Diane M. Janowicz, MDAssistant Professor of Clinical MedicineIndiana 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 IndianaList interventions taken to stop the outbreakIdentify 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 CountyAustin, Indiana

• Population: 4,200 • Unemployment rate:

10%• 19% below Federal

Poverty Line• 21% without high

school diploma• Ranked 92nd 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 30Epidemic 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 18-60• 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 Suppress

ion

Testing

Insurance

Treatment

EducationRisk Reduction

Behavioral &Mental Health

Expanding Services

Multi-pronged Coordination

LocalPartne

rs

Federal

Partners

StatePartne

rs

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 ExchangeProgram

Slide 11 of 30Needle 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 30Care 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 30HIV 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 30HIV 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 30Jail 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 30Continuum of Care

N=176

N=130

N=150

N=57Eligible Care

Coord.Engagedin Care

VirallySuppressed

% o

f Tot

al E

ligib

le

N=130Prescribed ART

86% 74%59%

32%

100%

Slide 20 of 30Increasing PrEP Availability• Improve awareness• Provider buy-in• Streamlined

algorithms specific to locale– Emergency Dept.– Primary Care Offices– Community Outreach

Slide 21 of 30Lessons 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 30Acknowledgements• 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