The United States is experiencing a syndemic of HIV, STIs, viral hepatitis, and overdose. STI, hepatitis, and overdose rates have increased dramatically in recent years and HIV outbreaks have been occurring across the country. Local health departments (LHDs) are uniquely situated to respond to the syndemic, as they work across the public health spectrum and have a broad range of partners and programs. Effectively combatting the syndemic will require LHDs to take a coordinated approach that centers people who use drugs (PWUD), as they are inequitably impacted by these trends, and prioritizes harm reduction strategies, as they can both directly and indirectly prevent and reduce the impact of HIV, STIs, hepatitis, and overdose.

Background
In 2021, the U.S. reached a grim milestone: more than 100,000 overdose deaths in a year. Meanwhile, STI cases set new records each year and disproportionately impact PWUD. In recent years, hepatitis A and C cases have skyrocketed, and progress against hepatitis B has stalled. In 2020, hepatitis A cases finally began to decline, after outbreaks in more than 33 states resulted in a 850% increase in incidence, with cases primarily among people experiencing homelessness and/or
engaged in drug use. Hepatitis C cases increased 71% between 2014 and 2018, with three-fourths of cases occurring among PWUD. Meanwhile, hepatitis B cases have plateaued nationally, driven in part by increases in states most impacted by the opioid epidemic—after years of declining rates. Additionally, at least 10 jurisdictions have reported HIV outbreaks among PWUD since 2015. (2018 Viral Hepatitis Surveillance Report: Cases of Hepatitis A and C Continue to Climb - NACCHO)

Overdoses, STIs, viral hepatitis, and HIV are closely intertwined in the U.S. Some of this overlap is due to shared risk factors. Sexual activity spreads STIs, including HIV and hepatitis B and C. Substance use, in particular injection drug use, spreads HIV and hepatitis B and C, and is the cause of overdose. These activities may also contribute to one another—use of certain substances can increase libido and reduce sexual inhibitions. However, another leading reason for the emergence of a syndemic has to do with the broader social context: HIV, STIs, hepatitis, and overdose inequitably impact many of the same populations and have shared root causes and risk factors. Poverty, unemployment, unstable housing, and poor access to healthcare are key risk factors for each of these diseases and conditions. Additionally, stigma and discrimination related to these diseases, conditions, and associated behaviors (e.g., substance use and sexual activity) can deter people from seeking and accessing health services. In addition to, and because of these shared risk factors, HIV, STIs, viral hepatitis, and overdose disproportionately impact many of the
same populations. As demonstrated above, PWUD face heightened risk for HIV, STIs, and viral hepatitis, but so do Black, Indigenous, and People of Color, LGBTQ+ populations, young people, and people who have been involved with the criminal justice system.

LHDs have the Tools to Address the Syndemic
Fortunately, we have the tools to combat the syndemic, and many LHDs already provide these services. Syringe services programs can prevent HIV and viral hepatitis, including half of hepatitis C cases. Pre-exposure prophylaxis (PrEP) can prevent HIV and highly effective vaccines can prevent hepatitis A and B. The distribution of naloxone can treat overdoses, and we have effective treatments against HIV, hepatitis, and STIs, including cures for hepatitis C and bacterial STIs. According to NACCHO’s National Profile of Local Health Departments, distributed every three years to a census of LHDs, 70% provide STI screening, 67% provide STI treatment, 62% provide HIV screening, and 46% provide HIV treatment. According to NACCHO’s Injury and Violence Prevention Survey, sent to a representative sample of 766 LHDs, stratified and weighted by jurisdiction size and U.S. Census region, more than one-fifth of LHDs provide or support syringe services, and more than half provide or support the distribution of naloxone. And according to a convenience sample of LHDs surveyed by NACCHO’s HIV, STI, & Viral Hepatitis team, more than 90% of LHDs offer hepatitis A and B vaccination, and many also offer testing and linkage to care.

Key Strategies: Harm Reduction, Centering PWUD, Integrating Services
PWUD have often been deemed “hard-to-reach” by the public health field. However, there has been criticism of this term in recent years as it can be used as an excuse, when in reality, the failure to effectively reach PWUD should be seen as a call to action. LHDs do face an uphill battle in reaching PWUD due to insufficient resources and the criminalization of substance use—which may make them wary of governmental institutions and services. Overcoming these challenges is critical to addressing the syndemic, given the effectiveness of harm reduction services and the inequitable impact of HIV, STIs, hepatitis, and overdose on PWUD.

As previously discussed, harm reduction strategies can directly prevent HIV, hepatitis, and overdose. Core strategies include the distribution of sterile syringes to prevent the transmission of infectious diseases, as well as the distribution of naloxone to reverse overdoses. However, new strategies are emerging. Emerging evidence suggests that the distribution of smoking supplies can encourage and enable PWUD to transition from injection to smoking, which reduces the risk for both infectious diseases and overdose.

Not only do harm reduction strategies directly prevent or treat HIV, hepatitis, and overdose, they also address the syndemic through more indirect ways. Harm reduction programs have a proven track record of effectively reaching and building trust with PWUD. Consequently, LHDs may be more effectively able to reach PWUD through harm reduction services than through their traditional clinical service delivery. The impact of these connections is powerful: people who visit a syringe services program (SSP) are five times more likely to enter treatment for substance use in the following year. It should be noted that the goal of harm reduction isn’t to reduce substance use in and of itself; rather, the goals are to meet people where they are, and provide services that reduce the harms of chaotic substance use and to improve the health and well-being of PWUD. This statistic demonstrates SSPs’ ability to effectively reach PWUD and promote uptake of health services, which often includes treatment for substance use disorder. Additionally, given the aforementioned connection between use of certain substances and sexual risk behaviors, SSPs can also reduce risk for STIs, including HIV and hepatitis B and C, by encouraging people to reduce chaotic substance use.

Integrating HIV, STI, hepatitis, and harm reduction services is another promising strategy for addressing the syndemic. Models for integration are as diverse as the organizations that provide these services, but common strategies include: a “one-stop-shop” approach where services are co-located and can be accessed simultaneously; satellite and mobile services, which often involve providing services in non-clinical and non-traditional settings to meet people where they are; and referrals, which may be prompted by screening or testing, or supported by case management, client navigation programs, or “warm handoffs,” in which service providers implement strategies to increase uptake of referrals, such as by helping a client schedule an appointment, or by providing financial support for transportation. While a “one-stop-shop” approach appears to be particularly promising, LHDs should consider what strategies are most feasible for their organization and community, and recognize that any efforts to increase connections between HIV, STI, hepatitis, and harm reduction services are valuable.

LHDs can also work to ensure their services are nonjudgmental, non-stigmatizing, and culturally competent, and that their providers are trained to communicate with PWUD in non-stigmatizing ways. Not only will this increase adherence in LHD services, but word-of-mouth can be an important communication channel for PWUD, and they will be more likely to visit the LHD if other PWUD and/or harm reduction providers have positive experiences with the LHD. Additionally, creating culturally competent, non-judgmental, and non-stigmatizing services to meet the needs of PWUD can also bring in other populations that are often underserved by the medical and public health communities.

Conclusion
The epidemics of HIV, STIs, viral hepatitis, and overdoses have merged into a syndemic in the U.S., inequitably impacting people who use drugs. A harm reduction approach that centers PWUD is critical to combating the syndemic, as harm reduction strategies directly prevent HIV and hepatitis and treat overdose, and as harm reduction programs are uniquely positioned to reach PWUD, offering a range of integrated health services. LHDs face myriad barriers in implementing harm reduction strategies and integrating HIV, STI, hepatitis, and harm reduction programs. These services are often underfunded and supported by different funding mechanisms; key harm reduction services are legally restricted in many jurisdictions; and building relationships and trust with PWUD and harm reduction providers requires intentional, dedicated efforts. However, harm reduction strategies and integration approaches are effective—overall and at addressing gaps and inequities in the public health and healthcare systems—allowing LHDs to maximize limited resources.

For more information, contact Kat Kelley at [email protected].