After years of running Minnesota's largest needle exchange, Brian Warden is beginning to see something new among the increasing numbers of suburban and rural heroin users coming to trade in used needles.
"What strikes me about it is they don't seem to have had what's traditionally called the gateway effect," Warden said from his office at Minnesota AIDS Project's Mainline exchange in Minneapolis. "I had a client here last week who has never smoked a cigarette, never smoked a joint, never taken a pill, she says, yet she knows how to shoot heroin."
As communities across the state continue to struggle with rising rates of heroin abuse, these users, who are also younger, seem to be contracting the potentially liver-destroying disease hepatitis C at higher rates, according to state data. And health officials suspect dirty needles may be to blame.
Minnesota's situation mirrors what's happening in other states with booming heroin rates, from Massachusetts to Wisconsin, and it's leading to what a report from the U.S. Department of Health and Human Services described as an "emerging epidemic" of hepatitis C.
MORE YOUNG PEOPLE DIAGNOSED
Hepatitis C is the most common blood-borne pathogen nationally. At least 3.9 million Americans live with chronic hepatitis C, according to the federal Centers for Disease Control and Prevention.
Kristin Sweet, an epidemiologist at the Minnesota Department of Health, says it's difficult to determine exactly how many people carry the virus. In 2012, 32 Minnesotans were newly diagnosed with hepatitis C. Sweet said the number of people being diagnosed with hepatitis C tends to lag behind the actual numbers of people contracting the disease because many people develop no symptoms and therefore aren't tested.
There is no vaccine for hepatitis C. Treatment of acute hepatitis C can reduce the possibility that the condition becomes chronic. But that's only if it's diagnosed.
"People generally don't know they have it unless they've been tested for it," Sweet said. "Some people develop symptoms of infection, those people are more likely to go in and get tested, but since not everyone has symptoms, not everyone will go in and get tested for it."
State data show young people make up an increasing share of new diagnoses. In 2001, only about 5 percent of new cases were in people under 30, but in 2012 that had risen to 13.5 percent.
"Certainly, hepatitis C is transmitted through injection drug use, so people who inject drugs are at high risk of getting hepatitis C," Sweet said. "If we see increases in injection drug use, it makes sense that we'd see hepatitis C as well."
Other states also have seen more young people being diagnosed with the disease.
A 2010 study in Massachusetts found that people between the ages of 15-24 were contracting hepatitis C at higher rates than in the past. Further studies in states like Wisconsin and Pennsylvania showed "rising rates of hepatitis C infection among young injectors, both male and female, primarily white, found in suburban and rural settings."
SCRAMBLING FOR FUNDING
Syringe exchanges give out clean needles in exchange for used ones. Their goal is to ensure that injectors don't unwittingly contract or pass on blood-borne infections like HIV or hepatitis C.
But finding funds for syringe exchanges can be difficult, said Daniel Raymond, policy director for the New York-based Harm Reduction Coalition which lobbies for programs like needle exchanges. Congress passed a ban on spending federal dollars to support needle exchanges 25 years ago under the assumption that needle exchanges would send the wrong message by encouraging drug use.
Even though government agencies, medical associations and academics have since come to a consensus that needle exchanges reduce transmission of blood-borne diseases and don't encourage drug use, the ban was reinstated by Congress in 2011 after a two year suspension.
Needle exchanges have also been the victims of their own successes as rates of HIV/AIDS infections have dropped, Raymond said.
"Especially in the last years with the economy, where states have had to cut back their budgets a lot, we've had them take a look at needle exchange programs and say, 'We're not seeing a lot of new HIV cases, so we probably don't need to spend the same amount of money that we spent back in the 90s on these.'"
The state of Minnesota's funding for needle exchanges is highly integrated with HIV prevention programs because the CDC doesn't hand out prevention grants for hepatitis C, according to a Minnesota Department of Health spokesperson. The agency estimates that it allocated a total of $22,361 for syringe exchange and disposal last year.
Colleen Bjerke, director of programs for the Minnesota AIDS Project, said their needle exchange program costs about $130,000 a year. In 2013, they distributed 230,000 clean needles to 3,251 people. The exchange also accepts and destroys hundreds of thousands of dirty needles every year.
"It's not an inexpensive program to do. You have to purchase syringes and you also have to have a way to dispose of syringes, and that's an expense as well," Bjerke said. "There's just not a lot of funding available, as a result I think that it would be something that an organization that didn't have appropriate funding should be reluctant to get into."
REACHING OUT TO GREATER MINNESOTA
Just three standalone needle exchanges operate in the state. That's partly due to lack of funding, but needle exchanges have also faced some public pressure that advocates say is fueled in part by stigma against injection drug users.
An attempt to open a needle exchange in downtown Duluth was initially batted down last year by worried elected officials, police and neighbors. The Duluth-based Center for Alcohol and Drug Treatment and the Rural AIDS Action Network proposed the exchange for the neighborhood that also included Last Place on Earth, a head shop that once sold synthetic drugs.
Duluth City Council President Linda Krug opposed the proposal. She said the controversy was largely a misunderstanding of what needle exchanges do amid the city's fight against Last Place on Earth.
"There was some concern about the needle exchange coming in and nobody knew about it," Krug said. "The perception is that we're going to have people hanging around and doing drugs and shooting up."
The needle exchange found a new place to operate elsewhere in Duluth in the fall of last year. Since then, Duluth police say the exchange has not drawn any crime. Krug said perceptions of the center have changed.
"Like other communities, heroin is an issue here, and I think we're talking about ways to try to deal with it," Krug said. "We do have an HIV and hepatitis C problem in this area, and I think needle exchanges are very valuable."
Rural Minnesotans have access to clean needles through the Minnesota Pharmacy Syringe Access Initiative, which was passed in 1998. It allows pharmacies to sell up to ten syringes, which advocates say helped keep down HIV infections in the state. But because it's voluntary, some rural counties, like Cass and Big Stone, don't have any participating pharmacies.
"We have a few in this area that we definitely send some people to who are really proactive and engaging and willing to do this," Warden of Mainline syringe exchange said of pharmacies participating in the program. "More often than not, there is a very awkward social pressure there of what the reaction from the pharmacist will be."
Warden said one couple routinely drives down from North Dakota, where there are no needle exchanges, and exchange 200 used syringes they've collected for clean ones.
Gary Olson, executive director of the Center for Drug and Alcohol Treatment, said the controversy over the Duluth needle exchange fostered a healthy debate that the community needs to continue if it's going to lower rates of hepatitis C.
"With opiates, I think that is a problem that has crept into communities that had not seen that problem initially, and they're unfamiliar with the breadth and depth of the problem," Olson said. "Once these drugs like opiates and heroin are in a community, it's very difficult to get them out -- this is a problem we're going to be dealing with and managing for a long time."