MISSOULA - As the H1N1 flu grabs headlines and dominates public health concerns, state officials and local advocates are focused on a "forgotten epidemic" they say has fallen under the radar in Montana.
Even without the glare of publicity, positive diagnoses of AIDS, HIV and hepatitis C have trended steadily upward for more than two decades in the Treasure State. Now, HIV testing becomes routine with a state law that went into effect on Oct. 1. Physicians and health care professionals must offer the blood draws - which people can decline - in their battery of tests. It's a move that public health authorities say could help drive the number of cases down.
With more individuals getting tested, experts say, the new standard could potentially decrease transmission rates from people who don't know they are positive, or who don't want to know because of the stigma.
"It has been a stigmatized disease, and people who usually make the decision to get tested have put themselves at risk," said Laurie Kops, supervisor of the state Department of Health's HIV/STD programs.
"Men who have sex with men and people who inject drugs have a lot of labels attached to them, and, for that population, walking into a physician's office to get tested is difficult. But, if everybody is being tested whether they had high-risk sex or were shooting up or just want to be safe, more people will know their status and have a baseline."
If the law results in more people getting tested, as Kops hopes it will, she expects to see a slight initial increase in the number of cases recorded in the state health department's books. But, she said, the rates will eventually taper off.
An estimated 21 percent of people living with HIV and AIDS in the United States are unaware of their infection, she said, and it's been shown that people who are not aware of their HIV-positive status are more likely to transmit the disease.
"I do think we are going to find a few surprises. I do think we will see an increase," she said.
"People need to not think it can't happen to you because it does, and we've had new positives lately where they were just absolutely astounded when they found out they were postive, and at very young ages."
At the end of September, 27 new cases of HIV were reported in Montana, compared with 22 in all of last year. Meanwhile, 943 new cases of hepatitis C cropped up last year, with the reported rate for American Indians nearly six times higher than that for whites.
Of the HIV numbers, Jessie Frazier, an epidemiologist at Montana's Department of Health and Human Services, said, "That's not a huge increase, but, in terms of raw numbers, it's higher."
At the end of December 2008, a total of 895 HIV/AIDS cases had been reported in Montana since 1985, when reporting began. Of those, 575 were first diagnosed in Montana, and 65 percent were living in the seven most populated counties, with Missoula and Yellowstone leading the pack.
The most frequent mode of exposure to AIDS and HIV is men who have sex with men, Frazier said, accounting for 53 percent of all diagnoses. Injection drug use accounts for 12 percent of those diagnosed.
And, while state health officials do not have the data to determine principal modes of exposure for hepatitis C, experts say the spike in cases is almost certainly due to the rising numbers of people abusing prescription drugs, which are often injected to obtain a high.
"Active injection drug users are mostly shooting pain pills," said Casey Rudd, an outreach worker who targets drug users and educates them on their risk behaviors.
"For a while, it was a big meth thing, but that's pretty much done. We don't see much meth on the streets anymore. People have switched to OxyContin and other opiates."
Rudd, 60, a former addict who spent time in prison, has been doing "street outreach" for the past decade. Her method of ground-level outreach work allows Rudd to interact directly with addicts who are at risk to contract diseases and who might not otherwise ask for help. Rudd, of Bozeman, is one of 14 outreach workers statewide who target high-risk populations.
"We help them make a plan for getting clean and moving forward with their lives, but we're also giving them resources to help them cut down on high-risk behaviors," Rudd said.
"We're testing them for HIV and hep C because they're at huge risk for both of those."
Because Rudd targets injection drug users, she said between 85 percent and 90 percent of the people she tests are positive for hepatitis C. In its later stages, hepatitis C can lead to liver cirrhosis and cancer.
Other outreach workers focus on men who have sex with men, educating them on prevention measures and offering free testing.
The outreach positions exist through a program called Montana Targeted AIDS Prevention, a program within the Missoula AIDS Council that is funded by the federal Centers for Disease Control.
Liz Murphy, executive director of the Missoula AIDS Council, said the positions are a critical component to AIDS prevention and risk reduction. Although her office offers free anonymous testing on a daily basis and provides risk reduction and counseling, the outreach workers tap into an otherwise invisible and unreachable group.
"In Montana, it's not very safe to be gay and out. Or to be bisexual or transgendered," she said. "We don't have sex clinics (where people can get tested) on every corner. We don't have gay bars. So these workers do outreach on the streets, at dealers' homes, out of their own homes, on street corners where people are shooting up, and they provide testing, referral services and counseling."
"They create a safe place for high-risk populations to go. A lot of these folks do not want to step through the doors of a health clinic because of the stigma. Stigma makes people afraid to ask their doctor of 20 years for a test. That's part of what makes outreach so crucial."
Murphy, who is working to renew the CDC grant, said Montana's outreach workers provide about 1,000 tests a year and have built up trust and credibility within their communities.
"For a while, Montana was a low-incident state for AIDS," she said.
"But, with people increasing their travel, it's not staying in the hubs as it once did. It's not just a disease of the gay or the poor or the prostitutes. It doesn't discriminate. It affects everyone."
Perhaps no one understands that better than Kris FourStar, the communicable disease officer for the Fort Peck Tribal Health Department.
In Roosevelt County, which is home to the Fort Peck Indian Reservation and has a population of less than 11,000, the state health department has documented nearly 500 cases of hepatitis C - more than anywhere else in Montana. Glacier County, where the Blackfeet Indian Reservation is located, has 396 cases.
"We've always known that there have been high hep C rates, but we just started addressing it in the last year and a half," said FourStar, who launched Montana's only needle-exchange program about four months ago.
"The program is primarily in response to our rising numbers of hepatitis C, which is only spread blood to blood. And injection drug use is the culprit."
Since 1988, the U.S. government has prevented local and state public health authorities from using federal funds for needle-exchange programs, which studies have shown to be effective in reducing infection rates among injection drug users.
But Fort Peck is sovereign and has its own health code, under which it is recognized as a public health authority. FourStar says it took about a year of meetings and research - including interviews with 51 injection drug users - before the program was launched.
The initial funding for the research came from Montana State University's Center for Native Health Partnership. The New York-based Syringe Access Fund then provided a $70,000 grant to purchase supplies. No tribal money is being used to pay for the program, he said.
"Since then, it's been fueled by word of mouth," FourStar said. "They are starting to trust that we're not law enforcement, that we're trying to make them safe and clean.
"The networks of users are really tight. It's such a small community here, and everyone knows everyone, so people are really wary of getting tested or reaching out for help."
Addicts contact the exchange program by calling or text-messaging a cell phone number printed on business cards advertising the program.
The addicts are then given a hard plastic container containing a clean syringe, which is called a "rig" on the street, and a separate compartment in which to discard the needle. They also receive a "cooker," or a spoon, cotton balls, sterile water, alcohol wipes, tie-offs or tourniquets and gauze pads.
"It's a one-for-one program," FourStar said. "We give them 10 rigs, and, when we get them back, they can get 10 more. The clients are very responsible because they know it would reflect poorly on them. Whatever rigs we give them, they bring them back."
During every interaction with the addicts, FourStar said, department officials discuss abstinence and safer injecting practices, such as cleaning the wound site and never sharing needles.
"There's an enormous lack of knowledge about the spread of communicable disease," FourStar said. "The best course of action, obviously, is abstinence, but, outside of that, it is using a new syringe every time they shoot up."
Kops, of the state health department, said the program is a positive step for the tribe, especially if it encourages more screenings for hepatitis C, which can go undetected for decades because it may not lead to illness in its early stages. Detection through a simple blood test is important, she said, because the disease can be treated and cured.
Kops said the prevalence of hepatitis C on reservations is a problem in Montana and across the country, particularly given the high rates of alcoholism.
"Because there are high rates of alcoholism, hepatitis C is even more likely to affect a person's health," she said. "Some people can fight it off, but, when you already have liver disease it's more difficult."
"It's tragic. The hep C rates on reservations are unbelievable," she said.