As health officials continue to battle an intravenous drug use–related HIV outbreak in a rural county in Indiana, the Centers for Disease Control and Prevention has issued an official health advisory stressing the need for vigilance at the state and local levels with respect to detecting and controlling similar outbreaks in other communities across the United States.
The Indiana outbreak began in November, with 11 new HIV infections diagnosed by January in Scott County, where fewer than 5 infections per year had been identified previously; since January, an unprecedented 135 infections have been confirmed, and 6 others are under investigation, according to Dr. Jerome M. Adams, Indiana State Health Commissioner.
“To put this in further perspective, from 2009 through 2013, the county only reported three new cases of HIV,” Dr. Adams said in a joint Indiana State Department of Health/CDC teleconference.
New cases are being reported every day on an hourly basis, he added.
The affected community includes only 4,200 people, and 84% of those diagnosed with HIV also tested positive for hepatitis C virus (HCV) infection, Dr. Joan Duwve, chief medical consultant, Indiana State Department of Health, said during the teleconference.
According to the CDC advisory, 96% of 108 infected individuals who were interviewed reported injecting dissolved prescription-type oxymorphone, as well as sharing syringes. The advisory states that “urgent action is needed to prevent further HIV and HCV transmission in this area and to investigate and control any similar outbreaks in other communities.”
Although the national incidence of HIV infections has declined markedly – by about 90% – since peaking in the 1990s, about 50,000 new infections occur each year in the United States, and about 8% of those are associated with intravenous drug use.
“The United States is facing an epidemic of prescription opioid abuse that must be addressed. Opioid poisoning deaths have nearly quadrupled from 1999 through 2011. This epidemic of opioid abuse has already contributed to a severe and growing epidemic of viral hepatitis among people who inject drugs,” said Dr. Jonathan Mermin, director of the National Center for HIV/AIDS Viral Hepatitis, STD, and TB Prevention, who also participated in the teleconference.
New CDC data on HCV show a 150% increase in reports of acute HCV infections nationwide between 2010 to 2013, he said.
“The majority of these infections are believed to be attributable to injection drug use, so we must act now to reverse this trend and to prevent this from undoing progress in HIV prevention to date,” he said.
To identify and control outbreaks quickly, the CDC made several recommendations for both health departments and healthcare providers.
Health departments should review the most recent sources of data on HIV and HCV diagnoses, overdose deaths, admissions for drug treatment, and drug arrests, looking specifically for recent increases in the number of HIV infections attributed to intravenous drug use, and the number of HCV infections among those aged 35 years and younger.
These, as well as high rates of prescription-type opioid abuse and overdose, drug treatment admissions, or drug arrests, are attributes of communities at risk for unrecognized clusters of infections, according to the advisory.
Other recommendations for health departments include ensuring complete contact tracing for new diagnoses and testing of all contacts, ensuring that people who inject drugs and those at high risk of drug injection have access to integrated prevention services, and reminding venues such as emergency departments and community-based clinical practices of the importance of routine opt-out of HIV testing as well as HCV testing per current recommendations.
Additionally, local health department should notify state health departments and the CDC of any suspected clusters of HIV or HCV infection.
Likewise, health care professionals should report suspected clusters to their local or state health department, ensure that HCV-infected patients are also tested for HIV and vice versa, and ensure that those receiving treatment for either HIV or HCV are adhering to prescribed therapy and are engaged in ongoing care.
Syringe-sharing and sexual partners of those diagnosed with HIV or HCV should be encouraged to undergo testing, and providers should report all newly diagnosed infections to the health department, and should refer all persons with substance abuse problems for medication-assisted treatment and counseling. Effective treatments should be used as appropriately indicated.
The risks and benefits of all pain treatment options, and the fact that long-term opioid therapy is not associated with reduced chronic pain, should be discussed with any person for whom opioids are under consideration for pain management, according to the advisory.