HIV Among People Who Inject Drugs

The risk for getting HIV is very high if an HIV-negative person uses needles, syringes, or other injection equipment that someone with HIV has used. Estimated annual HIV infections among people who inject drugs (PWID) declined 32% from 2010 to 2014 in the United States.^a However, injection drug use in nonurban areas has created prevention challenges and has placed new populations at risk for HIV.

The Numbers

HIV Diagnoses^b

• PWID accounted for 9% (3,425) of the 39,782 diagnoses of HIV in the United States in 2016 (2,224 cases were attributed to injection drug use and 1,201 to male-to-male sexual contact and injection drug use).
  • 73% (2,486) of PWID who received an HIV diagnosis were men, and 27% (939) were women.
  • 43% (1,466) of PWID who received an HIV diagnosis were white, 31% (1,063) were black/African American, and 21% (708) were Hispanic/Latino.^d
• Of the 18,160 AIDS diagnoses in 2016, 13% (2,431) were among PWID.

HIV Diagnoses Among People Who Inject Drugs, by Transmission Category, Race/Ethnicity, and Sex, 2016—United States

Source: CDC. Diagnoses of HIV infection in the United States and dependent areas, 2016. HIV Surveillance Report 2017;28. Transmission categories in CDC’s surveillance system are male injection drug use, male-to-male sexual contact and injection drug use, and female injection drug use.

Living With HIV

• At the end of 2014, an estimated 196,300 PWID were living with HIV in the United States. Of these, 7% were undiagnosed.
• Among PWID living with HIV in 2014,

• • 93% of male PWID (not including gay and bisexual men who inject drugs) had received a diagnosis, 58% received HIV medical care in 2014, 47% were receiving continuous HIV care, and 45% had a suppressed viral load.^e
  • 93% of gay and bisexual men who inject drugs had received a diagnosis, 71% received HIV medical care in 2014, 57% were receiving continuous HIV care, and 54% had a suppressed viral load.
  • 94% of female PWID had received a diagnosis, 67% received HIV medical care in 2014, 54% were receiving continuous HIV care, and 50% had a suppressed viral load.

Prevention Challenges

• The high-risk practices of sharing needles, syringes, and other injection equipment 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 PWID and 12% among Hispanic/Latino 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 a condom or without medicines 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.
• The prescription opioid and heroin epidemic has led to increased numbers of PWID, placing new populations at increased risk for HIV. The epidemic has disproportionately affected nonurban areas, where HIV prevalence rates have historically been low. These areas have limited services for HIV prevention and treatment and substance use disorder treatment.
• 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 HIV-positive PWID 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. Often, injection drug use is viewed as a criminal activity rather than a medical issue that requires counseling and rehabilitation. 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. Also, PWID who are living with HIV are more likely to take HIV medicines as directed if they are on MAT, which reduces their chance of transmitting HIV to others. 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 blood-borne and sexually transmitted diseases (STDs) such as viral hepatitis. Having another STD makes a person more likely to get or transmit HIV. For people living with HIV, getting hepatitis B or C can put them at increased risk for serious, life-threatening complications.

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 behaviors of PWID and the risks they face. For example, CDC

• Will award around $400 million per year under the current funding opportunity to health departments for surveillance and prevention efforts. This funding opportunity will direct resources to the populations and geographic areas of greatest need, while supporting core HIV surveillance and prevention efforts across the United States.
• Supports intervention programs that deliver services to PWID such as Community PROMISE, a community-level HIV/STD prevention program for populations at high risk 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 implement new or expand existing SSPs. SSPs can play a role in preventing HIV and other health problems among PWID. SSPs provide access to sterile syringes and risk reduction education, and ideally provide other comprehensive services such as help with stopping substance misuse; testing and linkage to treatment for HIV, hepatitis B, and hepatitis C; and other prevention services.
• Supports responses for outbreaks of HIV traced to injection drug use such as the 2015 outbreak in rural Indiana.
• Supports programs to deliver biomedical approaches to HIV prevention and treatment for PWID such as pre-exposure prophylaxis (PrEP) 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 examines the behaviors of PWID in jurisdictions with high HIV prevalence, including risk behaviors, testing behaviors, and use of HIV prevention services.

^a Unless otherwise noted, all numbers include infections attributed to injection drug use and those attributed to male-to-male sexual contact and injection drug use.
^b HIV diagnoses and AIDS diagnoses indicate when a person received a diagnosis, not when the person was infected. Estimated annual HIV infections are the estimated number of new infections (HIV incidence) that occurred in a particular year, regardless of when those infections were diagnosed.
^c The term male-to-male sexual contact is used in CDC surveillance systems to indicate a behavior that transmits HIV infection, not how individuals self-identify in terms of their sexuality.
^d Hispanics/Latinos can be of any race. People characterized as Hispanic/Latino in CDC surveillance systems are not counted in race categories (e.g., a person who is white and Hispanic is counted in the Hispanic/Latino, not the white, category).
^e A person living with HIV who takes HIV medicine as prescribed and gets and stays virally suppressed can stay healthy and has effectively no risk of sexually transmitting HIV to HIV-negative partners. Viral suppression is defined as having fewer than 200 copies of HIV per milliliter of blood on the most recent viral load test in 2014. Receiving continuous HIV care is defined as having two viral load or CD4 tests 3 or more months apart in 2014. (CD4 cells are the cells in the body’s immune system that are destroyed by HIV.)