Opioid Injection in Rural Areas Presents a Challenge to Ending HIV Epidemic in US

Jaime Rosenberg

As the United States continues to roll out initiatives to end the HIV epidemic by 2030, there are several challenges that stand in the way, including opioid injection in rural areas, according to a viewpoint appearing in JAMA.

Written by Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Disease (NIAID), and Andrea M. Lerner, MD, a clinical associate at NIAID, the viewpoint paints a picture of a challenge that is 2-fold: a growing amount of people are injecting opioids in rural communities, which is an emerging risk factor for HIV transmission, and these communities often lack the infrastructure or resources to prevent, diagnose, and treat HIV.

“Although injection opioid use can lead to various infectious complications, including viral hepatitis, infective endocarditis, osteomyelitis, and skin and soft tissue infections, the epidemic of injecting opioids in rural areas of the United States is especially significant as an emerging risk factor for HIV transmission,” they write.

The pair reflected on recent outbreaks in Lawrence and Lowell, Massachusetts, and the notable 2014 outbreak in Scott County, Indiana, which was driven by injection of the extended-release formulation of oxymorphone. In response to the Scott County outbreak, in 2015, a public health emergency was declared in a state executive order and the county implemented efforts to slow the outbreak, including a temporary syringe exchange program and expanded access to HIV testing, treatment, and other services.

Throughout the entirety of the outbreak, more than 200 people in a community of approximately 4400 had been diagnosed with HIV. In its aftermath, the CDC pinpointed 220 counties across 26 states that they considered vulnerable to an outbreak. They focused on people who inject drugs and identified factors associated with the rate of acute hepatitis C virus infection as a proxy for unsafe injection drug use (IDU). Using these factors, the CDC created a vulnerability score for counties.

Among the 220 counties, the overwhelming majority were rural, and the top 10% were in Kentucky, West Virginia, and Tennessee. As of last year, less than a quarter of the counties had implemented needle and syringe exchange programs.

“If an outbreak of the size that occurred in Scott County, Indiana, occurred in each of the vulnerable counties without access to needle and syringe exchange programs, the number of new HIV diagnoses in the United States would increase substantially,” wrote Fauci and Lerner. “This lack of harm-reduction services threatens to reverse decades of progress and recapitulate the devastating effects that IDU-related transmissions had during the earlier years of the HIV epidemic in the United States.”

While the ultimate goal is to address the epidemic of injecting opioids, until the issue is controlled, the pair argues that it is crucial to aggressively address infectious complications of the epidemic. In addition to the implementation of needle and exchange programs, interventions include pre-exposure prophylaxis and antiretroviral therapy treatment to suppress viral load.

Lerner A, Fauci A. Opioid injection in rural areas of the United States [published online August 1, 2019] JAMA. doi: 10.1001/jama.2019.10657.
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