HIV/AIDS Epidemiology Report 2017 page 91 HIV/AIDS Fact Sheet People Who Inject Drugs in King County Key Points New HIV diagnoses among people who inject drugs (PWID) and do not report other risk factors are relatively rare, with only 11 new diagnoses in 2016 among PWID who are not men who have sex with men (MSM). HIV prevalence is high (40-45%) among PWID who are MSM and inject methamphetamine. The majority (>70%) of HIV-infected PWID are virally suppressed. In 2016, the PHSKC Needle Exchange exchanged nearly 7 million syringes and launched an on-site buprenorphine treatment program. A survey of Needle Exchange clients found increasing rates of homelessness and methamphetamine use among PWID. Population Characteristics In King County, HIV diagnoses among people who inject drugs (PWID) and who do not report other risk factors are relatively rare. Using surveillance data from the Public Health—Seattle & King County (PHSKC) HIV/STD program and our estimate of the PWID population size (see below), we estimate that the HIV prevalence among PWID who are not men who have sex with men (MSM) is approximately 1%, and approximately 15% among PWID who are MSM. Data from the 2015 National HIV Behavioral Surveillance IDU survey found a slightly higher HIV prevalence of 3% among non-MSM PWID and 22% among PWID-MSM. The subset of PWID-MSM who inject methamphetamine have the highest HIV prevalence (40-45%). The prevalence of hepatitis C among all PWID is high at approximately 60-70%. The 2017 survey of PHSKC needle exchange clients found that the average age of PWID was 37 years, 33% were female, and 23% reported a non-White race. The majority were homeless (43%) or unstably housed (26%), a 19% increase from the 2015 survey. Nearly two-thirds (64%) reported that their primary drug was heroin or another opioid. However, polydrug use was very common and methamphetamine use in particular has increased substantially since 2011 (see Figure 1). One in five (22%) PWID reported sharing a syringe in the past 3 months, and 46% reported sharing any injection equipment. Population Size: In 2014, the PHSKC HIV/STD Program estimated that there were approximately 23,000 people in King County who had injected drugs in the past year based on the 2012 King County population. Applying these same calculations to 2016 population estimates, the number of PWID increased to approximately 25,000. We estimate that 4,000 of these PWID are MSM (an increase from 3,000 estimated in 2014). Note that the estimates used to derive the overall PWID number come from 1993-2008 populationbased survey data. Given that other local indicators suggest that injection drug use has likely increased since the mid-2000s, our King County figures probably underestimate the true population size. Primary Metrics HIV prevalence in 2016 Number of PWID prevalent cases Prevalence (%) Percent of all HIV cases HIV incidence (new diagnoses) 2016 incidence (# new diagnoses) 2016 diagnosis incidence rate 10 year trend (2007-2016) Estimated number of PWID in King County (2016) Viral suppression among HIV+ PWID* pwid non-msm pwid-msm 285 1-3% 4% 601 15-22% 9% 11 52 per 100,000 15 375 per 100,000 No sig. change ~50% decrease ~21,000 ~4,000 74% 79% * Among all PWID with diagnosed HIV-infection. Viral suppression defined as plasma HIV RNA < 200 copies/mL. Among those with ≥1 viral load reported in 2016, 87% of PWID (non-MSM) and 88% of PWID-MSM were virally suppressed. HIV Prevention and Care Interventions Needle and Syringe Exchange Program (NSEP): NSEPs are effective interventions for decreasing the risk of HIV transmission among PWID. The PHSKC NSEP is the second-longest running exchange program in the United States, and exchanged nearly 7 million syringes in 2016. Local research has shown that the rate of syringe sharing among PWID in King County has declined over time1, which aligns with declines in new HIV diagnoses in this population. HIV/AIDS Epidemiology Report 2017 Figure 1. Drug Use Trends Among King County Syringe Exchange Clients, 2011-2017 HIV Testing and Viral Suppression: HIV testing among PWID in the Seattle area declined over the past decade: in 2004, 64% of PWID reported an HIV test in the past year, compared with 47% in 2015.2 This decline reflects decreasing levels of HIV testing among non-MSM PWID. In part due to infrequent testing, a relatively high proportion of HIV-infected non-MSM PWID are “late diagnoses” – 46% of male and 24% of female PWID – meaning that they were diagnosed with AIDS within a year of their HIV diagnosis. By contrast, only 16% of MSM -PWID were late diagnoses. Fortunately, most HIVinfected PWID are able to link to care and achieve viral suppression. In 2016, 74% of non-MSM PWID and 79% of PWID-MSM were virally suppressed. PrEP Guidelines: In 2015, PHSKC and WA DOH issued implementation guidelines for HIV pre-exposure prophylaxis (PrEP).3 With respect to PWID, these guidelines state that health care providers should recommend PrEP initiation to patients who are MSM or page 92 transgender persons who have sex with men and who have used methamphetamine in the past year (including injection), and persons who have condomless sex with HIV serodiscordant partners who are not virally suppressed. Other PWID are encouraged to discuss initiating PrEP with their health care provider. MAX Clinic: The MAX Clinic is a walk-in HIV care clinic located within the PHSKC STD clinic at Harborview Medical Center. To be eligible for the MAX Clinic, patients must have had evidence of an inability to remain in traditional HIV care and have a detectable viral load at enrollment. The vast majority of patients have a substance use disorder, with most reporting methamphetamine use. Among the first 50 patients to enroll, 68% were PWID. Overall, 80% of MAX patients achieved viral suppression at least once by the end of 2016, highlighting the effectiveness of this model for this population. Opioid Task Force Recommendations: In response to the opioid overdose crisis in King County, the King County Executive and Seattle mayor formed the Heroin and Prescription Opiate Addiction Task Force in early 2016.4 Although the key objective was opioid overdose prevention, several of the recommended interventions would also result in reducing HIV transmission risk by reducing the frequency of injection and syringe sharing. These recommendations include the establishment of Community Health Engagement Locations (CHELs), also known as supervised injection facilities, and the expansion of low-barrier, on-demand buprenorphine treatment. In response to the latter recommendation, the PHSKC NSEP and Downtown Public Health partnered and began offering on-site buprenorphine in early 2017. Contributed by Sara Glick and Kathryn Klein References 1. 2. 3. 4. Burt RD and Thiede H. Reduction in needle sharing among Seattle area injection drug users across 4 surveys, 1994-2013. Am J Public Health 2016;106:301-7. Burt, RD and Glick, SN. A decline in HIV testing among persons who inject drugs in the Seattle area, 2004-2015. J Acquir Immune Defic Syndr 2017;75 Suppl 3:S346-S351. Public Health – Seattle & King County and Washington State Department of Health. Pre-exposure prophylaxis (PrEP) Implementation Guidelines 2015. http://www.kingcounty.gov/depts/health/communicable-diseases/hiv-std/patients/~/media/depts/health/communicable-diseases/ documents/hivstd/PrEP-implementation-guidelines.ashx. Accessed August 28, 2017. Heroin and Prescription Opiate Addiction Task Force Final Report and Recommendations. http://www.kingcounty.gov/~/media/ depts/communityhuman-services/behavioral-health/documents/herointf/Final-Heroin-Opiate-Addiction-Task-_Force-Report.ashx?la=en. Accessed August 28, 2017.