Looming Outbreak

Federal and state health officials have quietly been preparing for an opioid related outbreak of HIV in northern lower Michigan, but lawmakers and the governor have not been briefed.
"In response to the HIV outbreak in Scott County, Indiana, from Injection Drug Use (IDU), the CDC in Fall of 2015, performed an Analysis to Identify US counties where people who inject drugs (PWID) appear especially vulnerable to the rapid spread of HIV infection if introduced, as well as new or continued increases in hepatitis C virus (HCV) infection," wrote Erica Quealy, a spokeswoman for the Michigan Department of Health and Human Services. "This assessment identified counties that had similarities with Scott County Indiana that potentially makes them vulnerable for an HIV outbreak. This assessment identified that Michigan had 11 counties in the Northern Lower Peninsula that were deemed vulnerable (top 5 percent in the US) for an HIV outbreak from IDU. To date, MDHHS HIV Surveillance has detected no statistically significant increase in HIV cases in these counties associated with PWID."
Despite this information, the office of Republican Gov. Rick Snyder said last week he had not been briefed.
"We can't find any instance of the Governor having been briefed on the Hep C/HIV issue," wrote Snyder Spokeswoman Anna Heaton in an email. She referred questions about the situation to Michigan Department of Health and Human Services staff.
Quealy said as a result of those federal findings, last year the department authorized local departments in the affected counties to use up to 15 percent of their HIV education and prevention grant dollars for syringe programs. She said two departments have agreed to start such programs, and will be receiving additional funding for that in January 2018.
Quealy stressed that the CDC assessment was model and that no cases of needle related transmission of HIV in the at-risk counties had been verified to date.
Two members of the Senate Health Policy Committee — a Democrat and a Republican — confirmed their committee had not been briefed on the looming concern either. In the event of such an outbreak, lawmakers may be requested to shift funding in the state to respond.
The concerns over the potential outbreak have also led two leading Democrats vying for the party's gubernatorial nomination next year to call on Snyder to declare a public health emergency. Both former Senate Minority Leader Gretchen Whitmer and former Detroit Director of Public Health Dr. Abdul El-Sayed are calling for a declaration of emergency as it relates to the opioid crisis.
Both referred to the crisis as "biggest public health crisis in our lifetime." In addition, both said they wanted to see an immediate move to fund syringe access programming.
Kalamazoo Democratic State Rep. Jon Hoadley said he wanted to see action now before an outbreak occurred.
"Do we have the capacity to fund an emergency response? Perhaps," he said. "Could we try to move some money around to do some sort of immediate intervention? Perhaps.The question is, then, that will be more expensive and less effective than figuring out ways to get ahead of this issue that we know is coming. Every day we're waiting to see if it gets really bad so we actually have to take action is another day that it's just going to get worse. The real problem is that when you start looking forward and saying,'Well, how do we then sustain the response to actually limit the number of new HIV transmissions? How do we then provide the support so new infections that have occurred, the folks that are newly affected, received the treatment that they deserve, so then we're also preventing the further transmission of HIV?' I don't know where that room is in the budget. It is particularly with HIV care, or when they're talking about Hepatitis or HIV or a number of other health instance that we've been reviewing over the last couple of years. You just don't have flexibility in the budget. It's getting really scary."
The Detroit News reports that in 2015 there were 1,981 drug-related deaths statewide in Michigan, but in 2016 there were 2,335 such deaths. The majority of those deaths were opioid related the newspaper reports.
Her call for a state of emergency and release of state dollars for needle exchanges comes as state health officials have revealed a dramatic increase in Hepatitis C cases in northern Michigan. Those cases are tied to intravenous drug use, said Katie Macomber, director of the Division of HIV/STD programs at the Michigan Department of Health and Human Services.
"We know because of hepatitis rates, especially in upper Michigan, that people are likely getting infected with Hepatitis C through injection drug use," Macomber said. "We're not seeing HIV."
Unspoken was the word "yet." Macomber acknowledged that the most recent example of a massive outbreak of HIV in people who use drugs saw a dramatic increase in Hepatitis C cases before HIV made its way into the network. That was in rural Scott County Indiana in 2015. Nearly 200 people were ultimately diagnosed in the outbreak which required an emergency declaration by then Gov. Mike Pence to allow a syringe exchange program to help stem the tide of the outbreak. All the cases were tied to a network of people using the opioid Opana by crushing it up, dissolving it in water and injecting it with shared needles. Prior to that outbreak, the rural county in southern Indiana routinely registered only five new cases of HIV a year.
A study, published by the New England Journal of Medicine in July of 2016, reported that of those infected with HIV during the outbreak, just over 92 percent were co-infected with Hepatitis C. That study identified the outbreak of the liver virus as a precursor to the HIV outbreak.
"Third, HCV infection was highly prevalent in this network of persons who inject drugs," the authors wrote. "Reports of new HCV infections should be noted because they can serve as markers of communities at risk for HIV, and interventions to prevent further HCV infections, such as syringe-exchange programs, could possibly contribute to reducing the risk of an HIV outbreak."
State health officials have taken note of the increase in new cases of Hepatitis C. They've begun to ramp up HIV testing efforts in those 11 counties impacted.
"The Department funds about 50,000 HIV tests in local health departments and community-based agencies each year. In 2014, zero percent were performed in rural health departments, in 2015 zero percent were performed and in 2016 it was 1.6 percent of all tests or about 800 HIV tests," wrote MDHHS Spokeswoman Erica Quealy in an email. "So far, in 2017, we have funded about 45,000 tests, about 5.4 percent are in those low-morbidity health departments (about 2,440 tests)."
Macomber said that the state has a plan ready to go in the event HIV cases begin showing up in these networks.
But the Thomas Judd Care Center, a community clinic in Traverse City that treats those living with HIV, is not waiting for an outbreak of the disease to start. They've done a soft launch of a new HIV prevention clinic called PrEVENT. The new clinic will work with at-risk communities to access the HIV prevention drug Truvada for prevention services, said Victoria Cammarata, a social worker with the organization.
The CDC reports that using the anti-HIV drug for pre-exposure prophylaxis (PrEP) among injection drug users has an efficacy rate of 70 percent in preventing an HIV-negative person from acquiring HIV. That's 20 percent less than sexual prevention, but dramatically more effective than other prevention efforts.
"We thought," said Cammarata of the PrEP clinic, "All right, we got to get our thinking caps on and think of ways that we can reach out to all, not just those 11 counties [identified as at-risk for an opioid related outbreak], but all of our community and get the prevention message out there."