The number of confirmed cases of HIV in southeastern Indiana has climbed to 136 since November 2014, with six additional preliminary cases, CDC officials said Friday.
Approximately four out of five infected patients have reported injection drug use, and others have been named by partners as injection drug users, said , chief medical consultant of the Indiana State Department of Health, in Indianapolis, during a CDC telebriefing.
Coinfection with the hepatitis C virus (HCV) has been diagnosed in nearly 85% of patients, according to the CDC's (MMWR) released today.
In the past, fewer than five cases of HIV per year have been reported in Scott County, where a majority of the current infections have been.
Infections From Injections
"This is the first outbreak of its type that we have seen documented in recent years," said , director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, in Atlanta.
The rise in injecting oral opiates has presented new challenges for the public health system, Mermin added. "We have not seen an outbreak of HIV specifically associated with the injection of oral opiates previously."
The majority of cases have been linked to residents dissolving and injecting tablets of the prescription opioid oxymorphone (Opana ER) using shared syringes.
Injection drug use is a group activity in this population, with as many as three generations of a family along with multiple community members injecting together, wrote of the Indiana State Department of Health and colleagues in MMWR.
Patients have ranged in age from 18 to 57 years and are on average 35 years old. A total of nearly 55% are male.
Although Opana comes in an abuse deterrent form, users have found a way to "get around" that mechanism, said , Indiana's State Health Commissioner.
"It's important that we all understand that just because a drug comes in an abuse deterrent form, that doesn't automatically make it safe," he said.
The half life of Opana is approximately 4 hours and users begin to feel sick around this time, said Duwve. "We have heard that folks are injecting from 4 to over 10 times a day," she added.
The crushed drug is less dissolvable than heroin, requiring users to utilize a higher gauge needle to inject, Adams added. "That is making the sharing of needles an even higher risk activity, because you're being inoculated with higher amounts of HIV virus."
Indiana's Response
Needle exchange programs are currently illegal in Indiana.
In late March, Governor Mike Pence (R) signed an executive order authorizing a 30-day needle exchange program. He extended the program for another 30 days this past Monday.
Needle exchange alone is minimally effective, so it must be part of a comprehensive response, said Adams.
Indiana is taking a four-pronged approach to the outbreak, he added, including the development of a "one-stop shop" that provides testing, treatment, and follow-up; a needle-exchange program operated by the Scott County Health Department; a public awareness campaign; and additional HIV testing and treatment at a local health clinic.
The state also has a prescription drug monitoring program that lets health officials give physicians feedback about their prescribing habits, Adams said.
Part of a Larger Problem
Mermin warned that nationwide there has been a steep increase in the inappropriate prescribing of opioids that has contributed to addiction, overdoses, and increased infections.
"This outbreak that we're seeing in Indiana is really the tip of an iceberg of a drug abuse problem that we see in the U.S. that is ... putting people at very high risk for infectious diseases," he said.
The CDC released a to alert healthcare providers and health departments of the HIV outbreak and HCV coinfection.
The advisory contained recommendations about how to identify and prevent the spread of HIV and HCV and urges providers to refer patients with substance abuse problems for medication-assisted treatment and counseling.