Recent HIV Clusters and Outbreaks Across the United States Among People Who Inject Drugs and Considerations During the COVID-19 Pandemic

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Distributed via the CDC Health Alert Network
October 5, 2020, 11:00 AM ET


Since 2015, the Centers for Disease Control and Prevention (CDC) and health departments across the United States have identified several HIV clusters and outbreaks occurring predominantly among people who inject drugs (PWID). Long-term declining trends in HIV incidence among people who inject drugs have stalled. The purpose of this Health Advisory is to alert public health departments and healthcare providers to the possibility of new injection-related HIV infections and outbreaks. This HAN provides guidance for preventing, identifying, and responding to HIV among people who inject drugs. It also provides considerations for delivering services in the context of the COVID-19 pandemic.


HIV Outbreaks Among People Who Inject Drugs

Although HIV incidence among people who inject drugs declined substantially over many years, the ongoing misuse of opioids and other frequently injected substances are threatening this HIV prevention success. HIV diagnoses among people who inject drugs increased by 11% nationally from 2016 to 2018, with more pronounced increases among adults less than 40 years of age and non-Hispanic White adults.1 The COVID-19 pandemic complicates the delivery of essential services, including services for people who inject drugs, potentially hindering further efforts to address the increase in HIV transmission.

Multiple recent clusters and outbreaks have contributed to new HIV infections among people who inject drugs. Following a 2015 outbreak in Scott County, Indiana,2 increases in HIV among people who inject drugs, including several clusters and outbreaks of various sizes, have occurred across the United States in counties that span the rural-urban spectrum.3-14* People involved in such clusters and outbreaks frequently shared common characteristics: nonsterile injections multiple times per day; use of multiple substances (often opioids with methamphetamine or cocaine); marginalizing circumstances (homelessness or unstable housing, recent incarceration, exchange of sex for money or goods); and coinfection with hepatitis B virus (HBV), hepatitis C virus (HCV) and sexually transmitted infections (STIs).

CDC recently published a manuscript that synthesizes experiences and lessons learned from responses to six large HIV outbreaks among people who inject drugs.15 Although these outbreaks shared similarities, potential precipitating factors varied across outbreak settings. The outbreaks occurred in communities with varying levels of capacity to serve people who inject drugs; all offered some level of harm reduction services, including syringe services programs. Yet as part of outbreak response, health departments identified gaps in the delivery of harm reduction (e.g., limited access to syringe service programs and sterile injection equipment) and other services, highlighting the challenges of engaging a significantly marginalized population.

Syringe services programs are proven and effective community-based prevention programs that can provide a range of services, including access to sterile syringes and injection equipment, disposal of used syringes, vaccination, testing, naloxone, and linkage to medical care, including treatment for HIV and substance use disorder. Comprehensive syringe services programs and medication for opioid use disorder can independently reduce HIV and HCV transmission by half; when combined, these interventions can reduce transmission by more than two-thirds.16,17

Health departments can work with trusted community partners to effectively engage people who inject drugs with culturally competent practices. Prompt detection of and response to small numbers of HIV diagnoses may prevent larger outbreaks.

Clinical and Public Health Services to Address HIV Among People Who Inject Drugs in the Context of COVID-19

In the context of COVID-19, ongoing delivery of core clinical and public health services to address HIV and HCV among people who inject drugs is essential. Guidance for alternate means of service delivery when face-to-face services have been disrupted, and for minimizing the risk of SARS-CoV-2 transmission when services are provided in person, is provided in the recommendations. Also, service delivery models can be modified to reduce the number of face-to-face interactions. For example, syringe service programs can offer less restrictive, needs-based syringe distribution that does not limit the number of syringes a client can receive. That encourages clients to distribute sterile injection equipment to their peers who inject drugs (also known as secondary exchange). Fewer in-person visits can also help mitigate the effects of limited hours or closure of syringe service program sites that might occur because of COVID-19. Additionally, needs-based distribution models are the most effective at enabling people to use a sterile syringe with every injection.18,19


All Organizations Serving People Who Inject Drugs

People who inject drugs need comprehensive medical care. Providers and organizations serving people who use drugs can collaborate to ensure that people currently or previously injecting drugs, or who are at high risk of drug injection, have access to culturally competent prevention and care services, including during the context of COVID-19.

  • Recognize that any clinical encounter is an opportunity to provide multiple clinical and public health services for PWID, especially in the context of COVID-19.
  • Partner with other organizations to provide comprehensive medical care and services, including
    • Medication for opioid use disorder ((MOUD), also known as medication-assisted treatment, such as buprenorphine, methadone, and naltrexone) or other services for substance use disorder or other mental or behavioral health needs (as appropriate)
    • Education about safer injection practices and never reusing or sharing needles, syringes, or drug preparation equipment (e.g., cookers, water, filters) for people not yet motivated or able to stop injecting drugs
    • Screening and treatment for skin and soft tissue and other infections (HIV, HCV, HBV, STIs)
    • Vaccination against hepatitis A and hepatitis B
    • Sterile syringes (e.g., prescribe or refer to a syringe services program or to nonprescription sales through retail pharmacies, where legally permissible)
    • Naloxone (for overdose reversal)
    • Pre-exposure prophylaxis (PrEP) to prevent HIV acquisition
    • HIV post-exposure prophylaxis for persons potentially exposed to HIV through sex or injection within the past 72 hours
    • Counseling about other strategies to reduce risk of HIV transmission or acquisition, including limiting the number of sex partners and using condoms the correct way every time they have sex
    • Testing for HIV and HCV at least annually
      • HIV self-testing or use of a home specimen collection kit may be considered particularly in the context of COVID-19
      • If testing confirms HIV or HCV is present:
        • Rapidly link to care and treatment for HIV, HCV, or both infections to reduce viral load rapidly, improve patient outcomes, and prevent further transmission; and
        • Encourage injection partners and sex partners of people with HIV or HCV to get tested.

People who inject drugs can better access the diversity of needed services when services are provided in convenient locations, through mobile service delivery, or when services are co-located and integrated (often referred to as “one-stop shops”).

Clinical Providers

  • When patients present with possible complications of injection drug use (e.g., skin, soft tissue, or bloodstream infections; overdose):
    • Provide screening for substance use disorder;
    • Recommend and offer HIV, HCV, and STI testing;
    • Vaccinate against hepatitis A and hepatitis B; and
    • Offer or refer for substance use disorder treatment, including MOUD.
  • Report cases of newly diagnosed HIV or HCV to the health department.
    • Remain alert to, and notify the health department of, increases in or clusters of HIV or HCV diagnoses.
  • Monitor adherence and offer adherence support for PWID who receive medication for opioid use disorder or treatment for HIV, HCV, or both infections.
  • Connect patients with community resources, including harm reduction or syringe services programs, to ensure access to sterile syringes and to address other social and behavioral health needs.
    • If syringe services programs are not available, provide prescriptions for syringes or information about nonprescription pharmacy sales, in accordance with local laws.
  • Collaborate with public health officials to implement or expand routine opt-out HIV and HCV testing for PWID in settings such as correctional facilities, emergency departments, substance use disorder treatment centers, and community-based medical practices that are frequented by people who inject drugs.
  • Consult guidance for managing people with HIV who develop COVID-19.

Public Health Officials

  • Ensure contact tracing for all new HIV diagnoses.
    • Encourage HIV, HCV, and STI testing of all sex and injection partners and social contacts.
    • Consider retesting PWID, those engaging in high-risk sexual behavior, and those who have partners with HIV at least annually.
  • Routinely monitor your public health data to ensure timely identification of:
    • Recent increases in HIV diagnoses attributed to injection drug use, and
    • Recent increases in HCV diagnoses, particularly among people younger than 40 years of age.
  • Remain alert to high rates of or increases in homelessness or unstable housing, injection drug use, overdose events and deaths, admissions for drug treatment, and drug arrests.
  • Alert community partners to the potential for HIV outbreaks among people who inject drugs.
    • Work with community partners trusted by PWID to identify and strengthen policies and partnerships to enable rapid response to potential HIV outbreaks. Trusted partners may include those serving people experiencing homelessness or unstable housing, and substance use disorder treatment and recovery programs.
  • Work with clinical providers in settings frequented by people who inject drugs to implement or expand routine opt-out HIV and HCV testing for PWID. These settings may include correctional facilities, emergency departments, substance use disorder treatment centers, and community-based medical practices.
  • Implement or increase street-outreach testing or home testing or specimen collection.
  • Improve access to sterile syringes and injection equipment by establishing syringe services programs; amending policies to offer less restrictive, needs-based, and non-punitive syringe distribution models that promote secondary exchange; or increasing access to nonprescription syringe sales from retail pharmacies, in accordance with local laws.
  • Establish collaborations to improve coordination of essential services for people who inject drugs with key partners, including:
    • Clinics funded by the Health Resources and Services Administration’s Ryan White HIV/AIDS Program (RWHAP) and Health Center Program, which provide critical access points for health care and support services for people with HIV and people at risk for acquiring HIV
    • Harm reduction coalitions
    • Community-based organizations that serve PWID or people experiencing homelessness
    • Behavioral health providers
  • Engage with people who currently inject (or formerly injected) drugs as partners in developing recommendations for establishing or expanding essential services for PWID.

Additional Services in the Context of COVID-19

When services are provided in person, guidance is available for minimizing risk of COVID-19 transmission in clinical and field-based settings. When face-to-face services have been disrupted, monitor service delivery and consider alternate means to ensure services reach the needed population.

  • Consult guidance for delivering specific services in the context of COVID-19, including:
  • In the context of COVID-19, communicate options for clients to obtain extended supplies of medications such as antiretroviral therapy (ART), PrEP, and PEP through mail order

Clinical and public health encounters with people who inject drugs present additional opportunities to address COVID-19 risks.

  • To protect themselves and others from COVID-19, provide PWID with access to face masks, hand sanitizer, and education about avoiding close contact and other steps to reduce risk of exposure.
  • Screen PWID for symptoms of COVID-19. For those with suspected or confirmed COVID-19:
    • Provide or refer for urgent or non-urgent medical care, if necessary.
    • Isolate from other people to prevent spreading of infection.
      • Local health departments, housing authorities, homeless service systems, and healthcare facilities should plan to identify locations to isolate those with known or suspected COVID-19 until they meet the criteria to end isolation.
  • Consult guidance to assist people experiencing homelessness in the context of COVID-19.

For More Information


  1. Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Updated); vol. 31. Published May 2020.
  2. Peters PJ, Pontones P, Hoover KW, et al. HIV infection linked to injection use of oxymorphone in Indiana, 2014-2015. New Engl J Med. 2016;375(3):229-239.
  3. Tookes H, Bartholomew TS, Geary S, et al. Rapid identification and investigation of an HIV risk network among people who inject drugs—Miami, FL, 2018. AIDS Behav. 2019; 24:246–56.
  4. Furukawa NW, Blau EF, Reau Z, et al. Missed opportunities for HIV testing during injection drug use-related healthcare encounters among a cohort of persons who inject drugs with HIV diagnosed during an outbreak—Cincinnati/Northern Kentucky 2017-2018. Clin Infect Dis. 2020. Online ahead of print.
  5. Alpren C, Dawson EL, John B, et al. Opioid use fueling HIV transmission in an urban setting: an outbreak of HIV infection among people who inject drugs-Massachusetts, 2015-2018. Am J Public Health. 2020;110(1):37-44.
  6. Massachusetts Department of Public Health and Boston Public Health Commission. Clinical Advisory: increase in newly diagnosed HIV infections among persons who inject drugs in Boston. 25 January 2020.
  7. Minnesota Department of Health. Health Advisory: HIV outbreak in persons who inject drugs (PWID). 6 February 2020.
  8. Samoff E, Mobley V, Hudgins M, et al. HIV outbreak control with effective access to care and harm reduction in North Carolina, 2017–2018. Am J Public Health 2020;110:394–400.
  9. Oregon Health Authority. HIV infection among people who use drugs. June 20, 2019.
  10. Philadelphia Department of Health. Health advisory: HIV outbreak among people who inject drugs, October 16, 2019.
  11. Golden MR, Lechtenberg R, Glick SN, et al. Outbreak of human immunodeficiency virus infection among heterosexual persons who are living homeless and inject drugs — Seattle, Washington, 2018. MMWR Morb Mortal Wkly Rep. 2019;68(15):344-349.
  12. Atkins A, McClung RP, Kilkenny M, et al. Notes from the Field: Outbreak of human immunodeficiency virus infection among persons who inject drugs — Cabell County, West Virginia, 2018–2019. MMWR Morb Mortal Wkly Rep. 2020;69:499–500.
  13. West Virginia Department of Health & Human Resources, Bureau for Public Health. Health advisory #162: Human immunodeficieincy virus (HIV) infections among people who inject drugs — additional area seeing increase, others vulnerable.
  14. State of Alaska Department of Health and Social Services, Division of Public Health. Epidemiology Bulletin: HIV Update — Alaska, 2018.
  15. Lyss SB, Buchacz K, McClung RP, et al. Responding to outbreaks of human immunodeficiency virus among persons who inject drugs — United States, 2016–2019: perspectives on recent experience and lessons learned. J Infect Dis. 2020; 222(Suppl 5):S239–S249.
  16. Fernandes RM, Cary M, Duarte G, et al. Effectiveness of needle and syringe programmes in people who inject drugs – an overview of systematic reviews. BMC Public Health. 2017;17(1):309.
  17. Platt L, Minozzi S, Reed J, Vickerman P, Hagan H, French C, Jordan A, Degenhardt L, Hope V, Hutchinson S, Maher L, Palmateer N, Taylor A, Bruneau J, Hickman M. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database of Systematic Reviews 2017, Issue 9.
  18. Bluthenthal RN, Ridgeway G, Schell T, Anderson R, Flynn NM, Kral AH. Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users. Addiction. 2007;102(4):638-646.
  19. Harm Reduction Coalition. Guide to Developing and Managing Syringe Access Programs.

*Clusters and outbreaks have been identified in Florida (Miami);3 Kentucky (Northern Kentucky);4 Massachusetts (Lawrence and Lowell; Boston);5,6 Minnesota (Hennepin and Ramsey Counties);7 North Carolina (western North Carolina);8 Ohio (Hamilton County);4 Oregon (Portland);9 Pennsylvania (Philadelphia);10 Washington (Seattle);11and West Virginia (Cabell County; Kanawha County).12,13 Smaller increases in HIV diagnoses among PWID have been identified elsewhere, including in Alaska.14

The Centers for Disease Control and Prevention (CDC) protects people’s health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national and international organizations.

Department of Health and Human Services

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