Seattle HIV Case Cluster Stark Reminder of Risks to Homeless: Public Health Watch

The suffering continues for a group of homeless people in the Seattle area already dealing with substance abuse problems.

On August 30, 2018, Seattle and King County public health officials announced that they had discovered an HIV case cluster involving 8 people—all of whom were homeless, heterosexual, and regular users of injection drugs—in the North Seattle neighborhood through “a combination of routine HIV testing, investigation of newly reported cases and HIV testing outreach efforts.”

Several of the individuals who tested positive admitted to “exchanging sex for money or drugs,” prompting officials to express concern that more new cases among heterosexuals who use injection drugs and those who have unprotected sex with them in exchange for money and/or drugs may emerge.

Contagion® recently documented the unique health risks faced by urban homeless populations. And, unfortunately, case clusters of infectious diseases such as HIV and hepatitis C linked with opioid abuse are hardly anything new as well.

“Many people who use opioids in Seattle are homeless, and these 2 factors together put them at higher risk for HIV,” Julie Dombrowski, MD, MPH, deputy director, public health—Seattle & King County HIV/STD Program, and associate professor of medicine, University of Washington, told Contagion®. “They can acquire HIV through sharing syringes, which people are more likely to do if they lack access to clean injection equipment. When people are dealing with homelessness and a substance use disorder, they are less likely to use effective HIV prevention tools like condoms and HIV pre-exposure prophylaxis.”

Interestingly, though, at least in the Seattle area, HIV infection has historically been more closely linked with methamphetamine than opiate use, according to local officials, although there is some evidence suggesting that individuals are increasingly using both drugs. In King County, public health officials estimate that 2% of heterosexuals who inject drugs are infected with HIV. Overall, in 2018, there have been 19 confirmed cases of HIV among heterosexuals who inject drugs, well above the annual average of 10 cases and the 7 diagnosed cases for all of 2017.

“Many people in Seattle who use opioids also use methamphetamine, which increases the risk for getting HIV through sex,” Dr. Dombrowski said.

Notably, King County was among the first counties in the United States to achieve the 90-90-90 goals established by the World Health Organization (WHO) and UNAIDS—which call for governments to reach levels of having 90% of infected persons knowing their diagnosis, 90% of those diagnosed in care, and 90% of those in care virally suppressed (meaning they can’t transmit the virus) by 2020.

To address the current cluster of cases and decrease the risk for additional infections, local officials in Seattle and King County have augmented existing outreach and testing programs, worked to enhance educational initiatives for at-risk populations, and provided additional case management for newly-identified individuals, among other steps. Local hospitals have also stepped in to offer HIV testing in emergency departments and to distribute sterile injection equipment and condoms through needle exchanges.

Unfortunately, such needle exchange programs have been viewed negatively in some communities across the country. Still, there have been several success stories, and in Seattle, officials reported September 7, 2018, that no new cases have been added the existing cluster.

“[A number of organizations] have been working hard to improve health services for people who are homeless and for people who are injecting drugs,” Dr. Dombrowski noted. “That said, we clearly need to keep working to reach this population more effectively. We need to make sure that everyone who injects drugs has access to clean injection equipment through syringe services programs and, if they use opioids, to medication-assisted treatment. We need to find better ways of getting condoms, HIV/STD testing, and HIV pre-exposure prophylaxis to particularly vulnerable and marginalized populations like those who inject drugs and are homeless.”

“Homelessness has increased drastically in Seattle and King County over the last few years, and we need to keep working to change this,” she continued. “A lot of cities and states are trying to figure out how to improve HIV prevention for persons who inject drugs in the context of our country's massive opioid epidemic. In [Canada], Vancouver has been very proactive in working to improve the health of people who inject drugs, but they were also caught off-guard by drastic increases in overdoses there when the drug supply changed. I think we are all struggling to do better…”

For communities such as North Seattle. And, sadly, elsewhere.

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous health care-related publications. He is the former editor of Infectious Disease Special Edition.