If you think of a Venn diagram mapping two crises—the HIV/AIDS epidemic and opioid use—there would be a significant amount of overlap. They are analogous, in many ways: in terms of scope; the ways in which society has responded—or, more aptly, not responded—to them; and the populations most affected. The good news is that there is much we have learned from the past 30 years fighting HIV/AIDS that can be applied to the opioid crisis. And philanthropic funders are well positioned to be an important part of the solution.
In many ways, funders have gotten ahead of elected officials on this issue. Our community is already making a difference and leading by example. Recently, Funders Concerned About AIDS hosted a convening focused entirely on the intersection of HIV and opioids. The discussion highlighted key challenges and identified ways to expand on effective activities already taking place. Here is what we heard:
The current opioid epidemic bears many of the same hallmarks of the height of the AIDS crisis in the U.S.
In both cases, an incredibly slow response from the government resulted in countless deaths. Both crises disproportionately impacted marginalized populations initially—gay men in the earliest days of the AIDS epidemic, and injecting drug users today. The lack of attention and response to the impact on communities of color further connect these epidemics. As a result, stigma, victim blaming and the risk of criminalization prevents many from getting the help they need.
The slow government response in the 1980s resulted in woefully inadequate funding to address HIV/AIDS. We are witnessing a similar pattern with the opioid crisis.
With death rates from opioid overdoses having doubled between 2012 and 2016, it’s clear that the epidemic represents a public health crisis. More lives are lost due to opioids today than were lost at the height of the AIDS epidemic. According to the Centers for Disease Control (CDC), opioid overdoses kill, on average, 115 people a day. Yet, the recent omnibus bill allocated only $4.6 billion to fight this crisis. That is not nearly enough, particularly when considering that a 2017 White House report puts the cost of the opioid overdose epidemic at $500 billion in 2015 alone. If we are only replenishing a fraction of the resources being consumed to fight the epidemic, how can we expect to make a dent?
Demographics of people with HIV attributed to injection drug use are very similar to those most at risk for opioid addiction.
In the U.S., there are key groups who remain at significant risk of HIV infection. People who inject drugs (PWID) are among the most vulnerable, with HIV prevalence 28 times higher than the rest of the population. Injection drug use increases the risk of blood-borne infections—not just HIV, but also hepatitis and bacterial endocarditis—which spread efficiently through needle sharing. Recently, the CDC released data showing that more than one in four people who inject drugs reuse needles, and many not have had an HIV test in the last year.
This group is also at the epicenter of the opioid epidemic. As injected drugs have become more of a fixture within the opioid epidemic, so too has the risk for spreading HIV. Until 2016, the incidence of HIV among PWID was declining. Between 2014 and 2016, however, there were increased rates of HIV among some segments of this population. In fact, a well-documented HIV outbreak in Scott County, Indiana, has been linked explicitly to opioid use. This outbreak led to the first increase of HIV among PWID in two decades.
In addition, the rate of hepatitis C infections—referred to as a “canary in the coal mine” because it is a warning sign for increased rates of HIV infection—tripled between 2010 and 2015. Sixty percent of those new infections are among PWID. Addressing the opioid crisis, and limiting its impact on the spread of HIV, begins with this population.
Where can funders make a difference?
Philanthropic funders are adept at tackling issues that the government can’t or won’t. We also have no compunction about working with populations that are marginalized by others—in fact, we see it as our duty. Therefore, we must continue to lead in areas such as:
Talking about harm reduction. Until recently, the conversations around the opioid epidemic focused on overdose deaths, often ignoring the topic of harm reduction, which, according to the Harm Reduction Coalition is both a “set of practical strategies and ideas aimed at reducing negative consequences associated with drug use,” as well as a social justice-based movement to respect the rights of people who use drugs.
Our community is working to highlight the impact of harm reduction. For example, in a recent letter published in the New York Times, the Elton John AIDS Foundation’s executive director, Scott Campbell, called on local and national government leaders to discard their “outdated ‘tough on crime’ talking points,” and instead “focus resources and attention on integrated harm-reduction methods that will not only help stop the spread of infectious diseases, but also prevent overdoses.”
If you are already doing this work, be sure that you’re talking about it, too—loudly. We must raise awareness of harm reduction as a critical tool to address these conjoined epidemics. We know the government is leery of doing so, questioning the efficacy of programs like needle exchanges. But we also know, from decades of work on the frontlines of the HIV/AIDS epidemic, that such programs are highly effective. We must continue to be a voice for change and press for policies that we know work.
Mobilizing—and funding—at the local level. In 2015, then-Governor Mike Pence signed an executive order declaring a public health emergency in Scott County, Indiana, and approving a syringe exchange and harm reduction program. Since then, the Health Foundation of Greater Indianapolis has provided $150,000 in funding to eight counties in the state. These funds support the purchase of harm reduction supplies that curb the spread of HIV/AIDS, hepatitis C, and other communicable, blood-borne pathogens.
After the HIV outbreak in Indiana, the AIDS Funding Collaborative of Cleveland, Ohio, in partnership with city and county health departments, convened a meeting to initiate the process of modernizing, approving, and expanding syringe service programs across Cuyahoga County.
If scaled up and replicated elsewhere, programs like these can make real progress against the opioid crisis and the spread of HIV. But that requires ongoing funding and support, not only at the federal, but also the state level. Already, funders are stepping in to help fill in gaps in government resources. This is an area in which our assistance will continue to be critical.
Bridging the knowledge gap and leveraging untapped resources within the HIV infrastructure. Even within the HIV community, knowledge is lacking on harm reduction programs. This stands in the way of progress. By creating further awareness among our peers about the effectiveness of these programs—and the risks that exist in their absence—we will be better able to leverage networks and identify synergies. In so doing, we can identify resources that already exist within the broader HIV infrastructure that can be applied to the current crisis.
As just one example, amfAR’s new Opioid and Health Indicator’s database can be of vital assistance in helping to bridge this knowledge gap. It provides an enormous amount of information about the opioid epidemic’s impact across the country, including vital statistics as well as details on available health services and policies at the state and community level. This information is useful in educating others, both within the HIV/AIDS community and beyond.
There is no question that philanthropic funders have much to contribute to address the intertwined epidemics of opioids and HIV/AIDS. And if the discussion at FCAA’s recent meeting is any indication—and I believe it was—there is a great deal of desire on our part to do so. We stand ready once again to step up and fight.
About the Author:
John Barnes is Executive Director of Funders Concerned About AIDS, the leading voice on philanthropic resources allocated to the global AIDS epidemic. For nearly 30 years, Barnes has worked in government, non-profit and corporate settings, and with community-based organizations, to serve people with HIV/AIDS and other critical illnesses.