Persistent Challenges of HIV Transmission
Control in Injection Drug Use:
Lessons from the Indiana Outbreak
Diane M. Janowicz, MD
Assistant Professor of Clinical Medicine
Indiana University School of Medicine
Indianapolis, Indiana
FORMATTED: 12/09/15
New Orleans, Louisiana: December 15-17, 2015
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 2 of 30
Slide 3 of 30
Persons Living
with HIV
as of
December 2014
New HIV/AIDS
Reports
Total Persons
Living with
HIV/AIDS
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 92nd in a variety of
health and social indicators,
including life expectancy
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 5 of 30
9.24.2015
Curve
Epidemic
Epidemic Curve
Slide 6 of 30
22
18
17
14
11
9
9
9
8
7
9
5
1 1
2
1 1
00
0
5
5
3
33
1
0
5
0
4
2
1 2 1
0 1 000 0 0
00 00
HIV Outbreak
Slide 7 of 30
• 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
Multi-pronged Coordination
Slide 9 of 30
Testing
Federal
Partners
Expanding
Services
Behavioral &
Mental Health
Insurance
State
Partners
Viral
Suppression
Treatment
Local
Partners
Academic
Partners
Risk Reduction
Education
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)
Slide 10 of 30
– Care coordination
(142)
– Department of
Workforce
Development (65)
– Needle
Exchange
Program
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 11 of 30
Rehabilitation Services
Slide 12 of 30
• 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
HIV Care Goals
Slide 13 of 30
• 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.)
Care Collaborations
Slide 14 of 30
• 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
HIV Clinic
Slide 15 of 30
• 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
*Indiana University
• First Clinic: March 31, 2015 School of Medicine,
IU Health Physicians
HIV Clinic
Slide 16 of 30
• 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
Themes in HIV Care
•
•
•
•
Slide 17 of 30
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
Jail Care
Slide 18 of 30
• ~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
% of Total Eligible
Continuum of Care
100%
86%
Slide 19 of 30
74%
59%
32%
N=176
Eligible
N=150
Engaged
in Care
N=130
Care
Coord.
N=130
N=57
Prescribed
Virally
ART
Suppressed
Increasing PrEP Availability
• Improve awareness
• Provider buy-in
• Streamlined algorithms
specific to locale
– Emergency Dept.
– Primary Care Offices
– Community Outreach
Slide 20 of 30
Lessons Learned & Next Steps
Slide 21 of 30
“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
Acknowledgements
Slide 22 of 30
• 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