In the late 2010s, as towns across West Virginia were dealing with the effects of a flood of prescription painkillers, Dr. Anita Stewart realized that people addicted to opioids were at risk of HIV infection.
As prescription drugs became harder to obtain, many people turned to injecting heroin or fentanyl, and Stewart knew that clean syringes and needles were needed to prevent one of the deadliest epidemics in American history.
“They're at risk for HIV infection because of the lack of supplies,” said Stewart, the Nicholas County Health Department's top physician.
And it looks like her fears are becoming a reality: In the past 18 months, health care workers have found at least four positive HIV cases in Nicholas County, she said.
“We've never had a cluster here, and we haven't had any new HIV cases for years,” she said. “Until last year.”
The exterior of the Nicholas County Health Department building. Photo by Allen Siegler.
Epidemiologists warned of the spread of HIV in rural areas in 2021 after the West Virginia Legislature passed a bill restricting how harm reduction programs could operate, shutting down many syringe service programs. Now, another legislative decision — low state funding for local health departments — is making it harder to respond to the spread of that disease.
Lawmakers have underfunded local health departments in West Virginia for years, and implemented budget cuts earlier this year. The state health department recently restored its budget to last year's levels, but county health agencies still receive the same amount of state funding they did 15 years ago.
Budget limitations have prevented Stewart and the Nicholas County Health Department from providing the rapid HIV testing that's crucial to identifying and connecting people with HIV to treatment, and Stewart isn't yet sure whether there are more people with HIV who go undiagnosed in Nicholas County, as there are in the rest of the state.
“How many other cases are there that you don't know about?” she asked.
Greg Puckett, a member of the West Virginia Public Health Advisory Committee and a Mercer County commissioner, said county health agencies across the state already lack the funding they need for HIV prevention and treatment.
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 effects of the overdose epidemic.
“There's a huge amount of undocumented HIV out there,” Puckett said, “and we're 100 percent sure because we're not testing enough.”
But convincing lawmakers to do something about it could be tough. Republican Senate Majority Leader Tom Takubo, a Kanawha County pulmonologist, said local health departments, which are starved for HIV prevention and treatment, need to be improved.
But he said not all of his colleagues agree with him.
“They just don't like public health and stuff,” he said. “I can't speak for other council members, but I think we need to have a bigger vision for public health.”
Senate Majority Leader Tom Takubo (R-Kanawha) during a Senate Health Committee meeting on Feb. 14, 2023. Photo by Will Price/Courtesy of the West Virginia State Legislature
Service hub for rural communities
County health departments aren't the only organizations working to combat HIV in West Virginia: Hospital systems like Charleston Regional Medical Center have HIV treatment and prevention programs, and the state health department has a dedicated unit that responds to infectious disease outbreaks.
But unlike some groups, local health departments are mandated by law to prevent and control the spread of HIV in their communities.
William Cohen, who served as harm reduction program manager for the West Virginia Department of Health until last year, said his state's health department had been more aggressive in HIV prevention efforts than other states, especially local health departments.
“Each local health department acted as a hub for providing all these services,” he said.
In Ohio County, health care workers detected six new HIV cases in the first half of 2024. That's a significant increase in a county that averaged three cases per year from 2016-2020.
“Are there other cases? Probably there are,” said Howard Gamble, Wheeling-Ohio County Health Director.
Gamble's department has an advantage over other local health agencies in helping the county respond to a cluster outbreak: It runs one of the few syringe service programs left in West Virginia and has a staff of about 30 people.
A nurse administers an HIV test during a harm reduction event in 2020. Photo by Lauren Peace.
But only two health department staff members see patients, and those staff also have to deal with other disease outbreaks, like Legionnaires' disease, Gamble said.
Additionally, Gamble said that while officials are doing all they can to increase HIV testing, the department is struggling to pay for the rapid tests because the county doesn't receive enough of the state's local health department funding.
“That has a huge impact on how we respond to our day-to-day efforts,” Gamble said.
“That's up to the voters.”
As state lawmakers were crafting the 2025 budget, West Virginia, concerned about having to give $465 million back to the federal government, made cuts to its budget, including a 10% cut to local health departments, according to House Health and Human Resources Committee Chairwoman Amy Summers (R-Taylor).
In late spring, after lawmakers learned the state wouldn't lose its funding, state representatives and senators allocated an additional $5 million to the Department of Health's reserve fund. Summers said the additional funding is intended to support local health departments.
“Once we found out there were no judgments against the state, we held a special session and replenished the funds,” Summers said in an email.
Health and Human Resources Committee Chairwoman Amy Summers (R-Taylor) speaks on the floor during a special meeting in May. Photo by Perry Bennett/WV Legislative Photo Department.
But it's unlikely that the money will reach local health agencies. Gamble said the Department of Health told him local agencies can only access the $5 million in emergency situations, such as if a county building suffers flood damage.
“We don't anticipate the county health departments will benefit from it in any way,” he said.
The Department of Health used money from other sources this summer to restore funding to local health departments to last year's levels, according to department spokeswoman Annie Moore, who added that the department has not 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 said in an email.
But even with funding restored, inflation-adjusted state funding still gives local agencies millions less than it did 15 years ago, and the 2021 syringe service limits remain in effect.
“It's clear that we're going to see an increase in HIV as a result of these particular circumstances,” said Cohen, a former state health department harm reduction program manager.
Takubo, the West Virginia Senate Majority Leader, said that if he hears that local health departments need more funding for specific HIV prevention activities, he and his colleagues can try to help with the funding.
But he believes many state lawmakers have not wanted to increase health care spending in the past and it will be hard to convince them now.
“Some lawmakers are unwilling to change and learn,” he said. “That's up to the voters.”
Conversations with the community
Stewart, Nicholas County's health officer, knows that protecting West Virginians from HIV can be difficult. Prior to taking up her post in Summersville in 2023, she held the same position in Fayette County, where she helped run the county's harm reduction program.
Stewart kept working even when it got tough: After syringe services were restricted in 2021, she and her colleagues found ways to continue the program within the state's strict rules.
In the office of Nicholas County Health Officer Dr. Anita Stewart. Photo by Allen Siegler.
In Nicholas County, elected officials seem willing to discuss how best to stop the spread of HIV, and Stewart, who has struggled to have those conversations in southern West Virginia in the past, is hopeful that county commissioners will approve her department's recent application for a syringe services program.
Still, the application process and search for funding for a needle exchange could evoke feelings in Stewart that are common among doctors across West Virginia.
“It's tough when you can do something to make someone healthier, to make your community healthier, and you can't respond.”
