Distributed by e-mail on June 14, 2016
This update will provide information on:
- HIV outbreak among persons injecting drugs
- Opioid prescribing in Middlesex-London
1. Increase in HIV, iGAS, endocarditis and Hep C in persons who inject drugs (PWID)
The Middlesex-London Health Unit (MLHU) has identified an increase in HIV positivity rates among those who use injection drugs. The local rate in 2015 was 9 per 100,000, which is higher than the Ontario rate with 5.5 cases per 100,000. Two thirds (68.6%) of new HIV cases in Middlesex-London were found to be in PWID, whereas two-thirds of the new Ontario cases in 2013-14 occurred in men who have sex with men (MSM), while only 12% were in PWID.
An increasing in HIV rates is one of several public health issues currently affecting local PWID. Hepatitis C (HCV) infections in Middlesex-London have increased from 32.2 cases per 100,000 in 2005 to 53.7 cases per 100,000 in 2015, while provincial rates have decreased in the same period. We also noticed a recent clustering of HCV cases in Strathroy. Compared to 2010, the proportion of iGAS cases in PWID in Middlesex-London has increased two-fold, 19.0% in 2010 vs. 42.9% in 2016. Finally, there is an increase in the number of hospital admissions due to infective endocarditis, with London Health Sciences Centre reporting admissions for infective endocarditis in PWID rising from approximately 30 in 2009 to approximately 110 in 2014, likely due to injection of drugs not easily soluble (Oxycodone, Hydromorph Contin) and reuse of filters.
We would like to ask healthcare providers who work with high risk individuals to counsel them about safe injection practices and screen for blood-borne infections by ordering anti-HCV, HIV, HBsAg and anti-HBs. Individuals who test positive for hepatitis C antibody should undergo testing for anti-HAV, ALT, AST and HCV RNA. The latter requires a separate requisition which can be found at: http://www.publichealthontario.ca/en/eRepository/PHL_hepatitis_PCR_requisition.pdf
High-risk individuals refusing nominal testing for HIV can be referred for confidential testing at the MLHU STI clinic or anonymous testing at the Options clinic at the London Intercommunity Health Centre (LIHC). Highly active antiretroviral therapy (HART) for HIV is effective not only for treatment but also for prevention of HIV transmission (Treatment as prevention). Please refer your HIV positive patients to HIV care program at LIHC or My Care program at LIHC.
Hepatitis C is treatable and curable. Please consider referring any patient who is positive for Hep C RNA to the local Hepatitis C Care Team at LIHC, St. Joseph’s ID Care Program, Liver Care London, or other providers in ML.
2. Increase in opioid prescribing rates in Middlesex-London and CPSO guidelines
Please be advised that opioid prescribing rates are increasing in Middlesex-London. Among people on public formulary, opioid prescribing rates increased by about 70% in 15-64 year olds between 2006-2010 and 2011-2013 (10,649 to 17,272 per 1,000). This increasing trend is present across Ontario, which is already the province with the highest opioid prescription rate of any province in Canada. A major report on this is available here: http://odprn.ca/research/research-reports/opioid-prescribing-and-hospital-visits/
Opioids play an important role in pain control. However, as we have previously reported, opioids and their abuse are taking a major toll on the health of people in London and Middlesex. Overdose death rates were almost twice the provincial average before introduction of the Naloxone Program in 2014. The CPSO has a practice guideline and a separate practice toolkit here: http://www.cpso.on.ca/cpso-members/resources-for-physicians/national-opioid-guideline