Injection Drug Use-Related HIV Cases Increase in Massachusetts -- Is This the Start of a Trend?

Recently the Massachusetts Department of Public Health sent out this concerning notice:

The Massachusetts Department of Public Health (MDPH) has noted an increase in newly diagnosed and acute HIV infections among persons who inject drugs (PWID). To date in calendar year 2017 (through November 21), there have been 64 HIV infections reported among individuals who inject drugs in Massachusetts ... Over the past 5-10 years, newly diagnosed HIV infection in PWID amounted to 32-62 cases annually, representing a stable proportion of 4-8% of all reported HIV infections. Investigation of cases is ongoing.

Undoubtedly, one reason for the notice is that it stands in stark contrast to a long-term trend. Indeed, the drop in injection drug use-related HIV has been one of the unheralded success stories in the USA HIV epidemic.

Once a very prominent "transmission category," it has declined more than any other risk factor, now accounting for less than 10% of new HIV diagnoses per year. For a broader view, here are AIDS cases in the USA since the beginning of the epidemic, showing the steady decline in cases attributable to injection drug use since the mid-1990s:

Percentages of Stage 3 (AIDS) Classifications Among Adults and Adolescents With Diagnosed HIV Infection, by Transmission Categor and Year of Classification

This decrease in cases is even more remarkable when viewed in the context of our national opioid epidemic, a problem we ID doctors are reminded of on a daily basis -- not from HIV, but from serious invasive bacterial infections and, to a lesser extent, hepatitis C.

By contrast, new cases of HIV due to injection drug use alone are now relatively uncommon in the United States. A notable recent exception was the 2015 Indiana HIV outbreak, where nearly 200 new HIV infections occurred in four months in a rural community hard-hit by opioid addiction.

A skillful CDC investigation found that just one person with HIV was the source of the outbreak, which was then fueled by a needle-sharing network. The outbreak demonstrated the potential rapid spread of HIV in this population -- and then the ability of syringe exchange programs to control it.

Are we seeing the beginning of something like the Indiana outbreak now in Massachusetts? Or is this year's increase -- admittedly rather small to date -- just a temporary blip?

Regardless, good work by the MDPH in getting the word out -- vastly preferable to be early rather than late to recognize this trend.

I've heard anecdotally there might be other HIV outbreaks nationally among people who inject drugs. What's been your experience where you practice?

[Note from This article was originally published by Journal Watch on Dec. 10, 2017. We have cross-posted it with their permission.]