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