Ryan Fischer/The Herald-Dispatch Cabell-Huntington Health Department workers demonstrate how the INSTI finger-prick HIV test and the Ora-Quick Advance oral HIV test are conducted on Monday, May 13, 2019, at the Cabell-Huntington Health Department in Huntington.

Cabell County has the only known cluster of HIV cases in West Virginia. It is isolated to intravenous drug users, and more than half are homeless. At last count, the Cabell County cluster consisted of 49 people infected with HIV.

This is despite the needle exchange program run by the Cabell-Huntington Health Department that is aimed at preventing HIV as well as the spread of other diseases.

Yet, it could be worse. The needle exchange could be holding the HIV numbers down.

As described in an article by The Herald-Dispatch reporter Bishop Nash, the cluster is a significant increase from the baseline average of eight HIV cases per year in Cabell County over the past five years. All known cases in the cluster were contracted by intravenous drug use through the sharing of contaminated syringes.

Cabell County has an estimated 1,800 active IV drug users, so there is potential for the HIV cluster to grow even larger.

Public health officials say finding and helping undiagnosed IV users with HIV is a challenge. The health department is working with the state, the Centers for Disease Control and Prevention and community members who serve the homeless to find the at-risk IV users.

"A lot of them aren't from here, and they don't know folks who can help, and they don't know how to reach out to us," Lisa Cremeans, Tri-State AIDS Task Force executive director, told Nash.

The AIDS Task Force has been reaching out to the at-risk homeless and IV population by offering incentives such as food packages and gift cards to enter care. But this is a different population than previous ones that have contracted HIV, Cremeans said.

"Those HIV users are lost in their addiction," she said.

It's easy to stand on the sidelines and blame the needle exchange program, which started four years ago, for attracting IV users to the county and for enabling their addiction and, as a consequence, spreading HIV.

But no one can say for sure what the HIV cluster would look like without the needle exchange. Unlike the one in Kanawha County, which more or less passed out needles with few questions asked, the Cabell County exchange requires one needle in for every one that goes out. For all anyone knows, the HIV cluster could be much larger without the exchange, as IV users would continue using and passing around contaminated needles.

West Virginia as a whole has a low incidence of HIV. It also has a problem with IV drug use, so people in the other 54 counties should not think HIV clusters could not happen there. As Nash's article noted, Cabell County is well-equipped to handle the HIV cluster through the lessons it learned in battling the opioid epidemic a few years ago.

Each county will have to decide how it handles IV drug use and whether it wants a needle exchange. Law enforcement officials have advised against expanding exchanges. That's understandable, as they bear most of the cost and burden when things don't work as planned. That's part of what happened in Kanawha County.

The bottom line is that well-run needle exchanges are needed in West Virginia's population centers, but they will work only if the people who use them are themselves responsible with their needles and syringes. An outbreak of needle litter will kill an exchange faster than anything else.

We'll have to see if this cluster grows or if it dissipates. What's important now is that any opportunity to reach the most vulnerable parts of our community must be encouraged and supported.