State officials on Wednesday alerted Boston-area health care providers about a growing risk of HIV infections, asking for enhanced vigilance after seven new cases were identified recently among homeless people who inject drugs.
Those cases, most diagnosed in December, are among 25 HIV infections in an outbreak first recognized a year ago, stirring concerns about a deadly consequence of the opioid epidemic. The 25 individuals are people who inject drugs, have recently experienced homelessness, and have sought medical care in Boston.
“It’s another wake-up moment for us all,” said Kevin Cranston, director of the state health department’s Bureau of Infectious Disease and Laboratory Sciences. “Even a relatively small cluster in this population has great potential to expand to new cases.”
The state learned that lesson after an HIV outbreak exploded in Lowell and Lawrence, starting with a few cases in 2015 and eventually affecting 182 people by the end of 2019.
After a campaign to get affected people into treatment, reach and test their contacts, and improve access to services such as needle exchanges, the number of new Lawrence-Lowell cases dropped significantly starting in the summer of 2018.
But then, six new cases were diagnosed in Boston in December 2018. After similar efforts, the Boston cases had dropped down to about two a month — until late fall. Until health authorities interview the affected individuals, it will be hard to know exactly what underlies this new cluster, Cranston said.
Last week, Dr. Jennifer K. Brody, director of HIV services at the Boston Health Care for the Homeless Program, alerted colleagues in the area to the seven new cases. That prompted the state Department of Public Health to initiate its investigation and put out an alert on Wednesday.
Sent to nearly 24,000 physicians, nurse practitioners, and physician assistants in the Boston and Metro West areas, the alert urges providers to test for HIV often, quickly report any new infections to the Public Health Department, and immediately connect infected patients with treatment.
HIV is transmitted through the blood, and people can spread or acquire it by sharing needles and other injection equipment. The prevalence of illicit fentanyl in the drug supply has increased the risk, because fentanyl wears off quickly and people inject more often. Homelessness and periods of incarceration worsen the problem by cutting people off from regular health care.
Between 2000 and 2014, the number of HIV infections among people who inject drugs in Massachusetts declined by 91 percent, reaching a low of 60 new infections in 2014. But then the Lowell-Lawrence outbreak boosted the numbers back up to 2007 levels. As that outbreak abated, however, only 52 cases of HIV were reported among drug users in 2019. That number is likely to increase somewhat as new reports come in, Cranston said.
Health officials’ first step in responding to the Boston cases, Cranston said, will be to ensure the newly diagnosed people receive treatment and then to reach out to their sexual and needle-sharing contacts to have them tested.
Carl Sciortino, vice president of government relations for Fenway Health, said he didn’t find the Boston outbreak surprising.
“It’s a predictable outcome of the lack of a robust, dispersed harm reduction network that reaches people where they are,” Sciortino said.
The state has increased the number of needle exchanges, which provide clean injection supplies as well as training in how to avoid infections, from just five in 2015 to 33. But Sciortino noted that there are only two in Boston and not enough mobile units.
“What we’re seeing is the need for much more aggressive street outreach,” he said.
Last year, after the six new cases of HIV in Boston were reported, “There was a massive mobilization, exactly the public health response you would want to see,” said Brody, of Boston Health Care for the Homeless. City and state health officials worked with local providers to increase HIV testing, expand access to a drug that prevents HIV infection and a drug that treats opioid addiction, and boost efforts to keep people with HIV in treatment. For a time, it seemed the outbreak had died down.
Despite those efforts, with the arrival of methamphetamine, the city started seeing an increase in people with substance use disorders “falling into homelessness,” Brody said.
“We do seem to see a growing number of very, very vulnerable people with substance use disorder, with injection drug use, in great need for care,” she said.
Brody questioned whether the increased police presence, after an assault last summer in the area around Melnea Cass Boulevard and Massachusetts Avenue, may have had unintended consequences, if it discouraged people from coming in for the services clustered in that area.
She emphasized that she doesn’t blame the police and considers their involvement necessary but asked whether the community could have taken measures earlier to prevent the need for police action in the first place.
“How do we strike this balance between public safety and making sure we’re not criminalizing homelessness and making sure we’re not criminalizing substance use disorder?” she said.
Aubri Esters, secretary of the Boston Users Union, a group representing drug users, said in an e-mail that last summer’s police sweeps led to “homeless drug-using folks feeling less safe in the area.” She also said “police and neighborhood harassment of homeless folks being seen sleeping” has increased the use methamphetamine, to stay awake, and people are injecting more often to avoid getting caught possessing drugs.