Bangor public health director reflects on conditions that escalated Maine HIV outbreak

Penobscot County is grappling with Maine’s largest HIV outbreak in its history. Looking back, the top public health official for the county seat of Bangor described how the conditions existed for such an outbreak and how it is now difficult to know the full scope.

In a recent interview, Jennifer Gunderman, Bangor’s director of public health and community services, said HIV had dropped off the radar in Maine because the state has a low incidence of the disease, but then the risk factors started piling up: increased homelessness, wide drug use, disappearing syringe service providers and health care options, and fewer case management providers.

The challenges that arose made it more likely that an outbreak would balloon.

The first case in what was later determined to be a cluster was identified in October 2023. A year and a half later, Penobscot County had 21 confirmed cases. HIV is a virus that attacks the immune system and, if untreated, can lead to AIDS. However, people can live long and healthy lives with treatment.

In response to the outbreak, the state increased access to HIV and hepatitis C virus testing among those at risk, provided HIV and sexually transmitted infection prevention services, offered syringe services and other harm reduction services, and linked people diagnosed with HIV or hepatitis C to medical care and treatment.

The number of confirmed cases has still grown. As of April 24, Penobscot County reported at least 41 cases of HIV cumulatively since the outbreak’s start. Gunderman said the numbers are likely much bigger than the state has been able to track. Historically over the past decade, all of Maine usually saw fewer than 40 new HIV diagnoses each year.

The vast majority of known cases have been among people who are injecting drugs and who are unhoused, but Gunderman said there are likely additional cases among people who are housed and injecting drugs. There is sex work happening for money, support or housing, which increases the risk factors for spreading HIV, Gunderman said.

But it’s difficult to pin down just how many more cases could be out there. The Maine Center for Disease Control and Prevention is working with national experts to model the outbreak and try to answer that question, Gunderman said.

“Epidemiologically speaking, where are we in the outbreak? We don’t know until it’s over,” Gunderman said.

While the state leads the epidemiological investigation into the outbreak, Gunderman said the outbreak has underscored the importance of local public health work. The city’s public health department has expanded testing for HIV and sexually transmitted infections, distributed HIV self tests, and helped get people into housing. It has also set up an HIV case management program to help people get rides to appointments and apply for health insurance. In addition, the Bangor City Council this week voted to allow the public health department to apply for syringe service certification to give out sterile syringes to clients with HIV.

Bangor, which has one of the state’s two city public health departments, plans to use its experience to help other Maine communities that may have fewer resources but face the same conditions that could lead to an HIV outbreak, Gunderman said.

“Now, it’s like how do we understand those ingredients and see where other parts of the state might have these ingredients?” she said. “(We’re) trying to to help those communities increase testing, increase prevention messages, and understand what could be going on in their community and how to prevent an outbreak like we’re experiencing.”

Gunderman’s career in public health before joining the city in April 2024 gave her insight into a range of public health challenges. In the late 1990s, Gunderman started working as an epidemiologist with what is now the Maine CDC and was tasked with responding to a case of mumps on her first day. She also collaborated with many organizations focused on HIV and sexually transmitted diseases, and she gained experience establishing and coordinating statewide infectious disease surveillance.

Gunderman worked as the first public health liaison for the midcoast public health district with the state CDC from 2008 to 2011. She has also worked as an organic farmer and as a consultant providing assistance on global HIV surveillance and data for federally funded projects. She has taught public health and epidemiology at the University of New England, the University of Vermont and the University of Southern Maine.

Since she became director of Bangor’s public health department two years ago, several key public health challenges have generated scrutiny of the city, especially homelessness and drug use. The solutions to homelessness are bigger than what the city alone can accomplish and will require more than street medicine, emergency shelters or housing voucher programs, Gunderman said. It will take movement on many levels, with both short- and long-term solutions, she said.

“There’s a lot of tension and friction that happens around these conversations, but what I’m learning is that we all do have the same goal here, (which is) being a healthy, happy community for everybody,” she said.

The public health department responds to more than homelessness, drug use and infection control. The department also offers maternal mental health support, lactation programming and administers the Women, Infants and Children (WIC) program. In addition, it hosts a travel medicine clinic where people can get the required immunizations for different countries and recently received a $243,000 grant from the Peter and Carmen Lucia Buck Foundation to launch a community paramedicine program.

“Oftentimes, people think a local health department is for the most vulnerable of our community. That’s an important part of our work, but our local health department is to serve everybody,” Gunderman said.

This story was originally published by The Maine Monitor and distributed through a partnership with The Associated Press.