HIV and People Who Inject Drugs

People who inject drugs (PWID) are at high risk for getting HIV if they use needles, syringes, or other drug injection equipment—for example, cookers—that someone with HIV has used. New HIV diagnoses^a among PWID have declined in recent years in the 50 states and District of Columbia. However, injection drug use in nonurban areas has created prevention challenges and placed new populations at risk for HIV.

The Numbers

HIV Diagnoses

Source: CDC. Diagnoses of HIV infection in the United States and dependent areas, 2017 pdf icon[PDF – 6 MB] . HIV Surveillance Report 2018;29.

Source: CDC. Diagnoses of HIV infection in the United States and dependent areas, 2017 pdf icon[PDF – 6 MB]. HIV Surveillance Report 2018;29.

Source: CDC. NCHHSTP AtlasPlus. Accessed August 21, 2019.

Living With HIV

An estimated 189,600 PWID had HIV in the 50 states and the District of Columbia at the end of 2016.^b Of those, 93% had received a diagnosis. By comparison, 86% of all Americans with HIV had received a diagnosis.

Source: CDC. Selected national HIV prevention and care outcomes pdf icon[PDF – 3 MB][slides].

Deaths

4,929 PWID with diagnosed HIV died in 2016 in the US and dependent areas.^b These deaths could be from any cause.

Prevention Challenges

• The prescription opioid and heroin crisis has led to increased numbers of PWID, placing new populations at risk for HIV. The crisis has disproportionately affected nonurban areas, where HIV prevalence rates have been low historically. These areas have limited services for HIV prevention and treatment and substance use disorder treatment.
• The high-risk practices of sharing needles, syringes, and other drug injection equipment (e.g., cookers) are common among PWID. In a study of cities with high levels of HIV, 40% of new PWID (those who have been injecting for 5 years or less) reported sharing syringes. From 2005 to 2015, syringe sharing declined 34% among black/African American^d PWID and 12% among Hispanic/Latino^e PWID, but did not decline among white PWID. Young PWID (aged <30 years) are more likely to share syringes than older PWID.
• PWID may also engage in risky sexual behaviors, such as having sex without protection (like a condom or medicine to prevent or treat HIV), having sex with multiple partners, or trading sex for money or drugs. Studies have found that young PWID are more likely than older PWID to have sex without a condom, have more than one sex partner, and have sex partners who also inject drugs.
• Social and economic factors limit access to HIV prevention and treatment services among PWID. In a study of cities with high levels of HIV, more than half (56%) of PWID with HIV reported being homeless, 25% reported being incarcerated, and 16% reported having no health insurance in the last 12 months.
• PWID may face stigma and discrimination. Although substance use disorder is a health issue that requires treatment, it is often viewed as a criminal activity. Stigma and mistrust of the health care system may prevent PWID from seeking HIV testing, care, and treatment.
• PWID may not have access to substance use disorder treatment, including medication-assisted treatment (MAT). MAT can lower HIV risk among PWID by reducing injection drug use. Also, PWID who have HIV are more likely to take HIV medicine as prescribed if they are on MAT. Barriers to MAT may include lack of prescribers, legal and regulatory issues, insurance coverage, and misunderstandings about the use of MAT.
• PWID are also at risk for getting other sexually transmitted diseases (STDs), blood-borne diseases, and bacterial infections. Having another STD can greatly increase the likelihood of getting or transmitting HIV through sex unless the partner with HIV has an undetectable viral load. For people with HIV, getting hepatitis B or C can put them at increased risk for serious, life-threatening complications. PWID can also have other bacterial infections, such as endocarditis and methicillin-resistant staphylococcus aureus.

What CDC Is Doing

CDC and its partners are pursuing a high-impact prevention approach to maximize the effectiveness of current HIV prevention methods and to increase what we know about the experiences of PWID and the risks they face. For example, CDC

• Awarded around $400 million per year to health departments for surveillance and prevention efforts under the new integrated HIV surveillance and prevention cooperative agreement. This award directs resources to the populations and geographic areas of greatest need, while supporting core HIV surveillance and prevention efforts across the United States.
• Awarded about $42 million per year to community organizations under the flagship community-based organization cooperative agreement. This award directs resources to support the delivery of effective HIV prevention strategies to people at greatest risk.

• Awarded a new cooperative agreement in 2019 to strengthen the capacity and improve the performance of the nation’s HIV prevention workforce. New elements include dedicated providers for web-based and classroom-based national training and technical assistance tailored within four geographic regions.
• Supports intervention programs that deliver services to PWID such as Community PROMISE, a community-level HIV prevention program that uses role-model stories and peer advocates to distribute prevention materials within social networks.
• Provides guidance about which syringe services program (SSP) activities can be supported with CDC funds and how CDC-funded programs may request to direct resources to support SSPs.
• Provides technical assistance on SSP implementation. SSPs are proven and effective community-based prevention programs that provide a range of services, including access to and disposal of sterile syringes and injection equipment, vaccination, testing, and linkage to infectious disease care and substance use treatment. SSPs play a key role in preventing HIV and other health problems among PWID.
• Uses cutting-edge technology to detect and respond to clusters of HIV transmission, and supports state and local responses to HIV outbreaks pdf icon[PDF – 2 MB] traced to injection drug use.
• Supports programs to deliver biomedical approaches to HIV prevention and treatment for PWID such as pre-exposure prophylaxis for people at high risk, post-exposure prophylaxis (PEP) to lower the chances of becoming infected after an exposure, and antiretroviral therapy (ART) or daily medicines to treat HIV.
• Maintains the National HIV Behavioral Surveillance (NHBS) system among populations at risk for HIV. Every three years, NHBS collects information on HIV infection and behaviors from PWID in jurisdictions with high HIV prevalence, including drug use and sexual risk behaviors, testing behaviors, and use of HIV prevention services.

^a HIV diagnoses refers to the number of people who received an HIV diagnosis during a given time period, not when the people got HIV infection.
^b Includes infections attributed to injection drug use and those attributed to male-to-male sexual contact and injection drug use (men who reported both risk factors).
^c Unless otherwise noted, the term United States (US) includes the 50 states, the District of Columbia, and the 6 dependent areas of American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, the Republic of Palau, and the US Virgin Islands.
^d Black refers to people having origins in any of the black racial groups of Africa, including immigrants from the Caribbean, and South and Latin America. African American is a term often used for Americans of African descent with ancestry in North America. Individuals may self-identify as either, both, or choose another identity altogether.
^e Hispanics/Latinos can be of any race.