BOSTON – A rise in the number of hepatitis C cases in a certain area of Indiana, which likely reflected a rise in the number of people abusing injection drugs there, may have been a signal that the area could have been at risk of additional public health issues, including an HIV outbreak, according to presentations at the 2016 Conference on Retroviruses and Opportunistic Infections.

In 2 back-to-back presentations at the meeting, John T. Brooks, MD, of the CDC, and  Sumathi Ramachandran, PhD, of the CDC’s division of viral hepatitis discussed an HIV outbreak in a rural community in Indiana.

There had been less than 5 HIV patients annually reported with HIV in the county, but since the start of the outbreak in late 2014, 188 people have now been diagnosed with the virus in that area. The median age of those affected by the outbreak has been 33 years, with age ranges from 18 to 60. Almost all patients are coinfected with hepatitis C, the physicians noted. The outbreak was associated with the injection of a common prescription painkiller. 

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“Drug use was multigenerational. Some times it was a grandparent, their children, and their grandchildren injecting drugs together,” Dr Brooks explained. He said the total number of injections was between 4 and 15 per day, which, he said was usually because the people who were injecting the drugs were hoping to stave off withdrawal symptoms.

Dr Ramachandran reported data from a CDC-developed tracker, called GHOST, short for Global Hepatitis Outbreaks and Surveillance Technology, which showed that HCV prevalence had been increasing among the area’s injection drug users for some time before the HIV outbreak. Both physicians noted that this increase, combined with a lack of HIV and hepatitis C care in the area – the closest clinics were 45 minutes away before this outbreak – likely contributed to the quick spread. 

“Injection drug use leaves behind footprints … Rates of hepatitis C have been steadily increasing in this part of the country, and if you look at Indiana in particular in 2006, there were very little cases of hepatitis C, but by 2012, this place was experiencing a lot of problems with hepatitis C. This suggests more injection drug use,” Dr Brooks noted. 

Following the first reports of the outbreak, the physicians noted that health officials launched a media awareness campaign, using billboards, news stories, and other sources to get the word out about the rising rates of HIV.

Next, a “one stop shop” for health services was established in the community. This clinic was open 7 days a week, from early morning until late at night, so that people could come in and exchange needles, have access to HIV and hepatitis testing, and, be provided with assistance in enrolling in health insurance plans.


1. Brooks JT. Plenary Session. Evolving Epidemiology of HIV Infection in Persons Who Inject Drugs: Indiana 2015. Presented at: CROI 2016. Feb. 22-25. 2016. Boston.