HUNTINGTON – The county health department remains open only to them late, so after dinner, a dozen men get out of the drug rehab at Lifehouse, where they lived, and board a battered white van.
It would be a short trip through a familiar landscape. Abandoned houses. Sidewalks hung. Graffiti vortex walls. A woman leaned over and looked for the weed. A girl chasing a puppy in the glow in the late afternoon. "It's a beautiful dog," said one. Moreover, they rode in silence.
After years of drug abuse, this came to these men: a nerve ward at a health ward, where a nurse explained to them, "We invited you guys here for HIV testing. "
She was handing out forms and pens. "We usually have about five to eight a year."
Now, she says, they have diagnosed 80 cases since early 201
For years, employees worry that the next step in the opioid epidemic will be a bigger public health problem. Here, in a city that has seen some of the worst of the crisis, it is thought that the next issue is underway in the form of HIV infections.
As the nurse collected the forms and prepared to call the men separately for testing, the question was whether the 81st, 82nd, or 83rd HIV case in Cable County could sit in the waiting room. "We obviously want to identify people quickly," the nurse said. "The sooner we can identify you and make you care, the better you will be and the better you will be in health."
Men were also wondering. "I used dirty needles," one of them said. "I lifted them up immediately from the earth."
"Jesus, I, too," said another. "But don't be negative."
"Negator is what you want here."
Others nodded. His knees bounced. The knuckles cracked, then cracked again. The nurse called the first patient.
Even as Huntington seeks to determine the severity of his HIV problem, there are indications that the national opioid epidemic underlying the problem may be slowing. CDC data released earlier this year show that the national fatal overdose rate has dropped by 5 percent in 2018, the first dip since 1990, largely due to a decrease in heroin overdose and prescription opioids.
But the scenes on the ground in Huntington suggest that any optimism may be premature.
"There is no doubt that this will happen again and again nationwide," says Judith Feinberg, a professor of behavioral medicine and psychiatry at the University of West Virginia who works to prevent infection among state dependents in rural areas. "All these infections are spread to the general public sooner or later."
Huntington is located on the far western edge of West Virginia, a place that makes it particularly susceptible to both the HIV cluster and the drug use considers it his cause. Ohio is directly from the Ohio River to the north. The Kentucky border is just west. When prescription painkillers arrived in the early 2000s, the city of 50,000 people became an attractive jumping-off point for consumers who buy prescription doctors. According to a drug management database obtained by The Washington Post, 65 million prescription pills were distributed in Cable County between 2006 and 2012, enough for 97 pills per person per year.
By early 2010, a report in the emergency department reported severe abscesses in deep tissue in the patient's hands and feet – common needle injection points – were the first indications that drug users were reaching for syringes. Easy access on the highway to major cities such as Columbus, Ohio, Louisville, Kentucky and Cincinnati has been holding back heroin that is being poured into the region. In 2015, over 900 reported overdoses were reported in Cable County, more than in the previous three years combined.
In response, county health officials have launched a needle exchange program in which users can swap used needles for sterile ones such as a way to reduce the overdose and transmission of infectious diseases such as hepatitis. Opening in September 2015, it was the first in West Virginia and within a few weeks had to extend its hours to meet demand.
"We thought we had seen the worst of it, and by early 2016, the overdose had been reduced," Michael Kilkenny, medical director of the Cable-Huntington Health Department, said of the early success. "But by the second half of 2016, fentanyl had replaced heroin in drug delivery."
Fentanyl, a synthetic opioid that in its purest form is 100 times more potent than morphine, increased the overdose in Cable County. Within five hours of August 15, 2016, 26 people were overdosing in Huntington from a batch of fentanyl-laden heroin, according to the CDC. National media attention was focused on the city and Huntington was named the "capital of America's overdose." The rate of fatal overdose rose to eight times higher than the national average. "2017 was our worst year," Kilkenny says.
But people also come to Huntington and seek help. The needle exchange was part of it: At the end of 2017, the program reported the distribution of 800,000 clean needles since it was opened. In addition, a network of recovery programs, such as Lifehouse, has spread throughout neighborhoods west of downtown. "Huntington has become a kind of recovery mecca," says Rocky Meadows, founder of Lifehouse.
"Every night between 6:00 PM. and 9:00 pm, I suppose there are at least 2000 people at AA or NA meetings, "he said, referring to anonymous alcoholics and anonymous drugs.
According to Kilkenny, there is evidence that the approach works; preliminary data from the State Department of Health shows that in 2018, Cable County overdoses have decreased by 25 percent. "We are one of only two counties in West Virginia that have had similar interventions," he said.
But then HIV cases started.
There were warning signs. In 2016, the CDC issued a report that lists 220 counties across the country that are at risk of HIV due to intravenous drug use. The cable was plugged. But historically, West Virginia also has a low annual incidence of HIV diagnoses – 4.3 per 100,000 residents in 2017 – especially compared to neighbors like Kentucky (7.9), Ohio (8.8) and Virginia (10, 3), according to the CDC.  Then, in February 2019, Kara Willenburg, medical director of the infection prevention department at Cable Huntington Hospital, learned that local doctors had recently diagnosed six new cases of HIV. "We knew immediately what was happening," she said.
Public health officials started their operations. They asked every doctor in the county, from GPs to emergency room physicians, to start testing patients. CDC specialists arrived in March to officially announce the HIV virus, showing a dramatic increase in infection in the needle population.
Because infections were confined to a specific group rather than the general public, the authorities refrained from defining the outbreak situation. Federal investigators have determined that the increase will begin in early 2018. Each patient who is tested positive is immediately assigned an appointment with an infectious disease specialist within 24 hours.
In March, the number of HIV diagnoses increased to 28. Between late April and late June, Cable began averaging a new HIV case a week; Between the end of June and the end of August, the rate increases to two cases each week. By mid-September their number was 80.
What was happening in Cable had happened before. Between 2011 and 2014, HIV spread through needle users in rural Scott County, Indiana. Ultimately, 215 HIV cases were diagnosed before authorities noticed a drop in numbers, a decline in much of the credit for setting up a needle exchange program.
But Cable's public health infrastructure outperforms Scott County. Since needle exchange has already taken place, Cable is referring to what public health advocates widely consider to be the best protection against infectious diseases transmitted by a population of drug users. As HIV cases continue to escalate, Huntington's staff remain left with the mystery of why, despite their best efforts, the cluster hits here.
"We had prevention on site," says Kilkenny of the health department. "We've done more than some of the other counties. It feels cosmically unfair. "
Not only why, but also how bad and how big, which is why the health department reached out directly to Huntington's recovery programs, asking them to take their residents for testing.
On the day that the 12 men of the Lifehouse were to be tried, the morning began in the usual manner in the house where they lived, known as the Farm. Bathrooms are cleaned, beds are made, verandas are swept away. After breakfast in the small fenced-in backyard, some of the men stood in groups smoking cigarettes with hand-rolled cigarettes and talking about their needles history, knowing that in a few hours they would learn if they had HIV.
"I'm more addicted to the needle than the drug," says a 37-year-old named Eric, who sleeps with a loaded syringe in his drawer by his bed for years, so his morning mending will be ready as soon as woke up. "I could touch and not even do it. I wouldn't even touch it unless I was with the needle. "
" I would use women's foundations on my hands to cover up the tracks, "said another man." Go to these places to continue to rise, you know? It was ridiculous. "
" Use that and on the dark circles under their eyes, "says a 40-year-old named Andy, who has been injecting meth in the last year.
All the men here knew about Huntington's prevention efforts. They had seen the bright red "Needle Dispenser Box" with its large biohazard symbol in front of the health ward. They were introduced to the materials of the health department on "How to clean your syringes"; rinse with clean water; disinfect with pure bleach; Rinse again with clean water. They knew about the risks as well, but none of them mattered.
"Man, when you have needles left, you don't care where you get them from," Eric went on. "I used other people Hell, I went out looking for needles I threw away. Go down the path, find the place where you threw it and start looking. Find it, you use it. Put water with mud, a creek, whatever, to mix your doping and put it right in my veins. "
" It's only $ 12 for a bag of needles at a medical parts store, "Andy says." Many people buy and sell them on the street to be able to climb high. "
used once, but I would use mine so much that you had to throw it like an arrow to get it through the skin, "Eric said." The end will look like a fish hook. When you pull it out, it will tear your skin. " "I'm pretty sure this girl removed her needles from mine just before I went to prison," Andy said, thinking of ways "That makes me paranoid."
"If I have one," Eric said, "I understand. I can not worry because if it gets in my head, I will worry too much and that will make me want to use it. "
He rolls his sweaters feet. The syringe tattoo runs up the calf, the tip is curved, the cylinder is filled not with fluid, but with skulls. "It's got a fishing crane instead of a needle, because that's what it does: it hooks me up every time," he says.
"You get this in jail, right?" Said Andy.
Eric nodded. "Staple," he said. "It took 16 hours."
"How much do you pay for it?" Andy asked. "Several packs of cigarettes?"
Eric laughed. "Three Soups Paid and a Bag of Coffee Paid."
There's another needle talk on the front porch of the house. A 50-year-old named Todd had left the program two days earlier. Now he came back, explaining to the peers who ran the recovery program that he needed to take the needles he left behind because they needed insulin injections at the health department.
Peer mentors exchanged glances.
"Hide this unless you want to get mixed up," one said as he handed Tod a clear, plastic medical box with syringes.
"Put this in a bag or something," said another. "Go straight there, dude."
"Or else you will definitely dive," replied the first.
Tod wraps the box in a garbage bag and heads to the health department, where people gather for the daily needle exchange. Many were homeless, with all their belongings packed in rucksacks. They were throwing energy drinks and walking, waiting for their turn to get fresh needles, and then they would slip out into the side streets.
The idea of governments giving needles to drug users has always been controversial. But Huntington's mayor, law enforcement and the state health department supported the exchange of Cable when it was discovered in 2015. According to the program, drug users could talk to counselors and nurses and were given 40 clean needles; if they wanted to come back, they had to come back with 40 dirty needles. The program became a model as other West Virginia cities opened their exchanges.
But criticisms of these programs also left West Virginia's needle exchange vulnerable to political concessions, including in Charleston, the state capital, which opened its own program shortly after Huntington.
There were complaints about discarded syringes illuminating Charleston. There have been complaints of homeless drug users pouring into the city. An audit by the state health department found that staff had incorrectly tracked the number of needles distributed. In response, city officials adopted guidelines restricting access to such an extent that the people running the exchange program decided that the better option would be to close.
In 2018, Huntington employees were faced with the same decision because of similar complaints and a report from police that violent crime had increased by 30 percent since the program began. Instead of closing the program, however, the health department decided to limit it to county residents only. This happened in July 2018. Previously, 62,000 needles were given out a month. In July, their number dropped to 18,600.
What officials know now: This was also the period that coincided with the first of HIV cases, or as Kilkenny acknowledged, "This was a remarkable decrease in service in 2018. ., just as the HIV cluster arrives in town. "
The dispute over the program has continued ever since. Local politicians and the recently formed civic group have called for a state audit of the exchange, even as health experts continue to support it. "You have to be on the ground preventing this in advance," Feinberg said, explaining why he thinks even a limited needle exchange program is better than no other program. "When you start doing this, when you realize the problem, you're already behind the eight balls."
Kilkenny said he agreed. "Our goal is to get everyone who has the infection identified and linked to care and treat it to undetectable levels," he said of how he sees the health department's role in the controversy. "We need sterile syringes to get them. We will certainly not be a community that has no services. "
To this end, the health department continues to hand out clean needles and test every drug user and ex-addict who walked in the door, including the 12 Lifehouse men, one of whom was now telling the others," I hope I don't have HIV . "
The process will be easy. Just a finger prick. Immediate analysis. Quick result.
Twenty minutes after the first man was called back, he returned to the waiting room.
"I'm negative," he said, walking out. "Peace, everyone."
"It doesn't sound like a negative person," one of the men said, breaking the silence.
It was called another name that left 10 men, including Eric and Andy.
"Анди! Какво не е наред – каза някой.
„Нервен“, отговори той.
„Молете се, приятелю“, каза мъж на име Дан. „Знам, че го направих. Седях точно тук и се молех: „Не позволявайте на Дан да има СПИН!“
Ерик заговори. „Молех се преди да излезем от къщата.“
Наречени са още имена. Петима мъже останаха в чакалнята и разговорите им се насочиха към какви болести те вече знаят, че имат.
„Хепатит съм“ – предложи един.
„Получих хепат“, каза Ерик. „Разкъсване на черния ми дроб.“
„Ако нямаш хеп, ти си полицията“, добави друг. Всички се смееха.
"Ерик?", Каза медицинската сестра.
„Предполагам, че тогава съм полиция", пошегува се един.
Сега в чакалнята не бяха останали мъже. Всички бяха събрани навън на паркинга, говорейки, шегувайки се и игнорирайки табелите „Без тютюн“, докато издухаха цигари.
Тестовете бяха извършени. Новините бяха добри. Всички бяха отрицателни. Те довършиха цигарите и се върнаха в микробуса, за да се върнат в Lifehouse, където ще продължат да се възстановяват, без ХИВ.
„Аз съм отрицателен!“, Извика един жител, докато той блъскаше да отвори входната врата.
"Винаги сте негативни!", Отговори някой от кухнята.
Някои от завръщащите се мъже се спуснаха на дивани. Други започнаха да търкалят още цигари. Сега други жители се редят на входната врата, за да влязат в микробуса, за да отидат до здравния отдел, за да разберат до кои години е дошла злоупотребата с наркотици.