Notes from the Field: Outbreak of Human Immunodeficiency Virus Infection Among Persons Who Inject Drugs — Cabell County, West Virginia, 2018–2019

Amy Atkins, MPA1; R. Paul McClung, MD2; Michael Kilkenny, MD3; Kyle Bernstein, PhD4; Kara Willenburg, MD5; Anita Edwards, MBA6; Sheryl Lyss, MD2; Erica Thomasson, PhD1,7; Nivedha Panneer, MPH2; Nathan Kirk1; Meg Watson, MPH2; Elizabeth Adkins, MS1; Elizabeth DiNenno, PhD2; Vicki Hogan, MPH1; Robyn Neblett Fanfair, MD2; Kathleen Napier1; Alison D. Ridpath, MD4; Michelle Perdue1; Mi Chen, MS2; Tamara Surtees, MPH1,8; Senad Handanagic, MD2; Heather Wood1; Daphne Kennebrew, MEd2; Caitlin Cohn1,8; Samira Sami, DrPH2,9; Scott Eubank1; Nathan W. Furukawa, MD2,9; Bridget Rose1; Antoine Thompson, MPA4; Lauren Spadafora, PhD1; Carolyn Wright2; Shawn Balleydier1; Dawn Broussard, MPH4; Pam Reynolds1; Neal Carnes, PhD2; Nils Haynes1; Tobey Sapiano, MPH2; Shannon McBee, MPH1; Ellsworth Campbell, MS2; Samantha Batdorf, MPH1; Melissa Scott1; Miracle Boltz, MHCA1; David Wills1; Alexandra M. Oster, MD2 (View author affiliations)

View suggested citation
Article Metrics

Views equals page views plus PDF downloads

Related Materials

In January 2019, West Virginia Bureau for Public Health (WVBPH) surveillance staff members noted an increase in diagnoses of human immunodeficiency virus (HIV) infection among persons who inject drugs in Cabell County, West Virginia (population approximately 91,900*). Cabell County, part of a medium-sized metropolitan statistical area and home to the city of Huntington (population approximately 46,000), had historically high rates of substance use disorder but low rates of HIV infection (1). During 2013–2017, an annual average of two diagnoses of HIV infection had occurred among Cabell County persons who inject drugs; however, in 2018, 14 diagnoses occurred, including seven in the fourth quarter.

WVBPH requested assistance from CDC for a public health investigation and response. WVBPH, the Cabell-Huntington Health Department (CHHD), and CDC investigated to characterize the outbreak and guide public health interventions. Initial investigation found that at the time this increase in diagnoses of HIV infection was detected, access to HIV testing and preexposure prophylaxis (PrEP) in Cabell County was limited. Although a harm reduction program, including access to sterile syringes, had been operating at CHHD since September 2015, stricter requirements, including proof of Cabell County residency, were initiated in May 2018, which limited access to these services. Moreover, knowledge about HIV, the outbreak, and treatment for substance use disorder was low, and initiation of treatment for HIV or substance use disorder among persons who inject drugs was also low.

Interventions to address these challenges were rapidly scaled up by staff members from WVBPH, CHHD, CDC, and community partners. A case was defined as a new diagnosis of HIV infection during January 1, 2018–October 9, 2019 in 1) a person who injects drugs (regardless of other risk factors), who resided or was homeless in Cabell County at diagnosis, whose HIV diagnosis occurred in Cabell County, or who reported injecting drugs or accessing syringe services in Cabell County; or 2) a sex or needle-sharing partner of someone meeting criterion 1; or 3) a person whose HIV-1 polymerase sequence was linked at a genetic distance of ≤0.5% to that of a person meeting criterion 1 (2).

CDC staff members provided surge capacity to interview persons with a new diagnosis of HIV and offer HIV prevention services to approximately 600 identified partners and social contacts of these persons. Screening events were conducted to test persons at high risk, provide health education, and link or reengage persons in HIV care. The team worked with local hospitals, clinics, substance use disorder treatment providers, and community-based organizations to scale up HIV testing at locations where persons who inject drugs accessed services. A social network strategy driven by peer recruitment was implemented to reach persons who inject drugs who were not already engaged in the harm reduction program and their sexual and social contacts. The team also partnered with local infectious disease providers and support staff members to improve linkage to HIV and hepatitis C virus care and reengagement for persons who were no longer in care. Interviews were conducted with persons who inject drugs who also reported exchanging sex for money or drugs to identify barriers (e.g., stigma, discrimination, and location and hours of services) that might hinder access to prevention services and to guide service delivery. In addition, the team expanded access to PrEP by training new providers and supporting PrEP implementation at CHHD and two community health systems.

As of January 26, 2020, a total of 82 persons had met the case definition (Table). Among 61 (74%) persons with a CD4+ count measured ≤3 months after diagnosis, median CD4+ count was 583 (range = 6–1,057), indicating that many infections were recent. Among 50 persons who had an available HIV-1 polymerase sequence test result, 46 (92%) were part of a single cluster of closely related infections, indicating rapid transmission. As a result of the combined response activities, approximately 450 new clients enrolled in the harm reduction program, including approximately 50 persons living with HIV infection. CDC assisted in the development of educational campaigns and materials related to HIV infection, substance use disorder, stigma, PrEP, safe injection, and safe syringe and needle disposal for persons who inject drugs and community members. WVBPH and CHHD continue to work together in this response, and WVBPH is improving preparedness for detecting and responding to other clusters and outbreaks statewide through enhanced surveillance.

Corresponding author: Amy Atkins,, 304-356-4021.

1West Virginia Bureau for Public Health, West Virginia Department of Health and Human Resources; 2Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 3Cabell-Huntington Health Department, West Virginia; 4Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 5Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia; 6HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, Washington, DC; 7Division of State and Local Readiness, Center for Preparedness and Response, CDC; 8Public Health Associate Program, CDC; 9Epidemic Intelligence Service, CDC.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.


  1. Allen ST, O’Rourke A, White RH, Schneider KE, Kilkenny M, Sherman SG. Estimating the number of people who inject drugs in a rural county in Appalachia. Am J Public Health 2019;109:445–50. CrossRef PubMed
  2. Oster AM, France AM, Panneer N, et al. Identifying clusters of recent and rapid HIV transmission through analysis of molecular surveillance data. J Acquir Immune Defic Syndr 2018;79:543–50. CrossRef PubMed
TABLE. Characteristics of persons with outbreak-associated human immunodeficiency virus infection — Cabell County, West Virginia, January 1, 2018–October 9, 2019*Return to your place in the text
Characteristic No. (%)
Total 82 (100)
Male 49 (60)
Female 33 (40)
Age group (yrs)
<20 0 (0)
20–39 61 (74)
≥40 21 (26)
White, non-Hispanic 75 (92)
Black, non-Hispanic 1 (1)
Hispanic 1 (1)
Other 5 (6)
Transmission category
Injection drug use 75 (92)
Male-to-male sex and injection drug use 6 (7)
Male-to-male sex 1 (1)
Exchanged sex for money or drugs 24 (29)
Laboratory evidence of current or past hepatitis C virus infection 72 (88)

* Data were last updated on January 26, 2020.

Suggested citation for this article: Atkins A, McClung RP, Kilkenny M, et al. Notes from the Field: Outbreak of Human Immunodeficiency Virus Infection Among Persons Who Inject Drugs — Cabell County, West Virginia, 2018–2019. MMWR Morb Mortal Wkly Rep 2020;69:499–500. DOI:

MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

All HTML versions of MMWR articles are generated from final proofs through an automated process. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version ( and/or the original MMWR paper copy for printable versions of official text, figures, and tables.

Questions or messages regarding errors in formatting should be addressed to

View Page In: PDF [119K]