Opioid-HIV connection a troubling trend

Drug syringe, amphetamine tablets, and cooked heroin

December 22, 2016 — Opioid abuse has become a major public health problem in the U.S. According to the Centers for Diseases Control (CDC), overdose deaths involving prescription opioids increased to about 19,000 deaths in 2014, more than four times the number in 2000. In 2012, according to the National Institute on Drug Abuse, an estimated 2.1 million people suffered from substance use disorders related to prescription opioid pain relievers, with an estimated 467,000 addicted to heroin.

Heroin and other opioids are often injected. According to Harm Reduction International, HIV prevalence is 28 times higher in people who inject drugs compared with the rest of the population.

On December 1, World AIDS Day, a symposium, “HIV and Opioids: Crisis in Indiana, Boston, and Beyond,” explored that connection. The event sponsored by the Harvard T.H. Chan School of Public Health AIDS Initiative, was moderated by Roger Shapiro, associate professor of immunology and infectious diseases at Harvard Chan School and an infectious disease physician at Beth Israel Deaconess Medical Center in Boston.

“I see a lot of the effects of opioids and HIV in my clinical work in Boston,” said Shapiro. “You can get HIV because someone else’s blood is contaminating the syringe and you can get HCV [Hepatitis C] because of that too.” He frequently sees cases of endocarditis, a bacterial infection of the heart valves, that can also be caused by contaminated syringes.

In 2015, experts were caught off guard when an HIV epidemic exploded in the rural Indiana town of Austin, which had a population of just over 4,000. Speaker John T. Brooks, who heads the CDC’s Epidemiology Research Team in the Division of HIV/AIDS Prevention, explained that prescription painkillers were being ground up and injected, often with shared needles, an easy route for HIV transmission.

Austin is in Scott County, which in addition to high unemployment and poverty, has the lowest life expectancy in Indiana. According to Brooks, as of February 2016, 188 cases of HIV were reported in the county, an HIV prevalence of 4.6 %. Eighty percent of the cases were in Austin.

“I think this is unprecedented, at least in the continental United States, to have such a concentrated outbreak of HIV infections. We know, having examined the virus and some of its aspects, that all of these infections were related and that they occurred very quickly,” said Brooks.

HIV treatment services, almost non-existent in Austin at the time of the outbreak, were put in place, along with interventions to reduce the risk of infection from unsafe injection of drugs, such as syringe service programs, opioid substitution therapy (OST), and other drug-dependence treatment.

Brooks outlined how, due to unsafe injection-drug use, a growing, predominantly rural population in the U.S. is becoming vulnerable to HIV, as well as hepatitis B and C infections. The threat of another HIV outbreak looms, not only in the U.S. but in other countries as well, as the makers of prescription opioids, such as OxyContin expand their sales and marketing across the globe.

Lisa Messersmith, associate professor of global health at Boston University School of Public Health, has conducted HIV/AIDS research in Vietnam, Ghana, and elsewhere. She reminded the audience that, according to the United Nations Office on Drugs and Crime, one in ten of new HIV infections worldwide are in people who inject drugs (PWID). It’s estimated that there are 12 million people who inject drugs worldwide; around 1.6 million are thought to be living with HIV.

Presenting a local perspective, Alexander Walley, associate professor of medicine at Boston University School of Medicine and medical director for the Massachusetts Department of Public Health’s Opioid Overdose Prevention Pilot Program, spoke about efforts to address the opioid crisis in Massachusetts, where 1,379 people died of an overdose last year. Overdose is the leading cause of death in HIV-infected PWIDs.

In addition to increased surveillance, Walley listed new strategies that could be implemented to address overdose, including post-overdose outreach, on-call recovery coaches, supervised injection facilities, and local pharmacy access to naloxone, a drug used to treat opiate overdoses.

Martha Henry

Photo: iStock