title: Successful control of a large outbreak of HIV infection associated with injection of cathinone derivatives in Tel Aviv, Israel.
abstract: OBJECTIVE
  Outbreaks of HIV infection have been linked to injectable drug abuse, but specific triggers often remain obscure. We report on an outbreak of primary HIV infection among people who inject drugs (PWID) in Tel Aviv, associated with a local shift in drug-use practices.
  
  
  METHODS
  A cluster of primary HIV infection cases in PWID was detected in May 2012. Retrospective and prospective multi-hospital case finding was initiated. PWID were interviewed and risk factors for primary HIV infection were identified. Starting in December 2012, a multifaceted intervention was implemented, including educational activities, increasing syringe exchange supplies, active screening, early initiation of antiretroviral therapy, and referral to drug withdrawal programmes.
  
  
  RESULTS
  Forty-two PWID with primary HIV infection were detected between May 2012 and April 2013. Compared with the corresponding pre-outbreak period, the annual incidence of primary HIV infection in PWID increased from 0 to 20 cases/1000 population (p <0.0001). Sixty-nine per cent were hospitalized because of concomitant bacterial infections and sepsis. Phylogenetic analysis of HIV isolates from case patients showed tight clustering suggesting a single common source of infection. The outbreak was temporally related to a widespread shift from heroin to injectable cathinone-derivatives and buprenorphine, which entailed high-risk injection practices. Targeted intervention resulted in a dramatic and sustained reduction in HIV infection in the PWID population.
  
  
  CONCLUSIONS
  Injectable amphetamines are gaining momentum among PWID worldwide. Tracing of this outbreak to cathinone use and implementing a targeted intervention programme effectively terminated the outbreak.
authors.affiliation: Infectious Diseases Unit, Tel Aviv Sourasky Medical Centre and Sackler School of Medicine, Tel Aviv University, Israel. Electronic address: katchman@014.net.il.
authors.forename: E
authors.initials: E
authors.lastname: Katchman
authors.affiliation: Infectious Diseases Unit, Tel Aviv Sourasky Medical Centre and Sackler School of Medicine, Tel Aviv University, Israel.
authors.forename: R
authors.initials: R
authors.lastname: Ben-Ami
authors.affiliation: Tel Aviv District Health Office, Israel.
authors.forename: M
authors.initials: M
authors.lastname: Savyon
authors.affiliation: Tuberculosis & AIDS Department, Ministry of Health, Israel.
authors.forename: D
authors.initials: D
authors.lastname: Chemtob
authors.affiliation: Infectious Diseases Unit, Tel Aviv Sourasky Medical Centre and Sackler School of Medicine, Tel Aviv University, Israel.
authors.forename: B
authors.initials: B
authors.lastname: Avidor
authors.affiliation: Infectious Diseases Unit, Tel Aviv Sourasky Medical Centre and Sackler School of Medicine, Tel Aviv University, Israel.
authors.forename: A
authors.initials: A
authors.lastname: Wasserman
authors.affiliation: Infectious Diseases Unit, Tel Aviv Sourasky Medical Centre and Sackler School of Medicine, Tel Aviv University, Israel.
authors.forename: I
authors.initials: I
authors.lastname: Zeldis
authors.affiliation: Infectious Diseases Unit, Tel Aviv Sourasky Medical Centre and Sackler School of Medicine, Tel Aviv University, Israel.
authors.forename: S
authors.initials: S
authors.lastname: Girshengorn
authors.affiliation: Tel Aviv District Health Office, Israel.
authors.forename: Z
authors.initials: Z
authors.lastname: Amitai
authors.affiliation: Tel Aviv District Health Office, Israel.
authors.forename: R
authors.initials: R
authors.lastname: Sheffer
authors.affiliation: Infectious Diseases Unit, Tel Aviv Sourasky Medical Centre and Sackler School of Medicine, Tel Aviv University, Israel.
authors.forename: D
authors.initials: D
authors.lastname: Turner
mesh_terms: D000328:Adult; D000470:Alkaloids / Q000009:adverse effects*; D000662:Amphetamines / Q000009:adverse effects; D004196:Disease Outbreaks / Q000517:prevention & control*; D005260:Female; D006678:HIV; D015658:HIV Infections / Q000150:complications / Q000453:epidemiology* / Q000517:prevention & control; D006801:Humans; D015994:Incidence; D007267:Injections / Q000009:adverse effects; D007557:Israel / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D016485:Needle Sharing / Q000009:adverse effects; D010802:Phylogeny; D011446:Prospective Studies; D012189:Retrospective Studies; D012307:Risk Factors; D015819:Substance Abuse, Intravenous / Q000150:complications / Q000453:epidemiology*; D011795:Surveys and Questionnaires
chemical_list: D000470:Alkaloids; D000662:Amphetamines; C023665:cathinone
keywords: Buprenorphine; Cathinone; Human immunodeficiency virus; Israel; People who inject drugs