability of using a contaminated syringe at any given moment.

“You basically break the chain of infection,” Gonsalves said.

In order to model the data, Yale researchers mapped the number of undiagnosed HIV-positive people in Scott County from 2011 to 2014 using data from the Indiana HIV Outbreak Team and the CDC. Comparing these diagnoses to the timeline of governmental response to the HIV outbreak, researchers concluded that the epidemic was winding down well before any substantial relief effort was organized.

Crawford hopes to use what happened in Scott County as a lesson for legislators on what to do when handling similar HIV epidemics.

“The outbreak in Scott County was a very vivid illustration of an HIV outbreak among a very vulnerable population. But it’s certainly not the only place in the United States and certainly not globally the only place that is at risk for an outbreak of infectious disease,” he said.

According to the study, the CDC has listed 220 counties in the United States that are in danger of a major HIV outbreak similar to that of Scott County. According to Crawford, needle exchange programs and HIV diagnosis testing centers can help reduce this risk, and this study can help spread the word of their effectiveness to other policymakers.

As for Pence, Crawford said, it remains to be seen whether he and Surgeon General Jerome Adams might use the study’s findings to guide public health decision-making and policymaking for the country in the future.

The first official United States needle exchange program was established in New Haven in 1986.

Matt Kristoffersen | matthew.kristoffersen@yale.edu

Correction, Sept. 25: This story incorrectly stated that the study was published in the research database ScienceDirect. In fact, it was published in the journal the Lancet HIV.