At age 70, when many longtime doctors have either retired or are contemplating it, longtime University of Cincinnati HIV expert Judith Feinberg, M.D., FIDSA, got an offer she wasn’t expecting: Move to the poverty-stricken, opioid-ravaged state of West Virginia to start up a research center at West Virginia University into the treatment of HIV and hepatitis C among injection-drug users.
Guess what? This New York native took the offer, packed her bags—and was soon becoming intimate with a state that is Ground Zero for the opioid crisis ravaging America. She is now board chair of the HIV Medicine Association. TheBody spoke to Feinberg about making the transition from an urban, decades-long HIV care provider to someone who now spends much of her time driving to remote rural pockets to set up studies that aim to prove the efficacy of treating both HIV and hepatitis C in active drug users.
Tim Murphy: Hi there, Dr. Feinberg. Thanks for talking to us about this very interesting new chapter in your career. So, jump right in and tell us how it came about.
Judith Feinberg: Sure. In 2005, when I’d been at the University of Cincinnati for 10 years, I realized that we had a new heroin problem. I was probably the first doctor in that area to realize it, which makes sense, since I’d come from Johns Hopkins in Baltimore, where injection-drug use was a major cause of HIV. Previously, that had never been a problem in southern Ohio. But I was seeing too many cases of endocarditis, an infection of the lining of the heart that can be life-threatening and often takes six weeks of intravenous antibiotics to cure or can require surgery. It’s often associated with injection-drug use [IDU], and I would see the track marks on patients’ arms.
I understood that IDU was a very efficient way to spread HIV as well as hepatitis B and C, so I started right away to gather people and resources to get a syringe program going [in which injection-drug users can access sterile needles and other paraphernalia so as not to get or transmit these diseases while using]. I worked on that for the next nine years. In 2014, after a long effort, I opened Ohio’s third syringe exchange program, in Cincinnati. There, we also taught people about safer vein care, gave out male and female condoms, and gave out IDU paraphernalia as well as syringes—because, sadly and unlike HIV, hep C can remain infectious on inanimate objects, like IDU spoons and cotton balls, for a long time.
TM: Why do you think you were suddenly seeing so much IDU in southern Ohio?
JF: It initially came from the counties east of Cincinnati, whose county, Hamilton, is the only one in southern Ohio that is not considered Appalachia. That area was just like Kentucky, West Virginia, and northeast Tennessee, where prescription opioids had been rampant, maybe because people had had a lot of injuries and pain from those hard-labor coal-mining jobs. Then it clearly became a drug of abuse. Then when authorities clamped down on prescribing, people turned to street drugs. If you look at the CDC map of counties in the U.S. at risk of an HIV outbreak, more than 50% of them were in that area.
So then, via a colleague, I heard that West Virginia University [WVU] had overwhelming rates of hep B and C and endocarditis. So they recruited me to come there and establish a research program that would be all about the intersection of IDU and infectious disease. So I started in December 2015 and have since started that program. I’m about to start a study of PrEP [pre-exposure prophylaxis] in IDUs. We just finished a NIDA [National Institute on Drug Abuse] grant to increase testing for HIV and hep C and to help communities develop harm-reduction programs in seven of these southern coalfield counties at the tip of the state—those most ravaged by the crash of the coal industry, and also those that had the highest rates of opioid prescriptions.
TM: What was new or striking to you about West Virginia?
JF: The sheer economic devastation there is pervasive and looks so much worse than in Appalachian Ohio. They have the highest rates of acute hep B and C, babies born in opioid withdrawal, deaths due to overdose. I have yet to meet a single person who has not been touched directly by the opioid epidemic. There are counties where 50% of the kids are in foster care.
And recently there have been HIV outbreaks. There was one [reported in 2018 (https://www.cdc.gov/mmwr/volumes/67/wr/mm6708a6.htm]) across several counties that included some people who had progressed to AIDS. The majority of infections were in men who have sex with men (MSM), but 9% of those infected had IDU as their primary risk. Then in late 2018, there was an outbreak in the second-biggest city, Huntington, where all the people were IDUs. And starting a couple months ago, there was an increase in cases reported in Charleston, the capital. The two biggest Ryan White clinics in the state, in Charleston and Morgantown, have seen an increase in HIV diagnoses where IDU was the factor.
TM: And what is the situation with needle exchanges in West Virginia?
JF: It’s currently legal. There are 16 programs in the state, two of which are run privately and 14 of which are in county health departments. But there are bills in the state legislature to either make needle exchange illegal or to put huge barriers on it, like having to put a barcode on every syringe. How would you keep them sterile doing that? Or having to have a photo ID to come to a needle exchange. We know that the most successful programs are the ones with the least barriers and the most hours. And in this poor state, sometimes the needle exchanges are open only two hours a month.
So these bills are apparently being discussed today, and it’s terrifying. There are a lot of people here who think mistakenly that if you just don’t give people sterile syringes, the IDU problem will go away. They don’t understand the nature of addiction. They think it’s a personality flaw. But it’s a disease where your brain has undergone changes that make you behave in a dangerous way to yourself and your loved ones. If you’re compelled to use drugs, you’ll use dirty needles if you have to.
TM: Can you tell us what you’ve found so far among the various studies you are doing?
JF: We are among an eight-site, multistate study into the efficacy of treating and curing active drug users for hep C. And we’re currently writing the paper, which I hope will be published—but I can tell you at this point that the vast majority of the people involved so far were cured.
We’re also actively recruiting pregnant women who have hep C, with the goal of seeing how frequently it is transmitted to infants. Old data tells us that about 6% of women with hep C alone pass the virus to their babies—about double that percent for those who also have HIV.
TM: Is the study with an eye toward screening and treating women for hep C while they are pregnant?
JF: Exactly. Ideally you would cure before pregnancy. Unlike HIV, hep C seems to be limited to being acquired by the baby during the birth process. You can also give HIV meds to unborn or newborn infants to prevent HIV, but hep C meds are currently approved only for children three years and older. There’s been no study so far into whether hep C meds are safe for infants or children, but they’re in very similar chemical families as HIV meds, so I would say it’s likely that they’re as safe to take during pregnancy as HIV meds.
TM: What’s a typical day like for you?
JF: So busy! You don’t even want to know. Every day is different and complicated. I spend a lot of time on the road, with my researchers taking me across the state, which is a big mountain from one end to the other. There is no state-wide public transport to speak of, only some bus service within cities or towns. I also spend a lot of time mentoring younger faculty and trying to build up clinical research at WVU in the areas of HIV and hep C in IDUs. I write a lot of grants.
TM: What are your thoughts about West Virginia culturally, as a newcomer?
JF: The people are just terrific. This is a population that has been taken advantage of, raped and pillaged, again and again, mainly by the coal industry. But as soon as people here know that you have a genuine concern for them and are not just here to gather data and walk away, they’re amazingly supportive and warm. I have not encountered hostility at all. It’s a small state, population-wise. I was in Ohio for 18 or 19 years before I met the head of the state department of health. Here, it took only six or seven months.
My heart breaks for the people here, because they’ve gotten a raw deal for a long time. The natural resources are beautiful, but it’s been the victim of extractive industries—and not just mining and fracking. Lumber is huge here. When I first arrived, I wondered why I seldom saw very old trees. Then a naturalist told me that the whole state has been clear-cut twice.
I work in a county without a grocery store. People buy milk and other food at the dollar store. Even the Walmart closed, so you can imagine what things are like.
TM: Wow. So what are your goals for the next five years?
JF: I turned 74 a month ago, but I have no plan to retire. My goal is to try to turn the tide on HIV, hep B and C, and the drug epidemic in West Virginia, to the extent of my ability for as long as I can. I don’t have a time limit. I don’t think in those terms. For the moment, I’m full-steam ahead.