HEALTH ADVISORY #162 Human Immunodeficiency Virus (HIV) Infections Among People Who Inject Drugs — Additional Area Seeing Increase, Others Vulnerable

HIV has long been present
across West Virginia, although at low levels. With the state’s opioid and now broader substance use epidemic, West Virginia has been increasingly vulnerable to HIV outbreak(s) among persons who inject drugs (PWID). The sharing of injection drug equipment as well as high-risk sexual practices associated
with substance use generate this vulnerability.

The West Virginia Bureau for Public Health (BPH) actively monitors HIV diagnoses across the state and works with local and federal partners to prevent,
investigate and respond to increases. In addition
to the Cabell
County increase previously reported, BPH has now identified an increase in HIV diagnoses
among PWID in Kanawha County (for more information visit www.hivawarewv.org). Although
state and local health officials are still investigating, epidemiologic evidence suggests the increase
in HIV among Kanawha County residents is distinct from the Cabell County
cluster and indicates increased and recent local transmission (e.g., the Kanawha
County increase is not simply an extension of
the Cabell County
cluster).

New HIV infections among PWID are clearly increasing in West Virginia.
From 2014 to 2019, the proportion of new HIV diagnoses
in West Virginia attributable to injection drug use (IDU) has increased over five-fold from 12.5% to 64.2%, primarily
driven by the Cabell County and now Kanawha County increases. The emergence
of HIV among PWID
in more than
one
part of the state
and
the vulnerability of other West Virginia
counties to HIV transmission indicate that enhanced surveillance and prevention activities are warranted statewide. As a result,
the BPH is asking all healthcare providers to increase
vigilance for potential HIV infection, especially among PWID, to increase
testing, to encourage
prevention efforts, and to rapidly
report new HIV infections to BPH. Prevention, prompt identification of cases and linkage to care improves
clinical outcomes and is critical
to reducing HIV transmission.

Recommendations

  1. Conduct a complete
    drug use and sexual risk assessment for every patient.
    This includes information about specific behaviors, such as drugs used and mode of drug delivery, unstable housing/homelessness, number
    of partners, types of sex (i.e., vaginal, anal, oral).
  • Test patients for HIV.
    • Everyone
      between 13 and 64 years of age should
      be
      tested for HIV at least once as part of routine
      healthcare.
    • Anyone engaging
      in IDU or high-risk sexual behaviors should be tested for HIV, hepatitis
      C virus (HCV), hepatitis
      B virus (HBV), and other STIs every 3-6 months.
  • Anyone presenting
    with injection or substance use disorder-related illness or conditions, including skin/tissue abscess, bacterial endocarditis, overdose, etc. should be tested for HIV
    and
    hepatitis.

3. For patients
currently using injection drugs who test negative for HIV:

  • Discuss strategies to prevent HIV including never sharing needles or other injection equipment, limiting the number of sexual partners,
    using condoms correctly every time, and abstinence from sex.
  • Consider
    pre-exposure prophylaxis (PrEP), as applicable.
    More information on PrEP is
    available at https://www.cdc.gov/hiv/risk/prep.
  • Provide
    or refer to substance use disorder
    treatment, including medication-assisted treatment.
  • Provide education about safer practices related to injection. For more information see https://www.cdc.gov/hiv/risk/idu.html.
  • Work to ensure
    use of/access to clean needles
    until the individual is ready to get into treatment and off drugs. This is most effectively done through referral to harm reduction
    services, where available. These play critical roles in preventing HIV and hepatitis
    among PWID, facilitate entry into drug treatment,
    do not increase drug use, and link individuals to other
    medical and prevention services.
  • Encourage patient
    to refer sex or
    needle sharing partners for
    testing and PrEP if HIV
    negative.

4. For patients
currently using injection drugs who test positive
for HIV:

  • Immediately link to HIV care
    and
    treatment. Focused
    efforts should be made to optimize treatment adherence and retain patients in care. Early treatment of HIV infection is essential to rapidly
    reduce viral load, improve
    patient outcomes and prevent
    further transmission.
  • Discuss strategies to prevent HIV transmission to others including
    never sharing needles or other injection equipment, limiting the number of sexual partners,
    using condoms correctly every time, and
    abstinence from sex.
  • Provide
    or refer to substance use disorder
    treatment, including medication-assisted treatment.
  • Provide education about safer practices related to injection. For more information see https://www.cdc.gov/hiv/risk/idu.html.
  • Work to ensure
    use of/access to clean needles
    until the individual is ready to get into treatment and off drugs. This is most effectively done through referral to harm reduction
    services, where available. These play critical roles in preventing HIV and hepatitis among PWID, facilitate entry into drug treatment, do not
    increase drug use, and
    link individuals to other medical and
    prevention services.
  • Encourage patient
    to refer sex or
    needle sharing partners for
    testing and PrEP
    if
    HIV negative.
  • Connect the person
    with community resources to address
    other social and behavioral health needs.
  • Contact the Disease Intervention Specialist (DIS) assigned to your area by calling
    the WV STD/HIV Hotline at 1 (800) 642-8244.
    DIS are skilled public health professionals who are trained to identify
    and locate contacts (e.g. partners) through in-depth case interviews, always maintaining patient confidentiality.
  • Report positive HIV cases (all stages) to BPH within one week. For more information on reporting, visit: http://www.dhhr.wv.gov/oeps/std-hiv-hep/disease_reporting/Pages/default.aspx.

To report
suspected clusters
or outbreaks
of HIV,
contact the
Division of
Infectious Disease Epidemiology (DIDE).

AdditionalResources

  • Ryan White HIV/AIDS Program
    Locator https://targethiv.org
  • WV Harm Reduction
    Programs At-A-Glance https://oeps.wv.gov/harm_reduction/pages/default.aspx
  • CDC HIV Resources
    https://www.cdc.gov/hiv
  • CDC HIV Risk Reduction Tool
    https://wwwn.cdc.gov/hivrisk
  • CDC HIV/AIDS Syringe
    Service Programs
    https://www.cdc.gov/hiv/risk/ssps.html
  • MidAtlantic AIDS
    Education and Training Center https://www.maaetc.org/
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