title: HIV Infection Linked to Injection Use of Oxymorphone in Indiana, 2014-2015.
abstract: BACKGROUND
  In January 2015, a total of 11 new diagnoses of human immunodeficiency virus (HIV) infection were reported in a small community in Indiana. We investigated the extent and cause of the outbreak and implemented control measures.
  
  
  METHODS
  We identified an outbreak-related case as laboratory-confirmed HIV infection newly diagnosed after October 1, 2014, in a person who either resided in Scott County, Indiana, or was named by another case patient as a syringe-sharing or sexual partner. HIV polymerase (pol) sequences from case patients were phylogenetically analyzed, and potential risk factors associated with HIV infection were ascertained.
  
  
  RESULTS
  From November 18, 2014, to November 1, 2015, HIV infection was diagnosed in 181 case patients. Most of these patients (87.8%) reported having injected the extended-release formulation of the prescription opioid oxymorphone, and 92.3% were coinfected with hepatitis C virus. Among 159 case patients who had an HIV type 1 pol gene sequence, 157 (98.7%) had sequences that were highly related, as determined by phylogenetic analyses. Contact tracing investigations led to the identification of 536 persons who were named as contacts of case patients; 468 of these contacts (87.3%) were located, assessed for risk, tested for HIV, and, if infected, linked to care. The number of times a contact was named as a syringe-sharing partner by a case patient was significantly associated with the risk of HIV infection (adjusted risk ratio for each time named, 1.9; P<0.001). In response to this outbreak, a public health emergency was declared on March 26, 2015, and a syringe-service program in Indiana was established for the first time.
  
  
  CONCLUSIONS
  Injection-drug use of extended-release oxymorphone within a network of persons who inject drugs in Indiana led to the introduction and rapid transmission of HIV. (Funded by the state government of Indiana and others.).
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Peters
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Pamela
authors.initials: P
authors.lastname: Pontones
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Karen W
authors.initials: KW
authors.lastname: Hoover
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Monita R
authors.initials: MR
authors.lastname: Patel
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Romeo R
authors.initials: RR
authors.lastname: Galang
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Jessica
authors.initials: J
authors.lastname: Shields
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Sara J
authors.initials: SJ
authors.lastname: Blosser
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Michael W
authors.initials: MW
authors.lastname: Spiller
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Brittany
authors.initials: B
authors.lastname: Combs
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: William M
authors.initials: WM
authors.lastname: Switzer
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Caitlin
authors.initials: C
authors.lastname: Conrad
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Jessica
authors.initials: J
authors.lastname: Gentry
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Yury
authors.initials: Y
authors.lastname: Khudyakov
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Dorothy
authors.initials: D
authors.lastname: Waterhouse
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: S Michele
authors.initials: SM
authors.lastname: Owen
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Erika
authors.initials: E
authors.lastname: Chapman
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Jeremy C
authors.initials: JC
authors.lastname: Roseberry
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Veronica
authors.initials: V
authors.lastname: McCants
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Weidle
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Dita
authors.initials: D
authors.lastname: Broz
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Taraz
authors.initials: T
authors.lastname: Samandari
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Mermin
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Walthall
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: John T
authors.initials: JT
authors.lastname: Brooks
authors.affiliation: From the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta (P.J.P., K.W.H., M.R.P., R.R.G., M.W.S., W.M.S., Y.K., S.M.O., V.M., P.J.W., D.B., T.S., J.M., J.T.B.); and the Indiana State Department of Health (P.P., S.J.B., C.C., J.G., E.C., J.C.R., J.W., J.M.D.), Indiana University School of Medicine (J.W.), and Indiana University Richard M. Fairbanks School of Public Health (J.M.D.), Indianapolis, Clark County Health Department, Jeffersonville (J.S., D.W.), and Scott County Health Department, Scottsburg (B.C.) - all in Indiana.
authors.forename: Joan M
authors.initials: JM
authors.lastname: Duwve
mesh_terms: D000293:Adolescent; D000328:Adult; D060085:Coinfection; D016358:Contact Tracing; D004196:Disease Outbreaks; D015658:HIV Infections / Q000453:epidemiology* / Q000635:transmission; D015497:HIV-1 / Q000235:genetics*; D006526:Hepatitis C / Q000453:epidemiology; D006801:Humans; D007196:Indiana / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D016485:Needle Sharing / Q000009:adverse effects; D010111:Oxymorphone / Q000008:administration & dosage*; D010802:Phylogeny; D012944:Social Support; D015819:Substance Abuse, Intravenous / Q000150:complications*; D055815:Young Adult
chemical_list: D010111:Oxymorphone