Update on the HIV outbreak in Indiana

John Brooks from the CDC in Atlanta provided an update on the HIV outbreak first identified in Indiana in December 2014. I reported on his first update from the IAS Conference in Vancouver in July last year.

A couple of things are very noteworthy from these presentations. The response to the outbreak was dramatic, all be it very costly, and effective. What is hugely upsetting is that it could have been prevented with a good public health approach to HIV in the first instance.

A small cluster of HIV infections were identified in a rural county in Indiana. Case follow-up and contact tracing has identified 188 infections. The vast majority of these were identified in the first half of last year with only 11 being identified more recently, and of those the majority had been approached but declined testing previously.

A lot of features made this a perfect storm: no needle and syringe program; high levels of injecting (4 - 15 times daily and sharing with 1 - 6 partners) the reason for this is that the main drug injected was oxymorphone, which sells on the street for up to $140 per tablet, so people inject small doses, regularly to manage withdrawal. High levels of intergenerational sharing, with the belief that this was protective.

The county has the lowest socio-economic profile. Access to health care was limited, many people were uninsured and not registered for social security, unlicensed, not working and did not have common documents such as birth certificates.

This is an excellent presentation which show how a significant epidemic can occur in close knit community with limited access to resources, education and information. Viral sequencing has demonstrated that these were very recent infections and all linked. 

The plenary

http://www.croiwebcasts.org/console/player/29695?mediaType=podiumVideo&

and all of the slides amd MP3 are available at http://www.croiwebcasts.org/y/2016/25?link=nav&linkc=date

There was an HCV positive rate of >90%. But the HCV, unlike the HIV was well established in the cohort, coming from multiple sources over many years. A complementary presentation by Sumathi Ramachandran, Networks of HCV Transmissions Among Persons Who Inject Drugs: Indiana, 2015  looks at hepattiis C infection in this community can be found at http://www.croiwebcasts.org/console/player/29742?mediaType=slideVideo& 

There has been considerable discussion about the potential for outbreaks in rural and remote communities in Australia. This experience is one which should be viewed by all involved in the public health response to HIV and by all those involved in policy making which impacts public health.