Over the past month we’ve been following the HIV and HCV outbreak in Southeastern Indiana (see Indiana Gov To Declare HIV Health Emergency In Scott County & Scott County HIV Epidemic Reaches 130 Cases) which has now grown to 142 cases.
Reportedly, at least 80% of these cases are injectable drug users, and this practice appears to be driving this epidemic.
Today the CDC, along with officials from the State of Indiana, held a 50-minute-long press conference in advance of the release of a CDC HAN message, and an early release MMWR called Community Outbreak of HIV Infection Linked to Injection Drug Use of Oxymorphone — Indiana, 2015.
The MMWR describes socio-economic situation in Scott County as:
Injection drug use in this community is a multi-generational activity, with as many as three generations of a family and multiple community members injecting together. IDU practices include crushing and cooking extended-release oxymorphone, most frequently 40 mg tablets not designed to resist crushing or dissolving. Syringes and drug preparation equipment are frequently shared (e.g., the drug is dissolved in nonsterile water and drawn up into an insulin syringe that is usually shared with others). The reported daily numbers of injections ranged from four to 15, with the reported number of injection partners ranging from one to six per injection event.
Like many other rural counties in the United States, the county has substantial unemployment (8.9%), a high proportion of adults who have not completed high school (21.3%), a substantial proportion of the population living in poverty (19%), and limited access to health care (1). This county consistently ranks among the lowest in the state for health indicators and life expectancy (2).
And the demographics of the outbreak:
The age range of the 135 patients is 18–57 years (mean = 35 years; median = 32 years); 74 (54.8%) are male. A small number of pregnant women were diagnosed with HIV infection and started on antiretroviral therapy during pregnancy. As of April 21, no infants had tested positive for HIV. Of the 135 persons with diagnosed HIV infection, 108 (80.0%) have reported injection drug use (IDU), four (3.0%) have reported no IDU, and 23 (17.0%) have not been interviewed to determine IDU status. Among the 108 who have reported IDU, all reported dissolving and injecting tablets of oxymorphone as their drug of choice. Some reported injecting other drugs, including methamphetamine and heroin. Ten (7.4%) female patients have been identified as commercial sex workers. Coinfection with hepatitis C virus has been diagnosed in 114 (84.4%) patients
Because the conditions described in Scott county are not necessarily unique to that part of the country, the CDC has issued a HAN Advisory to alert clinicians to be alert to signs of similar outbreaks in their communities, so that public health interventions can come sooner rather than later.
Some excerpts from a much longer HAN Advisory follow:
Distributed via the CDC Health Alert Network
April 24, 2015, 11:00 ET (11:00 AM ET)
The Indiana State Department of Health (ISDH) and the Centers for Disease Control and Prevention (CDC) are investigating a large outbreak of recent human immunodeficiency virus (HIV) infections among persons who inject drugs (PWID). Many of the HIV-infected individuals in this outbreak are co-infected with hepatitis C virus (HCV). The purpose of this HAN Advisory is to alert public health departments and healthcare providers of the possibility of HIV outbreaks among PWID and to provide guidance to assist in the identification and prevention of such outbreaks.
Recommendations for Health Departments
- Review the most recent sources of data on HIV diagnoses, HCV diagnoses (acute as well as past or present), overdose deaths, admissions for drug treatment, and drug arrests. Attributes of communities at risk for unrecognized clusters of HIV and HCV infection include the following:
- Recent increases in the:
- Number of HIV infections attributed to injection drug use,
- Number of HCV infections, particularly among persons aged < 35 years;
- High rates of injection drug use and especially prescription-type opioid abuse, drug-related overdose, drug treatment admission, or drug arrests.
- Ensure complete contact tracing for all new HIV diagnoses and testing of all contacts for HIV and HCV infection.
- Ensure persons actively injecting drugs or at high-risk of drug injection (e.g., participating in drug substitution programs, receiving substance abuse counseling or treatment, recently or currently incarcerated) have access to integrated prevention services,9 and specifically:
- Are tested regularly for HIV and HCV infection (consider more frequent testing based on frequency of injection drug usage or sharing of injection equipment);
- If diagnosed with HIV or HCV infection:
- Are rapidly linked to care and treatment services;
- If actively injecting drugs:
- Have access to medication-assisted therapy (e.g., opioid substitution therapy) as well as other substance abuse services, if not already engaged,
- Are counseled not to share needles and syringes or drug preparation equipment (e.g., cookers, water, filters),
- Have access to sterile injection equipment from a reliable source.
- If not HIV infected but actively injecting drugs:
- Remind venues that may encounter unrecognized infections, such as emergency departments and community-based clinical practices (e.g., family medicine, general medicine, prenatal care) of the importance of routine opt-out HIV testing as well as HCV testing per current recommendations13-15
- Local health departments should notify their state health department and CDC of any suspected clusters of recent HIV or HCV infection.
Recommendations for Healthcare Providers
- Ensure all persons diagnosed with HCV infection are tested for HIV infection,16 and that all persons diagnosed with HIV infection are tested for HCV infection.17
- Ensure persons receiving treatment for HIV and/or HCV infection adhere to prescribed therapy and are engaged in ongoing care.
- Encourage HIV and HCV testing of syringe-sharing and sexual partners of persons diagnosed with either infection.
- Report all newly diagnosed HIV and HCV infections to the health department.
- For all persons with substance abuse problems:
- Refer them for medication-assisted treatment (e.g., opioid substitution therapy) and counseling services,
- Use effective treatments (e.g., methadone, buprenorphine), as appropriately indicated.
- For any persons for whom opioids are under consideration for pain management:
- Discuss the risks and benefits of all pain treatment options, including ones that do not involve prescription analgesics.
- Note that long-term opioid therapy is not associated with reduced chronic pain.18
- Contact the state or local health department to report suspected clusters of recent HIV or HCV infection.