The Anatomy of an HIV Outbreak Response in a Rural Community

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Drug abuse with people sharing the same syringe to inject heroine

In a small, rural town in Southern Indiana, a public health crisis emerges.  In a community that normally sees fewer than five new HIV diagnoses a year, more than a hundred new cases are diagnosed and almost all are coinfected with hepatitis C virus (HCV).

How was this outbreak discovered, and what caused this widespread transmission? Indiana state and local public health officials – supported by CDC – set out to answers these questions and help stop the spread of HIV and HCV in this community.

The Outbreak

In January 2015, Indiana disease intervention specialists noticed that 11 new HIV diagnoses were all linked to the same rural community.  This spike in HIV diagnoses in an area never before considered high-risk for the spread of HIV, launched a larger investigation into the cause and impact of these related cases.

The investigation began by investigating the 11 newly diagnosed cases. This process involved talking to newly diagnosed individuals about their health and sexual behaviors, as well as past drug use. In the United States, HIV is spread mainly by having sex or sharing injection drug equipment such as needles with someone who has HIV.

Scanning electron micrograph of HIV-1 virions budding from a cultured lymphocyte.
Scanning electron micrograph of HIV-1 virions budding from a cultured lymphocyte.

In the case of the 11 related diagnoses in Indiana, almost all were linked to injection drug use. Investigators discovered that syringe-sharing was a common practice in this community–often used to inject the prescription Opana; opioid oxymorphone (a powerful oral semi-synthetic opioid medicine used for pain.)  HIV can be spread through injection drug use when injection drug equipment, such as syringes, cookers (bottle caps, spoons, or other containers), or cottons (pieces of cotton or cigarette filters used to filter out particles that could block the needle) are contaminated with HIV-infected blood. The most common cause of HIV transmission from injection drug use is syringe-sharing. Persons who inject drugs (PWID) are also at risk for HCV infection. Co-infection with HCV is common among HIV-infected PWID. Between 50-90% of all persons who inject drugs are infected with both HIV and HCV.

The Investigation

“Contact tracing” is the process of identifying all individuals who may have potentially been exposed to an ill person, in this case a person infected with HIV.  Contact tracing involves interviewing the newly diagnosed patients to identify their syringe-sharing and sex partners.  These “contacts” are then tested for HIV and HCV infection, and if found infected are likewise interviewed to identify their syringe-sharing and sex partners. This cycle continues until no more new contacts are located.

As of May 18, contract tracing and increased HIV testing efforts throughout the community identified 155 adult and adolescent HIV infections. The investigation has revealed  that injection drug use in this community is a multi-generational activity, with as many as three generations of a family and multiple community members injecting together and that due to the short half-life of the drug, persons who inject drugs may have injected multiple times per day (up to 10 in one case). may be needed .

Early HIV treatment not only helps people live longer but it also dramatically reduces the chance of transmitting the virus to others.  People who do not have HIV and who are at high risk for HIV can also benefit more directly from the drugs used to treat HIV to prevent them from acquiring HIV.  This is known as pre-exposure prophylaxis (PrEP). Post-exposure prophylaxis, or PEP, is an option for those who do not have HIV but could have been potentially exposed in a single event.

The Response

HIVTesting_Eng_webSo what is the next step in addressing this staggering outbreak? First, public health officials must work to get every person exposed to HIV tested. All persons diagnosed with HIV need to be linked to healthcare and treated with antiretroviral medication. Persons not infected with HIV are counseled on effective prevention and risk reduction methods; including condom use, PrEP, PEP, harm reduction, and substance abuse treatment. Getting messages about the benefits of HIV treatment to newly diagnosed individuals and prevention information to at-risk members of the community are key components to control this outbreak.

The underlying factors of the Indiana outbreak are not completely unique. Across the United States, many communities are dealing with increases in injection drug use and HCV infections; these communities are vulnerable to experiencing similar HIV outbreaks. CDC asked state health departments to monitor data from a variety of sources to identify jurisdictions that, like this county in Indiana, may be at risk of an IDU-related HIV outbreak.  These data include drug arrest records, overdose deaths, opioid sales and prescriptions, availability of insurance, emergency medical services, and social and demographic data. Although CDC has not seen evidence of another similar HIV outbreak, the agency issued a health alert to state, local, and territorial health departments urging them to examine their HIV and HCV surveillance data and to ensure prevention and care services are available for people living with HIV and/or HCV.

The work that has been done thus far, as well as the continued efforts being made to address this response, highlight importance of partnerships between federal, state and local health agencies. The work done by Indiana State Department of Health’s disease intervention specialist to link the initial HIV cases to this rural community, and the work of the local health officials to respond quickly and thoroughly to investigate all possible exposures and spread important health prevention information demonstrates the critical importance of strong public health surveillance and response.

The Division of HIV/AIDS Prevention commends the efforts of all the individuals involved in controlling the HIV outbreak in Indiana. The response illustrates that together we are committed to improving the health of our communities across the nation.




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9 comments on “The Anatomy of an HIV Outbreak Response in a Rural Community”

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    Incredible collaborative work. The case is unusual and shocking but so much can be learned from it. I try to share the CDC case submissions or the explanations of other events/disease with work colleagues. I am a nurse in a rural clinic.

    This is great news about how to stop the spread of H.I.V-AIDS. One method, However, that was not sufficiently addressed, is how to create effective public education programs that focus on multi-cultural issues, religious and political concerns. Public policy response must involve the church, community life and political life of people. This is where people are naturally gathered. Barriers must be broken down so the public can recognize that one’s attitude towards others sexual preferences and behavior and, drug use choice ought not to prevent society, and public and religious leaders and officials, from doing their best to address the issue of H.I.V-AIDS and drug abuse as public policy, and community challenges. Therefore, before this situation reach a critical mass, the greatest barrier to change, that ought to be broken down, is the mobilizing of all well-thinking persons, to help in get at-risks person to help in changing risky behavior. Meanwhile, Keep up the good work.

    Thank you very much for sharing this information. I have learned a lot especially on the contact tracing. How is convincing people to take the test like? In Africa, most people shy away from such tests which leads to more and more infections in the sexual social network. What kind of approach is employed by the state officials and the health experts to bring everyone on board?

    I really enjoyed reading about the process of tracking the outbreak in Indiana. It gives great insight onto how we get the information these diseases in the news. It also goes to show how we more education on how HIV can spread is a great idea. In Southern and Eastern Africa, a report showed that when education of people rose from 28% to 45%, HIV infection rate was halved between the years 2001 and 2009. Applying the same principal of education to the US even in areas we think have enough education could help prevent outbreaks like the one discussed from occurring.

    This article provides a great example of using “contact tracing” to identify individuals potentially exposed to HIV/HCV infections. Identification of this outbreak and the subsequent collaborative effort of the local and state public health agencies will undoubtedly make an impact on this at risk population. While the focus of this article was the response to an outbreak of HIV/HCV infections, the circumstances behind the dramatic increase in cases of new diagnoses lead into a pertinent related public health issue, IV drug use. Could an accessible needle exchange program have prevented this outbreak?

    The Indiana case showed the importance of continuous public health surveillance particularly in rural areas which are generally underserved medically. The process of contract tracing’s success largely depend not only on the techniques of public health practitioners but also on the collaboration of community members within the target community.

    This was a great example of how important community education programs are. This situation, while unique, is not uncommon for many communities in the United States. Preventative care is essential to avoid future outbreaks such as this. Education regarding the transmission of HIV and frequent testing for high risk individuals could assist the community in having a better understanding of how to avoid transmitting HIV and other communicable diseases. I also agree with Dana’s suggestion. I think that an easily accessible needle exchange program could be beneficial for this community.

    This was a really interesting article. I normally hear personal stories of HIV being contracted through sexual acts rather than needle sharing. It is important to hear about all of the ways this disease can be passed on. It was also interesting to see how public health officials reacted to an outbreak like this.

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Page last reviewed: November 3, 2015
Page last updated: November 3, 2015