CDC advises on HIV clusters and outbreaks across US and considerations during pandemic

Oct. 7, 2020

The Centers for Disease Control and Prevention (CDC) reported it has issued a Health Advisory to alert public health departments and healthcare providers to the possibility of new injection-related HIV infections and outbreaks.  

This advisory provides guidance for preventing, identifying, and responding to HIV among people who inject drugs. It also provides considerations for delivering services in the context of the COVID-19 pandemic. 

Since 2015, the CDC and health departments across the United States have identified several HIV clusters and outbreaks occurring predominantly among people who inject drugs (PWID). Long-term declining trends in HIV incidence among people who inject drugs have stalled. 

Although HIV incidence among people who inject drugs declined substantially over many years, the ongoing misuse of opioids and other frequently injected substances are threatening this HIV prevention success. HIV diagnoses among people who inject drugs increased by 11 percent nationally from 2016 to 2018, with more pronounced increases among adults less than 40 years of age and non-Hispanic White adults. The COVID-19 pandemic complicates the delivery of essential services, including services for people who inject drugs, potentially hindering further efforts to address the increase in HIV transmission. 

Multiple recent clusters and outbreaks have contributed to new HIV infections among people who inject drugs. Following a 2015 outbreak in Scott County, Indiana, increases in HIV among people who inject drugs, including several clusters and outbreaks of various sizes, have occurred across the United States in counties that span the rural-urban spectrum. People involved in such clusters and outbreaks frequently shared common characteristics: nonsterile injections multiple times per day; use of multiple substances (often opioids with methamphetamine or cocaine); marginalizing circumstances (homelessness or unstable housing, recent incarceration, exchange of sex for money or goods); and coinfection with hepatitis B virus (HBV), hepatitis C virus (HCV) and sexually transmitted infections (STIs). 

CDC recently published a manuscript that synthesizes experiences and lessons learned from responses to six large HIV outbreaks among people who inject drugs. Although these outbreaks shared similarities, potential precipitating factors varied across outbreak settings. The outbreaks occurred in communities with varying levels of capacity to serve people who inject drugs; all offered some level of harm reduction services, including syringe services programs. Yet as part of outbreak response, health departments identified gaps in the delivery of harm reduction (e.g., limited access to syringe service programs and sterile injection equipment) and other services, highlighting the challenges of engaging a significantly marginalized population. 

Syringe services programs are proven and effective community-based prevention programs that can provide a range of services, including access to sterile syringes and injection equipment, disposal of used syringes, vaccination, testing, naloxone, and linkage to medical care, including treatment for HIV and substance use disorder. Comprehensive syringe services programs and medication for opioid use disorder can independently reduce HIV and HCV transmission by half; when combined, these interventions can reduce transmission by more than two-thirds. 

Health departments can work with trusted community partners to effectively engage people who inject drugs with culturally competent practices. Prompt detection of and response to small numbers of HIV diagnoses may prevent larger outbreaks. 

In the context of COVID-19, ongoing delivery of core clinical and public health services to address HIV and HCV among people who inject drugs is essential. Guidance for alternate means of service delivery when face-to-face services have been disrupted, and for minimizing the risk of SARS-CoV-2 transmission when services are provided in person, is provided in the recommendations. Also, service delivery models can be modified to reduce the number of face-to-face interactions. For example, syringe service programs can offer less restrictive, needs-based syringe distribution that does not limit the number of syringes a client can receive. That encourages clients to distribute sterile injection equipment to their peers who inject drugs (also known as secondary exchange). Fewer in-person visits can also help mitigate the effects of limited hours or closure of syringe service program sites that might occur because of COVID-19. Additionally, needs-based distribution models are the most effective at enabling people to use a sterile syringe with every injection. 

People who inject drugs need comprehensive medical care. Providers and organizations serving people who use drugs can collaborate to ensure that people currently or previously injecting drugs, or who are at high risk of drug injection, have access to culturally competent prevention and care services, including during the context of COVID-19. 

·        Recognize that any clinical encounter is an opportunity to provide multiple clinical and public health services for PWID, especially in the context of COVID-19. 

·         Partner with other organizations to provide comprehensive medical care and services, including

·         Medication for opioid use disorder ((MOUD), also known as medication-assisted treatment, such as buprenorphine, methadone, and naltrexone) or other services for substance use disorder or other mental or behavioral health needs (as appropriate) 

·         Education about safer injection practices and never reusing or sharing needles, syringes, or drug preparation equipment (e.g., cookers, water, filters) for people not yet motivated or able to stop injecting drugs 

·         Screening and treatment for skin and soft tissue and other infections (HIV, HCV, HBV, STIs)

·         Vaccination against hepatitis A and hepatitis B

·         Sterile syringes (e.g., prescribe or refer to a syringe services program or to nonprescription sales through retail pharmacies, where legally permissible) 

·         Naloxone (for overdose reversal) 

·         Pre-exposure prophylaxis (PrEP) to prevent HIV acquisition 

·         HIV post-exposure prophylaxis for persons potentially exposed to HIV through sex or injection within the past 72 hours 

·         Counseling about other strategies to reduce risk of HIV transmission or acquisition, including limiting the number of sex partners and using condoms the correct way every time they have sex 

·         Testing for HIV and HCV at least annually 

·         HIV self-testing or use of a home specimen collection kit may be considered particularly in the context of COVID-19 

If testing confirms HIV or HCV is present: 

·         Rapidly link to care and treatment for HIV, HCV, or both infections to reduce viral load rapidly, improve patient outcomes, and prevent further transmission; and 

·         Encourage injection partners and sex partners of people with HIV or HCV to get tested. 

People who inject drugs can better access the diversity of needed services when services are provided in convenient locations, through mobile service delivery, or when services are co-located and integrated (often referred to as “one-stop shops”). 

Clinical Providers 

When patients present with possible complications of injection drug use (e.g., skin, soft tissue, or bloodstream infections; overdose): 

·         Provide screening for substance use disorder;

·         Recommend and offer HIV, HCV, and STI testing;

·         Vaccinate against hepatitis A and hepatitis B; and

·         Offer or refer for substance use disorder treatment, including MOUD.

·         Report cases of newly diagnosed HIV or HCV to the health department.

·         Remain alert to, and notify the health department of, increases in or clusters of HIV or HCV diagnoses.

·         Monitor adherence and offer adherence support for PWID who receive medication for opioid use disorder or treatment for HIV, HCV, or both infections.

·         Connect patients with community resources, including harm reduction or syringe services programs, to ensure access to sterile syringes and to address other social and behavioral health needs.

·         If syringe services programs are not available, provide prescriptions for syringes or information about nonprescription pharmacy sales, in accordance with local laws.

·         Collaborate with public health officials to implement or expand routine opt-out HIV and HCV testing for PWID in settings such as correctional facilities, emergency departments, substance use disorder treatment centers, and community-based medical practices that are frequented by people who inject drugs.

·         Consult guidance for managing people with HIV who develop COVID-19 

Public Health Officials 

·         Ensure contact tracing for all new HIV diagnoses.

·         Encourage HIV, HCV, and STI testing of all sex and injection partners and social contacts.

·         Consider retesting PWID, those engaging in high-risk sexual behavior, and those who have partners with HIV at least annually.

·         Routinely monitor your public health data to ensure timely identification of: Recent increases in HIV diagnoses attributed to injection drug use, and recent increases in HCV diagnoses, particularly among people younger than 40 years of age.

·         Remain alert to high rates of or increases in homelessness or unstable housing, injection drug use, overdose events and deaths, admissions for drug treatment, and drug arrests.

·         Alert community partners to the potential for HIV outbreaks among people who inject drugs.

·         Work with community partners trusted by PWID to identify and strengthen policies and partnerships to enable rapid response to potential HIV outbreaks. Trusted partners may include those serving people experiencing homelessness or unstable housing, and substance use disorder treatment and recovery programs.

·         Work with clinical providers in settings frequented by people who inject drugs to implement or expand routine opt-out HIV and HCV testing for PWID. These settings may include correctional facilities, emergency departments, substance use disorder treatment centers, and community-based medical practices.

·         Implement or increase street-outreach testing or home testing or specimen collection.

·         Improve access to sterile syringes and injection equipment by establishing syringe services programs; amending policies to offer less restrictive, needs-based, and non-punitive syringe distribution models that promote secondary exchange; or increasing access to nonprescription syringe sales from retail pharmacies, in accordance with local laws.

·         Establish collaborations to improve coordination of essential services for people who inject drugs with key partners, including: Clinics funded by the Health Resources and Services Administration’s Ryan White HIV/AIDS Program (RWHAP) and Health Center Program, which provide critical access points for health care and support services for people with HIV and people at risk for acquiring HIV Harm reduction coalitions, community-based organizations that serve PWID or people experiencing homelessness and behavioral health providers

·         Engage with people who currently inject (or formerly injected) drugs as partners in developing recommendations for establishing or expanding essential services for PWID. 

Additional Services in the Context of COVID-19 

When services are provided in person, guidance is available for minimizing risk of COVID-19 transmission in clinical and field-based settings. When face-to-face services have been disrupted, monitor service delivery and consider alternate means to ensure services reach the needed population. 

Consult guidance for delivering specific services in the context of COVID-19, including:

·         HIV testing

·         PrEP

·         Syringe services programs (where legally permissible)

·         STI clinical services

·         Substance use disorder treatment

·         HIV medical care and antiretroviral therapy 

When PWID need HIV care, discuss the risks and benefits of in-person visits versus telephone or virtual visits in the context of COVID-19. Factors to consider include the extent of local COVID-19 transmission, the health needs that will be addressed during the appointment, and the person’s HIV status (e.g., CD4 cell count, HIV viral load) and other underlying medical conditions. Telephone or virtual visits for routine or non-urgent care and adherence counseling may replace face-to-face encounters. 

In the context of COVID-19, communicate options for clients to obtain extended supplies of medications such as antiretroviral therapy (ART), PrEP, and PEP through mail order. 

Clinical and public health encounters with people who inject drugs present additional opportunities to address COVID-19 risks. 

To protect themselves and others from COVID-19, provide PWID with access to face masks, hand sanitizer, and education about avoiding close contact and other steps to reduce risk of exposure.

Screen PWID for symptoms of COVID-19. For those with suspected or confirmed COVID-19: 

·         Provide or refer for urgent or non-urgent medical care, if necessary.

·         Isolate from other people to prevent spreading of infection.

·         Local health departments, housing authorities, homeless service systems, and healthcare facilities should plan to identify locations to isolate those with known or suspected COVID-19 until they meet the criteria to end isolation.

·         Consult guidance to assist people experiencing homelessness in the context of COVID-19. 

CDC has the advisory

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