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

2. 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

3. Endocarditis Admissions at University Hospital 1999-2009

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

5. UH Endocarditis Study, 1999-2009  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

6. CaseDemographics 13 day hospitalization cost: Age, race, sex IVDU HCV HIV Insurance $85,643 59 year old black male Yes No None (Medicaid pending) 20 day hospitalization cost (AVR): Age, race, sex IVDU HCV HIV Insurance $173,753 47 year old black male Yes No Molina (Medicaid) 17 day hospitalization cost (AVR): Age, race, sex IVDU HCV HIV Insurance $267,037 47 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

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

8. 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)

9. 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

10. Hepatitis C: Fate of Acute Infection 15% Chronic 85% Spontaneous Resolution (15%) Alter MJ, et al. N Eng J Med. 1999;341:556-562. Chronic Infection (85%) Note: chronic hep C is the most common reason for liver transplantation in the U.S.

11. 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

12. Cincinnati IDU Survey Data GenderRace Male Female

13. Cincinnati IDU Survey Data Age 19-24 yrs. 25-34 yrs. 35-44 yrs. 13-18 yrs.

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

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

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

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

18. Heroin Arrests by Zip Code, 2009 *

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

20. Location of Most Overdose Deaths, Metro Cincinnati

21. Lower Price HIll

22. Lower Price Hill

23. Fairview

25. Outside Daycare Center, near UC

26. Daycare Center Backyard, near UC

27. 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

28. 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

29. 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