Diane M. Janowicz, MD Assistant Professor of Clinical Medicine Indiana University School of Medicine Indianapolis, Indiana Persistent Challenges of HIV Transmission Control in Injection Drug Use: Lessons from the Indiana Outbreak FORMATTED: 12/09/15 New Orleans, Louisiana: December 15-17, 2015

Slide 2 of 30 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

Slide 3 of 30 New HIV/AIDS Reports Total Persons Living with HIV/AIDS Persons Living with HIV as of December 2014

Slide 4 of 30 Scott County Austin, Indiana Population: 4,200 Unemployment rate: 10% 19% below Federal Poverty Line 21% without high school diploma Ranked 92 nd in a variety of health and social indicators, including life expectancy

Slide 5 of 30 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

Slide 6 of 30 Epidemic Curve

Slide 7 of 30 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 Male 57% 100% non-Hispanic white 160/174 (92%) co-infected with Hepatitis C

Slide 8 of 30 ‘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

Slide 9 of 30 Viral Suppression Testing Insurance Treatment EducationRisk Reduction Behavioral & Mental Health Expanding Services Multi-pronged Coordination Local Partners Local Partners Federal Partners Federal Partners State Partners State Partners Academic Partners Academic Partners

Slide 10 of 30 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

Slide 11 of 30 Needle Exchange Program Scott County Health Department On-site and mobile unit 197 individuals participating Unique ID cards, weekly exchange >50,000 needles dispensed

Slide 12 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

Slide 13 of 30 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.)

Slide 14 of 30 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

Slide 15 of 30 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

Slide 16 of 30 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

Slide 17 of 30 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

Slide 18 of 30 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

Slide 19 of 30 Continuum of Care N=176 N=130 N=150 N=57 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 Eligible Care Coord. Engaged in Care Virally Suppressed % of Total Eligible N=130 Prescribed ART 86% 74% 59% 32% 100%

Slide 20 of 30 Increasing PrEP Availability Improve awareness Provider buy-in Streamlined algorithms specific to locale – Emergency Dept. – Primary Care Offices – Community Outreach

Slide 21 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

Slide 22 of 30 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