Opioid Injection in Rural US is Challenging Efforts to End the HIV Epidemic

It’s no secret that the opioid crisis in the United States has presented new challenges for various areas of public health. An increase in injection opioid abuse has been linked to everything from hepatitis A outbreaks to wound infections to endocarditis and, of course, the HIV epidemic in the United States.

In February’s State of the Union address, President Trump announced his plan to end the HIV epidemic in the United States. The plan seeks to decrease the number of new HIV infections in the United States by 75% in 5 years, 90% in 10 years, and ending the epidemic once and for all by 2030.

In a new viewpoint published in JAMA, Andrea M. Lerner, MD, and Anthony S. Fauci, MD, both of the National Institute of Allergy and Infectious Diseases, address how injection opioid use in rural communities in the United States is a growing threat to attaining the goal of ending the HIV epidemic.

“This public health crisis is fueling a growing epidemic of people injecting opioids, especially in rural communities as individuals with opioid use disorder shift from taking prescribed oral opioids to injecting prescribed or illicit opioids,” the authors write.

Although injection drug use (IDU) has been linked with the HIV epidemic since the early ’80s, the rise of opioid injection use in rural American communities has increased the HIV risk in populations that are both demographically and geographically distinct from previously identified high-risk groups. Since 1999 nearly 400,000 people in the United States have died from opioid overdoses, with 47,600 deaths in 2017 alone.

This creates a complex situation, as some communities with historically low rates of HIV infection are now experiencing increased risks for HIV transmission and do not have the infrastructure or resources to control the situation.

Fauci and Lerner present the example of an HIV outbreak that was detected in Scott County, Indiana, in November of 2014, driven by the widespread injecting of an extended-release formulation of oxymorphone among the community.

On March 26, 2015, a public health emergency was declared in response to the outbreak. At the conclusion of the outbreak, more than 200 new cases of HIV had been confirmed in a community with a population of approximately 4400 residents.

An epidemiological analysis of the outbreak was conducted and through viral molecular sequencing health investigators determined that the HIV transmission in the county likely began in 2011 with accelerated growth occurring in 2014, suggesting that most of the infections transmitted during this outbreak had already occurred by the time the public health emergency was declared in 2015.

Following this outbreak, the US Centers for Disease Control and Prevention developed a vulnerability score using factors associated with the rate of hepatitis C infection as a proxy for unsafe IDU to identify counties at higher risk for HIV transmission. In total, 220 counties across 26 states were identified. For perspective, according to the 2016 US Census, there are 3141 counties in the nation, indicating that approximately 14% of America’s counties are vulnerable to the rapid spread of HIV among people who inject drugs.

Overall, the counties are “overwhelmingly rural” and the top 10% of the counties are located in Kentucky, West Virginia, and Tennessee. It is also concerning that fewer than a quarter of the 220 vulnerable counties were operating needle and syringe exchange programs, which have proven effective elsewhere.

These programs provide access to sterile injection equipment and facilitate safe disposal of used equipment, while also offering sexual health services and referrals for substance use disorder treatment.

“This lack of harm-reduction services threatens to reverse decades of progress and recapitulate the devastating effects that IDU-related HIV transmission had during earlier years of the HIV epidemic in the US,” Fauci and Lerner write.

How can this challenge be addressed?

According to the authors, the key is to employ interventions to prevent IDU-related HIV transmissions, including syringe programs, pre-exposure prophylaxis, and antiretroviral treatment to suppress viral loads.

Despite the barriers to adherence of prevention and treatment methods, the authors indicate that using a proactive strategy is fundamental to reducing the HIV transmission. It is also critical to offer sexual health services including HIV testing, counseling, and linkage to care in order to improve early detection of HIV transmission and prevent further outbreaks.

Failure to correct the misperception that HIV cannot affect previously uninvolved communities, along with neglecting to implement HIV prevention and treatment tools, will in turn increase the risk of a rebound in the incidence of IDU-related HIV cases, which would be an obstacle to ending the HIV epidemic in the US.