The county health department was staying open late just for them, so after dinner, a dozen men shuffled out of the Lifehouse drug rehabilitation shelter where they were living and climbed into a battered white van.
It would be a short ride through a familiar landscape. Abandoned houses. Buckled sidewalks. Graffiti-swirled walls. A woman bent over and searching a weedy lot. A girl chasing a puppy in the late afternoon glow. "That's a beautiful dog," one said. Other than that, they rode in silence.
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After years of drug abuse, this is what it had come down to for these men: a nervous walk into a health department where a nurse explained to them, "We've invited you guys here for HIV testing."
She handed out forms and pens. "We normally have around five to eight a year."
Now, she said, they had diagnosed 80 cases since early 2018 that have been tied exclusively to intravenous drug use as the cause, prompting the West Virginia Department of Health and Human Resources' Bureau for Public Health to declare Cabell County an HIV cluster.
For years, officials have worried that the next step in the opioid epidemic would be a larger public health issue. Here, in a city that has seen some of the worst of the crisis, that next issue is thought to be underway in the form of HIV infections.
As the nurse collected the forms and prepared to call the men back individually for testing, the question was whether Cabell County's 81st or 82nd or 83rd HIV case could be sitting in the waiting room. "Obviously we want to identify people quickly," the nurse said. "The quicker we can get you identified and get you into care, the better off you'll be, and the better you'll do as far as health."
The men were wondering, too. "I was using dirty needles," one of them said. "Picked them up right off the ground."
"Jesus, me too," another said. "But don't be negative."
"Negative's the thing you want here."
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Others nodded. Knees bounced. Knuckles cracked, then cracked again. The nurse called the first patient back.
Even as Huntington is trying to figure out the severity of its HIV problem, there are indications that the national opioid epidemic at the root of the problem may be slowing down. CDC figures released earlier this year showed that the national fatal overdose rate had dropped by 5 percent in 2018, the first dip since 1990, largely because of decreases in heroin and prescription opioid overdoses.
But the scenes on the ground in Huntington suggest that any optimism might be premature.
"There's no question this is going to happen again and again all over the country," said Judith Feinberg, a professor of behavioral medicine and psychiatry at West Virginia University who works to prevent infections among the state's rural addicts. "All these infections leach into the general public sooner or later."
Huntington sits on West Virginia's far western edge, a location that has made it particularly susceptible to both the HIV cluster and the drug use that is seen as its cause. Ohio is directly across the Ohio River to the north. The Kentucky border is just to the west. When prescription pain killers arrived in the early 2000s, the city of 50,000 people became an attractive jumping-off point for users shopping doctors for prescriptions. According to a Drug Enforcement Administration database obtained by The Washington Post, 65 million prescription pills were distributed to Cabell County between 2006 and 2012, enough for 97 pills per person per year.
By the early 2010s, an uptick in emergency room reports of severe deep-tissue abscesses in patients' arms and legs, common needle injection points, were the first indications that drug users were reaching for syringes. Easy highway access to big cities such as Columbus, Ohio, Louisville, Kentucky, and Cincinnati kept heroin pouring into the region. In 2015, Cabell County saw more than 900 reported overdoses, more than for the previous three years combined.
In reaction, county health officials started a needle-exchange program in which users could swap used needles for sterile ones as a way to cut down on overdoses and the transmission of infectious diseases such as hepatitis. Opening in September 2015, it was the first in West Virginia, and within a few weeks it had to extend its hours to meet demand.
"We thought we had seen the worst of it, and by early 2016 overdoses were down," Michael Kilkenny, the physician director of the Cabell-Huntington Health Department, said of the early success. "But by the second half of 2016, fentanyl had replaced heroin in the drug supply."
Fentanyl - a synthetic opioid that in its purest form is 100 times stronger than morphine - increased the overdoses in Cabell County. Within five hours on Aug. 15, 2016, 26 people overdosed in Huntington from a fentanyl-laced batch of heroin, according to the CDC. National media attention fixed on the city, and Huntington was named "the overdose capital of America." The fatal-overdose rate rose to eight times the national average. "2017 was our worst year," Kilkenny said.
But people also arrived in Huntington looking for help. The needle exchange was part of it: By the end of 2017, the program reported handing out 800,000 clean needles since its opening. In addition, a network of recovery programs, such as Lifehouse, spread through the neighborhoods west of downtown. "Huntington has become a kind of mecca for recovery," said Rocky Meadows, Lifehouse's founder.
"Every night between 6 p.m. and 9 p.m., I imagine, there are at least 2,000 people in AA or NA meetings," he said, referring to Alcoholics Anonymous and Narcotics Anonymous.
According to Kilkenny, there is evidence the approach has been working; preliminary data from the state health department shows that in 2018, Cabell County's overdoses were down by 25 percent. "We're one of only two counties in West Virginia that had interventions like that," he said.
But then the HIV cases started.
There were warning signs. In 2016, the CDC issued a report listing 220 counties across the nation that were at risk for HIV because of intravenous drug use. Cabell was included. But West Virginia also historically has had a low annual rate of HIV diagnoses - 4.3 per 100,000 residents in 2017 - especially when compared with neighbors such as Kentucky (7.9), Ohio (8.8) and Virginia (10.3), according to the CDC.
Then, in February 2019, Kara Willenburg, the medical director of the infection prevention department at Cabell Huntington Hospital, learned that local doctors had recently diagnosed six new cases of HIV. "We realized right away what was happening," she said.
Public health officials kicked into action. They asked every doctor in the county, from general practitioners to emergency room physicians, to begin testing patients. CDC specialists arrived in March, officially declaring an HIV cluster, indicating a dramatic rise of infection in a population linked by needle use. Because the infections were confined to a specific group rather than the general public, authorities held off from designating the situation an outbreak. The federal investigators determined that the increase began in early 2018. Every patient who tested positive was immediately given an appointment to see an infectious-disease specialist within 24 hours.
In March, the number of HIV diagnoses had risen to 28. Between late April and late June, Cabell began averaging one new HIV case a week; between late June and late August, the rate rose to two cases each week. By mid-September, the number was 80.
What was happening in Cabell had happened before. Between 2011 and 2014, HIV spread through needle users in rural Scott County, Indiana. Eventually 215 HIV cases were diagnosed before authorities saw a drop in the numbers, a decline credited in large part to the establishment of a needle-exchange program.
But Cabell's public health infrastructure outmatched Scott County's. With a needle exchange already in place, Cabell had what public health advocates widely consider to be the best defense against infectious diseases pushing through a population of drug users. As the HIV cases continued to increase, Huntington officials were left grappling with the mystery of why, despite their best efforts, the cluster hit here.
"We had prevention in place," the health department's Kilkenny said. "We did more than some of these other counties. It feels cosmically unfair."
It wasn't only why, though, but how bad and how big, which was the reason the health department reached out directly to Huntington's recovery programs, asking them to bring their residents in for testing.
On the day the 12 men from Lifehouse were to be tested, the morning began in the usual way in the house where they lived, known as the Farm. The bathrooms were cleaned, beds made, porches swept. After breakfast, in the small, fenced backyard, some of the men stood in groups, chain-smoking hand-rolled cigarettes and talking about their history with needles, knowing that in a few hours they would learn whether they had HIV.
"I was more addicted to the needle than to dope, I guess," said a 37-year-old named Eric who slept for years with a loaded syringe in the drawer next to his bed so his morning meth fix would be ready as soon as he woke up. "I could have dope and not even do it. I wouldn't even touch it unless I had the needle."
"I'd use women's foundation on my arms to cover up the track marks," another man said. "Go to those extents just to keep getting high, you know? It was ridiculous."
"Use that on the dark circles under your eyes, too," said a 40-year-old named Andy who had been injecting meth for the past year.
All of the men here knew about Huntington's prevention efforts. They had seen the bright red "Needle Disposal Box" with its large biohazard symbol outside the health department. They were familiar with the health department's material on "How to Clean Your Syringes"; rinse with clean water; disinfect with pure bleach; rinse with clean water again. They knew about the risks, too, but none of it had mattered.
"Man, when you run out of needles, you don't care where you get them from," Eric continued. "I've used other people's. Hell, I've gone outside looking for needles I've tossed out. Go down the road, find the spot where you threw it and start looking. Find it, you use it. Put mud-hole water, creek water, whatever, to mix my dope in, and put it right in my veins."
"It's only 12 dollars for a bag of needles at the medical parts store," Andy said. "Lot of people buy them and sell them on the street so they can go get high."
"Needles are supposed to be used once, but I would use mine so much you had to throw it like a dart to get it through the skin," Eric said. "The end would end up looking like a fish hook. When you pulled it out, it would tear your skin."
"I'm pretty sure this girl switched her needles out from mine right before I went into jail," Andy said, thinking about the ways he might have been exposed to the risk of infection. "That's got me paranoid."
"If I got it," Eric said, "I got it. I can't worry, because if it gets in my head, I'll worry too much and that's going to make me want to use."
He rolled up the leg of his sweatpants. A tattoo of a syringe ran up his calf, the tip curved, the cylinder filled not with liquid but with skulls. "It's got a fishhook on it instead of a needle because that's what it does: hooks me every time," he said.
"You got that in jail, right?" Andy said.
Eric nodded. "With a staple," he said. "Took 16 hours."
"How much you pay for that?" Andy asked. "Few packs of cigarettes?"
Eric laughed. "Paid three soups and a bag of coffee."
On the front porch of the house, another conversation about needles was underway. A 50-year-old named Todd had left the program two days earlier. Now he was back, explaining to the peer mentors running the recovery program that he needed to pick up the needles he had left behind because he needed them for insulin injections at the health department.
The peer mentors swapped looks.
"Hide this unless you want to get mugged," one said as he handed Todd a clear, plastic medical box of syringes.
"Put that in a bag or something," another said. "Go straight there, dude."
"Or else you'll definitely get mugged," the first replied. "For real."
Todd wrapped the box in a garbage bag and headed on foot toward the health department, where people were gathered for the daily needle exchange. Many were homeless, with all of their possessions stuffed into backpacks. They guzzled energy drinks and paced, waiting for their turn to get fresh needles, after which they would slip off down side streets.
The idea of governments handing out needles to drug users has always been controversial. But Huntington's mayor, law enforcement and the state health department all backed Cabell's exchange when it opened in 2015. Under the program, drug users could speak with counselors and nurses and were given 40 clean needles; if they wished to return, they had to come back with 40 dirty needles. The program became a model as other counties across West Virginia opened their own exchanges.
But criticism about these programs also left West Virginia's needle exchanges vulnerable to political pushback, including in Charleston, the state capital, which opened its own program shortly after Huntington's.
There were complaints about discarded syringes littering Charleston. There were complaints about homeless drug users pouring into the city. An audit by the state health department found that the staff had inaccurately tracked the number of needles distributed. In response, city officials passed guidelines restricting access to such an extent that the people running the exchange program decided the better option would be to close it down.
In 2018, Huntington officials were faced with the same decision because of similar complaints and a report from the police department that violent crime had increased by 30 percent since the program began. Rather than close the program, however, the health department decided to restrict it to county residents. That happened in July 2018. Before, as many as 62,000 needles were being handed out a month. In July, the number dropped to 18,600.
What officials know now: That was also the period that coincided with the first of the HIV cases, or as Kilkenny acknowledged, "It was a remarkable reduction of service in 2018, just as the HIV cluster was arriving in town."
The controversy over the program has continued since. Local politicians and a recently formed citizens' group have called for a state audit of the exchange, even as health experts have continued to support it. "You have to be on the ground preventing this in advance," said Feinberg, explaining why she thinks even a limited needle exchange program is better than no program at all. "When you start doing that when you become aware of the problem, you're already behind the eight ball."
Kilkenny said he agrees. "Our goal is to get everyone who has the infection identified and linked to care and get them treated to undetectable levels," he said of how he sees the health department's role as the controversy plays out. "We need sterile syringes to get those. We certainly are not going to be a community that has no services."
To that end, the health department continues to hand out clean needles and is testing every drug user and former addict who comes through the door, including the 12 men from Lifehouse, one of whom was now saying to the others, "I hope I don't have HIV."
The process would be straightforward. A simple prick on the finger. An instant analysis. A quick result.
Twenty minutes after the first man was called back, he returned to the waiting room.
"I'm negative," he said, heading outside. "Peace, y'all."
"Don't sound like a man that's negative," one of the men said, breaking the silence.
Another name was called, leaving 10 men, including Eric and Andy.
"Andy! What's wrong," someone said.
"Nervous," he answered.
"Pray on it, buddy," a man named Dan said. "I know I did. I sat right here and prayed, 'Do not let ol' Dan have AIDS!' "
Eric spoke up. "I did pray before we left the house."
More names were called. Five men were left in the waiting room now, and their talk turned to what illnesses they already knew they had.
"I got hepatitis," one offered.
"I got hep," Eric said. "Tearing my liver up."
"If you don't have hep, you're the police," another added. Everyone laughed.
"Eric?" the nurse said.
"I guess I'm the police then," one joked.
Now there were no men left in the waiting room. They were all gathered outside in the parking lot, talking and joking and ignoring the "Tobacco Free" signs while puffing away on cigarettes.
The tests were done. The news was good. Everyone was negative. They finished their cigarettes and got back into the van to return to Lifehouse, where they would continue their recovery, HIV-free.
"I'm negative!" one resident shouted as he banged open the front door.
"You're always negative!" someone replied from the kitchen.
Some of the returning men sank down onto couches. Others began rolling more cigarettes. Now other residents lined up at the front door to get into the van to go to the health department, about to find out what years of drug abuse had come down to.