The HIV/HCV Outbreak in Indiana: Could It Happen in Your State?

Jonathan Mermin, MD, MPH


August 24, 2015

Editorial Collaboration

Medscape &

This feature requires the newest version of Flash. You can download it here.

Hello. I'm Jonathan Mermin, director of CDC's Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Today I am going to discuss the recent outbreak of HIV and hepatitis C virus (HCV) in a small community in rural Indiana, and what doctors and public health professionals can do to prevent a similar outbreak from occurring where they live and work.

In January of this year, the Indiana State Department of Health began investigating an outbreak of HIV in the southeastern part of that state. The outbreak, which initially consisted of a handful of new diagnoses of HIV, eventually grew to more than 170 new cases of HIV infection, almost all of whom were coinfected with HCV.[1] The majority of HIV cases were due to syringe sharing among individuals who injected prescription oral opioid medication, primarily oxymorphone. There are lasting implications of this outbreak: Many people now require lifelong medical care and antiretroviral therapy, hundreds will require treatment for HCV infection, and the community must intensify disease prevention and drug treatment efforts indefinitely. The lifelong medical care costs alone for treating the persons newly diagnosed with HIV and HCV will be more than $80 million.

The underlying factors of this outbreak are not unique to Indiana. Across the United States, many communities are dealing with increases in injection drug use and HCV infection. These communities are vulnerable to experiencing similar HIV outbreaks. What can be done to prevent this situation from occurring in other places?

Public health officials can make use of available data to identify cases and potential outbreaks.[2] Monitoring HIV and HCV surveillance data, as well as information on drug overdose deaths, drug treatment, oral opioid sales, and prescribing patterns, can be useful. Additionally, social and demographic data can be helpful in assessing the risk profile of communities. Public health officials can also support evidence-based treatment and prevention programs for drug use, HIV, and HCV.

Healthcare workers can[3]:

  • Screen patients for substance-use and mental health disorders;

  • Provide medication-assisted treatment for opioid addiction or offer immediate referrals to substance-use treatment programs;

  • Test patients and their sex and drug-injection partners for HIV, HCV, hepatitis B virus, and sexually transmitted diseases, and offer immediate treatment to those who test positive;

  • Offer preexposure prophylaxis to prevent HIV infection among uninfected persons at continued substantial risk;

  • Provide hepatitis B vaccination;

  • Use current guidelines for prescription of opioid medication to effectively address pain management while reducing misuse;

  • Counsel patients who inject drugs about not sharing needles and syringes, and refer them to programs that provide access to sterile injection equipment; and

  • Notify state or local health departments about any clusters of HIV or HCV infection.

The spread of HIV and HCV in this outbreak has greatly decreased due to excellent work by community members, the state and local health department, and many partners who rapidly mobilized to address the crisis. But its effects will linger for decades, affecting many people's lives, and it has changed the community in profound ways. Proactively using sound public health and medical principles and tools can prevent a similar outbreak from occurring elsewhere.

Web Resources

CDC Health Advisory: Outbreak of recent HIV and HCV infections among persons who inject drugs. April 24, 2015.

Conrad C, Bradley HM, Broz D, et al. Community outbreak of HIV infection linked to injection drug use of oxymorphone — Indiana, 2015. MMWR Morb Mortal Wkly Rep. 2015;64:434-444.

Jonathan Mermin, MD, MPH, is the director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP). Prior to his appointment, Dr Mermin served as director of the Division of HIV/AIDS Prevention, NCHHSTP, from 2009 to 2013. Under his leadership, the Division spearheaded a new approach to HIV prevention, called High Impact Prevention, that aligned funding with epidemiology and ensured that program and research activities had the greatest effect on reducing incidence and improving health equity.

A captain in the US Public Health Service Commissioned Corps, Dr Mermin served as director of CDC-Kenya and HHS Public Health Attaché for the US Embassy from 2006 to 2009, where he oversaw CDC's largest country office, implementing programs and research involving a broad range of infectious diseases, including HIV, malaria, tuberculosis, and emerging infections.

From 1999 to 2006, he was director of CDC-Uganda where he oversaw CDC's HIV prevention and care programs, including implementation of the first antiretroviral treatment program funded by CDC outside of the United States, and the development of a basic care package that was incorporated into PEPFAR and World Health Organization guidelines.

Dr Mermin began his career at CDC in 1995 as an EIS officer with the Foodborne and Diarrheal Diseases Branch. He completed an internal medicine residency at San Francisco General Hospital and a preventive medicine residency at CDC and the California Department of Health Services. He is a graduate of Harvard College and Stanford University School of Medicine, and received his MPH from Emory University. He has coauthored more than 150 scientific articles. He currently serves as an adjunct professor at Emory University School of Public Health.