BANGOR — Over the last two years, Penobscot County has quietly become the epicenter of an HIV outbreak that is among the largest in Maine’s history.

What officials initially described as a “cluster” of HIV infections was classified as an outbreak earlier this year, with 27 people in Bangor testing positive for the virus since October 2023. Penobscot County previously averaged just two new HIV infections a year.

HIV (human immunodeficiency virus) attacks the body’s immune system and makes it more vulnerable to other sicknesses. It is generally transmitted through unprotected sex or contact with blood, such as when people share syringes. HIV is not curable but has become treatable in recent decades with new medical advancements.

Of those infected in the current outbreak, 26 reported they had injected drugs and 24 had experienced homelessness in the 12 months before their diagnosis, according to data from the Maine Center for Disease Control and Prevention. Although those populations are at higher risk, public health officials stress that increases in homelessness or injection drug use didn’t cause the outbreak.

Rather, they say, the outbreak is a culmination of numerous larger issues that have compounded atop one another for years, simultaneously fueling the spread of HIV and making it more difficult to detect.

As with much of Maine, Penobscot County has faced an acute housing shortage over the last decade, pushing many onto the streets or into homeless encampments, mostly in Bangor. The city’s public health director, Jennifer Gunderman, and other officials say injectable drugs like fentanyl and heroin have become increasingly prevalent, especially among homeless populations. And all the while, northern Maine’s health care system has faltered, marred by hospital closures, financial losses and high turnover among staff.

Those factors have contributed to what is believed to be the largest outbreak of people infected with HIV in state history, according to Bangor public health officials and a Press Herald analysis of publicly available data from the federal and Maine CDC and local news archives.

“If we have had other outbreaks, they may have been different in terms of magnitude — the number of people — or in relation between the cases,” said Anne Sites, the Maine CDC’s director of infectious disease prevention. “But I do believe that this is somewhat of a unique occurrence.”

An already thin support structure is being stretched to its limits, local health providers warn, and is expected to face more strain as cases rise and as the federal government cuts public health budgets, slashes workforces and shifts its policies away from harm reduction, an approach that emphasizes treatment and prevention rather than criminalization.

“This is the toughest time I’ve ever worked in public health professionally. That’s just the reality of it,” said Jennifer Gunderman, director of Bangor Community Health and Community Services. “But we’re going to be creative, we’re going to keep going, and we’re going to try and figure it out.”

The conditions that have made Bangor vulnerable to the outbreak exist in other parts of Maine as well, and advocates say understanding the timeline of the outbreak is essential, for both preventing further spread and informing future outbreak responses.

JANUARY 2024

The first positive HIV test in the Bangor outbreak came in October 2023. The Maine CDC designated it as a “cluster” of cases after two more people tested positive the following January.

All three people had previously been homeless and used injection drugs. And because people who are homeless generally lack steady access to medical care, experts expected the real number of people infected to be larger.

“When we think about the population that’s impacted here, it speaks to all the societal and economic factors that make a population or a community more vulnerable to outbreaks,” said Dr. Puthiery Va, director of the Maine CDC. “When the conditions are right, it spreads.”

At that time, Bangor was seeing a marked increase in homelessness. Encampments had grown and drug use was on the rise, Gunderman said. Though basic harm reduction services like clean syringes and access to the overdose reversing drug naloxone were available, public health experts said the city’s ability to handle such an outbreak was limited.

HIV testing was critical to understanding just how big a response would be needed.

Mobile clinics parked at nearby encampments, offering free HIV tests on site. Providers set out to provide rapid finger prick tests that could offer results in 20 minutes and self tests that could do the same.

“It’s important to expand testing immediately,” Va said. “You want to understand how many individuals are impacted and what we are working with here.”

With wider outreach and more testing through the spring, public health officials soon recognized the January cluster was not a blip.

MAY 2024

New cases stayed steady through spring 2024. Three new people were diagnosed in March. Four more tested positive by May.

“We went from a baseline red flag to thinking, ‘Wait, we should be concerned,’” Va said.

Officials began planning a longer term response.

“We now have people living with HIV who are going to be living with HIV for the rest of their lives,” said Gunderman, Bangor’s public health director. “How do we build that system to provide continuous support?”

Public health agencies at the local and state level began coordinating on how to lower barriers to care. Groups like Bangor Public Health and Needlepoint Sanctuary ramped up preventive measures, including syringe exchange programs where people can trade used needles for clean ones. More organizations began offering free rapid testing.

“(Our partners) deliver street medicine daily in outreach activities — going out into the community to locate individuals, provide primary care as well as HIV services,” said Sites, with the Maine CDC. “It’s bundled, complimented with behavioral health and other services.”

But even with a strong emphasis on testing, officials said they knew they didn’t have a full grasp of the outbreak. It was difficult to test and treat people in large part because of the mobile nature of the population, Sites said.

Many lack stable transportation and housing. Some bounce in and out of incarceration. Others don’t have the personal stability to manage the treatment regimen that follows a positive test. All of those factors make it even more challenging to provide the lifelong treatment needed after an HIV diagnosis, Maine CDC and Bangor public health officials said.

Positive HIV tests continued coming in through summer 2024. By July, the total number of people known to be infected had risen to 13. The situation was snowballing and the collaborative effort between local health care providers would soon start showing its first signs of cracking under pressure.

OCTOBER 2024

To this point, the Bangor Health Equity Alliance was a key part of the city’s approach to the outbreak. The organization provided clean syringes, HIV testing, transportation to medical appointments and other social services to several hundred people.

In October, the group abruptly ceased services and closed the doors to their Bangor community center. In January, the Maine CDC revoked the alliance’s license to provide clean syringes, saying in a letter that the group lacked “timelines, action steps and accountabilities” around data collection and staff training. The organization announced the closure in a social media post and subsequently left the area’s other health organizations with a huge hole for services they suddenly needed to fill.

Wabanaki Public Health and Wellness, an organization that had been providing syringe exchanges and HIV treatment to Indigenous communities, stepped in to fill that void.

“We have an outbreak. We have the means. We have the knowledge, and we have the capacity to serve,” said Lisa Sockabasin, the organization’s CEO. “How do you not serve when you live by Wabanaki values? To be the best neighbors, to roll up your sleeves, and to help?”

Wabanaki Public Health and Wellness picked up where the health equity alliance had left off, setting up needle exchange programs, drop-off boxes and on-demand cleanup efforts, where residents could report needles on the ground for volunteers to arrive and pick up.

In October 2024, the group received 403 needles, either through their exchange programs or needle pickups where volunteers collect syringes littered on the ground. A month later, the group took in over 6,100. That number more than doubled by December, as did the number of clean syringes the organization had given out.

“We were primarily serving the Indigenous population, but now, because there was a need in the community, we needed to increase our capacity quite quickly,” Sockabasin said. “Demand has grown dramatically. I mean, over 2,000% dramatically.”

By the fall, Bangor’s largest encampment, referred to by some as either Tent City or Camp Hope, had grown to about 100 residents, by Gunderman’s count. The need for both health care and harm reduction services rose right along with it.

Around this time, the outbreak in Bangor became the largest in Maine’s history, when compared to decades of publicly available infection data.

FEBRUARY 2025

The first two months of 2025 saw the largest increase in positive tests yet. Eight people were diagnosed with HIV in January and February, more than in the prior six months combined. Health officials partly attribute the increase to expanded testing efforts; the more you test, the more cases you’ll find. But still, they know the true number is almost certainly higher.

In late February, the city cleared the homeless encampment where much of the outbreak and outreach was centered. While hundreds were displaced or moved into other temporary or permanent housing, officials said the move likely had little impact on the increase in positive HIV tests.

Instead, February was the month when Bangor Public Health and Community Services began what Gunderman said has been the most effective testing strategy yet: offering incentives, such as $10 Dunkin’ gift cards. The approach has been tried successfully in Massachusetts and other states with similar outbreaks among homeless populations, she said.

“They can get incentives when they get lab work done, and then they can get a larger incentive when they reach viral suppression,” she said. “What we’re also doing is building relationships, trusting relationships, because adding that glue to someone’s life, particularly someone who struggles so much, reaps big rewards.”

The increase in HIV cases also coincided with a rise in Hepatitis C, a viral blood-borne disease that attacks the liver and is curable with antiviral treatment. Nearly all of those who had tested positive for HIV had also tested positive for Hep C, but officials worried that both diseases could begin spreading statewide.

Parallel efforts to test for Hep C began picking up steam in early 2025. Maine Family Planning, which had been offering testing through its mobile health clinic for months, began offering antiviral Hepatitis treatment and ramping up street outreach with volunteers distributing self testing kits. The organization quickly became a key pillar of the response to both outbreaks.

“If folks are ending up sharing injection supplies, that has the potential to transmit infectious diseases like Hepatitis C and HIV,” said Ellen Taraschi, a nurse practitioner with Maine Family Planning who works on the Bangor outbreak response. “That’s why it’s so important to have these syringe exchanges. It’s a huge public health intervention.”

But as public health organizations scaled up their work, questions began rising about their ability to continue providing services as access to federal funding grew more uncertain.

JULY 2025

The first half of 2025 drastically altered the outlook on Bangor’s outbreak response.

After already cutting public health budgets and workforces, the federal government moved in April to freeze about $2 million in funding to Maine Family Planning as part of the “Big Beautiful Bill” that was signed by President Donald Trump on July 4. The group has since sued the government to have the funding reinstated.

Maine Family Planning has offered free HIV testing across the state for years, and its mobile health clinic has become a critical part of the response to Bangor’s outbreak. Taraschi and other officials said it’s unclear just how much their work will be disrupted by the frozen funds.

What could have larger impacts are cuts to MaineCare, the state’s Medicaid program, which many of those recently diagnosed with HIV rely on for health insurance.

“Over 90% of the patients I see at the mobile unit have MaineCare. For many of those patients, that good, solid health insurance is the only thing going right in their lives,” Taraschi said.

In early July, the Regional Medical Center at Lubec abruptly ended its Northern Maine HIV program, which manages lifelong treatment plans for more than 140 HIV positive people, many in the Bangor area. The organization provided HIV case management through the Bangor Health Equity Alliance and had to shutter the program after the alliance closed, an official confirmed.

Penobscot County’s public health agencies say the closure has left a large gap in the long-term care needed to support people with HIV that other area health providers like Northern Light, also facing the stress of Medicaid cuts and budget shortfalls, are struggling to fill.

Coupled with public scrutiny over harm reduction efforts at both the state and local level, advocates say the collaborative effort between health organizations faces a precarious path forward. But for those involved in the outbreak response, the only option is to treat patients anyway.

“Everyone is already sort of overextending in a manageable way. But if our workforce shrinks even more, we’re not only going to lose important resources for the community, we’re going to have less people who can help,” said Gunderman, Bangor’s public health director. “But we can’t say that we can’t address this outbreak. That’s not an option. We have to focus our research and our efforts. There’s no other option here.”

Editor’s note: Naloxone is available through the state for individuals at www.getmainenaloxone.org. If you or a loved one is struggling with a substance abuse disorder, reach the Maine Department of Health and Human Services’ toll-free help line by calling 211.