1. Diane M. Janowicz, MD Assistant Professor of Clinical Medicine Indiana University School of Medicine Indianapolis, Indiana Persistent Challenges of HIV Transmission Control in Injection Drug Use: Lessons from the Indiana Outbreak FORMATTED: 3/11/2016 Atlanta, Georgia: April 8, 2016 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

2. Slide 2 of 20 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 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

3. Slide 3 of 30 New HIV/AIDS Reports Total Persons Living with HIV/AIDS Persons Living with HIV, December 2014 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

4. Slide 4 of 30 Scott County Population: 4,200 10% unemployment rate 19% below Federal Poverty Line 21% without high school diploma ranked 92 nd in a variety of health and social indicators Austin, Indiana From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

5. Slide 5 of 30 HIV Outbreak Due to IDU Almost exclusively related to IDU – Primarily oxymorphone – Rare reports of methamphetamine, heroin Injection Practices – Multigenerational – 2-20 injections per day – Up to 20 needle-sharing partners Average of 9 syringe/sex/social partners at risk From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

6. Slide 6 of 30 Onset of the Outbreak 55 confirmed, 13 preliminary cases 3 new HIV diagnoses Late 2014 January 23 rd 8 more infections February 27 th State alerts CDC March CDC support requested March 26 th Public Health Emergency Declared From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

7. Slide 7 of 30 Epidemic Curve From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

8. Slide 8 of 30 HIV Outbreak Public Health Emergency: N = 170 (June 2015) – 444/513 contacts located, offered testing Point of care rapid test/simultaneous blood draw – 0 contacts remain to be traced – 38% positivity rate among tested contacts Continued surveillance of high risk individuals 188 people diagnosed with HIV infection (2016) From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

9. Slide 9 of 30 HIV-Infected Population Median age 33 years, range 18-60 Male 57% 100% non-Hispanic white 160/174 (92%) co-infected with Hepatitis C Low annual income (<$10,000) From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

10. Slide 10 of 30 Viral Suppression Testing Insurance Treatment EducationRisk Reduction Behavioral & Mental Health Expanding Services Multi-pronged Coordination Local Partners Local Partners Federal Partners Federal Partners State Partners State Partners Academic Partners Academic Partners From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

11. Slide 11 of 30 Austin One Stop Shop – HIV, HCV testing – Vital records – Drivers License/State ID – Insurance enrollment – Immunizations – Rehabilitation, Mental Health Services – Care coordination – Department of Workforce Development – Needle Exchange Program From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

12. Slide 12 of 30 SEP Process Each visit: – sterile syringes, wound kit, harm reduction education – referrals to health and substance abuse services From April through June*: – 85% decline in sharing syringes (P = 0.04) – Decreased frequency of reusing syringes (P < 0.001) – Increased numbers of syringes exchanged *M. R. Patel, B. Combs, P. Hall, J. T. Brooks, P.J. Peters, D. Broz et al, Centers for Disease Control and Prevention, Scott County Dept of Health, IN State Dept of Health. ID Week, San Diego, CA 2015. From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

13. Slide 13 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 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

14. Slide 14 of 30 HIV Clinic March 25: ISDH requests IUSM* ID physicians to provide HIV care Once-weekly free clinic: 2 physicians – Appointments and walk-ins HIV testing, treatment, education PrEP First Clinic: March 31, 2015 *Indiana University School of Medicine, IU Health Physicians From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

15. Slide 15 of 30 HIV Clinic Comprehensive intake forms Prioritized HIV treatment – Stagger preventative care – Other medical problems addressed prn Simple, direct educational materials – HIV info specific per visit Consistent messaging to all patients Pharmacy Education From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

16. Slide 16 of 30 Jail Care ~20% of HIV-infected persons incarcerated Coordinate with jail, ancillary services: – Care coordination – Laboratory draws – Medication delivery 40+ patients initiated/continued on ART Continuity of care is critical upon release From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

17. Slide 17 of 30 Continuum of Care N=176 N=130 N=150 N=57 Total diagnosed=166 (166 confirmed). Persons were ineligible if deceased (n=1) or moved outside of the jurisdiction (n=4); estimates are based on the number of eligible persons (n=161); ** Percent virally suppressed increases to 10% when denominator changed to number engaged in care (11/112); Clinical services were initiated March 31, 2015 Eligible Care Coord. Engaged in Care Virally Suppressed % of Total Eligible N=130 Prescribed ART 86% 74% 59% 32% 100% From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

18. Slide 18 of 30 3 Evolving Epidemic Curve From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

19. Slide 19 of 30 Lessons 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 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.

20. Slide 20 of 30 Acknowledgements 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 From JM Janowicz, MD, at Atlanta, GA: April 8, 2016, IAS-USA.