Regarding: Outbreak of Recent HIV and HCV Infections among Persons Who Inject Drugs

Summary: The Indiana State Department of Health (ISDH) and the Centers for Disease Control and Prevention (CDC) are investigating a large outbreak of recent human immunodeficiency virus (HIV) infections among persons who inject drugs (PWID). Many of the HIV-infected individuals in this outbreak are co-infected with hepatitis C virus (HCV). The purpose of this HAN Advisory is to alert public health departments and healthcare providers of the possibility of HIV outbreaks among PWID and to provide guidance to assist in the identification and prevention of such outbreaks.

Background: From November 2014 to January 2015, ISDH identified 11 new HIV infections in a rural southeastern county where fewer than 5 infections have been identified annually in the past. As of April 21, 2015, an on-going investigation by ISDH with assistance from CDC has identified 135 persons with newly diagnosed HIV infections in a community of 4,200 people; 84% were also HCV infected. Among 112 persons interviewed thus far, 108 (96%) injected drugs; all reported dissolving and injecting tablets of the prescription-type opioid oxymorphone (OPANA® ER) using shared drug preparation and injection equipment.¹

This HIV outbreak was first recognized by a local disease intervention specialist. In late 2014, interviews conducted with three persons newly diagnosed with HIV infections in three separate venues (i.e., an outpatient clinic, a drug rehabilitation program, during a hospitalization) indicated that two of these persons had recently injected drugs and had numerous syringe-sharing and sexual partners. Contact tracing identified eight additional HIV infections leading to the current outbreak investigation, which has demonstrated that HIV had spread recently and rapidly through the local network of PWID. Without an attentive health department, active case finding, and additional testing provided as part of this investigation, this cluster may not have been identified.

Urgent action is needed to prevent further HIV and HCV transmission in this area and to investigate and control any similar outbreaks in other communities.

Injection drug use accounts for an estimated 8%²_ENREF_2 of the approximate 50,000 annual new HIV infections in the United States.³ _ENREF_2 HCV infection is the most common blood-borne infection in the United States and percutaneous exposure via drug-injecting equipment contaminated with HCV-infected blood is the most frequent mode of transmission. Nationally, acute HCV infections have increased 150% from 2010 to 2013,⁴ and over 70% of long-term PWID may be infected with HCV.⁵  Abuse of prescription-type opioids is increasing nationally⁶ and opioid-analgesic poisoning deaths have nearly quadrupled from 1999 through 2011.⁷  Rates of acute HCV infection are increasing, especially among young nonurban PWID, often in association with abuse of injected prescription-type opioids. These increases have been most substantial in nonurban counties east of the Mississippi River.⁸

Recommendations for Health Departments

• Review the most recent sources of data on HIV diagnoses, HCV diagnoses (acute as well as past or present), overdose deaths, admissions for drug treatment, and drug arrests. Attributes of communities at risk for unrecognized clusters of HIV and HCV infection include the following:

o    Recent increases in the:

• Number of HIV infections attributed to injection drug use,
• Number of HCV infections, particularly among persons aged < 35 years;

o    High rates of injection drug use and especially prescription-type opioid abuse, drug-related overdose, drug treatment admission, or drug arrests.

• Ensure complete contact tracing for all new HIV diagnoses and testing of all contacts for HIV and HCV infection.
• Ensure persons actively injecting drugs or at high-risk of drug injection (e.g., participating in drug substitution programs, receiving substance abuse counseling or treatment, recently or currently incarcerated) have access to integrated prevention services,⁹ and specifically:

o    Are tested regularly for HIV and HCV infection (consider more frequent testing based on frequency of injection drug usage or sharing of injection equipment);

o    If diagnosed with HIV or HCV infection:

• Are rapidly linked to care and treatment services;

o    If actively injecting drugs:

• Have access to medication-assisted therapy (e.g., opioid substitution therapy) as well as other substance abuse services, if not already engaged,
• Are counseled not to share needles and syringes or drug preparation equipment (e.g., cookers, water, filters),
• Have access to sterile injection equipment from a reliable source.

o    If not HIV infected but actively injecting drugs:

• Are referred for consideration of HIV pre-exposure prophylaxis¹⁰ and if potentially exposed within the past 72 hours (e.g., shared drug preparation or injection equipment with a known or potentially HIV-infected person) HIV post-exposure prophylaxis^11,12
• Remind venues that may encounter unrecognized infections, such as emergency departments and community-based clinical practices (e.g., family medicine, general medicine, prenatal care) of the importance of routine opt-out HIV testing as well as HCV testing per current recommendations^13-15
• Local health departments should notify their state health department and CDC of any suspected clusters of recent HIV or HCV infection.

Recommendations for Healthcare Providers

• Ensure all persons diagnosed with HCV infection are tested for HIV infection,¹⁶ and that all persons diagnosed with HIV infection are tested for HCV infection.¹⁷
• Ensure persons receiving treatment for HIV and/or HCV infection adhere to prescribed therapy and are engaged in ongoing care.
• Encourage HIV and HCV testing of syringe-sharing and sexual partners of persons diagnosed with either infection.
• Report all newly diagnosed HIV and HCV infections to the health department.
• For all persons with substance abuse problems:

o    Refer them for medication-assisted treatment (e.g., opioid substitution therapy) and counseling services,

o    Use effective treatments (e.g., methadone, buprenorphine), as appropriately indicated.

• For any persons for whom opioids are under consideration for pain management:

o    Discuss the risks and benefits of all pain treatment options, including ones that do not involve prescription analgesics.

o    Note that long-term opioid therapy is not associated with reduced chronic pain.¹⁸

• Contact the state or local health department to report suspected clusters of recent HIV or HCV infection.

For more information:

• Centers for Disease Control and Prevention. Integrated Prevention Services for HIV Infection, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis for Persons Who Use Drugs Illicitly: Summary Guidance from CDC and the U.S. Department of Health and Human Services. 2012: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6105a1.htm?s_cid=rr6105a1_w.
• Centers for Disease Control and Prevention. HIV and Injection Drug Use fact sheet. (http://www.cdc.gov/hiv/pdf/g-l/cdc-hiv-idu-fact-sheet.pdf
• Centers for Disease Control and Prevention. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. 2006; http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.
• Centers for Disease Control and Prevention and Association of Public Health Laboratories. Laboratory Testing for the Diagnosis of HIV Infection: Updated Recommendations.  http://dx.doi.org/10.15620/cdc.23447
• Centers for Disease Control and Prevention. Testing for HCV infection: an update of guidance for clinicians and laboratorians. MMWR Morb Mortal Wkly Rep. May 10 2013;62(18):362-365.
• Centers for Disease Control and Prevention. MMWR Integrated Services Report. (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6105a1.htm?s_cid=rr6105a1_w)
• Centers for Disease Control and Prevention. HIV and Injection Drug Use fact sheet. (http://www.cdc.gov/hiv/pdf/g-l/cdc-hiv-idu-fact-sheet.pdf)
• US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States – 2014 clinical practice guideline. 2014; http://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf.
• Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. 2015; http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.
• AASLD/IDSA/IAS–USA. HCV testing and linkage to care. Recommendations for testing, managing, and treating hepatitis C.  http://www.hcvguidelines.org/full-report/hcv-testing-and-linkage-care.

References

1. Spiller MW, Broz D, Wejnert C, Nerlander L, Paz-Bailey G. HIV Infection and HIV-Associated Behaviors Among Persons Who Inject Drugs – 20 Cities, United States, 2012. MMWR Morb Mortal Wkly Rep. Mar 20 2015;64(10):270-275.
2. Centers for Disease Control and Prevention. HIV Surveillance Report, 2013; vol. 25.  http://www.cdc.gov/hiv/library/reports/surveillance/, last accessed April 22, 2015.
3. Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006-2009. PLoS ONE. 2011;6(8):e17502.
4. Hagan H, Des Jarlais DC, Stern R, et al. HCV synthesis project: preliminary analyses of HCV prevalence in relation to age and duration of injection. The International journal on drug policy. Oct 2007;18(5):341-351.
5. Maxwell JC. The prescription drug epidemic in the United States: a perfect storm. Drug and alcohol review. May 2011;30(3):264-270.
6. Chen LH HH, Warner M. Drug-poisoning deaths involving opioid analgesics: United States, 1999–2011. NCHS data brief, no 166. Hyattsville, MD: National Center for Health Statistics. 2014.
7. Suryaprasad AG, White JZ, Xu F, et al. Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the United States, 2006-2012. Clin Infect Dis. Nov 15 2014;59(10):1411-1419.
8. Centers for Disease Control and Prevention. Integrated prevention services for HIV infection, viral hepatitis, sexually transmitted diseases, and tuberculosis for persons who use drugs illicitly: summary guidance from CDC and the U.S. Department of Health and Human Services. MMWR Recomm Rep. Nov 9 2012;61(Rr-5):1-40.
9. US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States – 2014 clinical practice guideline. 2014; http://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf.
10. Centers for Disease Control and Prevention. Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV in the United States Recommendations from the U.S. Department of Health and Human Services. 2005; http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm.
11. Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infection control and hospital epidemiology. Sep 2013;34(9):875-892.
12. Centers for Disease Control and Prevention. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. 2006; http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. Accessed April 22, 2015.
13. Centers for Disease Control and Prevention and Association of Public Health Laboratories. Laboratory Testing for the Diagnosis of HIV Infection: Updated Recommendations.  http://dx.doi.org/10.15620/cdc.23447. Accessed April 22, 2015.
14. Centers for Disease Control and Prevention. Testing for HCV infection: an update of guidance for clinicians and laboratorians. MMWR Morb Mortal Wkly Rep. May 10 2013;62(18):362-365.
15. AASLD/IDSA/IAS–USA. HCV testing and linkage to care. Recommendations for testing, managing, and treating hepatitis C.  http://www.hcvguidelines.org/full-report/hcv-testing-and-linkage-care. Accessed April 22, 2015.
16. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. 2015; http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed April 22, 2015.
17. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. 2015; http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed April 22, 2015.
18. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. Feb 17 2015;162(4):276-286.

The Centers for Disease Control and Prevention (CDC) protects people’s health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations.

The Pennsylvania State Nurses Association (PSNA), representing more than 218,000 registered nurses in Pennsylvania, will hold their Legislative Day press conference on Monday, April 20, 2015 at 12:30 pm in the Harrisburg Capitol Rotunda. The Nurse Hero theme recognizes nurses who take heroic action every day. Many look to nurses to be a hero – the hands that heal, the voice that comforts and the leader who guides them on the path to good health and safety.

The Rotunda event features nurse leader Rebecca M. Patton, MSN, RN, CNOR, FAAN. Patton is the immediate past, two-term president of the American Nurses Association (2006-2010) and holds the inaugural and first in the nation, Endowed Perioperative Nursing Chair, Atkinson Scholar in Perioperative Nursing at Francis Payne Bolton School of Nursing, Case Western Reserve University. As a nurse, author and lecturer, she has presented throughout the world. She has testified before Congress and met with major policy makers, including Presidents Obama, Bush and Clinton when she lobbied on issues affecting nurses and the public. Patton’s most recent book is the 2014 Nurses Making Policy: From Bedside to Boardroom.

“Rebecca’s journey in nursing has taken her from staff nurse to nurse advocate in our nation’s capital,” stated PSNA Chief Executive Officer Betsy M. Snook, MED, RN, BSN. “A much needed breath of fresh air within the policy arena, Ms. Patton brings a wealth of experience and knowledge to better position nurses to take on leadership roles in healthcare.”

In addition, PSNA will award its “Standing With Nurses” white lab coat to Rep. Mauree Gingrich (R-101) during the Rotunda event. This award is earned by legislators who have demonstrated their commitment to nurses and PSNA. PSNA will also briefly discuss legislative priorities including: Chief Nursing Officer of the Commonwealth (HB 389), Safe Staffing (HB 476) and the Marcellus Shale Health Registry (HB 252).

Patton and PSNA leadership will be available for questions immediately following the 12:30-1:30 pm Rotunda event.

# # #

The Pennsylvania State Nurses Association (PSNA) is the non-profit voice for nurses in the Commonwealth of Pennsylvania. Representing more than 218,000 nurses, PSNA leads, advocates, educates and connects with registered nurses across the Commonwealth. PSNA is a constituent member of the American Nurses Association. www.psna.org

On Wednesday, April 15, 2015, Chief Nursing Officer of the Commonwealth legislation HB 389 passed the House Health Committee by a vote of 18-8. The bill garnered support from all Republicans and 2 of the 10 Democrats voting. The bill now moves to the House floor for second consideration.

The Nursing Foundation of Pennsylvania (NFP), a supporting organization of the Pennsylvania State Nurses Association (PSNA), is a recipient of the Pennsylvania Association of Nonprofit Organizations’ (PANO) Seal of Excellence for successfully completing their rigorous Standards for Excellence^® accreditation program. NFP voluntarily opened itself up to analysis by a “jury of its peers.” The peer review team examined NFP for compliance with the Standards for Excellence^®: An Ethics and Accountability Code for the Nonprofit Sector, in areas including: Mission and Program, Governing Body, Conflict of Interest, Human Resources, Financial and Legal, Openness, Fundraising, Public Affairs and Public Policy.

PANO evaluates fundamental values such as honesty, integrity, fairness, respect, trust, responsibility and accountability, all of which are inherently important in the nonprofit world. NFP’s programs and services, management, fundraising and financial practices were subjected to in-depth examination prior to earning accreditation.

Elizabeth Walls, MBA, MSN, RN, president of NFP comments, “The Standards for Excellence^® endorsement is a magnificent honor. Trust, integrity and commitment are personified by the Standards for Excellence^® and NFP is extremely proud of our designation. With this respected accreditation in place, NFP will continue in its commitment to enhance nursing and health care by supporting nursing students.”

“The Seal of Excellence is granted to well-managed, responsibly governed organizations deserving of the public’s trust,” explains Tish Mogan, Standards for Excellence director for PANO. “NFP’s board and staff have shown an extensive level of commitment to this process, and their pursuit of the Seal of Excellence confirms that they believe strongly in promoting a culture of ethics in their operations and governance.” Anne Gingerich, PANO’s executive director, adds: “NFP can focus even more fully on advancing their mission of ensuring nurses for tomorrow because the Standards set the conditions for their internal systems to run as efficiently and effectively as possible. The Seal of Excellence is truly one of the ways that organizations can better position themselves to reach their fullest potential.”

PANO is committed to raising the level of principled and responsible practices within the nonprofit sector. PANO is licensed by the Standards for Excellence Institute^® to offer a model for organizations to implement in their operating plans so they can gain a deeper understanding of their effectiveness, improve their decision-making and minimize risks.

The NFP ensures nurses for tomorrow. The NFP is a recipient of the Pennsylvania Association of Nonprofit Organizations’ Seal of Excellence for successfully completing a rigorous Standards for Excellence^® accreditation program. The official registration and financial information of the NFP may be obtained from the Pennsylvania Department of State by calling toll-free within Pennsylvania, 800-732-0999.  Registration does not imply endorsement. (www.theNFP.org)

The Pennsylvania State Nurses Association (PSNA) is the non-profit voice for nurses in the Commonwealth of Pennsylvania. Representing more than 218,000 nurses, the Association works to be essential in advancing, promoting and supporting the profession of nursing to improve health for all in the Commonwealth. PSNA is a constituent member of the American Nurses Association. (www.psna.org)

PANO is a statewide membership organization amplifying the impact of the community benefit sector through advocacy, collaboration, learning, communication and support services.  PANO exists to support the incredible work of the nonprofit sector and highlight the critical role nonprofits serve. By coming together and recognizing our collective value, Pennsylvania communities and the power to do good will thrive. For more information on PANO and PANO’s Standards for Excellence® Program, visit www.pano.org.

The Standards for Excellence originated as a special initiative of Maryland Nonprofits in 1998 and has since expanded into a national program to help nonprofit organizations achieve the highest benchmarks of ethics and accountability in nonprofit governance, management and operations. The program has been formally adopted by 10 state, regional and national affiliate organizations, and is supported by 66 licensed consultants and over 100 volunteers with professional experience in nonprofit governance and administration. Since its inception, the program has accredited or recognized over 200 individual nonprofit organizations that completed a rigorous application and review process to demonstrate adherence to the Standards for Excellence: An Ethics and Accountability Code for the Nonprofit Sector. (www.standardsforexcellenceinstitute.org)

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The Pennsylvania State Nurses Association (PSNA) is hiring a Membership Engagement Specialist. PSNA is looking for an energetic, passionate individual who enjoys networking and being a liaison between the Association, our members and our potential members. The specialist will help nurses engage in their professional association. Experience in membership engagement is a plus, as is the ability to speak publicly, generate new ideas and use social media. RNs are encouraged to apply. This is a part-time position. Please send your resume highlighting previous speaking and engagement experience to cmellott@psna.org.

The Pennsylvania Nursing Congress on Practice, Education & Policy will meet on Monday, April 24, 2015 in Harrisburg (10 am – 2 pm). The Pennsylvania Nursing Congress, the state’s largest profession coalition of nursing organizations, acts as a change agent as it brings nurses of diverse specialties to the table in order to collaboratively advocate for patients and the profession. The event will be held at the Giant Community Center (2300 Linglestown Rd, Harrisburg, PA  17110). RSVP by April 22, 2015. The $50 registration fee includes lunch. Click here for the day’s agenda.

It is a staggering number — 218,000 Pennsylvania nurses! Every rural, urban and suburban community in Pennsylvania is served by this brave army of compassionate caregivers. For more than 110 years, PSNA has been the bugler for this extraordinary band of men and women. Join us as we take some time to celebrate the work and lifetime achievements of a special handful of individuals. Here’s to nurses! Here’s to veteran service and a rising generation of new leaders! Here’s to each of you who offers light and hope to neighbors in need!

Award Criteria

PSNA is accepting nominations for the following:

Distinguished Nurse Award

John Heinz Friend of Nursing Award

Lifetime Achievement Award

Emerging Nurse Leader Award (open to graduates of PSNA’s Star Leadership Institute)

Access the 2015 Nomination Template

Prior Recipient List

Click here to view our list of previous award recipients.

Dates to Remember

Deadline to submit is May 31, 2015.

Nominees and nominators will be notified of decisions by August 15, 2015.

Recipients will be recognized at their place of employment or a regional PSNA event.

Calling on all RNs practicing in Pennsylvania to take a short survey. The purpose of this survey is to identify the level of cultural competence education, access to cultural competence resources and the extent of culturally competent care that are currently provided by RNs who are licensed and practicing in the state of Pennsylvania.

Findings from this survey will be utilized to plan, implement and evaluate cultural competency education initiatives at the state and local levels.

The research team is looking for RNs who are licensed and practicing in the state of Pennsylvania to participate in the study.  To be able to participate, you must meet the below study inclusion criteria:

• Active license to practice as a Registered Nurse (RN) or Advanced Practice Nurse (APN) in the State of Pennsylvania
• Actively practicing in PA as an RN, or in  advanced  practice with a baseline RN License  in the State of  PA
• A willingness to devote approximately 20 minutes to complete the online survey
• Able to speak, read, write and understand English.

To participate in the survey, please go online to: https://www.surveymonkey.com/s/PADiverse

For more information about this study, you may contact the investigators at: askpadco@gmail.com

The Pennsylvania State Nurses Association (PSNA), representing more than 215,000 registered nurses in Pennsylvania, will host a continuing education series titled “Medical Marijuana: Myths & Medicine.” This half-day event will be offered in Lancaster (March 26) and Pittsburgh (April 10).

Agenda topics include the history of marijuana, the effects of marijuana on the central nervous system, and Pennsylvania legislation related to medical cannabis.

“Medical cannabis is a defining patient issue of our time,” stated PSNA Chief Executive Officer Betsy M. Snook, MEd, RN, BSN. “As medical cannabis changes our legislative landscape, it is the responsibility of health care professionals to be informed. This presentation provides an opportunity to explore the myths and realities at the center of this historical debate.”

Online registration for both sessions is now open. Pricing for this event is: $35, PSNA members / $49, non-PSNA member / $20, non-licensed student / $20, no CE awarded. Visit www.psna.org/medicalmarijuana to register. This activity has been submitted to PA State Nurses Association for approval to award continuing nursing education.

The Pennsylvania State Nurses Association (PSNA) is the non-profit voice for nurses in the Commonwealth of Pennsylvania. Representing more than 218,000 nurses, the Association works to be essential in advancing, promoting and supporting the profession of nursing to improve health for all in the Commonwealth. PSNA is a constituent member of the American Nurses Association (www.psna.org).