LOWELL, Mass. For many public health experts, Massachusetts near-universal health insurance coverage makes it the gold standard for access to care. Its the last place in the country where youd expect to find a spike in HIV cases alarming enough to pique the interest of the federal government.

But despite robust local health systems, the industrial cities of Lowell (population 110,000) and Lawrence (population 80,000) just 9 miles apart near the New Hampshire border have both seen a surge in new HIV cases among people who use intravenous drugs.

Between 2015 and 2018, there were 129 new HIV cases linked to drug use in the two cities, according to preliminary results from a joint investigation by the Massachusetts Department of Public Health and the U.S. Centers for Disease Control and Prevention. By comparison, from 2012 to 2014, an average of just 41 cases of HIV linked to injection drug use were diagnosed per year in the entire state of Massachusetts.

The report found that major factors that contributed to the outbreak, many of them outside the reach of traditional health care, are small-scale versions of nationwide trends.

Most notably, local stakeholders told investigators that Lawrence had a local illegal fentanyl manufacturing operation, which made the synthetic opioid an efficient vector for HIV because its short high leads to more frequent injections both pervasive and cheap. Meanwhile, rampant homelessness disrupted treatment for those most at risk. And even though community leaders in Lawrence and Lowell pushed for clean needle exchanges, a known method for stopping infectious disease spread, they only did so after the outbreak began.

As fentanyl spreads across the U.S. and drug use patterns evolve, other areas of the country with this same constellation of risk factors should take note.

This tells us we cannot rest on our laurels, said Thomas Stopka, an infectious disease epidemiologist and assistant professor at Tufts University School of Medicine. There are potentially other communities that are at great risk as well. HIV can and is raising its head again in places where risks align.

If the outbreak had happened in a less aggressively surveilled state Massachusetts has one of the best HIV and hepatitis C surveillance systems in the country it likely would have been much worse, according to Amy Nunn, executive director of the Rhode Island Public Health Institute.

This may be forecasting what could conceivably happen around the country, said Nunn, who was not involved in the investigation.

Tracing An Outbreak

Staff at the Greater Lawrence Family Health Center were used to seeing one new HIV case each month, only a fraction of which were drug-related. Some months, they didnt see any new cases at all. But in 2016, the center diagnosed five new cases in June and July. It didnt slow down from there. By the end of the year, the states health department had gotten involved and had recorded 23 new HIV diagnoses among people using injection drugs in the two cities.

By 2017, those diagnoses had more than doubled to 52 new cases.

Prior to the outbreak, HIV had been declining among all at-risk groups in Massachusetts. And nationally, only 9 percent of all HIV diagnoses in 2016 were linked to injection drug use, according to the CDCs National HIV Surveillance System.

The uptick of 2016 and 2017 might not seem dramatic on paper, but its well outside the norm. Concerned state health department staff called in backup from the federal government, including a rapid response team of Epidemic Intelligence Service officers disease detectives from the CDC who swoop in at the behest of local authorities to help investigate urgent public health problems.

Over the course of a five-week investigation this spring, this joint local-federal task force interviewed law enforcement, homeless services, members of local government and people who injected drugs. Other task force members worked in the laboratory, collecting specimens and doing RNA virus sequencing to trace the movement of the virus through the community.

The team presented their initial findings on July 24.

The most striking finding was the sheer number of cases, said Stopka, who attended the meeting. The fact of the 129 newly diagnosed cases definitely caught a lot of folks attention and really spoke to the great need in terms of a response. Sixty-seven of the 129 cases were previously diagnosed instances of HIV that investigators now understood were linked to the current outbreak.

The majority of cases were among white men between the ages of 20 and 39, and 90 percent of them had also been infected with hepatitis C at some point in their lives. Hepatitis C infection tends to correlate strongly with injection drug use.

Its a significant outbreak, said Dr. Charles Alpren, a CDC officer who investigated the outbreak. Still, he stressed that its important to consider local context.

Why here? Why now? he asked. That was very much one of the things we were looking into what makes Lawrence and Lowell different?

Its Spreading Around Like Wildfire