Rural Indiana HIV Spike Linked to Injected Oxymorphone Use

The injection use of extended-release oxymorphone led to the rapid transmission of human immunodeficiency virus (HIV) in a small Indiana community according to an investigation conducted by the Centers for Disease Control (CDC). The investigation was reported by a group of researchers led by Philip J. Peters, MD, and their report was published in the New England Journal of Medicine on July 21, 2016.

The community, located in Scott County, had just 5 HIV infections reported between 2004 and 2013. Then, in January of 2015, “the Indiana State Department of Health (ISDH) began investigating a cluster of 11 newly diagnosed HIV infections, which was identified by an alert disease intervention specialist, among residents,” say the researchers. This investigation led to the establishment of 5 HIV testing centers in the area.

Between November 18, 2014, and November 1, 2015, the investigators found 181 outbreak-related cases of HIV. Of those, 159 reported injecting oxymorphone during the previous 12-months. The authors say that intervention specialists identified 536 people who were considered contacts of the 181 infected HIV patients; 468 of them were contacted and tested and 287 were negative.

The most common co-infection virus to HIV is hepatitis C (HCV) and the researchers said that that overall, there were 167 patients coinfected with HCV. “In response to this outbreak, a public health emergency was declared on March 26, 2015,” say the researchers. Free testing for both HIV and HCV were rapidly expanded, and HIV treatment services, along with substance-use services, were provided.

The authors identified several aspects of this outbreak that could be useful in preventing other outbreaks. The detection of the first cases through routine screenings triggered an alert disease specialist, which shows the importance of expanding public services such as screenings in rural areas. The authors also note that the size of the network of drug users injecting drugs and sharing syringes was surprising due to the sparse population of the area. Clinicians should be aware that such networks exist in rural areas. Finally, a large number of HCV infections could be a marker for HIV risk.

The researchers conclude that this outbreak “highlights the vulnerability of the growing numbers of persons who inject drugs in rural communities to the introduction and transmission of HIV.” They add, “the implementation of HIV testing and treatment, syringe-service programs, and medication-assisted treatment are necessary to help prevent a similar outbreak in the future.”