John T. Brooks, MD Senior Medical Advisor, Division of HIV/AIDS Prevention - PowerPoint Presentation

John T. Brooks, MDSenior Medical Advisor, Division of HIV/AIDS PreventionNational Center for HIV/AIDS, Viral Hepatitis, STD, and TB PreventionCenters for Disease Control and PreventionAtlanta, Georgia Persistent Challenge of HIV Transmission Control in Injection Drug Use: The Indiana Outbreak FINAL: 04/11/2016 Washington DC: April 15, 2016 From JT Brooks, MD, at Washington, DC: April 15, 2016, IAS-USA.

Learning ObjectivesAfter attending this presentation, participants will be able to: Characterize the challenges faced when responding to a rural outbreak of HIV infection among persons who inject drugs Describe how patterns of injection drug use are changing in the United States From JT Brooks, MD, at Washington, DC: April 15, 2016, IAS-USA.

In 2014, what fraction of new HIV diagnoses were estimated as attributable to injection drug use: 1. 24% 2. 18%3. 12% 4. 6% 1

In the last 5 years, the number of new HIV diagnoses estimated as attributable to injection drug use has been: Stable Declining Rising All over the place 1

Male-to-male sexual contact Heterosexual contact Injection drug use Number of HIV Infections Diagnosed among Adults and Adolescents, by Transmission Category, 2005–2014 - United States and 6 Dependent Areas 2,364 6,408 63% decline over 10 years 6% of all HIV infections in 2014 Diagnoses, n Year

Rural southeastern region of stateScott County ranked 92nd in many health and social indicators among Indiana’s 92 counties Lowest life expectancy 9% unemployment 19% poverty 21% no high school Many uninsured Indiana HIV Outbreak: Geography Scott County pop. 24,000; Austin city pop. 4,200

Indiana HIV Outbreak SummaryIn early 2015, 11 new HIV infections diagnosed in Scott County, INOver past decade, <1 HIV new infection in Scott County per yearAs of February 1 , 2016  188 new HIV diagnosis >90% coinfected with hepatitis C virus Response required a large and intensi ve collaboration of local, state and federal public health resources in partnership with the community Establish extent of the HIV infections Institute prevention and control measures Transmissions occurred in a dense network of persons who inject drugs Opioid analgesic oxymorphone

Demographics of HIV-infected Cases (N=181) Peters P et al., in press Median age 34 years, interquartile range 28 - 42 58% male99% non-Hispanic white 96% injected drugs in past 12 months

Diagnoses of HIV Infection Among Persons Who Inject Drugs by Sex and Race/Ethnicity, 2014—United States and 6 Dependent Areas Black, African-American Hispanic/Latino a White Other 41% 28% 27% 34% 43% 19% Historical demography Mostly urban Male > female Mostly non-white Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays,  but not for incomplete reporting. a Hispanics/Latinos can be of any race.   4% 4%

Diagnoses of HIV Infection Among Persons Who Inject Drugs by Sex and Race/Ethnicity, 2014—United States and 6 Dependent Areas Black, African-American Hispanic/Latino White Other 69% 62% Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays,  but not for incomplete reporting. a Hispanics/Latinos can be of any race.   Historical demography Mostly urban Male > female Mostly non-white

Demographics of HIV-infected Cases (N=181) Median age 34 years, interquartile range 28 - 4258% male 99% non-Hispanic white96% injected drugs in past 12 months 92% oxymorphone 27% heroin, 23% methamphetamine, 9% cocaine Peters P et al., in press

Drug Use among HIV-infected Cases (N=108) Multigenerational usersDaily injections: 4-15 Number of needle-sharing partners per injection event: 1-6Sharing of injection equipment common Early Release, MMWR Morb Mortal Wkly Report 2015, April 24, 2015 Oxymorphone ER with INTAC Tablet Images* GENERIC oxymorphone ER Tablet Images*

HIV Diagnoses by Week, Indiana HIV Outbreak (N=188) Peters P et al., in press and Indiana State Department of Health Detect and confirm

HIV Diagnoses by Week, Indiana HIV Outbreak (N=188) Deploy emergency command, HIV testing,contact tracing, services Peters P et al., under review and Indiana State Department of Health Detect and confirm Jail-based testing: local and sentinel Teams of disease intervention specialists Point-of-care rapid test Venous blood draw (e.g., confirmation, acute HIV, HCV) Provided prevention education Directed to services: Treatment – antiretroviral therapy Prevention – addiction and harm reduction, PrEP

HIV Diagnoses by Week, Indiana HIV Outbreak (N=188) Peters P et al., under review and Indiana State Department of Health Detect and confirm Deploy emergency command, HIV testing, contact tracing, services Consolidate case management, HIV treatment, prevention services

HIV Diagnoses by Week, Indiana HIV Outbreak (N=188) Retesting “blitz” Consolidate case management, HIV treatment, prevention services Peters P et al., under review and Indiana State Department of Health Detect and confirm Deploy emergency command, HIV testing, contact tracing, services

HIV Diagnoses by Week, Indiana HIV Outbreak (N=188) Retesting “ blitz” Peters P et al., under review and Indiana State Department of Health *estimated population age > 18 years, U.S. Census Detect and confirm Adult prevalence as of February 1, 2016 Scott County ( 18,264*) : 1.0 % Austin , if home for 80% of cases (3,143*): 4.6 % Deploy emergency command, HIV testing, contact tracing, services Consolidate case management, HIV treatment, prevention services

HIV Diagnoses by Week, Indiana HIV Outbreak (N=188) Retesting “blitz” Peters P et al., under review and Indiana State Department of Health Detect and confirm Declined earlier testing Finally came in for testing or diagnosed at incarceration Deploy emergency command, HIV testing, contact tracing, services Consolidate case management, HIV treatment, prevention services

157 isolates Single strain of HIV-1 Mean nucleotide identity 99.7 % (1302 base pairs) No antiretroviral drug resistance detected All infections epidemiologically linked to Scott County Availability of near real-time pol sequencing confirmed limited geographic spread of outbreak* Laboratory Investigation, 2015 Indiana HIV Outbreak Phylogenetic A nalysis of pol Sequences and Recency Testing* Indiana outbreak investigation Indiana reference sample (non-outbreak related) GenBank reference SOURCE OF SAMPLE *Poster 215: Campbell et al., Infer and characterize a transmission network in an opioid-driven HIV-1 outbreak

157 isolates Single strain of HIV-1 Mean nucleotide identity 99.7 % (1302 base pairs) No antiretroviral drug resistance detected All infections epidemiologically linked to Scott County Availability of near real-time pol sequencing confirmed limited geographic spread of outbreak 85% of infections recent* (limited in time) Laboratory Investigation, 2015 Indiana HIV Outbreak Phylogenetic A nalysis of pol Sequences and Recency Testing* * Recency testing was performed using a Modified BioRad 1/2 Plus O Assay with avidity i ndex cutoff set at 30%, corresponding to approximately 221 days Indiana outbreak investigation Indiana reference sample (non-outbreak related) GenBank reference SOURCE OF SAMPLE

Major Logistical Challenges Responding to Outbreak Very few affected persons were employed or insured Lacked documents* to enroll in state-supported program (“One-S top Shop”) Limited HIV awareness, substantial misinformation Unaware of transmission risks and treatment benefits Distrust between PWID community and law enforcement No outpatient HIV/HCV care available in the community Insufficient addiction services, including medication-assisted therapy Syringe service program not permitted by state law * Birth certificate, driver’s license, Social Security card

http://ohioaidscoalition.org/wp-content/uploads/OAC-Policy-Update-5_8_15.pdf Emergency Declaration and New Law Permitted Syringe Exchange in Response to Outbreak

Federal funds can be used for syringe service programs (except purchase of needles and syringes) i f – in consultation with CDC – a need is demonstrated (i.e., significant increase in hepatitis infections, HIV outbreak)

Impact of Syringe Exchange in Scott County Reductions in sharing syringes and injection equipment (n=148) p <0.001 p <0.001 p <0.001 Patel et al. IDWeek 2015, abstract: Open Forum Infect Dis (Fall 2015) 2 ( supplement 1): S69-S70 (median 10 weeks after first visit)

Why Did this Event Happen?

What Had Changed?

Time Magazine, June 15, 2015

Rates of motor vehicle traffic and drug overdose deaths, United States 1980-2010 Source: DHHS, Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities , September 2013 *

Source: DHHS, Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities , September 2013* MMWR Wkly Rep 2016, 64(50): 1378-82 **http://www-nrd.nhtsa.dot.gov/Pubs/812219.pdf 2014 47,055 * 32,675 ** Rates of motor vehicle traffic and drug overdose deaths, United States 1980-2010

Source: DHHS, Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities , September 2013 * 1999: Opioids involved: 30% of drug overdoses Rates of motor vehicle traffic and drug overdose deaths, United States 1980-2010

2010: Opioids involved: 60% of drug overdoses Source: DHHS, Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities , September 2013 * 1999: Opioids involved: 30% of drug overdoses Rates of motor vehicle traffic and drug overdose deaths, United States 1980-2010

Rates of opioid overdose deaths, opioid sales, and opioid substance abuse treatment admissions, United States Source: DHHS, Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities , September 2013

Rates of opioid overdose deaths, opioid sales, and opioid substance abuse treatment admissions, United States Source: DHHS, Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities , September 2013 Increasing opioid use  Increasing injection of drugs

Suryaprasad Clin Infect Dis; 2014, 59(10):1411-1419 2006 2012 Rapid expansion of injection drug use heralded by epidemic of new HCV infections in areas with historically low rates of HIV infection 0-1 >1-10 >10-20 >20-40 >40 Acute HCV infections i ncidence per 100,000 population 2006 2012 0-1 >1-10 >10-20 >20-40 >40 Acute HCV infections i ncidence per 100,000 population

0-1 >1-10 >10-20 >20-40 >40 Acute HCV infections i ncidence per 100,000 population Suryaprasad Clin Infect Dis ; 2014, 59(10):1411-1419 2006 2012 Rapid e xpansion of injection drug use heralded by epidemic of new HCV infections in areas with historically low rates of HIV infection 0-1 >1-10 >10-20 >20-40 >40 Acute HCV infections i ncidence per 100,000 population

Nonurban areas Urban areas 2006 2007 2008 2009 2010 2011 2012 Number of cases per 100,000 population 0 1 2 3 4 Kentucky, Tennessee, Virginia, West Virginia Zibbell J et al. MMWR Morb Mortal Wkly Rep 2015, 64(17): 444-448, Rapid e xpansion of injection drug use heralded by epidemic of new HCV infections in areas with historically low rates of HIV infection Incidence nonurban more than twice urban, a nd increasing faster

Needle and Syringe Programs Reduce HIV Incidence 56% reduction in risk of HIV infection Aspinall E J et al. Int J. Epidemiolog. 2014, Courtesy of Richard Needle

MacArthur G J et al. BMJ 2012, Courtesy of Richard Needle Opioid Substitution Therapy Reduces HIV Transmission 64% reduction in risk of HIV infection

Explosive Increases in HIV Prevalence among PWID, 1978-1998 UN Reference Group on HIV/AIDS Prevention and Care among IDU in Developing and Transitional Countries, www.idurefgroup.org , Courtesy of Richard Needle 40% and higher prevalence may be reached within 1-2 years

What can we do?Assess and reduce vulnerability to an outbreakDetermine if unsafe injection of drugs is occurring Employ syringe service programsDiagnose and treat substance use disorderEnhance capacity to detect a change in HIV and HCV infections Test at drug treatment service sites, jails/prisons, hospitalsPrepare an action plan in the event of an outbreakDelineate landscape of HIV/HCV prevention and treatment Establish relationships with local law enforcement

Lessons from Indiana The U.S. is experiencing an expanding prescription drug and heroin epidemic that is driving increases in injection drug use

Lessons from Indiana The U.S. is experiencing an expanding prescription drug and heroin epidemic that is driving increases in injection drug use A new and growing group of U.S. residents has become vulnerable to potentially explosive spread of HIV and HCV infection

Lessons from Indiana The U.S. is experiencing an expanding prescription drug and heroin epidemic that is driving increases in injection drug use A new and growing group of U.S. residents has become vulnerable to potentially explosive spread of HIV and HCV infection The events in Indiana were devastating …

Lessons from Indiana The U.S. is experiencing an expanding prescription drug and heroin epidemic that is driving increases in injection drug use A new and growing group of U.S. residents has become vulnerable to potentially explosive spread of HIV and HCV infection The events in Indiana were devastating but they were preventable

Lessons from Indiana The U.S. is experiencing an expanding prescription drug and heroin epidemic that is driving increases in injection drug use A new and growing group of U.S. residents has become vulnerable to potentially explosive spread of HIV and HCV infection The events in Indiana were devastating but they were preventableOther communities are at risk …

Lessons from Indiana The U.S. is experiencing an expanding prescription drug and heroin epidemic that is driving increases in injection drug use A new and growing group of U.S. residents has become vulnerable to potentially explosive spread of HIV and HCV infection The events in Indiana were devastating but they were preventableOther communities are at risk and the number could grow

Lessons from Indiana The U.S. is experiencing an expanding prescription drug and heroin epidemic that is driving increases in injection drug use A new and growing group of U.S. residents has become vulnerable to potentially explosive spread of HIV and HCV infection The events in Indiana were devastating but they were preventableOther communities are at risk and the number could grow I t could happen again …

Lessons from Indiana The U.S. is experiencing an expanding prescription drug and heroin epidemic that is driving increases in injection drug use A new and growing group of U.S. residents has become vulnerable to potentially explosive spread of HIV and HCV infection The events in Indiana were devastating but they were preventableOther communities are at risk and the number could grow I t could happen again but it doesn’t have to

AcknowledgmentsScott and Clark County Health Departments Scott County Sheriff’s Office Foundations Family MedicineScott Memorial Hospital Indiana State Department of HealthIndiana Family and Social Services AdministrationIndiana University School of Medicine School of Public Health Louisville 550 Clinic Centers for Disease Control and PreventionDivision of HIV/AIDS Prevention Division of Viral Hepatitis Division of STD Prevention National Center for Injury Prevention and Control Office of Public Health Preparedness and Response Health Resources and Services Administration Substance Abuse and Mental Health Services Administration