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Action requested:

  • Be aware that a cluster of new HIV diagnoses has occurred among heterosexuals who inject drugs and are living homeless, some of whom exchange sex, in north King County, WA.
  • Clinicians caring for patients who inject drugs, who are living homeless or who exchange sex should routinely test those persons for HIV and syphilis if the patient has not been tested in the prior 6 months, or if they present with fever, rash, a wasting illness, a sexually transmitted infection (STI) or STI syndrome or any illness associated with immunosuppression (e.g. zoster, pneumonia, diarrhea).

  • Advise people who exchange sex, particularly those who are living homeless and/or inject drugs, to consider initiating HIV pre-exposure prophylaxis (PrEP). Patients can access PrEP at the PHSKC STD Clinic at Harborview Medical Center, the Safe.Healthy.Empowered (SHE) Clinic on 89th and Aurora, and from other medical providers listed on the Public Health website:


Since February 2018, Public Health has identified a cluster of six cases of newly diagnosed HIV infection among persons who inject drugs (PWID) and are living homeless. All six newly diagnosed persons reside in north King County and, to date, all have reported only opposite gender sex partners. Several have exchanged sex for money or drugs.

The HIV epidemic in King County, WA is highly concentrated in men who have sex with men (MSM), and it is unusual for Public Health to identify clusters of cases in heterosexual PWID or people who exchange sex. In 2016, only 11 cases of newly diagnosed HIV occurred among PWID who were not also MSM, and only four women who reported exchanging sex were diagnosed with HIV in King County from 2014 to 2016. A 2016 survey of mostly street-based women who exchange sex found that 4% were HIV positive. In recent years, King County has experienced a change in drug use patterns, with greater mixing between heroin users – a population that has traditionally experienced a low risk of HIV infection – and persons who inject methamphetamine, a population at higher risk for HIV. The county has also experienced an increase in homelessness and, based on a 2017 survey of PHSKC needle exchange clients, and the majority of PWID in King County are homeless or unstably housed. These changes have the potential to foster HIV transmission in a local population that has not traditionally experienced high rates of HIV. It is too early to conclude that the area is experiencing a new trend in HIV infection. However, community members, health care providers and others who work with PWID, people living homeless, and people who exchange sex should be aware of that these populations may be experiencing a rising risk for HIV infection and follow the guidance recommended above.

Contact Public Health's HIV/STD Program with questions at 206-263-2000.