Mass Dept of Health HIV advisory Feb 5, 2019

The Massachusetts Department of Public Health (MDPH) has detected an increase in newly diagnosed HIV infections among persons who inject drugs (PWID) in multiple areas across the Commonwealth. Recent HIV transmission is evidenced by several new cases diagnosed during the acute stage of HIV infection. The primary risk factor reported among identified cases is injection drug use (IDU).  Injectable substances linked to this outbreak include heroin, fentanyl, and methamphetamine.  MDPH is asking healthcare providers to enhance their vigilance for, increase their testing of, and to rapidly report new HIV infections in PWID to DPH. Prompt identification of cases and linkage to care improves clinical outcomes and is critical to reducing HIV transmission.

 In 2018 MDPH and CDC investigated an outbreak of HIV infection in PWID in the Cities of Lowell and Lawrence, involving over 150 cases between 2015 and 2018. Since mid-November 2018, a small cluster of new infections attributed to IDU has been identified in the City of Boston, which prompted a joint Clinical Advisory with the Boston Public Health Commission.  Preliminary evidence also points to a possible cluster of 5 cases among PWID in the City of Worcester. Surveillance data indicate that new HIV infections attributed to IDU exposures are increasing statewide. From 2014 to 2017, the proportion of new HIV diagnoses in Massachusetts attributable to IDU exposures has increased from 5% to 17%

Recommendations:

1. Remain alert to the potential for HIV infection (including acute HIV infection) in PWID:
   1. Elicit behavioral risk history including IDU, transactional sex, opioid/stimulant use, and unstable housing/homelessness.
   2. Encourage 4th generation HIV testing and  HCV antibody/HCV  RNA confirmatory testing for at-risk individuals, and follow current national recommendations for screening, even among persons recently tested

• Evaluate patients for HIV infection presenting with injection or substance use disorder-related illness, including skin/soft tissue abscess and infectious endocarditis

1. Link all HIV+ persons to care for full evaluation, follow-up, and prompt initiation of antiretroviral therapy. Focused efforts should be made to optimize treatment adherence and retain patients in care. Early treatment of acute HIV infection is essential to rapidly reduce viral load, improve patient outcomes, and to prevent further transmission.
2. Refer patients who currently use injectable substances to harm reduction services in your community (e.g., syringe services programs, see listing below).
3. Report all new cases of HIV infection to MDPH promptly, with as much risk history, clinical, and demographic data as you can obtain. To report a new case of HIV infection to MDPH, call the HIV Surveillance Program at 617-983-6560.
4. Field epidemiologists from MDPH will be deployed to assist in HIV follow-up, including partner notification and linkage to care, support services, and insurance. To request field epidemiologist services for HIV partner notification and linkage to support services and insurance, call the Division of STD Prevention and HIV/AIDS Surveillance at 617-983-6940.
5. Send specimens from HIV+ PWID cases to the State Public Health Laboratory for molecular epidemiologic analysis. Call 617-983-6940 to inquire about specimen submission.

For information about substance use disorder treatment programs: https://helplinema.org/

For a current listing of syringe service programs:

https://www.mass.gov/syringe-service-programs