Public health officials are struggling to contain an outbreak of HIV among homeless drug users in Boston that has persisted since early 2019 and likely worsened as the pandemic limited access to services such as testing.
So far the outbreak has affected 113 people, with 13 new cases identified between Jan. 1 and Feb. 28. And the virus, which is deadly when untreated, is thought to be spreading undetected among people who inject drugs and lack stable housing.
“It is astounding that we have as many cases as we do,” said Dr. Jennifer José Lo, medical director of the Boston Public Health Commission. “It is not easy to transmit HIV. It’s a very preventable, very treatable disease. . . . It’s impacting a community that is already encountering many significant challenges.”
HIV cases were happening before the recent outbreak, but increases in homelessness and fentanyl use have accelerated its spread.
“It’s continuing. It’s not like this is new,” said Dr. Larry Madoff, medical director of the state health department’s Bureau of Infectious Disease and Laboratory Sciences. “The fact is, it’s really hard to control.”
A sharp drop-off in HIV testing occurred when the state issued the stay-at-home order in March 2020. The state public health laboratory performed more than 3,000 HIV tests in January 2020 but only about 200 in April of that year. Testing has gradually increased but has not returned to previous levels.
Testing is critical to controlling HIV, because once the disease is detected, it can be readily treated, and people who stick with their one-pill-a-day treatment can no longer spread the virus.
“There have been people with HIV who likely were not diagnosed for an extended period of time,” and thus continued to spread the virus, Lo said.
HIV is transmitted through the blood and can spread when people who inject drugs share needles.
With the onset of the opioid crisis, Massachusetts has seen its progress combating HIV reverse course. From 2000 to 2014, infections had declined by 47 percent overall and by 91 percent among people who inject drugs. But starting in 2015 infections trended upward again with an outbreak in the Lowell and Lawrence areas that ultimately affected 182 people. In January 2019, a separate cluster of six cases was detected among Bostonians who had injected drugs and experienced homelessness, the beginning of the continuing Boston outbreak.
Health officials believe the increasing use of illicit fentanyl, whose effects are more fleeting than heroin, has thrown gasoline on the fire, because more frequent injections create more chances to get infected. Similarly, methamphetamine, newly prevalent in the Boston area, also tends to be injected often and is linked to opioid use.
“Meth is sometimes used so people can stay awake and stay safe,” Madoff said. “It also seems to drive riskier sexual behavior.”
West Virginia is currently facing a severe HIV outbreak that federal officials this month labeled the most concerning in the country. The explosion of HIV in West Virginia has been linked to the state’s decision to shut down a needle exchange program. Such programs reduce the virus’ spread by providing users with clean syringes and other equipment.
In contrast, the Boston Public Health Commission runs an active syringe services program, AHOPE, which enjoys the full support of city and state officials. Testing and treatment are also available free of charge in Massachusetts.
But the persistence of the current outbreak shows that even Boston’s efforts are not enough, said Dr. Joshua Barocas, an infectious diseases specialist at Boston Medical Center. “We needed more investment even before the pandemic started,” he said. “The resources we were putting into harm reduction were not sufficient then and they’re certainly not sufficient now.”
City and state health officials have alerted health care providers who may come in contact with people at risk of HIV, urging them to test for HIV and refer people to treatment. The state Department of Health is directing federal money to Boston Medical Center and Massachusetts General Hospital to beef up HIV detection in the emergency room, Madoff said.
Asked why, at a time when tens of thousands of Massachusetts residents are sick with COVID-19, the 113 cases of HIV are so concerning, Barocas said, “It’s a marker of how well we’re treating our marginalized communities. . . . This is yet another fully preventable epidemic. And it is associated with us not providing for our most vulnerable.”