Diane M. Janowicz, MD Assistant Professor of Clinical Medicine

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: 12/09/15 New Orleans, Louisiana: December 15-17, 2015

2. Learning Objectives • Describe the HIV Outbreak in rural Indiana • List interventions taken to stop the outbreak • Identify key elements for HIV treatment in a rural outbreak After attending this presentation, participants will be able to:

3. Persons Living with HIV as of December 2014 New HIV/AIDS Reports Total Persons Living with HIV/AIDS

4. Scott County Austin, Indiana • Population: 4,200 • Unemployment rate: 10% • 19% below Federal Poverty Line • 21% without high school diploma • Ranked 92nd in a variety of health and social indicators, including life expectancy

5. HIV Outbreak Affects PWID • Related to IDU • Primarily oxymorphone • Rare reports of methamphetamine, heroin • Injection Practices • Multigenerational • 2-20 injections per day • Up to 20 needle-sharing partners • Commonly shared equipment

6. Epidemic Curve

7. HIV Outbreak • 184 people diagnosed with HIV infection • 444/513 contacts located, offered testing • 0 contacts remain to be traced • 38% positivity rate among tested contacts • Median age 33 years, range 18-60 • Male 57% • 100% non-Hispanic white • 160/174 (92%) co-infected with Hepatitis C

8. ‘Wish List’ to Contain Outbreak • Community-wide baseline surveillance • Contact-tracing + door-to-door testing • Include transient populations • Combined Treatment Programs • Outreach Services • Peer Educator Programs • Local providers work with experts for long-term model of care

9. Multi-pronged Coordination Testing Expanding Services Insurance Federal Partners State Partners Viral Suppression Behavioral & Mental Health Treatment Local Partners Academic Partners Risk Reduction Education

10. Austin One Stop Shop • HIV, HCV testing • Vital records (314) • Drivers License/State ID (180) • Insurance enrollment (465) • Immunizations (454) • Rehabilitation, Mental Health Services (114) • Care coordination (142) • Department of Workforce Development (65) • Needle Exchange Program

11. Needle Exchange Program • Scott County Health Department • On-site and mobile unit • 197 individuals participating • Unique ID cards, weekly exchange • >50,000 needles dispensed

12. 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

13. HIV Care Goals • Treatment as Prevention • Decrease individual, community viral loads • Engage all HIV-infected patients in care, including incarcerated • Prevent new infections • PrEP • Needle Exchange Program (local health dept.)

14. Care Collaborations • Local providers offer community-specific knowledge: • Locate difficult-to-find patients • Provide close, personal follow-up • Identify distinct needs of individuals, populations • Identify unique roles of practitioners • Establish a local, sustainable treatment paradigm

15. HIV Clinic • March 25: ISDH requests IUSM* ID physicians to provide HIV care • Once-weekly free clinic: 2 physician model • Appointments and walk-ins • HIV testing, treatment, education • PrEP • First Clinic: March 31, 2015 *Indiana University School of Medicine, IU Health Physicians

16. HIV Clinic • Comprehensive intake forms • Simple, direct educational materials • HIV clinic visits (specific per visit) • General information at One Stop Shop • Algorithms for streamlined care • Permits all levels of providers to treat • Pharmacy Education

17. Themes in HIV Care • Wide range of knowledge bases • Necessary to address stigma, myths • Assurance of privacy • Emphasis on long-term care • Prognosis AND adherence • “Welcoming, non-judgmental, respectful environment” for one and all

18. Jail Care • ~20% of HIV-infected patients are incarcerated • IUSM ID Physicians provide HIV care • Coordinate with jail and local ancillary services • Laboratory draws • Care coordination • Prescription medication delivery • 35+ new patients initiated on ART • Continuity of care is critical upon release

19. Continuum of Care 100% 86% 74% % of Total Eligible 59% 32% N=57 N=150 N=130 N=130 N=176 Care Coord. Engaged in Care Prescribed ART Virally Suppressed Eligible Total diagnosed=166 (166 confirmed). Persons were ineligible if deceased (n=1) or moved outside of the jurisdiction (n=4); estimates are based on the number of eligible persons (n=161); ** Percent virally suppressed increases to 10% when denominator changed to number engaged in care (11/112); Clinical services were initiated March 31, 2015

20. Increasing PrEP Availability • Improve awareness • Provider buy-in • Streamlined algorithms specific to locale • Emergency Dept. • Primary Care Offices • Community Outreach

21. 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

22. 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