Rural Areas of the United States Continue to Grapple with Outbreaks of HIV

In a story that could be straight out of the 1980s, health officials in the state of West Virginia have stated they are dealing with a major outbreak of HIV infections in the southern part of the state.

According to a report from the local newspaper, the Charleston Gazette-Mail, Rahul Gupta, MD, state health officer and commissioner for West Virginia’s Department of Health and Human Resources (DHHR) Bureau for Public Health stated that the outbreak comprises individuals from 15 counties. “The number of cases qualified as an outbreak because more cases than expected occurred in a window of time,” said Dr. Gupta. “The DHHR found linkages, meaning common sexual partners.” Officials purport that the virus spread through male—male sexual contact, with only some of the individuals becoming infected through intravenous drug use.

State officials first noticed an increase in HIV infections in the southern portion of the state in 2015, when 68 cases were reported. Another increase was observed in August 2017. This spurred officials to step up surveillance and identify who was infected, according to the reports. After identification, officials focused on linking those infected with care.

According to the Centers for Disease Control and Prevention (CDC), 1 in 302 West Virginians will be diagnosed with HIV in their lifetime. And, while the state is known to have the highest incidence of acute hepatitis B and C, a total of 28 counties have also been identified as high-risk for HIV.

As of the week of November 6, 2017, a total of 60 new cases were reported across the state. The latest reports have indicated that the outbreak has since been contained as many of those who were infected were identified and connected with treatment.

This is not the first time in recent years that a rural area of a US state has seen an outbreak of HIV. In 2016, Contagion® covered a report on 220 counties in the United States that were identified as being potentially vulnerable to HIV (and hepatitis C virus) infections “among people who inject drugs within the context of the national opioid epidemic.” These counties were identified after a cluster of 194 HIV cases were reported in the rural community of Austin, Indiana, in 2015. That outbreak was directly linked with the sharing of needles.

To stop more outbreaks from happening because of needle-sharing, many states have set up what have been called “harm-reduction programs,” which include needle-exchange services.

Outbreaks in rural areas may just be the tip of the iceberg when it comes to new fears on HIV. This is because, according to a new report, the virus is becoming increasingly resistant to the antiretroviral (ART) medications that are vital to treating (and preventing) the infection. Chris Beyrer, MD, professor of epidemiology with the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, and lead author on the report stated in a press release that, “Current trends in HIV drug resistance are very concerning. Resistance levels have been found to be highest in ART-exposed infants and children, which is a real concern since children are already among the least-treated age group in many developing countries.”

About half of the world’s population of individuals with HIV (19.5 million) are currently being treated with ART, according to the press release.

This new report on increasing resistance will certainly put a major damper on hopes that the world will be able to hit the United Nations’ and World Health Organization’s 90-90-90 targets, which include eliminating AIDS as a public health threat by 2030, and ensuring that 90% of individuals who are infected with HIV have access to ART by 2020. According to Dr. Beyrer, accomplishing this will be, “enormously difficult. WHO and experts from the CDC acknowledged that ART effectiveness is increasingly at risk, with HIV drug resistance having shot up from just 11% in 2001 to 29% today.”

The main driver in this resistance is a familiar one: lack of adherence to the [ART] medication regimen, which enables the virus to mutate and develop resistance to the drugs.

What can be done?

“The research team advocates placing more focus on prevention by hastening the development of an effective vaccine and by ratcheting up the use of Truvada, the HIV prevention regimen also known as PrEP,” according to the press release. PrEP has been found to curb the risk of becoming infected with HIV up to 90%. In addition, the release states that Dr. Beyrer recommends “those already infected, but not yet treated, should be given access to newer types of ART cocktails, including drugs such as dolutegravir that have higher genetic barriers to resistance." At this time, experts are reporting that resistance to PrEP is seen as “very rare.”

The bottom line is that the health care community needs to remain vigilant in surveillance of HIV infections, connecting individuals at-risk and infected to care as soon as possible, and conducting ongoing research on the virus and effective medication to treat and prevent infection.