Drug-related HIV outbreak spurs CDC to issue nationwide alert

Executive Summary

The Centers for Disease Control and Prevention has issued a national health advisory in light of its investigation with the Indiana State Department of Health of a large outbreak of recent HIV infections among persons in Indiana who inject drugs. Many of the HIV-infected individuals in this outbreak are co-infected with hepatitis C virus.

• Injection drug use accounts for an estimated 8% of the approximate 50,000 annual new HIV infections in the United States.
• Hepatitis C infection is the most common U.S. bloodborne infection. Percutaneous exposure via drug-injecting equipment contaminated with hepatitis C-infected blood is the most frequent mode of transmission.

The Centers for Disease Control and Prevention (CDC) has issued a national health advisory in light of its investigation with the Indiana State Department of Health of a large outbreak of recent HIV infections among persons in Indiana who inject drugs. Many of the HIV-infected individuals in this outbreak are co-infected with hepatitis C (HCV) virus. (Review the National Health Advisory, available at http://1.usa.gov/1bQR2jf.)

Know that similar cases could be in your area. Injection drug use accounts for an estimated 8% of the approximate 50,000 annual new HIV infections in the United States.¹ The hepatitis C virus (HCV) is the most common U.S. bloodborne infection. Percutaneous exposure via drug-injecting equipment contaminated with HCV-infected blood is the most frequent mode of transmission, according to the Centers for Disease Control and Prevention.

In January 2015, the Indiana State Department of Health in Indianapolis began an ongoing investigation of an outbreak of HIV infection after state disease intervention specialists reported 11 confirmed HIV cases traced to Scott County, a rural county in southeastern Indiana. Historically, fewer than five cases of HIV infection have been reported annually in this county.²

Syringe sharing

Public health officials noted most cases were in residents of the same community and were linked to syringe-sharing partners injecting the prescription opioid oxymorphone, which is a powerful oral semi-synthetic opioid analgesic.

As of late April 2015, 142 individuals had tested positive for HIV; 136 were confirmed, and six were preliminary results.³ Two counties in Indiana (Scott and Jackson) have reported at least five cases, which is the state’s minimum threshold for identifying counties that have positive cases.

“New cases of HIV are still being identified every day, but the number of people seeking services, medical treatment, and substance abuse treatment is also growing,” said Jerome Adams, MD, MPH, Indiana’s health commissioner. “We likely haven’t reached the peak of this outbreak, but we hope to soon through the continued comprehensive response made possible by the joint efforts of so many people and organizations.”

State, local, and federal officials are moving on several fronts, including the establishment of a one-stop shop for services at Scott County’s Austin Community Outreach Center, a weekly HIV testing and treatment clinic, a needle exchange program operated by the Scott County Health Department, and an HIV public awareness campaign named “You Are Not Alone.” The campaign focuses on substance abuse treatment, safe sex, needle disposal, and HIV testing and treatment. (Take a look at the campaign at http://bit.ly/1GL2uo8.)

Campaign expanded

The You Are Not Alone campaign is currently being expanded to include messages aimed at reaching travelers and truck drivers along Interstate 65 between Louisville and Indianapolis, says Ken Severson, spokesperson for the Indiana State Department of Health. The messages encourage drivers to know their HIV status and to protect themselves by avoiding risky sexual behavior, he notes.

The You Are Not Alone campaign is running on radio, TV, online digital, social media, and in some print publications, notes Severson. The messages include the phone numbers for the Indiana HIV Service Hotline [(866) 588-4948] and the federal Substance Abuse and Mental Health Services Administration National Helpline, also known as the Treatment Referral Routing Service [(800) 662-HELP (4357)]. The Treatment Referral Routing Service is a confidential, free, 24-hours-a-day, 365-days-a-year information service, in English and Spanish, for individuals and family members facing mental health and/or substance use disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations.

The CDC has been involved with the state’s public health response, through an active emergency response team consisting of disease intervention specialists and epidemiologists in Scott County since March 2015. The federal agency also is assisting state and local officials with their efforts to provide risk reduction education, as well as providing consultation on prevention services that might be implemented in the response, including substance use treatment, HIV treatment for those who are infected, pre-exposure prophylaxis (PrEP) for those who are HIV-negative, and syringe service programs.

Take steps in your area

The CDC issued its health advisory to alert public health departments and healthcare providers nationwide of Indiana’s increasing hepatitis C epidemic and the possibility of current or future HIV outbreaks among people who inject drugs. The advisory also provides guidance on how to identify and prevent such outbreaks.

“We’re asking states to take a close look at their most recent data on HIV and hepatitis C diagnoses, as well as overdose deaths and admissions for drug treatment and drug arrests, to help identify communities that could be at risk for unrecognized clusters of hepatitis and HIV infections, as well as those who would benefit from expanded prevention efforts,” says Donnica Smalls, MA, CDC spokesperson. “We are also recommending increased testing and follow-up of contacts for all newly diagnosed cases of HIV.”

Ensure access to services

Health departments and providers can help ensure that all individuals injecting drugs or at high risk for injecting drugs have access to comprehensive prevention services, including:

• regular HIV and HCV testing;
• rapid links to care and treatment for those infected;
• access to substance abuse treatment, risk reduction counseling, and sterile injection equipment for those who are actively injecting drugs to ultimately help them stop using drugs and to protect them from infectious diseases;
• referrals to PrEP for those who are HIV-negative and at high risk for infection and post-exposure prophylaxis for those recently exposed.

REFERENCES

1. Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006-2009. PLoS ONE 2011; 6(8):e17502.
2. Conrad C, Bradley HM, Broz D, et al. Community outbreak of HIV Infection linked to injection drug use of oxymorphone — Indiana, 2015. Morb Mortal Wkly Rep 2015; 64(16):443-444.
3. Indiana State Department of Health. HIV Cases Grow as Response Continues in Indiana. Press release. Available at http://bit.ly/1GL0XP1