Clinician Alert: HIV increase among people who use methamphetamine or inject drugs

Local public health is responding to a recent increase in HIV infections among people who use methamphetamine or inject any drugs. Risk groups overlap with those for the ongoing syphilis outbreak, an increase in sexually transmitted drug-resistant Shigella and efforts to prevent a local outbreak of Hepatitis A via vaccination.

Multnomah, Clackamas, and Washington County health care providers who see patients who use methamphetamine or inject drugs should:

1. Test for HIV

2. Prescribe HIV pre-exposure prophylaxis (aka Truvada or PrEP) to those who are clinically eligible or refer for PrEP and syringe exchange services.

3. Test for syphilis

4. Give Hep A containing vaccine to patients who are unimmunized

5. For unstably housed patients, collect accurate contact information for our public health interviewers, including an emergency contact

Shigellosis is now a sexually transmitted infection

Sexual behaviors that expose patients to feces can transmit Shigella bacteria. Recently, clusters of drug-resistant shigellosis have primarily involved men who have sex with men.

For sexually active patients with possible Shigellosis:

1. Consider Shigellosis an indication to test for HIV and syphilis and other STI’s.

2. Know that there is resistance to many first-line antibiotics in local Shigella strains. Collect and submit a stool specimen for culture and susceptibility testing to guide therapy.

3. Help prevent a Hepatitis A outbreak by vaccinating those without documentation of immunization

4. For unstably housed patients, collect accurate contact information for our public health interviewers, including an emergency contact

Multnomah County Health Department staff at 503-988-3702 can assist with test interpretation, locating patients to give results, link to care, and facilitate partner notification. They may also connect you to the health department of the county where your patient resides.

Summary background

• In the last 18 months, 42 new cases of HIV among men and women who report drug use have been identified in Multnomah County. Nearly half of the newly diagnosed cases had tested negative for HIV test in the past two years, suggesting these are new infections. By contrast, only 25 cases reported in 2016 and 2017 combined had injection drug use as a risk factor for HIV infection.

• Syphilis continues its sharp increase in Multnomah County and the region that began a decade ago. Locally infections have remained primarily among men who have sex with men, but female cases went from 52 in 2017 to 87 in 2018 and continue to increase in 2019. Congenital syphilis case counts have mirrored the rise in female cases.

• Until recently Multnomah County typically got about 20 Shigella case reports per year, compared to 95 locally acquired infections in 2018. Local disease patterns show that sexual activity accounts for half to two thirds of cases. A significant number of Shigella strains are resistant to first line antibiotics including fluoroquinolones, macrolides and/or third generation cephalosporins.

There has been no recent increase in cases of Hepatitis A. Outbreaks in cities and counties across the country among people using drugs, men who have sex with men, and those living homeless, have increased awareness of the importance of vaccination.

Diseases of Concern

HIV

Priority groups

• Any meth use
• Any injection drug use
• Men who have sex with men
• Sexual partners of any of the above

Intervention

• 4th generation p24 antigen/antibody test
• Any point of care (POC) test
• Testing is voluntary with no special informed consent. Patient must be notified and have the opportunity to decline.
• If positive, call county health department where patient resides for help with results notification, linkage to care, and notifying partners
• If negative offer (or refer for) PrEP and/or refer to syringe exchange

Syphilis

Priority groups

• Any meth or injection drug use
• Men who have sex with men
• Sexual partners of either of the above
• All pregnant women

Intervention

• RPR
• Some labs start with treponemal test and reflex to RPR
• See current CDC STD treatment guidelines
• Oregon Health Authority recommends that all pregnant women should be screened at first prenatal visit, early third trimester and at delivery

Shigella

Priority groups

• Men who have sex with men
• Anyone unstably housed

Intervention

• If compatible symptoms, stool for culture and susceptibilities
• Some labs do not do culture; we are working to make stool culture more widely available
• Empiric treatment may not be indicated; consult with infectious disease specialist before treating; Consult with infectious disease specialist before treating
• Counsel patients to avoid sex x 3 weeks if they or their partners have had diarrhea
• Counsel patients to avoid sex.

Hepatitis A

Priority groups

• Men who have sex with men
• Anyone unstably housed
• Anyone using drugs

Intervention

• Vaccinate
• The first dose of any two or three dose vaccine series offers good protection against Hep A.  
• For those individuals who may be unlikely to follow up, a single antigen Hep A vaccine is preferred; all others should start the Twinrix series.
• Most school kids through 11th grade have been vaccinated

Other Resources

Oregon Health Authority information about HIV.

Oregon Health Authority  information about Syphilis.

CDC information about Shigella. 

Information about the local 2015-16 outbreak of Shigellosis in the Portland metro area.

CDC information about Hepatitis A.

Oregon ALERT immunization database

Local Health Departments

• Clackamas: 503-655-8411

• Clark County (WA): STD reporting line 564.397.8082; all other notifiable conditions call: 564.397.8182

• Multnomah: 503-988-3702

• Washington: 503-846-3594