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On February 5, 2019, President Trump announced in the State of the Union Address a plan to decrease the number of new HIV infections in the US by 75% in 5 years and by 90% in 10 years, thereby ending the United States HIV epidemic by 2030. The details of this plan were recently discussed in a Viewpoint1 that pointed out that the tools are already at hand to accomplish this goal in the form of prevention and treatment modalities, notably, antiretroviral therapy for individuals with HIV infection and preexposure prophylaxis (PrEP) for people at increased risk of HIV infection, as well as access to needle and syringe exchange programs and treatment of opioid use disorder when needed. Implementation of these tools in the demographic and geographic hot spots of infection will be critical to the success of the plan. However, an insidious threat to the achievement of this goal is a growing risk factor for HIV transmission—opioid injection in rural areas of the United States—that involves demographically and geographically distinct populations from those seen earlier in the HIV epidemic.
Injection drug use (IDU) has been associated with the HIV epidemic since the first reports of AIDS in 1981. In the United States, the proportion of HIV transmission attributable to IDU (considering IDU, combination IDU, and male-to-male sexual contact risk groups) reached a high of more than 30% in the early 1990s. This proportion has gradually declined to less than 10% in recent years and represents a major achievement in HIV prevention in the United States.2 Although multiple factors are responsible for this decrease, needle and syringe exchange programs have clearly been among the most important and effective. Needle and syringe exchange programs provide access to sterile injecting equipment and facilitate safe disposal of used equipment. In addition to serving as a vital tool to prevent IDU-associated transmission of HIV, these programs often offer other services as well, such as referrals for treatment of substance use disorder and sexual health services, testing for HIV and viral hepatitis, and linkage to HIV care.
The United States is currently facing an opioid crisis, rooted in a quadrupling of opioid pain reliever prescriptions between 1999 and 2010, and an increased incidence of opioid use disorder.3 From 1997 to 2011, there was a 900% increase in people seeking treatment for opioid use disorder,4 and since 1999, almost 400 000 people have died of opioid overdoses, with 47 600 deaths in 2017 alone.3 This public health crisis is fueling a growing epidemic of people injecting opioids, especially in rural communities, as individuals with opioid use disorder shift from taking prescribed oral opioids to injecting prescribed or illicit opioids.5 According to pooled data from the National Survey on Drug Use and Health conducted annually from 2002 through 2011, four of 5 heroin users reported that their opioid use began with prescription opioid pain relievers.4
Although injection opioid use can lead to various infectious complications, including viral hepatitis, infective endocarditis, osteomyelitis, and skin and soft tissue infections,3 the epidemic of injecting opioids in rural areas of the United States is especially significant as an emerging risk factor for HIV transmission. In this regard, communities with historically low rates of HIV infection are now at risk of increased rates of HIV transmission. These communities often lack the infrastructure or resources to prevent, diagnose, and treat HIV. Outbreaks of HIV transmission due to injecting opioids, along with multiple other smaller clusters, have recently been reported in Lawrence and Lowell, Massachusetts,3 and most notably in Scott County, Indiana, detected in November 2014 and driven by injection of the extended-release formulation of the prescription opioid oxymorphone. When the Scott County outbreak was over, more than 200 people in a community of about 4400 had been diagnosed with HIV.6
Preventing outbreaks of HIV infection is always preferable and more effective than responding to the outbreak once it has occurred. On March 26, 2015, a public health emergency was declared in a state executive order in response to the outbreak of HIV transmissions in Scott County, Indiana. Official response efforts included permission to start a temporary syringe exchange program, as well as expanded access to HIV testing, treatment, and other services.7 An analysis combining epidemiological and viral molecular sequencing data suggested that HIV transmissions in Scott County first began in 2011 and underwent an accelerated growth phase in 2014 and suggested that most new infections had likely already occurred by the time the public health emergency was declared in 2015.6
In the aftermath of the Scott County outbreak, the Centers for Disease Control and Prevention identified 220 counties in 26 states vulnerable to the rapid spread of HIV among people who inject drugs by identifying factors associated with the rate of acute hepatitis C virus (HCV) infection as a proxy for unsafe IDU, and used these factors to create a vulnerability score.5 The 220 counties are overwhelmingly rural, and the top 10% are in Kentucky, West Virginia, and Tennesee.5 As of 2018, fewer than a quarter of the 220 vulnerable counties identified were operating needle and syringe exchange programs.7 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. This lack of harm-reduction services threatens to reverse decades of progress and recapitulate the devastating effects that IDU-related HIV transmissions had during earlier years of the HIV epidemic in the United States.
Paramount to the prevention of infectious complications of injecting opioids is addressing the epidemic of injecting opioids. In this regard, there is an ongoing attempt to vigorously contain and eliminate this compelling public health problem.3 However, until this problem is controlled, it is essential to aggressively address the complications at hand. In 2019, interventions are available to prevent IDU-related HIV transmissions, namely needle and syringe exchange programs, PrEP, and antiretroviral treatment of HIV infection to suppress viral load; these approaches must be fully implemented where they are needed most. PrEP recently received an A recommendation from the US Preventive Services Task Force,8 ensuring that all private insurers must pay for this treatment. Merely responding to outbreaks of IDU-related HIV transmissions as or after they occur is not good enough. To end the HIV epidemic, these preventive interventions, along with other services on the harm reduction continuum, including access to HIV testing, counseling, and treatment of HIV and concomitant substance abuse disorders must be preemptively accessible to these vulnerable rural communities. Although there are significant challenges with encouraging uptake of these services, addressing these at-risk communities using a proactive strategy is fundamental to reduce HIV transmissions, as well as to improve earlier detection and mitigation of outbreaks. The challenges of stigmatization must also be addressed, both for people who inject drugs and for people living with HIV. This, as well as the misperception that HIV cannot affect previously uninvolved communities, are well-recognized barriers to the successful implementation of these interventions.
In summary, to achieve the goal of ending the HIV epidemic in the United States, the emerging epidemic of opioid injection in rural areas, which represents an important risk of accelerated HIV transmission, must be addressed. Interventions are available to mitigate that risk, and it is essential to implement these tools proactively. Failure to do so increases the risk of a substantial rebound in the incidence of IDU-related HIV that would be an obstacle to the success of the plan to end the HIV epidemic in the United States within the next 10 years.1
Corresponding Author: Anthony S. Fauci, MD, Office of the Director, National Institute of Allergy and Infectious Diseases, 31 Center Dr, MSC 2520, Bldg 31, Room 7A-03, Bethesda, MD 20892-2520 (email@example.com).
Published Online: August 1, 2019. doi:10.1001/jama.2019.10657
Conflict of Interest Disclosures: Dr Lerner is a clinical associate at the National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health; Dr Fauci is director of the NIAID.
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Lerner AM, Fauci AS. Opioid Injection in Rural Areas of the United States: A Potential Obstacle to Ending the HIV Epidemic. JAMA. Published online August 01, 2019. doi:10.1001/jama.2019.10657
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