John Brooks presented two papers on behalf of the Indiana Dept of Health and CDC which described the recent HIV outbreak in a small town in Indiana and then looked in more detail at the molecular epidemiology of the events. This is a truly shocking story. Some of you may have been following it on HIV list serves, but these two papers eloquently and emphatically demonstrated just what can go wrong and how quickly. This should be essential viewing for many politicians and policy makers, particularly those who oppose harm minimisation strategies or question the need for surveillance.
The location is a small town in Indiana late last year 3 new HIV diagnoses were made in one month. Previously only 8 diagnoses had occurred in town. A surveillance office saw this and look into it. It became apparent that they were connected through a common vector and were all injected oxymorphone (morphine prescription tablets) 8 additional cases were identified and an outbreak notified to the CDC.
Subsequent contact tracing has revealed 170 infections (as of 14 June) where the data was analysed and a further four cases have been identified since then. The outbreak has plateaued.
There is a very high level of injecting prescription morphine pills in the town. Many families have 3 generations injecting, unemployment is high, until recently NSP was illegal in Indiana. There was no HIV education and education levels low. Many people were not registered for Medicaid. There was very low HIV literacy, and little education there was no school based HIV education program. People thought injecting "at home" or "with the family" protected from HIV.
Philogentic testing had been performed on about 60 samples. These showed 2 groups one of three individual and all the rest in one amorphous mass. These are the clearest clusters i have ever seen. When HCV sequencing was performed on the same samples it revealed a number of clusters and a great many unrelated cases. What this shows is that HCV had entered this community over time from many different sources and that the HIV outbreak is an actual outbreak. Once HIV came into the community it spread like wildfire.
The response has been excellent. It took a little while to get into full swing. But this was put done to the need for confidentiality and to initiate contact tracing in a confidential and privacy sensitive manner. Indiana has passed a law allowing NSP (perhaps just in this location) and they have mobile as well as a fixed site. People have been registered for Medicade, tested for a range of STI and BBV, vaccinated where needed and available. Linked to care and encouraged into treatment. 70% are in care and of those 40% are on treatment and this is being actively pursued.
There are billboards promoting HIV prevention and public campaigned promoting safety. Ryan Whites mother has addressed a public meeting in the town, in an attempt to curb discrimination. A number of people are on PrEP and even more are asking for it as awareness about it grows.
As was commented in the session. It is terrible that this is occurring now in a developed country. NSP should be universally available. The costs associated with this outbreak will keep on costing. What is scary is just how quickly this occurred. They were recent infections and so highly infectious. Injecting provided a very efficient route of transmission. If those 3 people had not been identified late last year would it even have been noticed now. But even more scary, could this be happening elsewhere.