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“I think it’s really exciting that they have been the leaders in this and are showing the state the way to go and are jumping right in,” Elaine Martin, director of HIV prevention services with the Virginia Department of Health, said Wednesday.

Martin said the health department has completed a review of the application and conducted a site visit, and it expects to authorize the program soon.

The opioid crisis has driven a spike in hepatitis C cases in Virginia. Among 18- to 30-year-olds — those most likely to contract hepatitis C through drug injection — 2,141 new cases of the disease were reported last year, up from 840 six years earlier, according to the Health Department.

Hepatitis C rates per 100,000 in Virginia in 2017

Hepatitis C case rates per 100,000 residents in localities in Virginia in 2017. In 2017, there were 2,141 new reported cases of hepatitis C among 18 to 30 year olds, and a new case rate of 140.9 in the state. Source: Virginia Department of Health

A bill to legalize needle exchange programs became effective in July, adding Virginia to the list of 28 other states that have authorized public health organizations to distribute syringes.

A total of 55 localities are eligible to apply to start an exchange. But to date, Wise County is the only one to submit an application, although Martin said she knows of other localities working through the process.

“We anticipated it to roll out maybe a little quicker than it has,” she said in March.

Prevention experts say the application required in Virginia is more challenging than in other states. One significant barrier: Agencies that want to operate a syringe exchange program must get letters of support from local law enforcement agencies, which are not always on board with the idea of giving needles to drug users.

“There are not many places where that is the case,” said Keifer Paterson, government relations manager for the Harm Reduction Coalition, a New York-based national organization that advocates for syringe exchanges. “That creates a higher barrier of entry for a startup.”

Not just about needles

Syringe exchange programs provide clean needles to drug users and give them a place to discard dirty needles. But needles generally represent just a small part of the programs. Sites also provide services such as HIV testing, hepatitis C screenings and referrals for medical or drug treatment programs. Research indicates that these other services — and the human connections that are forged — are what make such programs successful, and evidence collected over more than two decades indicates that these programs reduce the spread of infectious diseases but don’t increase drug abuse.

Syringe exchanges first emerged in the late 1980s in places such as New York City and San Francisco in response to the HIV/AIDS epidemic. Public officials wanted to find a way to reduce the spread of the disease through needle sharing among drug users.

Only in the past few years have exchanges come to smaller cities and rural areas, as the death toll from the opioid epidemic continues to rise.

In response to the increasing problem of opioid addiction, Virginia lawmakers introduced numerous bills during the last General Assembly session to tackle various angles of the problem, including needle exchanges.

“I think that we need a multi-pronged approach to the opioid epidemic and the drug issue that we have in Southwest Virginia,” said Del. Sam Rasoul, D-Roanoke, who voted in favor of the needle exchange bill. “We need to make sure we’re open to the data and what the data is telling us, and that’s things like syringe exchanges work in many cases.”

Last year, 1,227 people in Virginia died from overdosing on opioids, which includes illicit drugs such as heroin as well as prescription painkillers, according to preliminary data from the health department. That’s an increase of more than 50 percent since 2015.

Beyond the threat of an overdose is the risk of being exposed to hepatitis C and HIV, both expensive and possibly fatal illnesses.

According to the health department, Roanoke has one of the highest rates in the state of hepatitis C linked to the opioid crisis, with 85 reported cases last year, up from six cases six years earlier.

“Especially in Southwest Virginia and Roanoke, the dramatic increases in hepatitis C have been concerning,” Martin said. “Hepatitis C comes before HIV, so we’re really trying to get services in place to stop that from happening.”

The number of new cases of HIV in Virginia has remained steady at an average of 940 for the past six years, according to health department data.

Localities with high hepatitis C rates are among the 55 that are eligible to open syringe exchanges. Six localities are in the Roanoke and New River valleys.

“There is a lack of providers that have experience in treating hepatitis C, so you can tell someone they have it, but then it’s harder to refer them to get treated,” said Bruce Taylor, the health department’s drug user health coordinator. “Particularly in rural areas, that’s an issue, and preventing it is what keeps it from getting too big.”

Hangup in Roanoke

Local health districts and community organizations that want to open a needle exchange need to demonstrate that they have the infrastructure to support a program — as well as the support of the local governing body and law enforcement.

The Drop-In Center in Roanoke started the application process soon after the bill was signed into law. The center, which is next door to the police department in downtown Roanoke, offers informational services as well as resources for the prevention of HIV, hepatitis C and sexually transmitted diseases.

“We want to be able to give people a little control with their lives,” said Colin Dwyer, program coordinator at the Drop-In Center. “I’ve seen people who are hostage to their addiction, and they don’t want to stay this way forever, but with some empowerment they may be able to take the next step to pull themselves out of their situation.”

But the center has hit a wall in moving forward with a syringe exchange. The impediment: law enforcement.

“I felt like this was not in the best interest of the police department,” police Chief Tim Jones said. “For me to sign on to this would be basically condoning illegal activities, especially in an arena where we are heavily trying to discourage the use of an intravenous substance like heroin.”

The center received a letter of support from Mayor Sherman Lea, who said he appreciates the chief’s position.

“But we think we can help people with an addiction, and an exchange is an opportunity,” Lea said.

The state law protects employees at syringe exchanges from being charged under paraphernalia and drug possession laws, but it doesn’t cover program participants. The Drop-In Center hoped that by providing participants with identification cards, police wouldn’t charge them with paraphernalia offenses.

Jones said he prefers abstinence as the preferred strategy to combat the opioid problem. The Roanoke Police Department is a partner in the Hope Initiative, which invites people struggling with addiction to walk into the Bradley Free Clinic as the first step toward getting treatment.

“I empathize with folks who find themselves dependent on heroin or any other substance,” Jones said. “I did some soul-searching with the exchange program about whether I’m helping or hurting the problem, and I just felt like the police department’s goal is to get people the assistance they need to resume a drug-free life.”

Dwyer said he plans to keep trying to open an exchange in Roanoke.

A focus on education

Education played a role in turning around Wise County Sheriff R.D. Oakes.

He said he was skeptical about needle exchanges at first. But after Sue Cantrell, director of the Lenowisco Health District, talked to him, he became a strong supporter of the effort.

“It’s bad here in Wise County,” with dirty needles lying on the ground that the public can come into contact with, he said last month.

Oakes said he hasn’t gotten too deep into discussions about what the sheriff’s office would do when his deputies encounter people with paraphernalia who are in the program.

“The main goal is to get people help with clean needles and counseling and encourage them to get into treatment,” Oakes said.

Last year at a Board of Health meeting, state health commissioner Dr. Marissa Levine raised the issue that law enforcement leaders were reluctant to write letters of support. The department has been focusing on education, meeting with law enforcement or hosting town halls to talk about harm reduction and syringe exchanges. Diana Jordan, director of the state’s Division of Disease Prevention, said having law enforcement members who are on board with harm reduction talk to their peers is useful.

“I wouldn’t consider the roll-out of the programs slow, but we’re taking the approach that each community has the buy-in first in order for these services to be the most effective,” Jordan said.

Exchanges in states like North Carolina and West Virginia show that because law enforcement and public health professionals may not share the same ideas about addressing the opioid crisis, finding a balance is key.

In North Carolina, 26 syringe exchanges are operating in health departments, pawn shops, fire departments, even cars. The state legalized their operation in 2016 and made it easy to open an exchange, said Tessie Castillo, advocacy and communications coordinator for the North Carolina Harm Reduction Coalition.

Castillo said there are still issues with law enforcement. Sometimes officers will rip up participants’ cards or ignore them, she said. Even though the charge will usually get dropped in court, she said the experience makes people rethink the hassle of getting clean needles. Still, Castillo said working with law enforcement is important to help them understand how the exchange works and to minimize conflict.

“It helps to have a good relationship,” she said.

West Virginia, which has the highest opioid overdose death rate in the country, doesn’t have any legislation either authorizing or prohibiting syringe exchanges. Dr. Michael Kilkenny, the Cabell-Huntington public health chief, runs an exchange in Huntington that opened in September 2015 and has counted more than 4,400 new clients since then. The program has received support from the local government and law enforcement, which is how other exchanges have gone about opening in West Virginia. In another locality, the city council passed an ordinance creating regulations for exchanges.

Kilkenny said he’s aware of people who have entered the syringe exchange program and have gone on to seek treatment. He also said people involved in the program can be trained to administer naloxone, a drug that can reverse the effects of an opioid overdose.

“People are generally very distressed by what they’re doing,” he said. “Anything you can do that allows them to make a positive decision in regard to their health benefits them in ways we can’t measure.”

Kilkenny said police use discretion when arresting people for possessing paraphernalia. But the health department also does training with the syringe exchange, and officers carry naloxone and disposal kits for needles.

“The police have a job to do, and we found that in our relationship with them, we need to stay in our lane, and they stay in their lane,” Kilkenny said. “We’re trying to prevent disease, and they’re trying to prevent crime, and we don’t have a problem with each other as agencies.”