HIV-HCV Outbreak Among Injection Drug Users in the Heartland

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A large increase in HIV and hepatitis C virus (HCV) infections in Indiana among injection drug users prompted the CDC to issue a nationwide public health alert on April 24, 2015.

"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," the CDC said in a health advisory.

A total of 142 individuals in Scott and Jackson counties have tested positive for HIV either on a confirmed or preliminary basis since last November, the Indiana State Department of Health announced. Normally, fewer than 5 HIV cases are found annually in rural Scott County.

The CDC reported that 84% of those with newly diagnosed HIV infections in these southeastern Indiana counties--a community of 4,200--also tested positive for HCV. Of 112 individuals with HIV who were interviewed, 96% had injected drugs.

"All reported dissolving and injecting tablets of the prescription-type opioid oxymorphone using shared drug preparation and injection equipment," stated the agency.

Indiana Governor Mike Pence last month reluctantly authorized a needle exchange program for Scott County so injection drug users can swap used needles for sterile ones in an attempt to limit the number of infections.

The CDC advised health departments to watch for recent rises in HCV infections, especially among individuals aged 35 years or younger, and in HIV infections attributed to injection drug use. The agency also recommended that all contacts of people with newly diagnosed HIV infections are tracked down and tested for HIV and HCV.

Recommendations for Healthcare Providers

The advisory specifically addressed what healthcare providers can do:

• Ensure all persons diagnosed with HCV infection are tested for HIV infection, and that all persons diagnosed with HIV infection are tested for HCV infection.
• 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 (opioid substitution therapy) and counseling services, and use effective treatments (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. The advisory noted that long-term opioid therapy has not been demonstrated to reduce chronic pain.
• Contact the state or local health department to report suspected clusters of recent HIV or HCV infection.

The advisory noted that injection drug use accounts for an estimated 8% of the approximate 50,000 annual new HIV infections in the United States. Abuse of prescription-type opioids is increasing nationally and opioid-analgesic poisoning deaths have nearly quadrupled from 1999 through 2011. Rates of acute HCV infection are increasing, especially among young, nonurban people who inject drugs, often in association with abuse of injected prescription-type opioids.

The health advisory is available on the CDC website.