State of the State: HIV, STDs and Viral Hepatitis 2016 October 25, 2017 DPH/EPI Section/CDB HIV/STD/Hepatitis Surveillance Unit

Where to find HIV/STD Information? Add something about the slide sets being available http://epi.publichealth.nc.gov/cd/stds/figures.html

SEXUALLY TRANSMITTED DISEASES IN NORTH CAROLINA North Carolina DHHS HIV/STD Surveillance Unit

Chlamydia Cases by Gender North Carolina, 2007-2016 58,078 Data Source: North Carolina Electronic Disease Surveillance System (data as of May 1, 2017).

Age Distribution of Chlamydia Cases by Gender, 2016 Data Source: North Carolina Electronic Disease Surveillance System (data as of May 1, 2017)

Chlamydia Cases by Race/Ethnicity, North Carolina 2012-2016 *Non-Hispanic/Latino. Data Source: North Carolina Electronic Disease Surveillance System (data as of May 1, 2017)

Chlamydia Rates by County, North Carolina 2016 Data Source: North Carolina Electronic Disease Surveillance System (data as of May 1, 2017)

Gonorrhea Cases by Gender North Carolina, 2007-2016 Data Source: North Carolina Electronic Disease Surveillance System (data as of May 1, 2017)

Age distribution of Gonorrhea Cases by Gender North Carolina, 2016 Data Source: North Carolina Electronic Disease Surveillance System (data as of May 1, 2017)

Gonorrhea Cases by Race/Ethnicity, North Carolina 2012-2016 *Non-Hispanic/Latino. Data Source: North Carolina Electronic Disease Surveillance System (data as of May 1, 2017)

Gonorrhea Rates by County North Carolina 2016 Data Source: North Carolina Electronic Disease Surveillance System (data as of May 1, 2017)

Early Syphilis (Primary, Secondary, Early Latent) Cases by Gender North Carolina, 2000-2016 Data Source: North Carolina Electronic Disease Surveillance System (data as of May 1, 2017)

Age Distribution of Early Syphilis (Primary, Secondary, and Early Latent Syphilis) Cases by Gender, North Carolina, 2016 Data Source: North Carolina Electronic Disease Surveillance System (data as of May 1, 2017)

Early Syphilis (Primary, Secondary, and Early Latent Syphilis) Cases by Race/Ethnicity, North Carolina, 2012-2016 *Non-Hispanic/Latino. Data Source: North Carolina Electronic Disease Surveillance System (data as of May 1, 2017)

Early Syphilis (Primary, Secondary, and Early Latent Syphilis) Rates by County North Carolina 2016 data Data Source: North Carolina Electronic Disease Surveillance System (data as of May 1, 2017)

Congenital Syphilis, Cases by Birth Year North Carolina, 2007-2016 Data Source: Sexually Transmitted Disease Management Information System (STD*MIS) and North Carolina Electronic Disease Surveillance System (NC EDSS) (data as of May 1, 2017).

SYPHILIS CO-INFECTION WITH HIV North Carolina DHHS HIV/STD Surveillance Unit

Early Syphilis (Primary, Secondary, and Early Latent) Percentage of People with HIV* by Gender 2000-2016 data *HIV diagnosed prior to OR within 30 days of syphilis diagnosis. Data Source: North Carolina Electronic Disease Surveillance System (NC EDSS) (data as of May 1, 2017) and enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

Early Syphilis (Primary, Secondary, and Early Latent) Percentage of People with HIV* by Race/Ethnicity, 2012-2016 data *HIV diagnosed prior to OR within 30 days of syphilis diagnosis. **Non-Hispanic/Latino. Data Source: North Carolina Electronic Disease Surveillance System (NC EDSS) (data as of May 1, 2017) and enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

HIV IN NORTH CAROLINA North Carolina DHHS HIV/STD Surveillance Unit

North Carolina HIV Infection Rates by Year of Diagnosis, 2000-2016 *Based on most recent address in eHARS as of December 31 of the given year. **New cases are only among adults and adolescents (13 years and older). Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017) and North Carolina Vital Statistics, Volume 2: Leading Causes of Death 2000-2015.

Age Distribution of People Diagnosed with HIV and Living in NC*in 2016 *Based on most recent address in eHARS as of December 31, 2016 Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

Newly Diagnosed HIV among Adult/ Adolescents (13 years and older) by Gender North Carolina, 2000-2016 Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

Gender Distribution of Newly Diagnosed Adult/Adolescent (13 years and older) HIV North Carolina, 2016 Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

Age Distribution of Newly Diagnosed Adult/Adolescents (13 years and older) HIV by Gender in North Carolina, 2007 Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

Age Distribution of Newly Diagnosed Adult/Adolescents (13 years and older) HIV by Gender in North Carolina, 2012 Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017). Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

Age Distribution of Newly Diagnosed Adult/Adolescents (13 years and older) HIV by Gender in North Carolina, 2016 Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

North Carolina Population: Newly Diagnosed HIV Cases among Adults/Adolescents (13 years and older) by Race/Ethnicity North Carolina 2016 vs North Carolina Population 2016 HIV Cases: 1,399 North Carolina Population: 8,507,543** **US Census Bureau North Carolina 2016 Adult and Adolescent population estimate *Non-Hispanic/Latino. Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

Newly Diagnosed HIV Rates among Adult/Adolescents (13 years and older) by Race/Ethnicity, 2012-2016 *Non-Hispanic/Latino. Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

Newly Diagnosed HIV Rates by County North Carolina, 2016 Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

HIV Exposure (Hierarchical Risk)

Hierarchical Risk^ for HIV Exposure among Newly Diagnosed HIV Rates among Adults and Adolescents (13 years and older) North Carolina 2016 N = 1,399 ^Unknown risk has been redistributed. Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

North Carolina 2016 HIV Rate: 16.4 per 100,000 Estimated HIV Infection Rates among Newly Diagnosed Adults and Adolescent (13 years and older) Gay and Bisexual Men and Other Men who have Sex with Men^ in North Carolina 2016 North Carolina 2016 HIV Rate: 16.4 per 100,000 ^Unknown risk has been redistributed. People who were classified as MSM and IDU were excluded. ^^Grey et al (2016). JMIR Public Health Surveill; 2(1): e14. https://publichealth.jmir.org/2016/1/e14/ *Non-Hispanic/Latino. Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

North Carolina 2016 HIV Rate: 16.4 per 100,000 Estimated HIV Infection Rates among Newly Diagnosed Adults and Adolescents (13 years and older) Heterosexual Women^ in North Carolina 2016 North Carolina 2016 HIV Rate: 16.4 per 100,000 ^Unknown risk has been redistributed. ^^Defined as individuals reporting heterosexual contact with a known HIV-positive or high-risk individual and cases redistributed into the heterosexual classification from the “unknown” risk group. People exposed to HIV through injection drug use (IDU) are excluded. *Non-Hispanic/Latino. Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

Newly Diagnosed HIV among Adults and Adolescents (13 years and older) Exposed through Injection Drug Use (IDU)^ by Gender, North Carolina 2012-2016 ^Unknown risk has been redistributed. This includes people classified as MSM/IDU. *Non-Hispanic/Latino. Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

Newly Diagnosed HIV among Adults and Adolescents (13 years and older) Exposed through Injection Drug Use (IDU)^ by Gender and Race/Ethnicity, North Carolina 2016 ^Unknown risk has been redistributed. This includes people classified as MSM/IDU. *Non-Hispanic/Latino. **Includes American Indian/Alaska Native, Asian/Pacific Islander, and Multiple Race. Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 27, 2017).

NORTH CAROLINA HIV CONTINUUM OF CARE North Carolina DHHS HIV/STD Surveillance Unit

2015* HIV Continuum of Care for North Carolina Viral Suppression in Ryan White programs Ryan White Part B (2015): 70% ADAP (2015): 83% NHAS goal by 2020: 80% *2015 data are preliminary (do not include vital records or national death matches). 2015 data includes labs and services from CAREWare (all Ryan White services excluding Part A), AIDS Drug Assistance Program (ADAP), and Medicaid data sources. **At least 1 care marker in a given year. ***Retained in care is defined as having 2 or more care visit (VL or CD4 test) at least 90 days apart in a given year. Thick orange includes ARV dispenses and if they were virally suppressed during the given year. Legend: year shown refers to the year in which care measures were evaluated; cases were diagnosed and reported between the year prior. Data Sources: enhanced HIV/AIDS Reporting System (eHARS) (data as of June 2013 and June 27, 2016), CAREWare , ADAP, and Medicaid claims (data for calendar year 2015).

Viral Hepatitis Update North Carolina DHHS HIV/STD Surveillance Unit

North Carolina Introduction Between 2010 and 2016, there was a four fold increase in the number of acute cases of hepatitis C reported in North Carolina. During this time frame, there is also a marked increase in acute hepatitis B cases reported in North Carolina. Drug use is the main factor cited in both acute HBV and HCV cases reported. CDC Vulnerability Study identified five counties at high risk for outbreak in North Carolina NC estimates that there are upwards of 150,000 HCV-infected persons living in North Carolina. The majority of these cases are reported in the western part of the state; however, some southeastern counties (New Hanover) are seeing marked increases in injection drug use. Discuss vulnerability study and CD analysis to determine Reg 1-3, 8

Age Distribution of Acute HBV Cases by Gender, North Carolina, 2016 Data Source: North Carolina Electronic Disease Surveillance System (NC EDSS) (data as of June 1, 2017).

Acute HBV Cases by Race/Ethnicity North Carolina 2012-2016 Data Source: North Carolina Electronic Disease Surveillance System (NC EDSS) (data as of June 1, 2017).

Age Distribution of Acute HCV Cases by Gender, North Carolina, 2016* *Case definition for acute HCV changed in 2016. Data Source: North Carolina Electronic Disease Surveillance System (NC EDSS) (data as of June 1, 2017).

Acute HCV Cases by Race/Ethnicity North Carolina 2012-2016* Zack, note the increase among Hispanics here. Among people with HIV, Hispanic IDU have the worst care outcomes (lowest viral suppression). All indicates there is a population of Latino/a people who inject drugs that we need to be thinking about. *Case definition for acute HCV changed in 2016. Data Source: North Carolina Electronic Disease Surveillance System (NC EDSS) (data as of June 1, 2017).

Acute HCV County Rates in North Carolina 2016* *Case definition for acute HCV changed in 2016. Data Source: North Carolina Electronic Disease Surveillance System (NC EDSS) (data as of June 1, 2017).

Hepatitis C Most commonly transmitted through injection drug use 75%‒85% of infected develop chronic illness HCV is a viral infection most frequently transmitted through injection drug use. Although can be acute and self-limiting, approximately 75%‒85% of infected people go on to develop chronic illness. As seen in this CDC schematic, …develop chronic cirrhosis over a period of 20-30 years, and … Chronic HCV infection is the leading indication for liver transplants in the United States. CDC, 2010

NC Hepatitis C: Test, Link, Cure (NC TLC) Outreach: Test high-risk populations for hepatitis B (HBV), hepatitis C virus (HCV), HIV, and other sexually transmitted infections (STIs). Vaccinate high-risk populations against hepatitis A/B. Focused screening of high risk individuals through collaboration with the NC State Laboratory of Public Health (SLPH). Surveillance: Electronic Laboratory Reporting of Chronic HCV: January 1, 2017 Provider reporting of acute HCV Receipt of Viral Hepatitis Surveillance Grant (1703) starting May, 2017 Of course IDU maybe appear to us as “unknown”

NC Hepatitis C: Test, Link, Cure (NC TLC) Linkage to Care and Cure: Hepatitis C Bridge Counselors Link patient to first medical visit Coordinate with SA/MH services Expanded primary care capacity to treat HCV Engagement of FQHCs and LHD providers Academic Mentorship Program (CHAMP) Clinical algorithm for evaluation, treatment and referral Impact Of course IDU maybe appear to us as “unknown”

North Carolina Safer Syringe Initiative (NC SSI) 25 active SEPs covering 30 counties, with individuals commuting from an additional 24 counties and out of state Of course IDU maybe appear to us as “unknown” *Residents from these counties without SEP coverage traveled to receive services in a SEP target county Source: North Carolina Division of Public Health, September 2017 Analysis: Injury Epidemiology and Surveillance Unit 49

Program Successes North Carolina Hepatitis Academic Mentorship Program (CHAMP) SLPH hepatitis B and C high-risk screening No-cost Twinrix Program HIV/HCV Coinfection linkage to cure project Acute Hepatitis B DIS investigation in progress Close collaboration with the NC Safer Syringe Initiative Close collaboration with AIDS Care Program, ADAP, HIV/STD Prevention Program and Surveillance Viral Hepatitis Bridge Counselors (6 in progress) Development of HCV Care Cascade Longer follow up Case tracking and investigation Of course IDU maybe appear to us as “unknown”

Questions? Jacquelyn M. Clymore, MS HIV/STD/Viral Hepatitis Director Communicable Disease Branch jacquelyn.clymore@dhhs.nc.gov (919) 546-1708