Examining trends in the incidence of HIV infection among people with a history of drug use to inform an outbreak investigation and response: A retrospective cohort study.

BACKGROUND: In the context of an outbreak of HIV among people who inject drugs in Glasgow, Scotland, identified in 2015, our objectives were to: (1) develop epidemiological methods to estimate HIV incidence using data linkage, and (2) examine temporal changes in HIV incidence to inform public health responses. METHODS: This was a retrospective cohort study involving data linkage of laboratory HIV testing data to identify individuals with a history of drug use. Person-years (PY) and Poisson regression were used to estimate incidence by time period (pre-outbreak: 2000-2010 and 2011-2013; early outbreak: 2014-2016; ongoing outbreak: 2017-2019). RESULTS: Among 13 484 individuals tested for HIV, 144 incident HIV infections were observed from 2000 to 2019. Incidence rates increased from pre-outbreak periods (1.00/1000 PY (95% confidence interval, CI: 0.60-1.65) in 2000-2010 and 1.70/1000 PY (95% CI: 1.14-2.54) in 2011-2013) to 3.02/1000 PY (95% CI: 2.36-3.86) early outbreak (2014-2016) and 2.35 (95% CI 1.74-3.18) during the ongoing outbreak period (2017-2019). Compared with the pre-outbreak period (2000-2010), the incidence rates were significantly elevated during both the early outbreak (2014-16) (adjusted incidence rate ratio (aIRR) = 2.87, 95% CI: 1.62-5.09, p < 0.001) and the ongoing outbreak periods (2017-19) (aIRR = 2.12, 95% CI: 1.16-3.90, p = 0.015). CONCLUSIONS: Public health responses helped to curb the rising incidence of HIV infection among people with a history of drug use in Glasgow, but further efforts are needed to reduce it to levels observed prior to the outbreak. Data linkage of routine diagnostic test data to assess and monitor incidence of HIV infection provided enhanced surveillance, which is important to inform outbreak investigations and guide national strategies on elimination of HIV transmission.

Impact of the COVID-19 Pandemic on HIV Test Uptake Among People Who Inject Drugs in the Context of an HIV Outbreak.

Glasgow, Scotland's largest city, has been experiencing an HIV outbreak among people who inject drugs (PWID) since 2015. A key focus of the public health response has been to increase HIV testing among those at risk of infection. Our aim was to assess the impact of COVID-19 on HIV testing among PWID in Glasgow. HIV test uptake in the last 12 months was quantified among: (1) PWID recruited in six Needle Exchange Surveillance Initiative (NESI) surveys (n = 6110); linked laboratory data for (2) people prescribed opioid agonist therapy (OAT) (n = 14,527) and (3) people hospitalised for an injecting-related hospital admission (IRHA) (n = 12,621) across four time periods: pre-outbreak (2010-2014); early-outbreak (2015-2016); ongoing-outbreak (2017-2019); and COVID-19 (2020-June 21). From the pre to ongoing period, HIV testing increased: the highest among people recruited in NESI (from 28% to 56%) and on OAT (from 17% to 54%) while the lowest was among people with an IRHA (from 15% to 42%). From the ongoing to the COVID-19 period, HIV testing decreased markedly among people prescribed OAT, from 54% to 37% (aOR 0.50, 95% CI 0.48-0.53), but increased marginally among people with an IRHA from 42% to 47% (aOR 1.19, 95% CI 1.08-1.31). In conclusion, progress in increasing testing in response to the HIV outbreak has been eroded by COVID-19. Adoption of a linked data approach could be warranted in other settings to inform efforts to eliminate HIV transmission.

A Qualitative Analysis of Barriers to Accessing HIV Prevention Services During an HIV Outbreak among Persons who Inject Drugs in West Virginia.

In response to an increase in HIV diagnoses among persons who inject drugs (PWID) in Kanawha County, West Virginia, West Virginia Bureau for Public Health and CDC conducted a qualitative assessment in Kanawha County to inform HIV outbreak response activities. Interviews with 26 PWID and 45 community partners were completed. Transcribed interviews were analyzed to identify barriers to accessing HIV prevention services among PWID using the risk environment framework. Participants identified numerous political, physical, social, and economic community-level barriers that influenced access to HIV prevention services among PWID. Political factors included low community support for syringe services programs (SSPs); physical factors included low SSP coverage, low coverage of HIV testing outreach events, low HIV preexposure prophylaxis availability, and homelessness; social factors included stigma and discrimination; economic factors included community beliefs that SSPs negatively affect economic investments and limited resources for HIV screening in clinical settings. Individual-level barriers included co-occurring acute medical conditions and mental illness. Community-level interventions, such as low-barrier one-stop shop models, are needed to increase access to sterile syringes through comprehensive harm reduction services.

An outbreak of HIV infection among people who inject drugs in northeastern Massachusetts: findings and lessons learned from a medical record review.

BACKGROUND: We conducted a medical record review for healthcare utilization, risk factors, and clinical data among people who inject drugs (PWID) in Massachusetts to aid HIV outbreak response decision-making and strengthen public health practice. SETTING: Two large community health centers (CHCs) that provide HIV and related services in northeastern Massachusetts. METHODS: Between May and July 2018, we reviewed medical records for 88 people with HIV (PWH) connected to the outbreak. The review period included care received from May 1, 2016, through the date of review. Surveillance data were used to establish date of HIV diagnosis and assess viral suppression. RESULTS: Sixty-nine (78%) people had HIV infection diagnosed during the review period, including 10 acute infections. Persons had a median of 3 primary care visits after HIV diagnosis and zero before diagnosis. During the review period, 72% reported active drug or alcohol use, 62% were prescribed medication assisted treatment, and 41% were prescribed antidepressants. The majority (68, 77%) had a documented ART prescription. HIV viral suppression at < 200 copies/mL was more frequent (73%) than the overall across the State (65%); it did not correlate with any of the sociodemographic characteristics studied in our population. Over half (57%) had been hospitalized at least once during the review period, and 36% had a bacterial infection at hospitalization. CONCLUSIONS: Medical record review with a field investigation of an outbreak provided data about patterns of health care utilization and comorbidities not available from routine HIV surveillance or case interviews. Integration of HIV screening with treatment for HIV and SUD can strengthen prevention and care services for PWID in northeastern Massachusetts.

Index testing among HIV-positive patients is feasible and successful in identifying additional HIV infections in Pakistan.

OBJECTIVE: To assess the feasibility of index testing approach to test the parents and siblings of human immunodeficiency virus (HIV)-positive children, and identify HIV-positive individuals. METHODS: The study was conducted at Ratodero, Pakistan. Study participants were enrolled from September 2019 to February 2020. The list of HIV-positive persons was provided by the Sindh AIDS Control Programme. Families of 706 HIV-positive persons were approached and all of them agreed to participate. The first test was performed by trained outreach workers. All those with a reactive first test were transported to the nearest health facility for further testing and confirmation. Mothers and siblings were tested at home while additional visits were carried out to reach the fathers. RESULTS: A total of 1766 persons were tested through HIV index testing. Biological siblings accounted for 81% of the contacts. We were able to test 413/463 (89.2%) mothers, 232/413 (56.2%) fathers and 1121/1392 (80.5%) siblings. Out of these, 7 mothers (1.7%) and 22 siblings (2.0%) were confirmed to be HIV-positive, while no one was found to be positive among the fathers. The overall HIV prevalence was 1.6% (29/1766). All HIV-positive persons were guided for treatment and care. CONCLUSIONS: Results indicate that index-testing approach is feasible in Pakistan to expand HIV testing services through home visits.

Regulation of quackery amid unprecedented HIV outbreak in Sindh, Pakistan.

OBJECTIVE: To assess the problem of unlicensed practitioners and quacks in Sindh, Pakistan. METHODS: A cross-sectional study was conducted in 29 districts of Sindh province in Pakistan from December 2019 to January 2020. Initial data available with Sindh Health Department about locations where quacks were practicing was used to identify unlicensed practitioners. A structured questionnaire was developed which contained information about certification of practitioners and an observational checklist was developed to assess infection prevention and control practices (IPC) and injection safety. RESULTS: A total of 4315 private practitioners were inspected out of which 3022 (70%) were unlicensed health practitioners belonging to different categories. Within the six surveyed divisions of Sindh, the highest proportion of unlicensed practitioners were documented in Shaheed Benazirabad division (n=739; 24.5%) followed by Hyderabad (n=599; 19.8%). In Mirpur Khas, there were 510 (16.9%), in Karachi 310 (10.3%), in Sukkur 484 (16%) and in Larkana there were 380 (12.6%) unlicensed practitioners. Poor IPC was observed in 89.4% (3861/4315) of all health providers. Reuse of syringes and intravenous drip sets was observed among 78.7% (1916/2432) of the untrained providers across the province. It was also found that 155 MBBS doctors had given their names on rent to be used as a signboard outside the clinics of some of the unlicensed practitioners. CONCLUSION: The problem of quackery is widespread in the Sindh province. It can be proactively addressed by shutting down all unlicensed practitioners and educating the community to avoid visiting them in order to reduce the probability of exposure to unsafe healthcare practices.

Evaluation of the scale-up of HIV testing among people who inject drugs in Scotland in the context of an ongoing HIV outbreak.

BACKGROUND: A large outbreak of HIV among people who inject drugs (PWID) has been ongoing in Glasgow city centre (GCC), Scotland since early 2015. The outbreak is associated with high levels of homelessness, cocaine injecting and injecting in public places. A key component of the public health response was the scale-up of HIV testing in a range of services engaged with PWID. Our aims were to: 1) evaluate the extent of and change in HIV testing over the course of the outbreak and 2) examine factors associated with reporting an HIV test. METHODS: Self-report of an HIV test in the last 12 months was collected for 15,081 PWID interviewed in six national cross-sectional bio-behavioural surveys during 2008-2018. Multi-variate logistic regression was undertaken to determine trends in HIV testing by region of recruitment (GCC; rest of Glasgow; other Scottish city centres (SCC); and rest of Scotland) and outbreak period (pre: 2008-14; early: 2015-16; ongoing: 2017-18). RESULTS: HIV testing increased across all regions and was most pronounced in GCC comparing the ongoing (67%) to the pre-outbreak period (33%) (aOR=4.68, 95% CI 3.23 to 6.77, p<0.001). However, compared to other SCCs pre-outbreak (with 46% reporting testing), those recruited in GCC had a lower odds of HIV testing early outbreak (aOR=0.37, 95% CI 0.27 to 0.54, p<0.001) and more modest increased odds in the ongoing outbreak period (aOR=1.41, 95% CI 0.97 to 2.05, p=0.069). Among PWID recruited in the whole of Glasgow in the ongoing phase, reporting an HIV test was associated with injecting cocaine or in public places (aOR=2.20, 95% CI 1.53 to 3.17, p<0.001), receipt of methadone (aOR=1.48, 95% CI 1.01 to 2.17, p=0.042) and incarceration in the last year (aOR=1.72, 95% CI 1.18 to 2.51, p=0.004). CONCLUSIONS: Relatively low levels of HIV testing pre- and early-outbreak likely hindered efforts to control the spread of infection among PWID in Glasgow. Uptake has since increased with expansion of testing across multiple settings, particularly among those at high risk of infection. Further effort is needed to ensure the vast majority of PWID are regularly tested, not just in the epicentre of the outbreak but in other areas with low population prevalence of infection.

Human Immunodeficiency Virus (HIV) Outbreak Investigation Among Persons Who Inject Drugs in Massachusetts Enhanced by HIV Sequence Data.

BACKGROUND: The Massachusetts Department of Public Health and the Centers for Disease Control and Prevention collaborated to characterize a human immunodeficiency virus (HIV) outbreak in northeastern Massachusetts and prevent further transmission. We determined the contributions of HIV sequence data to defining the outbreak. METHODS: Human immunodeficiency virus surveillance and partner services data were analyzed to understand social and molecular links within the outbreak. Cases were defined as HIV infections diagnosed during 2015-2018 among people who inject drugs with connections to northeastern Massachusetts or HIV infections among other persons named as partners of a case or whose HIV polymerase sequence linked to another case, regardless of diagnosis date or geography. RESULTS: Of 184 cases, 65 (35%) were first identified as part of the outbreak through molecular analysis. Twenty-nine cases outside of northeastern Massachusetts were molecularly linked to the outbreak. Large molecular clusters (75, 28, and 11 persons) were identified. Among 161 named partners, 106 had HIV; of those, 40 (38%) diagnoses occurred through partner services. CONCLUSIONS: Human immunodeficiency virus sequence data increased the case count by 55% and expanded the geographic scope of the outbreak. Human immunodeficiency virus sequence and partner services data each identified cases that the other method would not have, maximizing prevention and care opportunities for HIV-infected persons and their partners.

New HIV-1 circulating recombinant form 94: from phylogenetic detection of a large transmission cluster to prevention in the age of geosocial-networking apps in France, 2013 to 2017.

BackgroundEnding the HIV pandemic must involve new tools to rapidly identify and control local outbreaks and prevent the emergence of recombinant strains with epidemiological advantages.AimThis observational study aimed to investigate in France a cluster of HIV-1 cases related to a new circulating recombinant form (CRF). The confirmation this CRF's novelty as well as measures to control its spread are presented.MethodsPhylogenetic analyses of HIV sequences routinely generated for drug resistance genotyping before 2018 in French laboratories were employed to detect the transmission chain. The CRF involved was characterised by almost full-length viral sequencing for six cases. Cases' clinical data were reviewed. Where possible, epidemiological information was collected with a questionnaire.ResultsThe transmission cluster comprised 49 cases, mostly diagnosed in 2016-2017 (n = 37). All were infected with a new CRF, CRF94_cpx. The molecular proximity of this CRF to X4 strains and the high median viraemia, exceeding 5.0 log10 copies/mL, at diagnosis, even in chronic infection, raise concerns of enhanced virulence. Overall, 41 cases were diagnosed in the Ile-de-France region and 45 were men who have sex with men. Among 24 cases with available information, 20 reported finding partners through a geosocial networking app. Prevention activities in the area and population affected were undertaken.ConclusionWe advocate the systematic use of routinely generated HIV molecular data by a dedicated reactive network, to improve and accelerate targeted prevention interventions. Geosocial networking apps can play a role in the spread of outbreaks, but could also deliver local targeted preventive alerts.

A hepatitis C outbreak preceded the HIV outbreak among persons who inject drugs in Athens, Greece: Insights from a mathematical modelling study.

People who inject drugs (PWID) comprise one of the major transmission risk groups for human immunodeficiency virus (HIV) and hepatitis C virus (HCV). In 2011, Athens experienced a large HIV outbreak among PWID. Significant public health interventions were implemented in response to the HIV outbreak. The aims of this study were to estimate the indirect effects of the HIV interventions on HCV infection and to evaluate the concept of the association between HCV and HIV infections in the case of Athens. A dynamic, stochastic, individual-based model was developed to simulate HCV transmission among PWID. We calibrated the model to reproduce the observed HCV prevalence among PWID in Greece. Two years prior to the HIV outbreak, an undetected HCV outbreak has occurred. In 2009, the incidence of HCV infection increased from 640 (495, 842) cases in 2008 to 1260 (1060, 1500). The mean time from initiation of injecting drug use to HCV acquisition decreased from 29 months in 2008 to 13 months in 2009. After HIV interventions, HCV incidence declined by 64.8% in 2012, compared to 2009. The averted HCV incidence cases attributed to the HIV-implemented interventions were 2200 (1950, 2480), during 2012-2015. The cumulative number incident HCV cases in Athens during 2002-2015 was about 9900 (7800, 12 100). Our results highlight that before the 2011 HIV outbreak in Athens, an HCV outbreak occurred in 2009. Prevention measures for HIV that took place in the Athens metropolitan area in 2012 reduced significantly the incidence of HCV.

Detailed Transmission Network Analysis of a Large Opiate-Driven Outbreak of HIV Infection in the United States.

In January 2015, an outbreak of undiagnosed human immunodeficiency virus (HIV) infections among persons who inject drugs (PWID) was recognized in rural Indiana. By September 2016, 205 persons in this community of approximately 4400 had received a diagnosis of HIV infection. We report results of new approaches to analyzing epidemiologic and laboratory data to understand transmission during this outbreak. HIV genetic distances were calculated using the polymerase region. Networks were generated using data about reported high-risk contacts, viral genetic similarity, and their most parsimonious combinations. Sample collection dates and recency assay results were used to infer dates of infection. Epidemiologic and laboratory data each generated large and dense networks. Integration of these data revealed subgroups with epidemiologic and genetic commonalities, one of which appeared to contain the earliest infections. Predicted infection dates suggest that transmission began in 2011, underwent explosive growth in mid-2014, and slowed after the declaration of a public health emergency. Results from this phylodynamic analysis suggest that the majority of infections had likely already occurred when the investigation began and that early transmission may have been associated with sexual activity and injection drug use. Early and sustained efforts are needed to detect infections and prevent or interrupt rapid transmission within networks of uninfected PWID.

Design and baseline findings of a large-scale rapid response to an HIV outbreak in people who inject drugs in Athens, Greece: the ARISTOTLE programme.

AIMS: To (i) describe an intervention implemented in response to the HIV-1 outbreak among people who inject drugs (PWIDs) in Greece (ARISTOTLE programme), (ii) assess its success in identifying and testing this population and (iii) describe socio-demographic characteristics, risk behaviours and access to treatment/prevention, estimate HIV prevalence and identify risk factors, as assessed at the first participation of PWIDs. DESIGN: A 'seek, test, treat, retain' intervention employing five rounds of respondent-driven sampling. SETTING: Athens, Greece (2012-13). PARTICIPANTS: A total of 3320 individuals who had injected drugs in the past 12 months. INTERVENTION: ARISTOTLE is an intervention that involves reaching out to high-risk, hard-to-reach PWIDs ('seek'), engaging them in HIV testing and providing information and materials to prevent HIV ('test') and initiating and maintaining anti-retroviral and opioid substitution treatment for those testing positive ('treat' and 'retain'). MEASUREMENTS: Blood samples were collected for HIV testing and personal interviews were conducted. FINDINGS: ARISTOTLE recruited 3320 PWIDs during the course of 13.5 months. More than half (54%) participated in multiple rounds, resulting in 7113 visits. HIV prevalence was 15.1%. At their first contact with the programme, 12.5% were on opioid substitution treatment programmes and the median number of free syringes they had received in the preceding month was 0. In the multivariable analysis, apart from injection-related variables, homelessness was a risk factor for HIV infection in male PWIDs [odds ratio (OR) yes versus no = 1.89, 95% confidence interval (CI) = 1.41, 2.52] while, in female PWIDS, the number of sexual partners (OR for > 5 versus one partner in the past year = 4.12, 95% CI = 1.93, 8.77) and history of imprisonment (OR yes versus no = 2.76, 95% CI = 1.43, 5.31) were associated with HIV. CONCLUSIONS: In Athens, Greece, the ARISTOTLE intervention for identifying HIV-positive people among people who inject drugs (PWID) facilitated rapid identification of a hidden population experiencing an outbreak and provided HIV testing, counselling and linkage to care. According to ARISTOTLE data, the 2011 HIV outbreak in Athens resulted in 15% HIV infection among PWID. Risk factors for HIV among PWID included homelessness in men and history of imprisonment and number of sexual partners in women.