Over the past eight years, the effects of the opioid epidemic can be seen more clearly in Cabell County than perhaps anywhere else in West Virginia. Residents have died from overdoses at a rate higher than any county in the state. Babies in the county are more likely than other West Virginia babies to be born exposed to illicit or prescription drugs. And the area’s high amount of injection drug use led to an HIV outbreak in 2019, a crisis which is ongoing.
But the one of the county’s main tools for combating the dangerous consequences of injection drug use could soon be in jeopardy. The makeup of the Cabell County Commission is changing: voters ousted one of the current members, and another did not seek reelection. Now, starting next year, two of the three commissioners have a track record of publicly criticizing the Cabell-Huntington Health Department needle exchange — a program that lets people who inject drugs exchange used needles for clean ones and connect with treatment resources.
The commission’s changing members, paired with a new state law, makes it likely the program will soon be restricted or halted.
“This is going to be devastating to our state, not just Cabell County, if that program closes,” said Drema Hill, who has served on multiple boards and task forces aimed at addressing the state’s opioid epidemic. “It is the model by which other programs are built. And it works.”
Services offered at a critical time
Cabell County’s syringe exchange first opened in 2015. But it was expanded in 2019, after health officials began noticing an uptick in HIV cases among people who inject drugs.
These kinds of syringe exchanges — ones with few barriers to dissuade people using the service — had already proved successful in slowing other HIV outbreaks around the country. And it seemed to work in Cabell County, too: after making it easier for people to pick up sterile needles, the county’s program doubled the number of people who used it — and the number of newly-identified HIV cases decreased soon thereafter.
But three years later, there are signs the virus is spreading at outbreak levels again. As of Nov. 16, state data shows there have been 48 new cases of HIV among people who inject drugs in Cabell County so far this year — an increase from both 2020 and 2021.
“My fear is that what the health department found is still just the tip of the iceberg,” said Sydnee McElroy, a Marshall Health family physician and member of Cabell-Huntington’s harm reduction advisory board.
Her fears are backed up by two studies, one of which estimates the number of Cabell residents who use injection drugs and the other the percent of whom have undetected HIV. In spite of some limitations, these findings, when taken together, indicate there are many undiagnosed cases in Cabell County.
To McElroy, Huntington’s high HIV numbers indicate why the harm reduction program is more essential now than ever. She also noted that the services reduce the community’s shared economic costs spent on emergency rooms trips.
“That’s a huge financial burden on Mountain Health Network [and] the state,” McElroy said.
But Cabell County Commissioner Kelli Sobonya, who has been on the commission since 2018 and served as a state delegate for 16 years before that, says she has seen the program increase needle litter in the county.
“If you’ve talked to people who’ve been into gas stations and convenience stores, [needles] are found all over the place,” she said.
Peer-reviewed research indicates that syringe services have the opposite impact on litter; as they become more available, proper needle disposal often increases. Scientists have also not found convincing evidence that the programs increase crime.
From 2018 to 2021, the Cabell County program got nearly as many used needles back as what it gave out; in 2018 and 2019, more syringes were returned than they distributed each year according to data provided by the Cabell-Huntington Health Department.
Michael Kilkenny, Cabell-Huntington’s health officer, said that complaints to the agency about syringe disposal have decreased each of the last three years. He also noted that “anecdotal evidence is not strong enough to make public policy.”
Kilkenny said the real safety threat to his county is legislation like Senate Bill 334, a 2021 set of guidelines that limits harm reduction programs. According to Kilkenny, the laws have resulted in his health department having to scale back some of the 2019 expansions — expansions that had slowed the ongoing spread of HIV.
“Whether restricted by law, policy, or budgetary constraints, each restriction diminishes the effectiveness and benefit of the program,” he wrote in an email.
Despite the national studies, local data and public health officer’s testimony, Sobonya believes the service threatens her constituents who don’t inject drugs.
“What about the public and their protection?” she asked.
Legislative bill endows more oversight for county commissions
Starting next year, Sobonya will be in a position to change or eliminate the county’s program if she chooses. All syringe service programs in West Virginia are now required to get annual approval from the programs’ city council and county commission. And in January there will be a majority of Cabell County commissioners with a record of opposing these types of harm reduction efforts.
John Mandt Jr. has previously publicly opposed the health department’s harm reduction services. In 2019, while serving in the House of Delegates, Mandt joined Sobonya in requesting an audit of the county’s syringe exchange service. In a brief interview, Mandt said he couldn’t comment until further studying the county’s opioid crisis. He did not respond to multiple follow-up calls and emails for comment.
Both Sobonya and Mandt say the audit was aimed at providing the public with more information, but it came on the heels of a similar audit in Kanawha County. That effort led to the program shutting its doors, an outcome that many believe catalyzed an HIV outbreak in the capital city.
In a phone call, Liza Caldwell, who will serve as the third commissioner, said she supports harm reduction efforts and that elected officials should “step back and allow public health experts to take the lead.” But, as the only member who has publicly supported the exchange program, she likely will not be able to protect it.
Kilkenny said he is resigned to accepting whatever the commission decides.
“If that is their political will, despite all of the information we can provide them, the law is the law,” he said. “The health department will follow the law.”
But there’s one final move that could extend the Cabell syringe program’s life.
Current commissioner Jim Morgan lost his reelection bid to Caldwell. But in his last month in office, he wants to explore whether he and fellow commissioner Caleb Gibson — who’s also leaving office in January — can protect the program in some way.
“It would be a mistake to end it,” Morgan said. “If the new commissioners would agree to a different plan that would end in similar results and stop the spread of disease, that would also be okay. But to just have no plan and no needle exchange would be a terrible mistake.”
The Commission will meet twice in December, and Morgan is trying to figure out whether there’s a way to extend the program’s approval for another year.
“Knowing that there’s a dark cloud hanging over the program, if it can be done, I would certainly hope to do that,” he said.