An HIV Outbreak Among People Who Inject Drugs in Cabell County, West Virginia, 2018–2019

Cabell County, West Virginia — population approximately 91,900, home to the city of Huntington — had long had high rates of substance use disorder but low rates of HIV. From 2013 to 2017, it averaged two HIV diagnoses a year among people who inject drugs. In 2018 there were 14, seven of them in the last quarter. State surveillance staff noticed the rise in January 2019, and the West Virginia Bureau for Public Health asked CDC for help.

Conditions that let HIV spread

The investigation, by the state, the Cabell-Huntington Health Department and CDC, found:

• limited access to HIV testing and to PrEP, the medicine that prevents HIV
• a harm reduction program with sterile syringes, running since September 2015, that had tightened its rules in May 2018 — requiring proof of county residency — cutting access
• low awareness of HIV, of the outbreak and of treatment for substance use disorder
• few people who inject drugs starting treatment for HIV or substance use disorder

Who was affected

A case was a new HIV diagnosis from January 1, 2018 to October 9, 2019 in a person who injects drugs with ties to the county, a sex or needle-sharing partner of such a person, or someone whose virus was genetically linked to theirs. By January 26, 2020, 82 people met that definition.

Two findings showed the virus was spreading fast:

• Among 61 people whose CD4 count was measured within three months of diagnosis, the median was 583 — high enough to show many infections were recent.
• Of 50 people with a genetic sequence result, 46 (92%) belonged to a single cluster of closely related infections.

The response

State, local and CDC staff and community partners scaled up quickly:

• CDC staff helped interview newly diagnosed people and offered prevention services to approximately 600 partners and social contacts.
• Screening events tested people at high risk, taught about HIV, and linked or re-linked people to care.
• HIV testing expanded at hospitals, clinics, addiction treatment providers and community groups where people who inject drugs get services.
• A peer-recruitment social network strategy reached people outside the harm reduction program and their contacts.
• Local infectious disease providers improved linkage to HIV and hepatitis C care.
• Interviews with people who exchanged sex for money or drugs identified barriers — stigma, discrimination, and the location and hours of services.
• New providers were trained to prescribe PrEP, now offered at the health department and two community health systems.
• Education campaigns covered HIV, substance use disorder, stigma, PrEP, safe injection and safe syringe disposal.

About 450 new clients joined the harm reduction program, approximately 50 of them living with HIV. The state continues the response and is strengthening surveillance to catch and answer other clusters statewide.

Sources

Based on Atkins A, McClung RP, Kilkenny M, et al., "Notes from the Field: Outbreak of Human Immunodeficiency Virus Infection Among Persons Who Inject Drugs — Cabell County, West Virginia, 2018–2019," MMWR Vol. 69, No. 16, CDC, with the passage cut off in the imported copy completed from the same report in PubMed Central (PMC7188413); a work of the United States government in the public domain.