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In March 2015, the governor of Indiana declared a state of emergency in order to authorize a needle exchange program.
This was done as part of a state health department effort to control an alarming HIV outbreak in a rural southeastern county. Before this outbreak, fewer than five HIV cases were reported annually in the county.1,2
“We have now identified over 150 HIV positive cases. The number of positives is slowing down. I would not say we have it completely under control yet. You can’t just draw a line around it,” state health commissioner Jerome Adams, MD said in an interview in May. “We were able to identify the pattern early. This could have been much worse.”
This is the first outbreak of HIV associated with injection of a prescription painkiller. 2, 3
More than 90% of people infected in the outbreak and interviewed by the Centers for Disease Control and Prevention (CDC) reported dissolving and injecting the prescription opioid Opana as well as sharing drug preparation equipment.
More than 80% of those infected with HIV were also infected with HCV.
In April, the CDC issued a health advisory for primary care providers and state health departments all over the country to be on the alert for HIV and HCV infections in persons who inject drugs (PWID). 1
The Growing Link Between HIV and Prescription Drug Abuse
“Prescription opioid use and opioid overdose is increasing everywhere. These drugs are not coming from robbing pharmacies or from the Internet. Over 80% of these drugs start out as a prescription from a primary care provider. Over 80% of abusers say they got opioids from a friend or family member,” said Joan Duwve, MD, chief medical consultant for Indiana’s state health department.
“In my day, kids would hide behind the bleachers and share a beer. Today they may be sharing pills. Kids say [the pills] are easy to get and think they are safe because they are prescribed. The scary statistic is that one in 15 kids who start abusing prescription opioids will become an IV drug [abuser],” warned Adams.
While HIV in PWID has leveled off, HCV in PWID has skyrocketed since 2010.
Rates are up by about 150%. This coincides with the increase in abuse of prescription opioids and could be the harbinger of a new and emerging HIV epidemic.
“In most cases, HCV precedes HIV and is a marker for high-risk behavior. The HCV epidemic could be the canary in the coal mine,” said Adams.
“This has been called an iatrogenic epidemic. There is plenty of blame to go around, including pharmacies, drug companies, and insurance companies that would rather pay for a pill than a comprehensive approach to pain management. We need to change the perception that opioids are the best treatment for chronic pain,” said. Duwve.
Lessons for State Health Departments
“The first lesson is to know your baseline HIV and HCV numbers. If you don’t know what your baseline is, you could miss the outbreak. The second lesson is to increase testing,” said Adams.
The CDC has issued these recommendations for state health departments:
- Review statistics on HIV and HCV infections, overdose deaths, drug treatment admissions, and drugs arrests, especially in people younger than 35.
- Trace and test all contacts of people with recent HIV or HCV infection.
- Increase access for medication-assisted therapy, needle exchange programs, and other substance abuse services for all PWID.
- Alert ERs, prenatal care, and community-based practices of the importance of opt-out HIV and HCV testing, and report any positive clusters to state health departments and the CDC.
“Opt-out testing is not the same as optional testing. It is the primary care provider’s role to make sure high-risk patients know how important this testing is for them and for everyone else. Finally, we need to change the way we all think about substance abuse. We need to start treating it as the chronic disease that it is,” said Duwve.
There is currently a federal funding ban on needle exchange programs, which is why it took a state of emergency to get one approved in Indiana. Many legislators still view needle exchange as counterintuitive. But needle exchange reduces HIV and HCV. 3
“The needle exchange program can be an opportunity for substance abuse health services. Each touchpoint is an opportunity we need to capitalize on. If we use these touchpoints for harm reduction and not stigmatization, we can start to change the direction of the epidemic,” said Duwve.
“Medication-assisted therapy – substituting a drug like methadone or Vivitrol – can be a tough sell in Indiana. But statistics show that this type of therapy works better for recovery from opioid abuse. We need to do a better job of educating the public about these programs,” said Adams.
Lessons for Primary Care
For primary care providers, the CDC recommends:
- Test all your patients with HIV for HCV and all your patients with HCV for HIV.
- Report all newly diagnosed cases to your state health department.
- Make sure patients diagnosed and being treated are in compliance with treatment.
- Test all contacts of these patients who may have shared needles or had unprotected sex.
- Encourage needle exchange, medication-assisted substance abuse treatment, and counseling.
- When considering opioids for pain control, discuss all the risks and benefits. Keep in mind that there is very little evidence to support opioid use for chronic pain.
“Primary care doctors should not delegate the prescription of opioids to their nurse practitioners or physician assistants. All providers need to ask about high-risk behaviors. Testing for HIV and HCV should be presented as an assertive recommendation. Each encounter is an opportunity to teach and test. We can turn the tide a little bit with each encounter,” said Adams.
Medically reviewed by: Pat F. Bass III, MD, MS, MPH
References
2. The Hill, CDC sounds alarm over Indiana HIV outbreak.
3. Harm Reduction Coalition, Injecting Opana: Indiana’s HIV Outbreak and America’s Opioid Epidemic.
