INJECTION DRUG USE IN METROPOLITAN CINCINNATI Judith Feinberg, MD Professor of Medicine University of Cincinnati College of Medicine November 12, 2012

Disclosures  Advisory Board: Janssen, GlaxoSmithKline/ViiV & Merck  Shareholder: Pfizer (stock)  Grant Recipient: Janssen, Tobira, GSK/ViiV, Boehringer Ingelheim & Bristol Myers Squibb  Speakers Bureau: Janssen, Merck, BMS & GSK/ViiV

Endocarditis Admissions at University Hospital

*also includes Batavia, Blue Ash, Amberley, Butler County, Clermont County, Cleves, Madeira, Mariemont

UH Endocarditis Study,  2-fold increase in hospital admissions for endocarditis  4-fold increase in patients with chronic hepatitis C  6-fold increase in positive toxicology screens  reflects a sharp local increase in IDU, from 1999 to 2009  These rates underestimate the true numbers because most endocarditis patients were not tested

CaseDemographics 13 day hospitalization cost: Age, race, sex IVDU HCV HIV Insurance $85, year old black male Yes No None (Medicaid pending) 20 day hospitalization cost (AVR): Age, race, sex IVDU HCV HIV Insurance $173, year old black male Yes No Molina (Medicaid) 17 day hospitalization cost (AVR): Age, race, sex IVDU HCV HIV Insurance $267, year old white male Yes No None (Medicaid pending) Hospital costs* for 3 representative UH admissions * does not include physician charges or 5-7 week stay in SNF for IV antibiotics

Who is at greatest risk for encountering used syringes?  First Responders  Police  Firemen  EMTs  Sanitation workers  Parks & recreation workers  Children

Health Risks for First Responders  HIV  Acute & chronic hepatitis C (HCV)  Chronic HCV #1 reason for liver transplantation in the U.S.  Acute & chronic hepatitis B (HBV)  HIV plus chronic HCV and/or chronic HBV co- infection  Infections at puncture site (cellulitis, abscesses)

Health Risks for IDUs  All of the infections listed for First Responders, plus..  Bloodborne bacterial infections  Endocarditis (infection of lining of heart)  Osteomyelitis (bone infection)  Septic emboli, esp lung (infections that are spread throughout the body by blood)  Brain abscesses  All of which require at least 6-8 weeks of intravenous antibiotics, plus other interventions

Hepatitis C: Fate of Acute Infection 15% Chronic 85% Spontaneous Resolution (15%) Alter MJ, et al. N Eng J Med. 1999;341: Chronic Infection (85%) Note: chronic hep C is the most common reason for liver transplantation in the U.S.

Cincinnati IDU Survey Data  N = 101 completed surveys  4 reported already being HIV+  26 reported already being HCV+  All reported sexual behavior risk factors in addition to drug use for HIV & HCV transmission or acquisition

Cincinnati IDU Survey Data GenderRace Male Female

Cincinnati IDU Survey Data Age yrs yrs yrs yrs.

Cincinnati IDU Survey Data  Age at first use of IV and other drugs Age Percentage

Cincinnati IDU Survey Data  69/101 (68%) reported finding used/dirty syringes

Cincinnati IDU Survey Data  39% reused found syringes, half without cleaning them (many used inadequate cleaning methods)

PLWHCV* by Zip Code, 2009 * people living with hepatitis C

Heroin Arrests by Zip Code, 2009 *

PLWHA* by Zip Code, 2009 * people living with HIV/AIDS

Location of Most Overdose Deaths, Metro Cincinnati

Lower Price HIll

Lower Price Hill

Fairview

Outside Daycare Center, near UC

Daycare Center Backyard, near UC

Syringe Exchange Programs (SEPs)  16 peer-reviewed scientific studies performed from 1996 to 2007 have shown that SEPs reduce the transmission of HIV, hepatitis B and hepatitis C  6 studies looked at the effect on substance abuse, and all found that this type of program does not promote substance abuse  8 studies also looked at drug treatment enrollment, and all found that SEPs increase enrollment in drug treatment programs

Why SEPs Work to Protect the Public  “one for one” exchange of sterile syringe for a dirty one gives street value to used syringes  IDUs will collect used syringes found in public places to turn in for clean ones  this helps ‘police’ public places and keep them needle-free…  …protecting first responders, other public workers, and children as well as IDUs themselves from chronic viral and serious bacterial infections

Services/Logistics of Proposed Cincinnati SEP (“Cincinnati Exchange Project”)  “ one for one” program: a sterile syringe for a dirty one  safer sex materials and bleach kits for appropriate cleaning or used syringes  naloxone kits for preventing fatal overdoses  rapid tests for HIV, hepatitis C, and pregnancy  abscess and wound care education  linkage to medical care  referrals to mental health services & drug treatment programs  CEP will utilize a customized RV, with rotating locations  plan on 3 initial sites, based on our zip code data