Challenges in HIV Transmission Control: Lessons from Indiana Outbreak

Addressing the persistent challenges of HIV transmission control in injection drug use, Dr. Diane M. Janowicz's presentation delves into the HIV outbreak in rural Indiana, interventions to halt the spread, and key elements for HIV treatment amidst the crisis.

• HIV
• transmission control
• Indiana outbreak
• injection drug use
• lessons

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1. Persistent Challenges of HIV Transmission Control in Injection Drug Use: Lessons from the Indiana Outbreak Diane M. Janowicz, MD Assistant Professor of Clinical Medicine Indiana University School of Medicine Indianapolis, Indiana FORMATTED: 3/11/2016 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA. Atlanta, Georgia: April 8, 2016

2. Learning Objectives After attending this presentation, participants will be able to: Describe the HIV Outbreak in rural Indiana List interventions taken to stop the outbreak Identify key elements for HIV treatment in a rural outbreak From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA. Slide 2 of 20

3. Slide 3 of 30 Persons Living with HIV, December 2014 New HIV/AIDS Reports Total Persons Living with HIV/AIDS From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

4. Slide 4 of 30 Scott County Austin, Indiana Population: 4,200 10% unemployment rate 19% below Federal Poverty Line 21% without high school diploma ranked 92nd in a variety of health and social indicators From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

5. Slide 5 of 30 HIV Outbreak Due to IDU Almost exclusively related to IDU Primarily oxymorphone Rare reports of methamphetamine, heroin Injection Practices Multigenerational 2-20 injections per day Up to 20 needle-sharing partners Average of 9 syringe/sex/social partners at risk From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

6. Onset of the Outbreak Slide 6 of 30 55 confirmed, 13 preliminary cases March 26th March February 27th Late 2014 January 23rd From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

7. oNumber of contacts named in previous 2 weeks: 2 oNumber newly identified contacts: 0 oPositivity rate among named, tested contacts as of 8/4/15: 38% oAverage number of unique contacts per case: 8 (range: 0-80) Epi Curve: Epidemic Curve Epidemic Curve 9.24.2015 Slide 7 of 30 22 18 17 14 11 9 9 9 9 8 7 5 5 5 5 3 4 33 1 1 1 2 2 0 1 2 1 1 11 0 0 0 00 0 0 0 0 0 0 0 0 0 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

8. Slide 8 of 30 HIV Outbreak Public Health Emergency: N = 170 (June 2015) 444/513 contacts located, offered testing Point of care rapid test/simultaneous blood draw 0 contacts remain to be traced 38% positivity rate among tested contacts Continued surveillance of high risk individuals 188 people diagnosed with HIV infection (2016) From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

9. Slide 9 of 30 HIV-Infected Population Median age 33 years, range 18-60 Male 57% 100% non-Hispanic white 160/174 (92%) co-infected with Hepatitis C Low annual income (<$10,000) From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

10. Multi-pronged Coordination Slide 10 of 30 Testing Expanding Services Insurance Federal Partners State Partners Viral Behavioral & Mental Health Treatment Suppression Local Partners Academic Partners Risk Reduction Education From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

11. Slide 11 of 30 Austin One Stop Shop HIV, HCV testing Vital records Drivers License/State ID Insurance enrollment Immunizations Rehabilitation, Mental Health Services Care coordination Department of Workforce Development Needle Exchange Program From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

12. Slide 12 of 30 SEP Process Each visit: sterile syringes, wound kit, harm reduction education referrals to health and substance abuse services From April through June*: 85% decline in sharing syringes (P = 0.04) Decreased frequency of reusing syringes (P < 0.001) Increased numbers of syringes exchanged *M. R. Patel, B. Combs, P. Hall, J. T. Brooks, P.J. Peters, D. Broz et al, Centers for Disease Control and Prevention, Scott County Dept of Health, IN State Dept of Health. ID Week, San Diego, CA 2015. From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

13. Slide 13 of 30 Rehabilitation Services Behavioral/Drug Rehab & Mental Health Inpatient, outpatient services Expanded access Permanent location in Austin Medication Assisted Therapy (MAT) Increased access to naloxone Training programs for buprenorphine, naltrexone From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

14. HIV Clinic Slide 14 of 30 March 25: ISDH requests IUSM* ID physicians to provide HIV care Once-weekly free clinic: 2 physicians Appointments and walk-ins HIV testing, treatment, education PrEP First Clinic: March 31, 2015 *Indiana University School of Medicine, IU Health Physicians From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

15. Slide 15 of 30 HIV Clinic Comprehensive intake forms Prioritized HIV treatment Stagger preventative care Other medical problems addressed prn Simple, direct educational materials HIV info specific per visit Consistent messaging to all patients Pharmacy Education From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

16. Jail Care Slide 16 of 30 ~20% of HIV-infected persons incarcerated Coordinate with jail, ancillary services: Care coordination Laboratory draws Medication delivery 40+ patients initiated/continued on ART Continuity of care is critical upon release From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

17. Continuum of Care Slide 17 of 30 % of Total Eligible 100% 86% 74% 59% 32% N=57 Virally Suppressed N=150 Engaged in Care N=130 Care Coord. N=130 Prescribed ART N=176 Eligible From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

18. oNumber of contacts named in previous 2 weeks: 2 oNumber newly identified contacts: 0 oPositivity rate among named, tested contacts as of 8/4/15: 38% oAverage number of unique contacts per case: 8 (range: 0-80) Epi Curve: Epidemic Curve 9.24.2015 Evolving Epidemic Curve Slide 18 of 30 22 18 17 14 11 9 9 9 9 8 7 5 5 5 5 3 4 33 1 3 1 1 2 2 0 1 2 1 1 11 0 0 0 00 0 0 0 0 0 0 0 0 0 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

19. Slide 19 of 30 Lessons Learned & Next Steps Seek, Test, Treat, and Retain Continued surveillance testing, awareness Engagement in care Treatment as prevention (HIV, HCV) Retention in care Behavioral and mental health rehabilitation Sustainability planning with local options From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

20. Acknowledgements Centers for Disease Control and Prevention Division of HIV/AIDS Prevention (DHAP) Division of Viral Hepatitis (DVH) Epidemic Intelligence Service (EIS) Program Office Indiana State Department of Health Scott and Clark County Health Departments Foundations Family Medicine Scott County Jail DIS Officers MATEC-Indiana Indiana University School of Medicine, Division of Infectious Diseases Slide 20 of 30 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.