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How HIV Spreads Between MSM and Heterosexual Opioid Users

The U.S. may be at greater risk for more HIV outbreaks due to opioid users, according to new research presented at the Conference on Retroviruses and Opportunistic Infections (CROI 2017)

The outbreak of HIV among white, largely rural, heroin users in Indiana in 2015, which received national attention, concerned many health officials there are conditions for more outbreaks among heterosexual people who inject drugs in the United States.

There is currently a serious opioid epidemic in the U.S. with over 91 Americans dying each day from an opioid overdose, according to statistics published by the Centers for Disease Control and Prevention (CDC). In 2015, deaths caused by heroin overdose surpassed deaths related to gun violence for the first time, with 13,000 people dying from heroin overdoses.

In addition to the concern of opioid overdose, many health experts also worry about how this increase in opioid users may affect current HIV prevention efforts. Several researchers at CROI this year presented one worrisome potential scenario, where there would be a crossover of HIV from men who have sex with men (MSM) to those who are heterosexual and inject drugs, leading to potential HIV outbreaks around the country.

What makes this scenario likely is this potential new generation of heterosexual people who inject drugs (PWID) are not connected to conventional drug services, they are sharing needles, and they are increasingly interested in methamphetamine.

Evidence from one census, conducted in King County in Washington State, has sent warning signs that conditions exist for a crossover of HIV from MSM to heterosexuals due to a rise in heterosexuals injecting methamphetamine – and evidence that a significant proportion are sharing needles with MSM who are HIV-positive.

Sara Glick, from the University of Washington in Seattle, said that HIV prevalence is high for MSM who inject drugs, at about 35-40 percent, but only about three percent of heterosexual PWID have HIV, suggesting that a potential outbreak could be likely if these two demographics started to share needles.

The number of people who inject meth has been increasing by MSM and heterosexual people alike. The Seattle area of the National HIV Behavioral Surveillance survey showed that the number of MSM injecting meth rose from 55 percent in 2005 to over 80 percent in 2009. In the King County survey methamphetamine was used by over 80 percent of MSM who inject drugs from 2013 onwards.

In heterosexual women who inject drugs, meth usage rose similarly from 26 to 65 percent in the NHBS survey and 25 to 61 percent in the King County one.

The most pressing concern for health experts is how common it is to share needles between MSM and heterosexuals. Drug use is often a communal activity, and in MSM who admitted sharing injection equipment, their last sharing partner had been a woman in 31 percent of cases and a heterosexual man in 14 percent. In females who inject drugs, their last sharing partner had been an MSM in 15 percent of cases and in heterosexual men, seven percent of cases.

Moreover, studies have found that injecting methamphetamine is increasing in black MSM communities at the same time that HIV is also increasing in black communities.

Two CDC surveys looked at trends in methamphetamine use, both injected and non-injected, in MSM in the U.S. Both found that trends in drug use in gay men in general had stayed flat but that who was using them had changed: use in black and poorer men had increased at almost exactly the same rate as it had decreased in white men.

The results from the presentations indicate that there is an urgent need for education, opiate therapy programs and needle exchange programs around the country. One study, in particular, showed the potential benefits of an opiate therapy program, also known as medication-assisted therapy programs.

The study looked at all positive effects of opiate substitution therapy (OST), finding that those receiving OST not only suffer from fewer injection-related illness, but they share needles less and pass on fewer infections to others.

They also initiate fewer people into injecting drugs for the first time. In one survey, the PWID who were on an OST program were 38 percent less likely to have helped a first time user inject than those who were not.

“We need to make a serious commitment to expanding harm reduction and drug treatment,” said Daniel Raymond, Policy Director of the Harm Reduction Coalition. “We know syringe exchange is the most effective way to reach these people, protect their health and link them to care and treatment. Five years from now, I hope we can look back and say that this outbreak [Indiana 2015 outbreak] was an anomaly, and not a harbinger of a resurgent HIV epidemic.”