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A 6-year-old program that has reduced overdose deaths while simultaneously preventing new cases of HIV in one of the country’s biggest HIV hot spots is under attack by lawmakers. Its closure would be a public health disaster.

Six and a half years ago, the worst drug-fueled HIV outbreak in U.S. history began to emerge in Scott County in southeastern Indiana. By June 2019, 235 people in Austin, a city of approximately 4,300 people in the county, had been diagnosed with HIV. But as devastating as the outbreak was, it could have been much worse.

The first cases were detected in December 2014. It took until April 2015 for the state to allow Scott County to open a syringe services program (SSP) —sometimes called a needle exchange program — something that was previously illegal in the state. This program provided an essential way to connect people who use drugs and people who were living with HIV to services such as addiction and recovery, HIV prevention, hepatitis C treatment, applying for health insurance, counseling, and the like. The community partnership with the SSP had an immediate impact and was so successful that by the summer of 2015 new HIV transmissions had been halted.


At the time, one of us (W.C.) was a physician coordinating these efforts and treating patients in Austin. The other (G.G.) and a colleague showed that the HIV outbreak in Scott County could have been avoided if HIV prevention programs like the syringe services program had been established years earlier, as local public health experts and officials with the Indiana Department of Health had been warning of an impending HIV outbreak. Yet these warnings went unheeded.

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The consequences of ignoring this sensible public health advice will be felt for decades as the cost of caring for the more than 200 individuals living with HIV in the county is predicted to cost the state millions of dollars.


The Scott County HIV outbreak was a wake-up call for a nation in denial about the seriousness of the opioid crisis and the escalating threats that HIV and hepatitis C pose to communities across the country. The evidence had been there for years that SSPs are an effective way to prevent HIV and hepatitis C infection among people who inject drugs.

So in 2015, Indiana lawmakers voted to change state law to allow the establishment of these lifesaving programs. Part of that law put decisions about SSPs in the hands of locally elected county commissioners. The Scott County commissioners rose to the occasion by supporting the SSP, and have been essential allies since then to keep another HIV outbreak from happening.

The results speak for themselves. An active recovery community organization partner, THRIVE, has emerged from this work as more and more people who were using drugs have entered into recovery. In 2019, Scott County saw a 20% decline in overdose deaths. In 2020, the county had just one new case of HIV. During this time, people have requested fewer syringes from SSP while returning more than 90% of them to the program.

But times have changed. Despite all the program has done to roll back the number of HIV and hepatitis C infections, stem the tide of overdoses, and get people into drug treatment and into recovery, two of three new Scott County commissioners, Mike Jones and Randy Julian, want to shut down the SSP in June.

Neither of the new commissioners were witnesses to the profound human and economic suffering the 2015 outbreak inflicted on the county and seem prepared to ignore the lessons Scott County has learned from elected officials refusing to listen to facts.

We and others have tried to educate them, and they are aware of the consequences of closing the SSP from the recent experiences in two counties in West Virginia when elected officials closed their programs and caused the most concerning HIV outbreak in the United States currently underway.

Drug use is a growing problem nationwide. Closing the Scott County syringe services program won’t make drug use go away. It will only drive people who use drugs back underground and away from those who are trying to help them. It is heartless, cruel, and bad public health policy to yank away the only access many people who use drugs have to a place that has shown them compassion and hope, and given them new opportunities to live healthier lives.

If the Scott County commissioners vote to close the SSP in June, they are tossing aside six years of success and inviting HIV and hepatitis C back into the community.

Supporting SSPs is not a partisan issue. Both the Trump and the Biden administrations have endorsed SSPs as a vital tool in ending the HIV epidemic. This isn’t about red or blue states, but hope versus fear, science versus stigma.

Working together, we can address the problems of drug use and HIV. Scott County and Austin, Ind., could become the beacon of hope for communities across the nation that are locked in life-and-death struggles with drug use. Overdose deaths in the U.S. spiked in 2020, making it the nation’s deadliest year in decades in the opioid epidemic. Now more than ever, letting fear and stigma drive policy is dangerous.

We urge the Scott County commissioners to make the right decision and keep the syringe services program open. Too much is at stake to simply repeat the mistakes of the past.

William Cooke is a physician specializing in family medicine, addiction medicine, and HIV medicine. A recipient of the Ryan White Distinguished Leadership Award, he is also the author of a book about the Scott County HIV outbreak, “Canary in the Coal Mine” (Tyndale Momentum, June 2021). Gregg Gonsalves is an associate professor at the Yale School of Public Health, and an associate (adjunct) professor at the Yale Law School, and a 2018 MacArthur Fellow.

  • This seems to be a sequel to a prior (early May) STAT written article. Despite all the benefits for one group, I can understand the reason for closing. If people are not going to stop shooting drugs, and if a needle exchange is beneficial to curb HIV, then what is being done to bring the drug users to understand the concept of “exchange” of all those many more needles ? Backlash to these programs is unavoidable if a non-users’ living environment gets endangered by infected needles randomly dumped by the users. The littering problem MUST be addressed. Helping drug users can not and should not come at the cost of safety of law-abiding non-using regular citizens.

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