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Challenges in HIV Transmission Control in Injection Drug Use: Lessons from the Indiana Outbreak

This presentation discusses the persistent challenges faced in controlling HIV transmission among injection drug users, using the Indiana outbreak as a case study. It highlights interventions taken to stop the outbreak and identifies key elements for HIV treatment in rural areas.

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Challenges in HIV Transmission Control in Injection Drug Use: Lessons from the Indiana Outbreak

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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 • 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: From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

  3. 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. 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. 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 55 confirmed, 13 preliminary cases Public Health Emergency Declared State alerts CDC 3 new HIV diagnoses 8 more infections CDC support requested March March 26th Late 2014 February 27th January 23rd From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

  7. Epidemic Curve From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

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

  11. 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. 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 Deptof Health, IN State Deptof Health. ID Week, San Diego, CA 2015. From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

  13. 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 • March 25: ISDH requests IUSM* ID physicians to provide HIV care • Once-weekly freeclinic: 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. 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 • ~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 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 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA. 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

  18. Evolving Epidemic Curve 3 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

  19. 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 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

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