APHL workshop advances integration of HIV, HCV and syphilis testing

Attendees of the testing algorithms pre-HIV Diagnostic Conference workshop listen to a presentation.

Integrating HIV, hepatitis C virus (HCV) and syphilis testing is a laboratory best practice that improves detection of common co-infections and expedites treatment, but integrating these tests is not always easy. Each health department is unique, so they must take a customized approach to implementation based on their distinct set of requirements. To succeed, a health department and its public health laboratory must share common goals and be willing to work together to forge a mutually acceptable agreement.

Until recently, laboratories aiming for test integration had no venue to discuss the practical issues involved. This changed in 2019 when APHL sponsored a one-day workshop prior to the HIV Diagnostics Conference to review HIV, HCV and syphilis testing algorithms; discuss diagnostic testing challenges for each of the three pathogens; and compare recommended methods and protocols to those in use at attendees’ laboratories.

Modeled upon similar APHL workshops for influenza, the workshop brought together representatives from 20 states, the three CDC divisions that funded the workshop and professionals from related areas of public health. Participants exchanged information on common issues such as educating providers and submitters about HIV and syphilis algorithms, appropriate use of nucleic acid testing (NAT) for confirmation of HIV infection, access to ribonucleic acid (RNA) testing for confirmation of HIV and HCV infection, and selection of the optimal syphilis algorithm. Participants like Mary Louise Walmsley, MT(ASCP)—a public health microbiologist in the Alaska State Virology Laboratory’s Department of Immunology—were enthusiastic about the workshop: “Because of the workshop, new and pertinent information regarding HCV and syphilis will be incorporated into the programs at our facility. This was a fantastic workshop, and I hope APHL hosts another one.”

Pending available funding, APHL hopes to continue to sponsor this workshop at future conferences, with a possible return to the HIV Diagnostics Conference, which is held every two to three years. However, given this interval between conferences, APHL is also exploring options at conferences of partner organizations whose work relates to HIV, HCV and STD testing.

In related efforts, APHL has urged the US Department of Health and Human Services (HHS) to develop an STD Federal Action Plan that aligns with other HHS initiatives to combat overlapping epidemics. Additionally, APHL is supporting the Ending the HIV Epidemic plan and efforts to eliminate HCV.

The post APHL workshop advances integration of HIV, HCV and syphilis testing appeared first on APHL Lab Blog.

APHL workshop advances integration of HIV, HCV and syphilis testing

Attendees of the testing algorithms pre-HIV Diagnostic Conference workshop listen to a presentation.

Integrating HIV, hepatitis C virus (HCV) and syphilis testing is a laboratory best practice that improves detection of common co-infections and expedites treatment, but integrating these tests is not always easy. Each health department is unique, so they must take a customized approach to implementation based on their distinct set of requirements. To succeed, a health department and its public health laboratory must share common goals and be willing to work together to forge a mutually acceptable agreement.

Until recently, laboratories aiming for test integration had no venue to discuss the practical issues involved. This changed in 2019 when APHL sponsored a one-day workshop prior to the HIV Diagnostics Conference to review HIV, HCV and syphilis testing algorithms; discuss diagnostic testing challenges for each of the three pathogens; and compare recommended methods and protocols to those in use at attendees’ laboratories.

Modeled upon similar APHL workshops for influenza, the workshop brought together representatives from 20 states, the three CDC divisions that funded the workshop and professionals from related areas of public health. Participants exchanged information on common issues such as educating providers and submitters about HIV and syphilis algorithms, appropriate use of nucleic acid testing (NAT) for confirmation of HIV infection, access to ribonucleic acid (RNA) testing for confirmation of HIV and HCV infection, and selection of the optimal syphilis algorithm. Participants like Mary Louise Walmsley, MT(ASCP)—a public health microbiologist in the Alaska State Virology Laboratory’s Department of Immunology—were enthusiastic about the workshop: “Because of the workshop, new and pertinent information regarding HCV and syphilis will be incorporated into the programs at our facility. This was a fantastic workshop, and I hope APHL hosts another one.”

Pending available funding, APHL hopes to continue to sponsor this workshop at future conferences, with a possible return to the HIV Diagnostics Conference, which is held every two to three years. However, given this interval between conferences, APHL is also exploring options at conferences of partner organizations whose work relates to HIV, HCV and STD testing.

In related efforts, APHL has urged the US Department of Health and Human Services (HHS) to develop an STD Federal Action Plan that aligns with other HHS initiatives to combat overlapping epidemics. Additionally, APHL is supporting the Ending the HIV Epidemic plan and efforts to eliminate HCV.

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“We need to commit to and invest in the changes we seek”: Insights from the MSF Scientific Research Day

“We need to commit to and invest in the changes we seek”: Insights from the MSF Scientific Research Day   Posted August 19, 2018 by post-info In recognition of World Humanitarian Day 2018, PLOS ONE

Scaling-up viral load testing in Ghana is critical to stopping HIV

Scaling-up viral load testing in Ghana is critical to stopping HIV | www.APHLblog.org

By Robyn Sagal, specialist, Global Health, APHL; Samantha Dittrich, manager, Global Health Security, APHL

When HIV first struck Ghana in 1986, it didn’t adhere to global trends. There was a high prevalence of HIV in females, not males. The spread began in rural areas, not urban centers. Regions with more polygamy had lower rates of HIV, not higher. Over 30 years later, Ghana has made significant headway in slowing new infections, but there continues to be an upward trend that’s deeply concerning.

The top HIV/AIDS experts around the world see substantial evidence that antiretroviral therapy (ART) can be highly successful in suppressing the virus in infected people and decreasing the likelihood of transmission. In fact, evidence shows that when the virus is suppressed to the point of being undetectable, the infected individual has low or no risk of transmitting the virus to others. Given these facts, one key to slowing and eventually halting the transmission of HIV is close monitoring of every infected person’s viral load (testing for the amount of HIV in the blood). Regular and consistent viral load testing can determine whether ART is a success or failure. If ART is successful, viral load testing will indicate viral suppression; if not, as when treatment is inconsistent or the virus has become drug resistant, it will show either no change or an increase in viral load. Viral load testing is critical to determining next steps for individual treatment as well as determining whether the epidemic is progressing or regressing.

In keeping with global HIV response efforts, Ghana is shifting their attention to scaling-up viral load testing per the World Health Organization’s (WHO) “treat all” recommendation. That is, not only should infected and high-risk individuals receive ART, they should also have access to regular viral load testing. Additionally, the country has adopted the UNAIDS 90/90/90 global targets aimed at ensuring that 90% of the people receiving treatment are virally suppressed, with the goal of ending HIV/AIDS by 2030. Scaling-up viral load testing requires increasing laboratory capacity, an undertaking to which Ghana and APHL are committed.

In order to develop the Ghana Laboratory Viral Load Testing Extension plan, APHL has worked closely with CDC-Ghana, the Ghanaian Ministry of Health (MOH), Ghana Health Service (GHS), the National AIDS Control Programme (NACP) and many other partners and stakeholders. This plan outlines a strategy to increase and monitor laboratory capacity for viral load testing. It includes an ambitious, targeted approach that balances achieving global goals of ART treatment monitoring with the limited resources available in the country. The plan accelerates the scale-up of viral load testing by defining national testing targets and a timeframe for achieving them, improving stakeholder collaboration and pooling available resources for better distribution.

In addition, APHL has collaborated with the Centre for Remote Sensing and Geographic Information Services (CERSGIS) to map all 245 ART centers in Ghana. This huge undertaking generated geo-referenced maps for each site, including the latitude and longitude of the ART centers along with other related attributes such as differentiated models of care sites, regional viral load centers, sector viral load centers, functional viral load centers, testing staff capacity, ART equipment at the centers and much more. Visualizing these data at various administrative levels provides national decision makers with a more nuanced understanding of program coverage and priorities for scale-up. By mapping rather than graphing or charting the data, users are better able to recognize important patterns.

As the global health community works to end AIDS by 2030, laboratory testing will continue to be essential for diagnosis, treatment and prevention. APHL’s viral load scale-up activities in Ghana will help those already afflicted by HIV/AIDS to receive effective treatment and  will ultimately decrease the number of new infections in the country.

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PLOS Medicine Announces a Call for Research Papers, on the Prevention, Diagnosis, and Treatment of Sexually Transmitted Infections

0000-0002-8715-2896 PLOS Medicine Announces a Call for Research Papers, on the Prevention, Diagnosis, and Treatment of Sexually Transmitted Infections   post-info AddThis Sharing Buttons above Guest editors Nicola Low of the University of Bern, Switzerland

Zimbabwe makes significant strides in the fight against HIV/AIDS

Zimbabwe makes significant strides in the fight against HIV/AIDS | www.APHLblog.org

From Zimbabwe’s first diagnosed case of HIV/AIDS in 1985 until 1997, the country’s health situation became increasingly dire: At the disease’s peak, 29% of the population was infected. Since then, Zimbabwe has made significant strides in the fight against HIV/AIDS. HIV prevalence has been reduced to 16% (2015 estimate) – 1.6 million people.

Now the nation is striving to achieve the UN’s 90/90/90 goals: 90% of people living with HIV know their status, 90% of people diagnosed HIV positive are on sustained antiretroviral treatment (ART), and 90% of those on ART have an undetectable viral load.

By 2012, the percentage of Zimbabweans living with HIV who knew their status was estimated to be 66%, and of those, ART coverage was at 55%. Viral load test availability was extremely low in 2015, but the 2016 figures are expected to increase dramatically thanks to the newly established viral load testing program. Developed with APHL’s support, six provincial super-laboratories now have the infrastructure, equipment, personnel and supply chain support to perform routine viral load testing.

Working in collaboration with Zimbabwe’s Ministry of Health and National Microbiology Reference Laboratory, APHL – the only PEPFAR laboratory partner in the country – has adopted a comprehensive approach to improving testing quality, one that leads to better diagnosis and treatment. The association is developing external quality assurance systems to verify test results. Already half of Zimbabwe’s 1,848 testing sites are using this method successfully to ensure the quality of laboratory services.

APHL has proved critical in the establishment of quality point-of-care testing, which has meant quicker and more reliable test results. This work has been implemented primarily by Shanette Nixon, APHL consultant, and Goodridge Mguni, APHL’s external quality assurance manager for Zimbabwe.

Together, they have built capacity at the National Microbiology Reference Laboratory to produce dried tube specimen panels – which can be preserved for up to a year without refrigeration – for health testing sites to ensure quality assurance and control. Given the country’s warm climate, these panels could be key to achieving universal access to quality HIV testing in Zimbabwe. However, they require new training for rapid diagnostic HIV testers who already shoulder many tasks. That is why Shanette and Goodridge work so hard to train as many people as possible.

Below Shanette and Goodridge talk about their work.

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What challenges do you face in your work?

GOODRIDGE:

Insufficient human and financial resources are huge challenges. There is a massive brain-drain here in Zimbabwe, so it can be difficult to find staff.

SHANETTE:

Yes, it can make the work very hard. Many folks say that point-of-care testing eliminates the barriers to HIV treatment in one step. The quick results are a huge advantage and the tests can be highly accurate—but only if properly trained people perform the tests.

GOODRIDGE:

I agree, but at least the use of lay counsellors in point-of-care testing has helped to mitigate the training issue a bit.

Financially, the Global Fund, PEPFAR and other donor organizations continue to assist, but the country will need resources beyond those external ones.

Another challenge is poor sample transportation networks. The country is working on an integrated network which will improve movement of test samples.

There has also been a lack of effective coordination between stakeholders, which has led to a lot of overlapping projects. Partners such as APHL, though, have supported Ministry of Health efforts to keep all implementing partners engaged to avoid duplicated efforts. For example, the technical working group, which APHL has actively participated in, allows key stakeholders to communicate regularly.

What does your work mean to you?

GOODRIDGE:

In the past, I witnessed patients receiving wrong HIV results and it’s a terrible sight—families can break apart. I want to keep those scenarios in the past.

That’s why I feel so blessed to go to each site, talk to scientists as my brothers and show them how we can succeed together. That one-on-one time makes all the difference.

Zimbabwe makes significant strides in the fight against HIV/AIDS | www.APHLblog.orgTo be clear, all of our teammates see the importance of accurate results, but it can take some doing to get people comfortable with the new steps to take and the changes they involve.

SHANETTE:

I’ve seen that, too. That’s why when I’m training a scientist, I keep in mind that I’m affecting one person who can affect millions. That’s why I do what I do. Every time I see that lightbulb go off in someone’s head, I’m thrilled.

GOODRIDGE:

Yes, it feels like a triumph when someone truly understands, and it’s extra special when I get comments from people doing the hard work in the field. In Masvingo, nurses told me that the program satisfies clients and motivates testers. “Keep it up!” they said. And in Manicaland, a nurse said, “Every health center should participate to enhance competence among testers.” That felt so good to hear, and I’m trying to make that happen. I’m excited that dried tube specimen is in 925 sites, halfway to our goal!

SHANETTE:

And once the Ministry gives us the go-ahead to train scientists in the remaining provinces, everyone will have full access no matter where they are!

What are your thoughts when you look to the future?

GOODRIDGE:

I sometimes worry that access to testing, no matter how high quality, isn’t enough. Since antiretroviral medication is for life, there has to be real follow-through for decades. I know you’ve preached sustainability, Shanette, so I’m always looking for ways to sustain the dried tube specimen approach if the current funding disappears.

SHANETTE:

Well we hope that never happens, but I’m glad you’re trying to be sustainable! Creating institutional memory and standardizing testing practices at the labs is so important. Plus, your easy way with people helps motivate them to keep up the techniques you’re teaching them. And I’ve seen how eager they are to ensure that you succeed.

GOODRIDGE:

Thank you, I hope so! I’m just glad to have an impact. When we reach the UN’s 90/90/90 goal, oh, will I celebrate!

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Small but mighty Zimbabwe lab team meets challenges in reaching HIV testing goals

For decades, APHL has worked in more than 30 nations to train and support lab professionals fighting HIV/AIDS, often under agreements with CDC and the US President’s Emergency Plan for AIDS Relief (PEPFAR). One of those nations is Zimbabwe.

In 2004, when PEPFAR was established, the HIV rate in Zimbabwe was 25% and the treatment rate for people with HIV was 13%. Today, Zimbabwe’s HIV rate is under 15%, and there’s a 60% treatment rate among people with HIV.

APHL is working closely with the Zimbabwe Ministry of health to provide leadership, mentorship and support in an effort to increase patient access to quality tests for monitoring HIV treatment. In addition to increasing testing capacity at six provincial laboratories of public health (aka, super laboratories), APHL and the Ministry of Health established a state-of-the-art transport system for blood samples so that patients in remote areas would gain access to testing. Levi Vere, an APHL consultant, supervises the in-country team to meet these objectives.

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By Levi Vere, Quality Monitoring Supervisor, APHL Global Health Consultant

Not long ago, some of my relatives were among the people who had to travel long distances to a city hospital for a test to learn if they had HIV. Sometimes they would line up at 4 a.m. and wait four hours for the clinic to open, only to be sent away because there were too many people seeking HIV services that day.

Today, they can access testing and treatment in clinics that are a stone’s throw from their homes. Those clinics connect to our six Ministry of Health super laboratories, with samples transported by a motorbike delivery network.

This is just one of the changes supported by our work in Zimbabwe. It seems simple, but these improvements have made an enormous difference in people’s health. Seeing these changes in their lives really touches my heart, and keeps me excited about the difference we are making every day.

High stakes and pervasive challenges

Handling logistics and samples is only one challenge. Zimbabwe faces a huge staff deficit in lab services.

Zimbabwe has historically had a strong university program, resulting in valuable laboratory expertise. We have 10 Zimbabweans on the APHL-Zimbabwe staff team: eight highly qualified medical technologists, a highly experienced database administrator and an office administrator.

But much of this country’s expertise has emigrated. The government typically can’t afford competitive salaries for laboratorians. University training capacity has also suffered under economic hardships. Current microscopy training isn’t sufficient for the complex tests required for monitoring HIV treatment.

The national budget for fighting the HIV/AIDS pandemic is tiny, and the total gross domestic product spent on health is small. The Ministry of Health’s allocation often must go to purchasing drugs, not to laboratories and testing. Hospitals struggle because so many patients can’t afford to pay.

And the challenge of sample transport needs further consistency and improvement. Better access for patients in remote areas would not only improve testing and treatment for HIV/AIDS, but would extend to surveillance for other diseases, such as tuberculosis and malaria.

Other challenges are cultural. HIV is a chronic issue, so people have become used to it and don’t have the same level of response as when it was seen as a crisis. Also, it’s culturally acceptable for men to have several wives which means several sexual partners. And because men face stigma in visiting a hospital, many don’t seek help until they’re quite sick.

People make the difference

Technical know-how alone will not change systems—it takes a change in the laboratory culture. I have seen a huge leap in commitment to quality.

When I began as a mentor, I experienced resistance to change. But when the laboratory personnel began to see the impact of their efforts and the improvements we were making together, they placed more value on the importance of their work.

The change in morale was remarkable: Staff don’t just come in and quietly head for their bench. Everyone’s ideas are welcome. We saw reductions in sick leave applications and absenteeism, and more punctuality. People are willing to go the extra mile.

 The three letters at the heart of change: QMS

Mistrust of test results can lead to resistance to treatment. Strengthening of Quality Management Systems (QMS) leads to more accurate testing and better compliance.

I supervise our mentors who coach and train the laboratory staff in organization, management of testing processes and quality assurance protocols. In order to pass proficiency testing and gain lab accreditation by international standards, they must learn and adhere to World Health Organization (WHO) and International Organization for Standardization techniques.

Lab monitoring of patients on treatment is another critical factor. APHL laboratory mentors at the six super laboratories help ensure quality of services from data to supplies to equipment maintenance.

In the past, we had to handle so many samples that lab equipment would often break down. I remember one mother in the infant HIV testing lab who was in tears because she couldn’t breastfeed her baby until lab results were in—and the machine had broken.

With technical assistance from APHL, including attention to routine maintenance, equipment downtime has been greatly reduced.

Increased and improved testing

With the new transport system bringing more tests from far-flung areas, our changes have opened the floodgates to testing. In the past year, we performed 25% more CD4 tests, a standard measure for HIV. We have more tests to do each day, and we’re improving them by every measure: completing them faster, with less spoilage, fewer rejection of samples and more accurate results.

Improvement in turnaround time of tests—the time from sample collection to release of the results to the patient—is particularly important. For instance, infant HIV test results used to take six weeks and now take five days—or even three. As I mentioned above, this time difference is critical for breastfeeding mothers—they need to know if their HIV status or medication will affect their children.

Our work has truly helped make the difference: fewer equipment breakdowns, more efficient use of supplies, improved understanding of quality and the use of standardized, streamlined processes.

What’s next? Expanded viral load testing

Until now, our focus was on building the capacity of the labs that we support. This year, we will focus on expanding viral load testing, which we have already launched in two of our super laboratories so far.

Viral load testing is a more sensitive test for monitoring efficacy of HIV treatment. It measures the rate of suppression of the virus itself, as opposed to CD4 testing which slowly monitors the impact of such suppression on the body’s defenses. With viral load testing, we can see resistance to treatment in a patient sooner and switch treatment quickly to one that works.

With the WHO promotion of a test-and-treat strategy, our focus is on ensuring quality of HIV tests, both in early infant diagnosis and in HIV rapid diagnostic testing.

The sooner patients start treatment, the better the outcome, so we are ramping up our efforts to get accurate results. We will then monitor treatment progress through viral load testing as quickly as possible. This entails adding more instruments and reagent supplies in all of our labs to keep pace with both the viral load testing demand and the increased numbers of people being tested.

90/90/90

For Zimbabwe, for Africa and for the world, the next goal is to reach the United Nations’ 90/90/90 goal: 90% of people are tested; 90% of these are on treatment; 90% of these have an undetectable viral load.

The fact that we can even discuss reaching this goal is amazing; it reflects the progress that we and other partners are making in Africa. As the Zimbabwean proverb says, “If you can envision it, you can accomplish it. If you can imagine it, you can reach the heavens.” In Zimbabwe, we are reaching for the heavens.

Interested in becoming an APHL global health volunteer? We offer consultancies for two weeks to 12 months in Africa, the Caribbean, Eastern Europe or Southeast Asia. Learn more about making a difference with APHL.

 

More people, more time, better data – what we need to ‘treat-all’ with HIV

redribbon-e1448993818437-640x320On World AIDS Day 2015 and as the 18th International Conferences on AIDS and STIs in Africa (ICASA) is in full swing, Helen Bygrave discusses the implications of the recently announced WHO ‘treat-all’ policy. On

Simple but elusive – why are we still talking about HIV drug delivery?

Ahead of the International AIDS Society (IAS) Conference held in 2015 in Vancouver, Canada (July 19-22), Helen Bygrave of MSF discusses her frustrations with the lack of implementation of simple, programmatic strategies for improving HIV care. My main memory of … Continue reading »

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The Anatomy of an HIV Outbreak Response in a Rural Community

Drug abuse with people sharing the same syringe to inject heroine

In a small, rural town in Southern Indiana, a public health crisis emerges.  In a community that normally sees fewer than five new HIV diagnoses a year, more than a hundred new cases are diagnosed and almost all are coinfected with hepatitis C virus (HCV).

How was this outbreak discovered, and what caused this widespread transmission? Indiana state and local public health officials – supported by CDC – set out to answers these questions and help stop the spread of HIV and HCV in this community.

The Outbreak

In January 2015, Indiana disease intervention specialists noticed that 11 new HIV diagnoses were all linked to the same rural community.  This spike in HIV diagnoses in an area never before considered high-risk for the spread of HIV, launched a larger investigation into the cause and impact of these related cases.

The investigation began by investigating the 11 newly diagnosed cases. This process involved talking to newly diagnosed individuals about their health and sexual behaviors, as well as past drug use. In the United States, HIV is spread mainly by having sex or sharing injection drug equipment such as needles with someone who has HIV.

Scanning electron micrograph of HIV-1 virions budding from a cultured lymphocyte.
Scanning electron micrograph of HIV-1 virions budding from a cultured lymphocyte.

In the case of the 11 related diagnoses in Indiana, almost all were linked to injection drug use. Investigators discovered that syringe-sharing was a common practice in this community–often used to inject the prescription Opana; opioid oxymorphone (a powerful oral semi-synthetic opioid medicine used for pain.)  HIV can be spread through injection drug use when injection drug equipment, such as syringes, cookers (bottle caps, spoons, or other containers), or cottons (pieces of cotton or cigarette filters used to filter out particles that could block the needle) are contaminated with HIV-infected blood. The most common cause of HIV transmission from injection drug use is syringe-sharing. Persons who inject drugs (PWID) are also at risk for HCV infection. Co-infection with HCV is common among HIV-infected PWID. Between 50-90% of all persons who inject drugs are infected with both HIV and HCV.

The Investigation

“Contact tracing” is the process of identifying all individuals who may have potentially been exposed to an ill person, in this case a person infected with HIV.  Contact tracing involves interviewing the newly diagnosed patients to identify their syringe-sharing and sex partners.  These “contacts” are then tested for HIV and HCV infection, and if found infected are likewise interviewed to identify their syringe-sharing and sex partners. This cycle continues until no more new contacts are located.

As of May 18, contract tracing and increased HIV testing efforts throughout the community identified 155 adult and adolescent HIV infections. The investigation has revealed  that injection drug use in this community is a multi-generational activity, with as many as three generations of a family and multiple community members injecting together and that due to the short half-life of the drug, persons who inject drugs may have injected multiple times per day (up to 10 in one case). may be needed .

Early HIV treatment not only helps people live longer but it also dramatically reduces the chance of transmitting the virus to others.  People who do not have HIV and who are at high risk for HIV can also benefit more directly from the drugs used to treat HIV to prevent them from acquiring HIV.  This is known as pre-exposure prophylaxis (PrEP). Post-exposure prophylaxis, or PEP, is an option for those who do not have HIV but could have been potentially exposed in a single event.

The Response

HIVTesting_Eng_webSo what is the next step in addressing this staggering outbreak? First, public health officials must work to get every person exposed to HIV tested. All persons diagnosed with HIV need to be linked to healthcare and treated with antiretroviral medication. Persons not infected with HIV are counseled on effective prevention and risk reduction methods; including condom use, PrEP, PEP, harm reduction, and substance abuse treatment. Getting messages about the benefits of HIV treatment to newly diagnosed individuals and prevention information to at-risk members of the community are key components to control this outbreak.

The underlying factors of the Indiana outbreak are not completely unique. Across the United States, many communities are dealing with increases in injection drug use and HCV infections; these communities are vulnerable to experiencing similar HIV outbreaks. CDC asked state health departments to monitor data from a variety of sources to identify jurisdictions that, like this county in Indiana, may be at risk of an IDU-related HIV outbreak.  These data include drug arrest records, overdose deaths, opioid sales and prescriptions, availability of insurance, emergency medical services, and social and demographic data. Although CDC has not seen evidence of another similar HIV outbreak, the agency issued a health alert to state, local, and territorial health departments urging them to examine their HIV and HCV surveillance data and to ensure prevention and care services are available for people living with HIV and/or HCV.

The work that has been done thus far, as well as the continued efforts being made to address this response, highlight importance of partnerships between federal, state and local health agencies. The work done by Indiana State Department of Health’s disease intervention specialist to link the initial HIV cases to this rural community, and the work of the local health officials to respond quickly and thoroughly to investigate all possible exposures and spread important health prevention information demonstrates the critical importance of strong public health surveillance and response.

The Division of HIV/AIDS Prevention commends the efforts of all the individuals involved in controlling the HIV outbreak in Indiana. The response illustrates that together we are committed to improving the health of our communities across the nation.