As West Virginia towns were dealing with the fallout of being flooded with prescription painkillers in the late 2010s, Dr. Anita Stewart recognized that people with opioid addictions were at risk of HIV.
Prescription pills became harder to get, leading many people to switch to injecting heroin and fentanyl. Stewart knew they needed clean syringes and needles to be protected from developing one of the deadliest infectious diseases in American history.
“Not having the supplies is why they’re at risk of HIV,” said Stewart, the top doctor at the Nicholas County Health Department.
And her fear appears to be coming to pass. Over the past 18 months, she said health workers have detected at least four positive HIV cases in Nicholas County.
“We’ve never had a cluster here, and we haven’t had a new case of HIV in several years,” she said. “Until last year.”
In 2021, epidemiologists warned of rural HIV spread after West Virginia lawmakers passed a bill restricting how harm reduction programs could operate, leading many syringe service programs to close. Now, another legislative decision — the low levels of state funding for local health departments — is making the ability to respond to that disease spread difficult.
Lawmakers have underfunded West Virginia’s local health departments for years and made cuts earlier this year. Although the state health department recently restored the funds to last year’s level, county health agencies are receiving around as much state budget money as they were 15 years ago.
That limited budget means that Stewart and the Nicholas County Health Department can no longer afford rapid HIV tests, which are important for identifying people with HIV and connecting them with treatment. She’s now unsure of whether, like in other parts of the state, Nicholas County has more undiagnosed people with the disease.
“How many other cases are out there that you don’t know about?” She asked.
Across the state, county health agencies already lacked the money needed to prevent and treat HIV, said Greg Puckett, a member of the West Virginia Public Health Advisory Committee and a Mercer County commissioner.
Combined with laws that give politicians more power to dictate health decisions, he said this is the opposite of what West Virginia needs to address the consequences of the overdose epidemic.
“We have massive amounts of HIV that is undocumented,” Puckett said. “I’m 100% confident of it, because we are not testing enough.”
But it could be difficult to convince lawmakers to address the situation. Sen. Tom Takubo, the Republican Senate Majority Leader and a Kanawha County pulmonologist, said local health departments running out of money to prevent and treat HIV needs to be fixed.
But he said not all his colleagues would agree with him.
“They just don’t like public health or something,” he said. “I can’t speak for other legislators, but I think we really need a bigger vision of our public health.”
A service hub for rural communities
County health departments aren’t the only West Virginia organizations that focus on addressing HIV. Hospital systems like Charleston Area Medical Center run programs aimed at treating and preventing it, and the state health department has a division dedicated to responding to infectious diseases outbreaks.
But unlike some groups, local health departments are mandated by law to try to control HIV and prevent it from spreading in their communities.
William Cohen was the West Virginia health department’s harm reduction program manager until last year. He said while he was there, the state’s local health agencies were more involved in HIV prevention efforts than their counterparts in other states, especially in rural areas.
“Health departments in each area acted as that hub that provided all of those services,” he said.
In Ohio County, health workers detected six new cases of HIV in the first half of 2024. It’s a significant increase in a county that averaged just three cases a year from 2016 to 2020.
“Are there additional cases out there? Probably,” said Howard Gamble, the Wheeling-Ohio County Health Department administrator.
Compared to some local health agencies, Gamble’s department has advantages that are helping it respond to the county’s cluster. It operates one of the few syringe service programs left in West Virginia, and it has a staff of about 30 people.
But only two of the health department’s workers see patients, and Gamble says these workers must respond to outbreaks of other illnesses, like Legionnaires’ disease.
Additionally, Gamble said that while his staff are doing what they can to increase HIV testing, the agency also struggles to afford rapid tests. His county’s portion of the state’s local health department funding isn’t enough.
“That makes a huge impact on how we can respond to the everyday efforts,” Gamble said.
“It’s going to be up to the voters”
When state lawmakers were writing the 2025 state budget, they worried that West Virginia would have to return $465 million to the federal government and made cuts. This included a 10% reduction in funding for local health departments, according to House Health and Human Resources chair Amy Summers, R-Taylor.
Later in the spring, after lawmakers learned the state wouldn’t lose that money, state delegates and senators allocated an additional $5 million to the reserves for the Department of Health. Summers said this additional money was intended to help local health departments.
“After we found out there was no judgement against the state, we had a special session and replaced the funding,” Summers wrote in an email.
But this money is unlikely to make its way to local health agencies. Gamble said he was told by the Department of Health that local departments could only access the $5 million for emergencies, like if a county’s building had water damage.
“I do not foresee that county health departments will be the recipients of that in any fashion,” he said.
Earlier this summer, the Department of Health used money from a different source to restore local health department funding back to last year’s level, according to department spokesperson Annie Moore. She added that the department hasn’t received any funding requests related to HIV clusters.
“[The Department of Health] remains committed to supporting local health departments, particularly in HIV testing and response,” Moore wrote in an email.
But even with funding restored, the state budget for local agencies is millions of dollars less than it was 15 years ago after adjusting for inflation. And the 2021 syringe service restrictions remain in effect.
“It’s very obvious that the consequence of these particular situations is that HIV is going to increase,” said Cohen, the former state health department harm reduction program manager.
Takubo, the West Virginia Senate Majority Leader, said if he hears that local health departments need more money for specific HIV prevention efforts, he and his colleagues could try to fund them.
But he said a lot of state lawmakers haven’t wanted to increase health spending in the past, and he thinks it’ll be hard to convince them of that now.
“Some legislators don’t want to change and learn,” he said. “It’s going to be up to the voters.”
Conversations with the community
Stewart, the Nicholas County health officer, knows that it can be difficult protecting West Virginians from HIV. Before starting in Summersville in 2023, she held the same position in Fayette County and helped run its harm reduction program.
Even as it got harder, Stewart continued the work. After the 2021 syringe service restrictions, she and her coworkers found a way to keep their program open within the stringent state rules.
In Nicholas County, elected officials seem willing to have discussions about how best to stop the spread of HIV. Stewart, who has sometimes struggled to have these conversations in Southern West Virginia in the past, is hopeful the county’s commissioners will approve her department’s recent syringe service program application.
Still, the application process and trying to find funds for a needle exchange can bring up a feeling in Stewart that’s familiar to doctors across West Virginia.
“That’s hard, knowing that there’s something that could be done to make someone healthier, to make communities healthier, and then not being able to respond.”
Rural West Virginia health departments are struggling to stop the spread of HIV amidst restrictions and underfunding appeared first on Mountain State Spotlight, West Virginia's civic newsroom.