Grant Targets "Perfect Storm" Threatening Lives

Yale School of Public Health Assistant Professor Gregg Gonsalves has encountered many challenges fighting the HIV epidemic over the past 30 years. What he sees now has him as concerned as he has ever been.

A rise in injection drug use tied to the nation’s raging opioid epidemic is causing a surge in new cases of HIV and Hepatitis C (HCV), said Gonsalves, an assistant professor of epidemiology (microbial diseases) and a member of the school’s distinguished Public Health Modeling Unit.

From 2004 to 2014, HCV rose by nearly 400% among young Americans age 18-29, while hospital admission for opioid injection soared by 622% for the same age group. The resulting syndemic has created a potentially deadly public health triple-threat of three interlocking epidemics – opioid use disorder, HIV and HCV.

“It’s a perfect storm of death and disability for young men and women across the U.S.,” Gonsalves said. “How many lives can be saved moving forward is going to depend on how we respond. Our current approach, which is to wait until an epidemic breaks out and then swing into action, is entirely inadequate. We must do better.”

Armed with a $1.5 million Avenir grant from the National Institute for Drug Abuse, Gonsalves is working with his modeling unit colleagues to develop a web-based tool that will carefully track - and potentially even predict – where any one or all three of the epidemics may play out across cities and towns, and even individual neighborhoods, over time.

“If we could detect new cases of HIV and HCV earlier, we could pre-deploy interventions in areas deemed of high risk and blunt or even avert new outbreaks,” Gonsalves said.

Gonsalves has proven the importance of early intervention. His investigation last year into health officials’ response to an HIV outbreak in Scott County, Indiana received national attention. Using modeling tools and computer simulations, Gonsalves, along with YSPH Associate Professor Forrest W. Crawford and others, found that the number of new HIV infections in Scott County from 2011 to 2015 could have been dramatically reduced - from a reported 215 individuals to as few as 10 - if local and state health officials had responded to warning signs earlier. Research conducted by the U.S. Centers for Disease Control and Prevention (CDC) indicates there are 220 other counties in the U.S. at risk of HIV and HCV outbreaks related to opioid injection similar to what was seen in Scott County. New cases of HIV among people who inject drugs are already being reported in West Virginia, Ohio, Kentucky and Massachusetts.

Gonsalves will test his predictive model by applying powerful computer algorithms to publicly available data provided by states like Ohio, Massachusetts and Connecticut. Gonsalves hopes to create evolving, real-time local maps that track community risks for overdose, HIV and HCV based on a variety of factors - from reported overdoses to population demographics, commercial districts and even the number of fast food restaurants. Health officials can use the maps to target high-risk areas for interventions ranging from needle exchanges to HIV testing and publicly accessible naloxone kits before overdoses rise and infectious diseases among people who use drugs takes hold.

“We don’t have good proxies for hotspots of undiagnosed HIV and HCV infection,” said Gonsalves. “With these new tools, we hope to identify the best places to test for new cases of HIV and HCV and to deliver services to the people who need it.”

Gonsalves will lead a diverse team of researchers, public health experts, clinicians and front-line service providers including numerous colleagues from Yale, as well as representatives from the Harvard School of Public Health, the AIDS Research Consortium of Atlanta, Massachusetts General Hospital, and the Ohio Department of Public Safety.

Dr. David Fiellin, professor of medicine, emergency medicine and public health and director of the Yale Program in Addiction Medicine, said Gonsalves’ many years of experience working with community providers in addressing the HIV epidemic, combined with his research prowess and modeling expertise, makes him perfectly matched to lead this Avenir project.

Fiellin agreed with Gonsalves that as the opioid epidemic continues unchecked, time is of the essence.

“We are in great need of rapid and strategic deployment of prevention and treatment resources for overdose, HIV and HCV in the context of the current opioid crisis,” Fiellin said.