HIV clusters among people who inject drugs are back, this time in Massachusetts, despite its reputation as the nation's gold standard for public health and healthcare.
Lawrence and Lowell, neighboring towns near the New Hampshire border Last year, there were 52 new cases in the region compared to 32 the year before.
While 52 new HIV cases may not sound dramatic, health experts fear that new diagnoses will explode.
Local health officials suspect that the virus is being widely spread by sharing needles, and they have asked the United States Centers for Disease Control and Prevention to investigate. CDC disease investigators are expected to arrive later this month to begin field interviews and identify the source of HIV clusters.
Fentanyl is thought to be a major cause across New England, according to several health experts, including health professionals in Lawrence and Lowell, and a professor working on opioid hotspots nationally.
Fentanyl, a synthetic opioid with a lethal potency 30 to 50 times more potent than heroin, has hit the region hard, partly because of the predominance of white powder heroin that looks identical. Traders in the area cut their heroin with the cheaper synthetic to increase profits, according to epidemiologists. As a result, New Hampshire and Massachusetts each ranked first and second in per capita fentanyl deaths. According to the Boston Globe, it kills more people than heroin overdoses in the two states.
Fentanyl's half-life is shorter than that of heroin, which means that the drug causes a more intense high, but also leaves the body faster. People who inject drugs need to inject fentanyl more frequently to avoid withdrawal symptoms. This may mean that fentanyl is injected eight or more times a day instead of two to four times as much as a heroin addict could inject on a daily basis, according to experts reducing the damage caused by drug use.
More injections means a Peter Friedmann, associate Dean for research at the University of Massachusetts Medical School and chief research officer at the nonprofit Baystate Health.
"If you have to inject several times a day to prevent the withdrawal, the syringe needles are dull and in the absence of extension of the syringe access more syringes is necessary," said Friedmann.
Dan Ciccarone, a professor of family and community medicine at the University of California, San Francisco, is hoping for the CDC The study will include a survey among drug addicts living in Lawrence and Lowell to determine the extent of opioid use. "We are still at this stage of counting only corpses," he said.
Following health experts' assessment of new HIV infections last year, Lowell launched a needle exchange with the support of the University of Baltimore. The replacement only works for about a year, and limited hours of use mean that clean needles still do not reach all the people who need them.
In Lawrence, most new infections are among people under the age of 40 who, according to local health experts, have not experienced the HIV / AIDS crisis of the 1980s and 1990s. Unless they know the lessons of this crisis, they are more likely to share the needles and are less willing to seek medical treatment, which could create an untold community of individuals with undiagnosed HIV who are not treated and transmit the virus ,  There has also been a lack of treatment options for substance use on a national level, particularly drugs such as suboxon and buprenorphine
. As in most of the country, there are not enough clinicians trained in Massachusetts to prescribe drug-assisted treatment (MAT) to all patients who so desire. A doctor must have a MAT certification to be able to prescribe the medication.
"We joke that as an intern on the ward, you can prescribe a patient a blood thinner," Dr. Alysse Wurcel, a medical doctor and assistant professor at Tufts University School of Medicine. While blood thinners can be life-saving, side effects include heavy bleeding that can be fatal.
"Suboxone, which has limited side effects, you can not prescribe," said Wurcel.
Other communities that had this risky A combination of limited access to clean needle and inadequate treatment options also suffered from outbreaks of infectious diseases, including a 2015 HIV outbreak in Scott County, Indiana
under the leadership of then-Gov , Mike Pence, Indiana suffered the worst HIV outbreak in the history of the state. During the months that Pence delayed the approval of a needle exchange in Scott County, 20 new HIV cases were diagnosed every week.
"Scott County is an extreme case," Ciccarone said of the 23,000-member community where HIV spread rapidly through the use of dirty needles.
Lawrence and Lowell are small post-industrial cities with more than three times the population of Scott County. "Think of America, dozens of places like Lawrence and Lowell," Ciccarone said.
More worryingly, Massachusetts has a public health system that is widely considered the best in the country. The state has also received a fierce response to the opioid epidemic, including the opening of the needle exchange, whereby the drug overdose reversal drug naloxone is widely used and money flows into substance abuse treatment.
But even the best public health system in the country has weaknesses. And if an outbreak in Massachusetts can happen, it can happen anywhere.
"We are not West Virginia and we are not rural Maine," Wurcel said. "We have exchanges and a good public health system, which makes it really scary."
When the outbreak spreads, other states and cities with high levels of injected drug use should interpret the HIV increase of Lawrence and Lowell as a warning sign.