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Opioid crisis also brings worry of spread of HIV, hepatitis C

BY Livia Gershon

1/9/2019
Photo/Edd Cote
Photo/Edd Cote
Juliet L'Esperance, a health navigator at AIDS Project Worcester, with a bag of syringes. The office has more than 1,600 people enrolled in its syringe services program.

In 2016, a Central Massachusetts woman named Nicole was at a low point in her life. Her opioid use had taken a toll on her, physically, emotionally, and financially. When she hit a point where she couldn’t afford $3 to buy fresh syringes at CVS, she turned to AIDS Project Worcester.
“I was very apprehensive about utilizing services because I did not want to be seen or known or give out my information,” she said. “They kept it very discrete…. They treated me like a human being.”
At that point, Nicole—who asked that only her first name be used here for privacy reasons—had no plans to quit.
“I was on a path to self-destruction,” she said. “I was pretty hopeless. I think the shame overpowered everything, and I didn’t see any way out.”
The staff at AIDS Project Worcester, known as APW, didn’t demand that she think about quitting, Nicole said. They gave her syringes and snacks—she hadn’t been eating much—and they listened without asking invasive questions or badgering her to enter treatment.
The opioid crisis, and, particularly, the rising use of the synthetic opioid fentanyl, presents a public health danger in Central Massachusetts. Local health officials, nonprofit agencies, and health care providers, are working to prevent the spread of infections, particularly HIV and hepatitis C, through infected needles. And one of their key tools is the kind of unconditional support Nicole received at APW. 
After months picking up syringes and talking with staff at APW, Nicole decided to enter a treatment program. She’s now 14 months sober. But Martha Akstin, APW’s director of prevention and screening, said the organization believes every client is equally worthy of help and support whether they want to stop using or not.
“We accept them where they are,” she said.

Along with serving people on site—Akstin said APW has more than 1,600 people enrolled in its syringe services program—the organization does outreach in the community.
“We go to areas that we know active injection drug use is occurring and sweep the area for syringes, give out bleach kits, and talk to the people about safe injection practices,” she said.
The importance of this kind of work was made clear this summer when the state and federal officials began investigating a spike in HIV cases among injection drug users in Lowell and Lawrence this summer.
Dr. Philip Bolduc, assistant professor of family medicine and community health at UMass Medical School and the HIV program and fellowship director of the Family Health Center of Worcester, said the Lowell-Lawrence area was particularly vulnerable because fentanyl was spread among injection opioid users there earlier than in many places. Compared with heroin, injected fentanyl provides a much shorter high, Bolduc said, so users often inject themselves more frequently.

“Obviously the needle use is going sky-high with that, and the sharing as well,” he said.
Fentanyl has been spreading across the state. Dr. Matilde Castiel, Worcester’s Commissioner of Health and Human Services, said use of the drug has been increasing since around 2010, but it’s really picked up over the past four or five years.
“I’m now doing urine screens and I see fentanyl,” she said. “I wasn’t two years ago.”
That makes Lowell and Lawrence a cautionary tale for this area.
“There’s no reason why it couldn’t happen here,” Bolduc said. “You just need the right conditions, someone who’s infected in the needle-sharing network, and boom, you could be off to the races.”
Beyond providing clean syringes and other support to active injection drug users, local health officials and providers are using a number of tools to prevent that outcome. Bolduc said the Family Health Center offers medication-assisted treatment using Suboxone, one of the best-proven methods for helping people quit opioid drugs. In addition, he said, doctors are now working closely with people who use opioid medications for chronic pain, helping to prevent them from developing dangerous dependency.

Meanwhile, Castiel said, with people below age 20 making up a large part of opioid users and people at risk for diseases transmitted through drug injection, the Worcester schools are playing an important role in educating young people about these dangers.
“You want people to be aware that this is how these diseases are transmitted,” she said. “We’ve been looking over, how do we communicate with the younger people, discussing these issues with them.”
Another side of the effort centers on people who have HIV. Thanks to advances in medicine, Bolduc said, people who receive proper treatment can keep HIV from progressing to AIDS, and won’t pass the infection to sexual partners. Bolduc said research hasn’t yet determined whether that’s also true of sharing needles, but, according to the CDC, keeping the virus at bay probably provides at least some protection for users.
Bolduc said that, years ago, many people with HIV were worried about the difficulty and side effects of maintaining the necessary medical regimen. But today medications are easy to take. That means that when people don’t keep their disease under control it’s often because of other issues in their lives, like mental illness, domestic violence or poverty. 
“We used to be wrangling with medical issues,” Bolduc said. “Now, to be honest, at least 80 percent of the time we’re wrangling over social issues that our patients face.”
As with HIV, medical advances have greatly improved the prospects of people with hepatitis C in recent years. Just a few years ago, treating the infection, which can lead to devastating liver failure, involved a difficult, unreliable medical regimen. But current drug options are highly successful in getting patients back to health. And, importantly, since 2016 MassHealth and most private insurance in Massachusetts have begun covering the treatment even for people who are active drug users.
“Before, you had to either be ‘clean’—quote unquote—or you had to have advanced liver disease to start a hepatitis C treatment,” Akstin said. “So that would be like if you were obese and had a heart attack and you went to the ER and they said we’re not going to treat your heart attack because you’re fat.”
While officials in some parts of the country are leery of tackling health issues in ways that support people even if they remain addicted to drugs, Akstin said local politicians have embraced the harm-reduction approach.
“I would call them champions of the program,” she said. “And our state reps are all supportive. They get it. And I think, the opioid crisis, I don’t know too many people who haven’t been touched by it.”