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![Page 1: Diane M. Janowicz, MD Assistant Professor of Clinical Medicine Indiana University School of Medicine Indianapolis, Indiana Persistent Challenges of HIV.](https://reader035.fdocuments.net/reader035/viewer/2022062523/5a4d1acd7f8b9ab059970160/html5/thumbnails/1.jpg)
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
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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
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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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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
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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
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Slide 6 of 30Epidemic Curve
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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
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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
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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
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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
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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
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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
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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.)
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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
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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
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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
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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
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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
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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%
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Slide 20 of 30Increasing PrEP Availability• Improve awareness• Provider buy-in• Streamlined
algorithms specific to locale– Emergency Dept.– Primary Care Offices– Community Outreach
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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
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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