A lot of my work in Southwestern Indiana takes place in small rural communities and county jails. Of the 11 counties I work in, you would need to add 7 of their populations together to equal the 181,000 people in Vanderburgh County. The first step in improving HCV care in these communities and jails hinges on us understanding that in these places fewer financial and organizational resources exist for the prevention and treatment of HIV/HCV and STDs. The problems needing to be addressed are intertwined with poverty, limited to nonexistent transportation, rising injection drug use and insurance access. We don't need to guess what can happen when health disparities like these begin to stack up higher and higher, in fact, everything we need to know came to light 20 months ago in almost the same spot on the other side of Indiana.
If by some chance you aren't familiar with Scott County, here's a quick recap. In 2015, Scott County was the epicenter of an HIV outbreak that has led to 200 positives, and a 90% HCV coinfection rate. The county has a population of 24,000, and for some time had severe health disparities with few available resources. This isolation was both unfortunate, and unnecessary considering Scott County is 40 minutes from Louisville, KY, and 90 minutes from Indianapolis, IN., two cities that have a combined population of 1.2 million. Scott County is a stone's throw away from two cities which possess vital health and treatment resources, but it doesn't benefit rural communities to be near resources if the people living in them are isolated because of issues like transportation.
Think of it like this. Around here, you can go from a county of 181,000 people to one of 24,000 in the same time it takes to cross a metropolitan U.S. city during rush hour traffic. If you travel from Evansville to Indianapolis along the new I-69 corridor, you will pass 6 rural counties with populations less than Scott County's. Now, I'm not saying all rural counties in Indiana are on the verge of having an HIV/HCV outbreak, but what I want to stress is that many of these rural counties are experiencing rising rates of injection drug use, HCV and shrinking resources that indicate they may be at high risk in the future.
What is happening in these counties may not be bad enough to warrant the label outbreak, or be noticeable in surveillance reports just yet, but at some point in the past neither was Scott County. Health disparities can act a bit like compound interest. Each new health or socioeconomic concern that arises will be added to the existing pool of problems which will lead to further tangling the knot.
The people in the communities I travel to want HCV education, testing and treatment resources. Many of these same rural communities are taking steps to address these issues in pragmatic and proactive ways. For example, there are rural counties actively seeking grants for the overdose reversal medication naloxone and training so that first responders and police can be equipped. They know that their surveillance data doesn't reflect a significant enough issue to win competitive grant funding and so they are creating systems to better track overdoses and rising HIV/HCV rates. They also know that the opioid epidemic sweeping rural America is likely to end up on their doorstep, so they are building coalitions and taking steps to limit the effects of hard to control opioid epidemic, but without more support in the form of early detection, education and treatment, HCV positive people in these areas will unnecessarily suffer poor health outcomes. There are a lot of stereotypical beliefs about rural communities being closed off, and slow to change, but I can tell you first hand my experience in Southern Indiana has been the complete opposite.
When you consider that an estimated 30% of the 2.7 to 3.9 million chronic HCV positive people in the U.S. will pass through the correctional system at some point in their lives it becomes clear that county jails and State and Federal Prisons play a pivotal role in addressing rural HCV needs.
In Indiana, when a person enters the prison system, they pass through a processing facility called the Reception & Diagnostic Center (RDC). During their brief stay they will receive a one-time HIV/HCV screening as well as many other medical tests and assessments. This means that as long as inmates are not in a "window period" they will know their status at the start of their incarceration. This may be the last time for quite a while they receive an HIV/HCV test, because in order to receive a screening while inside people have to admit to engaging in high risk behavior that often breaks facility rules. For this reason, many inmates stay silent to avoid having time added to their sentence. This is problematic because they do not receive screenings upon leaving the correctional system, and many of them will go back to rural communities where HCV screening and education is likely to not be easily available.
In part 2 I will cover the unique challenges that jails and State prisons face in providing HCV treatment and care. I will also go into detail of some ways these challenges can be overcome, and why if they go unaddressed poor health outcomes will persist and get worse. In the meantime, if you work or live in a rural community, I encourage you to leave a comment about your experience or to send me an email. I would like to hear about your experience.
Matthew Zielske currently works as a HIV/HCV special populations prevention specialist at an HIV services organization. He utilizes a harm reduction model in his work with the substance use population focusing pointedly on persons who inject drugs. He is currently conducting research on Health Literacy and hepatitis C for his Master's Thesis in Communications. www.umbrellaway.org