TY - JOUR
AU - Oster, Alexandra M
AB - Abstract In 2015, a large human immunodeficiency virus (HIV) outbreak occurred among persons who inject drugs (PWID) in Indiana. During 2016–2019, additional outbreaks among PWID occurred across the United States. Based on information disseminated by responding health departments and Centers for Disease Control and Prevention (CDC) involvement, we offer perspectives about characteristics of and public health responses to 6 such outbreaks. Across outbreaks, injection of opioids (including fentanyl) or methamphetamine predominated; many PWID concurrently used opioids and methamphetamine or cocaine. Commonalities included homelessness or unstable housing, previous incarceration, and hepatitis C virus exposure. All outbreaks occurred in metropolitan areas, including some with substantial harm reduction and medical programs targeted to PWID. Health departments experienced challenges locating case patients and contacts, linking and retaining persons in care, building support to strengthen harm-reduction programs, and leveraging resources. Expanding the concept of vulnerability to HIV outbreaks and other lessons learned can be considered for preventing, detecting, and responding to future outbreaks among PWID. HIV, people who inject drugs, outbreak response The number of annual human immunodeficiency virus (HIV) diagnoses among persons who inject drugs (PWID) in the United States declined substantially for many years. Over the past decade, this epidemiologic trend slowed [1] in the context of increases in acute hepatitis C virus (HCV) infection [2] and overdose deaths involving opioids and subsequently cocaine and psychostimulants, including methamphetamine [3, 4]. HIV diagnoses among PWID began to increase in some demographic groups [1], then, during 2016–2018, increased nationally [5]. Outbreaks in localized areas contributed to these increases, beginning with a 2015 outbreak in Scott County, Indiana [6]. During 2016–2019, multiple outbreaks of HIV among PWID were detected in the United States. Six such outbreaks are highlighted in this commentary [7–16] and briefly summarized in Box 1. Local and state authorities, frequently with invited technical assistance from the Centers for Disease Control and Prevention (CDC), responded by assessing the scope of the problem, investigating risk factors, and implementing control measures to limit transmission [18, 19]. Based on information disseminated by the responding health departments and CDC involvement, we offer perspectives about characteristics of these outbreaks, key elements of the public health responses, and lessons learned to consider for preventing, detecting, and responding to future outbreaks among PWID. Box 1. Human Immunodeficiency Virus Outbreaks Among Persons Who Inject Drugs, in Order of Detection—United States, 2016–2019 Lawrence/Lowell, Massachusetts: In August 2016, the Massachusetts Department of Public Health received reports of 5 new human immunodeficiency virus (HIV) cases among persons who inject drugs (PWID) from a community health center in the city of Lawrence [7, 8]. It invited the Centers for Disease Control and Prevention (CDC) to assist with the investigation, which revealed 159 HIV diagnoses linked epidemiologically or through molecular analysis during January 2015–December 2018 [8]. Homelessness and nonsterile injection of fentanyl were common [7]. The response included a substantial investment of new resources in the region, resulting in expanded HIV and hepatitis C virus (HCV) testing, enhanced field investigation to all new diagnoses, partnering and communications (including clinical advisories) with local community and care providers, expansion of syringe services, and enhanced efforts to link PWID to HIV and substance use disorder (SUD) treatment services. These control measures resulted in a significant decline in new HIV diagnoses. A 2016 change in state law—clarifying that local boards of health, rather than mayors, city councils, or other elected officials, would grant local jurisdiction approval for syringe services programs (SSPs)— facilitated the opening of the new SSP during the outbreak; in fact, the revised law, coupled with growing concern about the opioid epidemic, enabled a rapid statewide expansion of SSPs, from 5 in 2016 to 33 by 2019 (Kevin Cranston, personal communication, 4 March 2020). Northern Kentucky/Hamilton County, Ohio: Because 45% of Kentucky counties were among the 220 counties identified by CDC as most vulnerable to outbreaks should HIV be introduced [17], Kentucky health departments were on high alert. In December 2017–January 2018, Kentucky Department for Public Health reached out to the CDC and the Ohio Department of Health about an increase in HIV diagnoses among PWID in Northern Kentucky, across the river from Cincinnati, Ohio. In the Northern Kentucky/Hamilton County, Ohio, region, <20 HIV diagnoses typically occurred among PWID annually; 157 HIV cases were confirmed during January 2017–December 2018 [9]. The Kentucky and Ohio departments of health, the local health departments, and the CDC investigated. High rates of emergency department use [10] and incarceration among PWID with HIV suggested missed opportunities for earlier HIV diagnoses and indicated a need to screen PWID for HIV in these settings. Collaboration among health departments enabled a more cohesive investigation and response. Sharing and integrating data across 4 health departments were ongoing challenges. Seattle, Washington: In August 2018, Public Health—Seattle & King County (PHSKC) identified epidemiologic links among 3 persons living homeless who had received HIV diagnoses in June or July, leading to an investigation of HIV among persons experiencing homelessness, most of whom injected drugs, in a 3-square-mile area of Seattle [11, 12]. Epidemiologic and molecular analysis led to the identification of 22 linked cases diagnosed during February 2018–July 2019; an additional 9 diagnoses during 2008–2017 were molecularly linked to the cluster. Use of both methamphetamine and heroin was common among cluster members; exchange sex was common among women in the cluster. Overall, in King County, HIV diagnoses among PWID increased from 2017 to 2018, from 7 to 31 cases among women and men who inject drugs (excluding men who have sex with men) and from 10 to 21 among men who have sex with men and inject drugs [12]. PHSKC notified providers and the public about the outbreak and expanded services (including testing, medical care, and syringe exchange) in the affected geographic area. The outbreak is helping to shape the developing plan for Ending the HIV Epidemic in King County. Philadelphia, Pennsylvania: In September 2018, the Philadelphia Department of Public Health identified an increase in HIV diagnoses among PWID [13, 14]. Public health data indicate a 115% increase in HIV diagnoses among PWID from 33 cases in 2016 to 71 in 2018. Many of the new diagnoses occurred in emergency departments and jails. As part of outbreak response planning (and before the detection of the outbreak), a survey of all Ryan White care providers was completed; facilities were identified as one-stop shops if they provided a minimum set of services (including care for HIV, HCV, medication for opioid use disorder, naloxone distribution, and referral to SSPs) at least Monday through Friday (personal communication, S. Caitlin Conyngham, 4 March 2020). In response to the outbreak, the Philadelphia Department of Public Health issued a health advisory, developed new outreach materials, hosted a community engagement meeting, increased funding for and added locations to the SSP to improve access, and expanded testing and hepatitis A virus vaccination in this area. Cabell County, West Virginia: In January 2019, the West Virginia Bureau for Public Health noted an increase in HIV diagnoses among PWID in Cabell County [15], home to the city of Huntington, and one of the counties identified by CDC as most vulnerable to outbreaks of HIV and HCV [17]. From January 2018 through 9 October 2019, 82 diagnoses occurred among PWID in Cabell County, which, in previous years, had averaged 2 diagnoses among PWID annually. The West Virginia Bureau for Public Health, the Cabell-Huntington Health Department, and the CDC responded to strengthen surveillance and epidemiologic capacity; identify and address gaps in testing, pre-exposure prophylaxis (PrEP), prevention services, HIV care, and SUD treatment; and direct resources to ensure that these services reach the populations that need them most. Outreach to PWID was enhanced by implementing a social network strategy which used peer recruitment to link PWID to HIV testing, SSPs, PrEP, and other services. Portland, Oregon: In early 2019, the Oregon Health Authority detected an increase in HIV diagnoses among PWID or persons who use methamphetamine in Multnomah County (Portland) [16]. From January 2018 to June 2019, 42 HIV diagnoses occurred among people who reported drug use; nearly half had tested negative for HIV in the prior 2 years. Only 25 diagnoses occurred in 2016–2017 among PWID. A press release and a “dear colleague” letter to physicians were issued, encouraging physicians to test for HIV, syphilis, and HCV; vaccinate for hepatitis A and B virus; refer persons with HIV for case management; prescribe PrEP to HIV-uninfected patients; refer patients to SSPs and SUD treatment; and prescribe naloxone. DETECTION, INVESTIGATION, AND EPIDEMIOLOGY Detection All outbreaks were initially detected by localized increases in HIV diagnoses among PWID, identified by a clinical provider or health center, health department field staff (ie, partner services [PS] staff through contact tracing activities), or health department surveillance staff (through formal or informal analyses of trends in diagnoses reported among PWID). Health departments used other available data, particularly epidemiologic links (persons named as sex or injecting partners), molecular links, or local community knowledge, to confirm the outbreaks. Defining Cases in Outbreaks Health departments developed outbreak case definitions that focused on PWID in a city or county during a specific time frame. Many case definitions included cases in other risk groups or geographic areas or cases diagnosed before the defined start of the outbreak if they occurred among named injection or sex partners or were molecularly linked to an outbreak case. Some health departments also included cases among persons with features unique to the outbreak, such as noninjection methamphetamine use [16] or homelessness in an area heavily affected by drug use [11]. Many jurisdictions used information from both surveillance and PS interviews, including homelessness, drug use, or HIV testing or care in a geographic area; standard HIV surveillance data alone did not adequately capture all of these factors. The Role of Molecular Analysis Although outbreaks were detected based on increases in diagnoses, all health departments conducted molecular analysis as part of outbreak response. Multiple jurisdictions implemented collection of HIV-1 molecular sequences during the response. Sequences were typically obtained through laboratory reporting for persons receiving HIV drug-resistance testing during routine HIV medical care. Some health departments submitted specimens to the CDC for sequencing while they worked to implement routine sequence reporting. The CDC uses a genetic distance threshold of 0.5% to identify clusters of concern in national analyses [20]. Some responding jurisdictions expanded the genetic distance threshold to 1.5% to increase sensitivity for identifying persons potentially linked to the outbreak, particularly early in the investigation. Molecular analysis expanded investigations by linking cases that occurred in localities or time periods outside of the “core” case definition which helped health departments better understand the scope and size of the outbreaks [8, 21] and the geographic and temporal dynamics of transmission. The presence of molecular clusters at the tighter genetic distance of 0.5% also confirmed that HIV was being transmitted rapidly. Analysis of Existing Data and Collection of Supplemental Data To better understand the increase in HIV diagnoses among PWID, health departments reviewed existing data, including PS data; HIV, sexually transmitted infection, and hepatitis C surveillance data; and, in some jurisdictions, data on overdoses and other drug use information. Health departments that participate in National HIV Behavioral Surveillance also reviewed data collected from PWID on HIV infection, socio-demographic characteristics, risk behaviors and use of prevention services [14]. Jurisdictions collected supplemental data to elucidate the context and assess factors potentially related to increased HIV transmission. Some health departments added questions to PS interviews. Some conducted rapid assessments of needs for and barriers to services through interviews with PWID (through street outreach or purposeful selection) and local stakeholders (eg, healthcare providers, local emergency responders, and harm reduction programs); others held meetings to engage and receive input from stakeholders. Some jurisdictions, with supplemental staff from health departments, universities, or CDC, abstracted medical records of PWID at selected healthcare facilities. These activities provided information about injection and sexual risks among local PWID and identified opportunities to improve service delivery. Geography These outbreaks occurred in all 4 US census regions (ie, Northeast, Midwest, South, and West) (Figure 1). All occurred in metropolitan areas. Among the 13 outbreak counties (1–5 counties per outbreak), 4 were classified as large central metro counties, 8 as large fringe metro, and 1 as medium metro. (The 2013 National Center for Health Statistics urban-rural classification scheme for counties [22] defined the categories as follows: large central metro counties, those in metropolitan statistical areas (MSAs) of ≥1 million population that (1) contain the entire population of the largest principal city of the MSA (2) have their entire population contained in the largest principal city of the MSA, or (3) contain ≥250 000 inhabitants of any principal city of the MSA; large fringe metro counties, those in MSAs of ≥1 million population that did not qualify as large central metro counties; medium metro counties, those in MSAs with populations of 250 000–999 999; small metro counties, those in MSAs with populations <250 000; micropolitan (nonmetropolitan) counties, those in micropolitan statistical areas; and noncore (nonmetropolitan counties), nonmetropolitan counties that did not qualify as micropolitan.) Two outbreaks included a total of 3 counties that were among 220 counties identified by CDC as most vulnerable to outbreaks should HIV be introduced into a network of PWID [17]. Figure 1. Open in new tabDownload slide Human immunodeficiency virus outbreaks among persons who inject drugs (United States, 2016–2019). Abbreviations: MSM, men who have sex with men; PWID, persons who inject drugs. Figure 1. Open in new tabDownload slide Human immunodeficiency virus outbreaks among persons who inject drugs (United States, 2016–2019). Abbreviations: MSM, men who have sex with men; PWID, persons who inject drugs. Epidemiologic Commonalities Across outbreaks, most cases occurred among whites and among PWID aged 20–39 years, younger than PWID with diagnosed HIV infection reported historically [23]. Almost all outbreaks included more men than women; in most, few male PWID reported male-to-male sexual contact. The majority of PWID who had been tested had evidence of prior HCV infection; screening for HCV occurred in some, but not all outbreak responses. Evidence of transmission during the past couple years included history of HIV tests with nonreactive results, diagnoses during HIV seroconversion, high CD4 cell count at the time of diagnosis, or tight molecular clustering with very similar HIV strains (genetic distance <0.5%). Across outbreaks, injection of opioids (heroin or fentanyl) or methamphetamine predominated; many PWID with newly diagnosed HIV concurrently used opioids and methamphetamine or cocaine. Homelessness or unstable housing, previous incarceration, and exchange of sex for money or goods (particularly among women) were common in nearly all investigations. HIV TESTING AND CASE FINDING APPROACHES As part of outbreak response, local public health authorities expanded case finding through enhanced testing via PS, mobile services, or in settings frequented by PWID. In some jurisdictions, street outreach testing could be ramped up more easily than facility-based testing. Health departments increased the number of staff to conduct PS, intensified collaborations through existing partnerships (eg, community-based organizations, jails, healthcare facilities), and developed new partnerships (eg, with homeless service providers or libraries) for HIV testing. Partner Services Locating PWID with newly diagnosed HIV or those who had been potentially exposed was labor intensive, particularly because many PWID experienced homelessness or housing instability. Existing health department workflows and resources were often insufficient to maintain the prior workload and provide field services to PWID with newly diagnosed HIV. Responding health departments used multiple strategies, including expanding PS staffing (eg, hiring new staff, reassigning PS staff from other regions, or engaging federal PS staff), task shifting (eg, temporarily reassigning staff from elsewhere in the health department to assist with outreach testing and linkage or re-engagement to HIV care), reprioritizing PS cases (eg, prioritizing PS for cases with HCV RNA or antibody as a proxy for injection drug use when risk status was unknown [7] or discontinuing PS for persons with gonorrhea among those without HIV [24]), and collaborating with local healthcare providers to re-engage patients enrolled in their clinics who may have fallen out of care. HIV Testing in Emergency Departments Where PWID were tested for HIV in emergency departments (EDs), multiple infections were diagnosed. An investigation during one outbreak revealed that a large proportion of PWID with newly diagnosed HIV had accessed healthcare systems, including EDs, before diagnosis for conditions related to IDU (eg, overdose, injection-related infections), but were not tested for HIV; these visits were missed opportunities for earlier HIV diagnosis [9, 10]. During the outbreak, EDs in one jurisdiction implemented programs to screen PWID for HIV and HCV and to offer hepatitis A virus vaccination; alerts for visits related to IDU were incorporated into the electronic medical record. Data regarding healthcare use by PWID might inform healthcare systems about their potential role in prevention and treatment services for PWID. HIV Testing in Correctional Settings Recent incarceration was common among PWID in these outbreaks. During outbreaks, some jurisdictions increased HIV testing in jails; in others, testing in jails was complicated by issues related to voluntary consent, short sentences, varying systems for administering healthcare, and concerns about the cost of antiretroviral treatment for persons who test positive for HIV. However, in a recent policy clarification notice, the Health Resources and Services Administration stated that Ryan White HIV/AIDS program funds can now be used in local jails to support core medical and support services for inmates with HIV [25]. An HIV outbreak among PWID presents an opportunity to revisit partnerships between public health and correctional health and public safety. Multiple models exist for HIV testing in correctional settings and for linkage to HIV treatment after release [26]. HIV Testing in Syringe Services Programs and Substance Use Disorder Treatment Facilities HIV testing in syringe services programs (SSPs) was conducted to varying degrees during these outbreak responses. During most responses, few infections were diagnosed at SSPs. One jurisdiction implemented a social network strategy approach to increase case finding through an SSP [15]. SSPs are well positioned to offer hepatitis and HIV testing and other services to PWID. In states and jurisdictions with a demonstrated need, federal funds can be used to support testing, other services, and SSP administration (though currently not to purchase syringes or other equipment used exclusively for drug injection) [27]. PWID who live near an SSP are more likely to report having been tested for HIV in the past year compared with those who live farther from an SSP (odds ratio, 1.32) [28]. In a 2013 national analysis, most SSPs offered screening for HIV or HCV, but as few as one-third could track referrals to confirmatory testing, care, and treatment [29]. Scaling up linkage services at SSPs can strengthen comprehensive services for PWID [30]. Fewer than 30% of substance use disorder (SUD) treatment facilities offer testing for HIV or HCV [31, 32]. Integrating infectious disease screening into treatment facilities can increase testing rates [33]. The Substance Abuse and Mental Health Services Administration recently issued a “dear colleague” letter encouraging HIV testing as a routine component of SUD treatment [32]. Collaborations between SUD treatment providers and public health are essential for addressing barriers to HIV testing and developing mechanisms for routinely reporting test results to public health. SERVICES FOR PERSONS WITH HIV AND SUD Reaching Individuals with Needed Services Engaging PWID in implementing any response strategy is critical to ensuring that their needs are met. Interviews with PWID demonstrated that factors such as stigmatizing environments, lack of transportation, and restricted hours limit their engagement in healthcare, social, and other services. To create safe spaces where PWID will seek care, some jurisdictions implemented activities centered around decreasing stigma in the community and within healthcare organizations. Integrating HIV testing and other health services into community-based organizations frequented and trusted by PWID may increase health service use among this population [34]. Colocation of services, often referred to as “one-stop shops,” allow PWID to receive multiple services at a single locale. Some jurisdictions promoted programs offering HIV/HCV screening, hepatitis A and B virus vaccination, initiation of medication for opioid use disorder (MOUD) (sometimes referred to as medication-assisted treatment), and referral for HIV and substance use treatment in EDs. Others deployed mobile vans or street-based physicians to bring HIV testing, basic clinical care (including wound care), or other services to PWID. In some cases, transportation assistance was provided to help PWID access services. Some health departments, recognizing the tight social networks of PWID in their community, developed peer-driven recruitment strategies to reach PWID who might not otherwise access HIV prevention and care services. These programs varied in size, complexity, and the range of services provided. All linked PWID to HIV testing and health education and some to SSPs or pre-exposure prophylaxis (PrEP). Rates of recruitment and referral success varied. Challenges to these efforts included lack of adequate incentives to drive recruitment and difficulty supporting adequate staffing. However, such approaches show promise for efficiently and effectively reaching networks of PWID with critical services [35]. HIV Services Even after PWID were linked to care, HIV care providers reported housing and social instability related to SUD as a barrier to retention in HIV care and achievement of viral suppression. In some outbreaks, the percentage of PWID who achieved or maintained viral suppression was very low (<30%) in the first few months of the response and sometimes remained low despite enhanced response activities [15]. Approaches to improve HIV care outcomes included rapid follow-up after missed appointments, use of incentives for attending HIV care visits, flexible appointment times, education about and linkage to SUD treatment, and assistance with transportation and housing. These activities often used staff and resources from the Ryan White HIV/AIDS Program. Some health departments expanded high-intensity programs with low-barriers to services, specifically designed to meet the complex medical and social needs of PWID [36]. Viral suppression and retention in care outcomes are better when HIV care is integrated in settings offering treatment for SUD [37]. Health departments identified PWID with HIV who were not retained in care by using surveillance data or by collaborating with HIV care providers. Some of these activities were similar to data-to-care programming based on surveillance data [38], but responding jurisdictions recognized that routine data-to-care indicators (eg, being considered not in care if no CD4 cell count or viral load test result was reported in more than a year) were not sufficiently timely during an outbreak. For populations with newly diagnosed infection and high rates of homelessness or unstable housing, and among persons who have never achieved viral suppression, enhanced data-to-care indicators with a shorter time frame (eg, not more than 3–6 months) might be considered. Data on care engagement from HIV care providers, case managers, social workers or peer supporters, or data from pharmacies on medication pick-up, can be more timely than routine HIV surveillance data and may offer opportunities to collaborate with healthcare and social service providers to identify and address barriers to care. One underused tool in preventing HIV among PWID is PrEP. Daily PrEP use reduces the risk of HIV transmission from injecting drugs by at least 74% and of sexual transmission by about 99% [39]. In most of these outbreaks, when assessed, knowledge of and access to PrEP were low among heterosexual PWID, consistent with previously published reports [40, 41]. Efforts to expand PrEP access varied from provision of PrEP education to coordinated efforts to expand access and linkage to PrEP by training new providers and co-locating PrEP in SSPs and other locations PWID frequent. A variety of PrEP delivery models are possible in settings where PWID receive services, including health departments, substance use treatment facilities, community-based organizations, and healthcare settings [42]. SUD Services For patients with opioid use disorder, MOUD improves stability, reduces opioid use and relapses [43], improves antiretroviral treatment adherence and viral suppression [44], and can reduce transmission of infections [45]. MOUD access varied across jurisdictions experiencing HIV outbreaks; one common solution was to increase the number of providers with waivers to prescribe buprenorphine. Some jurisdictions considered other approaches to increase MOUD, including introducing low-barrier MOUD at SSPs to facilitate uptake and retention [46]. Correctional settings are also well positioned to initiate MOUD, which reduces substance use relapses, fatal overdoses, and recidivism [26, 47, 48]. Harm Reduction Services All 6 outbreaks occurred in localities which had some harm reduction services in place at the time the outbreak was recognized. As part of outbreak response, all health departments identified gaps in the delivery of harm reduction services and subsequently increased availability of harm-reduction services by increasing referrals to SSPs, opening new SSPs, expanding hours of operation, or implementing mobile syringe service delivery. Many jurisdictions encountered barriers, such as stigma and stakeholder resistance, to implementing evidence-based harm-reduction practices, including needs-based exchange. Limiting the number of syringes dispensed decreases the proportion of PWID who achieve 100% of their injections with a clean, sterile needle and increases risk of infection [49]. Responding health departments engaged community partners and law enforcement in expanding support for and access to services, and they identified policy, legal, and law enforcement practices that need to be addressed to more fully implement best-practice approaches to harm reduction. CHALLENGES TO MONITORING THE OUTBREAK AND RESPONSE Integrating multiple sources of routine and nonroutine data within and across jurisdictions was a common challenge. SSPs usually collect data on new and recurring visits, but many lack systems for managing or routinely analyzing data collected or do not have strong partnerships with health departments, making data sharing a challenge. Although jurisdictions implemented activities to increase referrals for HIV and SUD treatment during outbreaks, health departments typically had limited data on the success of referrals, treatment initiation, or retention in treatment for SUD. Addressing these barriers will improve data use for outbreak response and ongoing health department activities. INTERPRETATION AND IMPLICATIONS Precipitating Factors and Context The recent HIV outbreaks across the country demonstrate that these occurrences are not isolated events. Each of these outbreaks clearly resulted from HIV transmission in the setting of frequent, nonsterile injections. However, the particular factors precipitating increased transmission likely varied across outbreaks. In Cabell County, West Virginia, the recent introduction of HIV with rapid dissemination among a tightly networked community of PWID was indicated by the tight clustering of cases with molecular sequences in a single cluster [15], a finding also observed in Scott County [6]. In the recent outbreaks in more urban areas, multiple HIV clusters and multiple persons with unlinked sequences were identified [8, 9], suggesting that HIV was already present in the area, but that HIV transmission increased because of changes in injection behaviors or network characteristics [50]. For example, the outbreaks in northeastern Massachusetts and Philadelphia followed the introduction of fentanyl into the regional drug supply [7], and the Seattle outbreak followed an increase in methamphetamine injection among persons other than men who have sex with men [51]. Some responding jurisdictions theorized that an increase in homelessness or the break-up of homeless encampments may have led to increased HIV transmission [11, 14]. Factors such as homelessness and changes in the drug supply were also common in HIV outbreaks among PWID described in a recent international review [52]. Homelessness, recent incarceration, and exchange sex—common in these outbreaks—are known sequelae of IDU, and also risk factors for HIV. The contribution of sexual transmission among PWID or between PWID and persons of other transmission categories [53] during these outbreaks has been assumed but not well characterized. Because different substances injected are associated with differing injection and sexual risk behaviors, social network interactions, and SUD and HIV treatment engagement, outbreak responses may need to be tailored accordingly [54]. All outbreaks occurred in localities where harm reduction services were present, including some in jurisdictions with historically strong harm-reduction programs. This finding, also reported for some of the outbreaks in the recent international review [52], indicates that the presence of an SSP does not necessarily mean that syringe services are effectively reaching all PWID at risk. Investigations suggested that SSPs developed to meet the needs of a prior generation of PWID were not equipped to serve a new generation of PWID, for reasons including more frequent injection, lack of familiarity with safer injection practices among newer injection initiates, and locations and hours of SSP operation. Policies that limit SSP operations—such as 1:1 exchange, local policing, and accessibility of SSP sites—limit SSP effectiveness. Less restrictive, needs-based, and nonpunitive distribution models and adoption of secondary exchange improve access to sterile syringes and injection equipment at the individual and population levels [55]. All 6 outbreaks occurred in metropolitan areas. In 2016, following the Scott County outbreak [6] and in the context of the national opioid crisis, CDC conducted an analysis to identify and alert counties that might be most vulnerable to HIV outbreaks if the virus were introduced; 220 counties — many of which were rural and had little infrastructure for HIV services — were identified as most vulnerable [17]. The dissemination of these findings led to increased attention and resources for HIV among PWID in rural areas. Two of these 6 outbreaks included counties identified as most vulnerable, which likely contributed to the prompt recognition and response of the involved jurisdictions. Yet attention to the vulnerability of rural areas to HIV outbreaks among PWID also led to some misperception that metropolitan areas were not at risk for such outbreaks. However, HIV in the United States is concentrated in metropolitan areas. Furthermore, a certain population density may be required to support an illicit drug market (Don Des Jarlais, personal communication, 6 February 2020). Thus, although HIV may be disseminated rapidly if introduced in rural counties, the occurrence of these outbreaks in metropolitan areas, including some in large urban centers, demonstrates that risks for HIV outbreaks also exist in metropolitan areas in the United States. Outbreak Response Planning In the midst of these HIV outbreaks, some health departments experienced challenges designing, implementing, and maintaining an appropriately staffed response structure, particularly if other emergency responses, such as responding to hepatitis A outbreaks, were occurring simultaneously. Multiple health departments instituted an incident command structure to coordinate their response. Planning for outbreaks of HIV or viral hepatitis related to IDU may position health departments to respond more rapidly and efficiently. Health departments have benefited by using and further refining outbreak response plans [18, 56]. This involves clarifying roles of state and local health departments, including potential collaborations across states. Health departments can formulate options for surge capacity—for example, deploying staff and financial resources to specific geographic areas, prioritized activities, and relevant agencies, potentially including agencies not previously funded by the health department. Deploying PS staff from one region of the state to another was a particular challenge for many responses. A rapid response when even small increases in HIV diagnoses among PWID are detected may help prevent the development of a large outbreak. For example, intensive responses were implemented in Miami when 7 acute HIV seroconversions were identified among PWID at an SSP and in western North Carolina when a small HIV outbreak among PWID was recognized (Box 2) [30, 57]. In both Miami and North Carolina, case patients were rapidly linked to care, started on antiretroviral treatment, and achieved viral suppression. The number of diagnoses among PWID in Miami never increased above baseline. In North Carolina, molecular data confirmed that no additional linked cases were subsequently identified. These 2 responses suggest that early detection and rapid response may limit or even prevent the development of an outbreak. Box 2. Responses to Small Outbreaks or Potential Increases in Human Immunodeficiency Virus Transmission Among Persons who Inject drugs—Miami, Florida, and Western North Carolina, 2018 Miami, Florida: In February 2018, the IDEA Exchange, Florida’s first legal needle exchange program at the University of Miami began implementing routine, anonymous opt-out rapid human immunodeficiency virus (HIV) and hepatitis C virus (HCV) screening for clients of the program at enrollment and every 3 months thereafter [30]. During the subsequent 2 months, 3 HIV seroconversions were identified. Subsequent investigation and response in collaboration with the Florida Department of Health identified 7 HIV seroconversions among persons who inject drugs (PWID) who were experiencing homelessness and living within a close geographic area. In-depth contract tracing with disease intervention specialists (DIS) embedded in the syringe services program (SSP), daily outreach including syringe distribution in the affected geographic area, rapid linkage to HIV care and ART initiation, and case management resulted in all 7 PWID being linked to care and achieving viral suppression within a mean of 70 days (range, 14–158 days) after the first reactive HIV test and likely helped avert more extensive HIV transmission within this community. Western North Carolina: In January–March 2018, the North Carolina Department of Health identified an increase in HIV diagnoses among PWID in the western region of the state [57]; five counties in this region were considered among the 220 identified by CDC as most vulnerable to HIV and HCV outbreaks [17]. An analysis of partner services data revealed a group of 7 persons who reported injection drug use and were among a network of persons named as sexual or needle-sharing partners; 5 had received HIV diagnoses since January 2017 in 3 neighboring counties of the region. Community knowledge underscored concern for increased transmission among PWID, leading to a response focused on those 3 counties. The health department initiated an incident response, deployed 5 additional DIS, and engaged community-based organizations, SSPs, and local health departments for testing (HIV, hepatitis B virus [HBV], HCV, and syphilis), hepatitis A and B vaccination, distribution of harm reduction kits, and linkage to HIV, HBV and HCV care and to syringe exchange. Molecular analysis identified a cluster of 7 closely related infections, 6 among PWID. Almost all case patients were linked to care and have been virally suppressed since 2018. That no additional molecularly linked cases have been identified suggests that the outbreak was recognized early and contained. Strengthening Routine Programs Through Outbreak Response Outbreak response can offer opportunities to strengthen long-term health department capacity and implement new programs within health departments, healthcare, and other settings to promote screening, prevention, and treatment of HIV and SUD among PWID. For example, one jurisdiction significantly increased the number of PS staff in the state to expand PS to all persons with newly diagnosed HIV [7]. Others rapidly implemented HIV molecular sequence reporting and analysis [8, 9]. Some expanded HIV screening and other services for PWID, such as MOUD, in EDs. The CDC has recommended routine HIV screening for adults in healthcare settings since 2006 [58]; where ED screening of all persons does not routinely occur, expanded screening of PWID in EDs during an outbreak would increase case finding and may be a step toward more routine implementation of HIV screening in EDs [59]. CONCLUSIONS During 2016–2019, HIV outbreaks among PWID occurred across the United States in metropolitan areas, including some with substantial SSP programming and medical care targeted to PWID. This indicates a need to expand how vulnerability to HIV outbreaks is conceived. The context in which these outbreaks have occurred suggests that the “tipping point” for an outbreak may vary and could be related to changes in the drug supply, injection practices [60], social conditions, or access to services for PWID (including supply of clean injection equipment), or to the introduction of HIV into a network or community not previously affected by HIV. Lessons learned from these responses can be considered for future responses involving PWID. In fact, multiple other US jurisdictions are currently monitoring and responding to recent increases in HIV diagnoses among PWID [61, 62]. Ongoing evaluation within and across outbreak responses may help identify optimal allocation of resources during response. Robust, multifaceted, and early responses to increases in HIV infections among PWID are critical to lessen the severity of ongoing outbreaks, prevent future outbreaks, and ensure that progress toward the federal Ending the HIV Epidemic initiative is achieved [63]. Notes Acknowledgments. We thank the staff of the following health departments for their tremendous efforts on these responses and for communication with the Centers for Disease Control and Prevention (CDC) and with each other that has enabled those involved to better understand and respond to HIV outbreaks among PWID: Massachusetts (Massachusetts Department of Public Health); Northern Kentucky/Hamilton County, Ohio (Hamilton County Public Health, Ohio Department of Health, Northern Kentucky Health Department, Kentucky Department for Public Health); Seattle, Washington (Public Health—Seattle & King County); Philadelphia, Pennsylvania (Philadelphia Department of Public Health); Cabell County, West Virginia (Cabell-Huntington Health Department, West Virginia Department of Health and Human Resources Bureau for Public Health); Portland, Oregon (Multnomah County Health Department, Oregon Health Authority); Miami, Florida (Florida Department of Health), Western North Carolina (North Carolina Division of Public Health). Healthcare and service providers in these jurisdictions have been integral to these responses and have provided insight into the context for these outbreaks and the opportunities for and challenges to addressing the needs of PWID. The Outbreak Coordination Unit of CDC’s Division of HIV/AIDS Prevention has served as an important forum for discussing and recommending approaches and activities for these responses. The Geospatial Research, Analysis and Services Program, a division of the Agency for Toxic Substances and Disease Registry at CDC, provided geospatial support for the development of the map in this publication. Disclaimer. The findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Supplement sponsorship. This supplement is sponsored by the Centers for Disease Control and Prevention. Potential conflicts of interest. All authors: No reported conflicts. 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TI - Responding to Outbreaks of Human Immunodeficiency Virus Among Persons Who Inject Drugs—United States, 2016–2019: Perspectives on Recent Experience and Lessons Learned
JF - The Journal of Infectious Diseases
DO - 10.1093/infdis/jiaa112
DA - 2020-09-02
UR - https://www.deepdyve.com/lp/oxford-university-press/responding-to-outbreaks-of-human-immunodeficiency-virus-among-persons-x90DgR0mZB
SP - S239
EP - S249
VL - 222
IS - Supplement_5
DP - DeepDyve
ER -