1. Lessons from Indiana HIV and Hepatitis C Wisconsin HIV Community Planning Statewide Action Planning Group Meeting Green Lake June 25, 2015 1

2. Presenters Sheila Guilfoyle, Viral Hepatitis Prevention Coordinator, Wisconsin AIDS/HIV Program Brandon Kufalk, Disease Intervention Specialist, Wisconsin STD Program Lauren Stockman, Epidemiologist, Wisconsin AIDS/HIV Program 2

3. Indiana Races to Fight H.I.V. Surge Tied to Drug Abuse HIV and Hepatitis C in the Headlines 3 Associated Press: http://www.msn.com/en-us/health/medical/appalachia-gripped-by-hepatitis-c-epidemic-bracing-for-hiv/ar-BBkFNVH The New York Times article source: http://www.nytimes.com/2015/03/31/us/small-indiana-city-races-to-curb-hivs-spread.html Picture source: http://www.nytimes.com/2015/05/06/us/rural-indiana-struggles-to-contend-with-hiv-outbreak.html?_r=1

4. Background : Indiana HIV Outbreak In January 2015, the Indiana State Department of Public Health (ISDPH) initiated an investigation into the increase in HIV cases in Scott County (11 cases). This area historically had fewer than 5 cases of HIV reported annually. The cases were linked to syringe sharing and the use of the opioid Opana (oxymorphone). 4

5. Background : Indiana HIV Outbreak Centers for Disease Control and Prevention (CDC) partnered with ISDPH to conduct interviews and to do contact tracing. As of May 26, 2015, 159 cases of HIV were confirmed as part of the investigation. 5

6. Emerging Issues Related to Indiana Outbreak Access to harm reduction services (including syringe exchange) Access to HIV and hepatitis C virus (HCV) testing Use of Opana (oxymorphone) in Indiana Access to HIV and HCV care in rural areas 6

7. Scott County, Indiana Scott County is 30 minutes north of Louisville, Kentucky. So many people have moved in from Kentucky that this area is sometimes called Kentuckiana. 7

8. Specifically the north side Police Station Community Outreach Center Doctor’s Office Main Employer: Canning Factory Truck Stop (Huddle House) 8 HIV Infections in Austin, Indiana

9. Scott County Experience Linkage to care Make sure people who are HIV-positive have a care coordinator and are getting medical testing and treatment. Community Outreach Center provides “one-stop shopping” services, which include: Obtaining a photo ID and/or birth certificate. Enrollment in HIP 2.0, Healthy Indiana Plan (Medicaid). Immunization for hepatitis A, hepatitis B, and tetanus. Access and referral to drug rehabilitation services. Testing sexual and needle sharing partners for HIV, HCV, syphilis, and hepatitis B virus (HBV). Job counseling and local training. Harm reduction services (including syringe exchange). A new clinic for HIV-positive patients. A free shuttle service to Community Outreach Center. 9

10. Scott County Experience Retesting of negative partners Disease intervention specialists (DIS) find partners who have an initial negative test and perform a retest to confirm negative status. Many of the initial HIV tests were OraQuick (oral fluid rapid HIV test). Door-to-door screenings The first of the screenings were in the north Austin area. Screeners ask people if there are any risk factors, but also inform people about misconceptions regarding public health activities (HIV and needle exchange). 10

11. Scott County Experience CDC laboratory testing Blood testing is now used to confirm previous rapid test results and test new contacts. Specimens were sent to CDC for genetic analysis. Preliminary CDC laboratory genetic analysis indicates that most of the people infected in the outbreak have the same strain of HIV. 11

12. Disease Intervention Specialists (DIS) Assigned to Scott County DIS were deployed from Wisconsin, New Mexico, Vermont, Ohio, Georgia, Kentucky, New Jersey (2), and Oklahoma (6). DIS stayed for as little as 1 week to as long as 1 month. 12

13. Scott County Experience Harm reduction Clients can exchange needles either at the Community Outreach Center or from a mobile site. Scott County Public Health Needle Exchange operates the mobile van. Clients are given a card that allows them to openly carry needles in their car (which is normally illegal without a card). If pulled over, paraphernalia, while still illegal, is being overlooked temporarily by the police. However, the police will still arrest for seeing drugs. Clinic for HIV-positive clients Infectious disease doctors and nurse practitioners from Indianapolis see clients on Tuesdays from 10 a.m. to 4 p.m. Community Outreach Center is currently allowing HIV-positive clients to have blood drawn without seeing a doctor outside normal Tuesday hours. 13

14. Key Data From Indiana HIV Outbreak Recommendations for Health Departments Actions by Wisconsin AIDS/HIV Program 14

15. Key Data Over 80 percent of patients reported injection drug use. All crushed and cooked Opana. All shared injection equipment. Equipment was shared by one to six partners per injection. Patients reported injecting from 4 to 15 times a day. Most (84%) were already infected with HCV. 15

16. Recommendations for Health Departments Centers for Disease Control and Prevention (CDC) issued a health advisory on April 24, 2015: 1.Review HIV data for increases in cases attributed to IDU (injection drug use). 2.Review HCV data for increases among persons aged < 35. 3.Ensure people who inject drugs (PWID) have access to harm reduction and prevention services. 4.Encourage HIV and HCV testing in venues that serve high-risk individuals. 5.Local health departments should notify state of any suspected HIV or HCV clusters. 16

17. Actions by Wisconsin AIDS/HIV Program Review HIV reports for trends in IDU. Continue to investigate HIV reports. Partner Services on alert for any clustering. 17

18. Actions by Wisconsin AIDS/HIV Program 18 Monitoring new HCV infections in young adults HCV reports in people under age 35 2011 (n=588)

19. Actions by Wisconsin AIDS/HIV Program 19 Monitoring new HCV infections in young adults HCV reports in people under age 35 2014 (n=1064)

20. Actions by Wisconsin AIDS/HIV Program 20 Monitoring new HCV infections in young adults Notable increase over the average number reported HCV reports in people under age 35 2014 (n=1064)

21. Looking at Surveillance Data for HIV/HCV Coinfection HIV Reports in Wisconsin Residents HCV Reports in Wisconsin Residents Demographics and Trends HIV reports among people with HCV HCV reports among people with HIV Follow Up and Investigate HIV Partner Services Local health agency Risk factors for transmission 21

22. Programs in Place for HIV and HCV Testing of PWID Outreach agencies provide harm reduction services. Rapid HIV testing has been in place for more than 10 years. Rapid HCV testing began in 2012. As of May 2015, 2,804 rapid HCV tests were reported. A high percentage (72%) with HCV rapid tests also had HIV tests. 22

23. Next Steps Increase access to HCV testing, HIV testing, and Partner Services. Formalize the system for communication between HIV and HCV surveillance systems. Consider new sources of data to signal injection drug use, Opana use, and other opioid abuse. 23