hiv & hcv in tn: state of the state · 2019-12-09 · hiv & hcv in tn: state of the state...

HIV & HCV in TN: State of the State

Vanderbilt CCC HIV SymposiumNashville, TN / November 2, 2018

Carolyn Wester, MD, MPH | TDH HIV/STD/VH Program

Outline

• HIV• Epidemiology• HIV Continuum of Care• HIV Vulnerability

• HCV

• Harm Reduction

• Opportunities for 2019

TDH HIV/STD/Viral Hepatitis Program

HIV

HIV & AIDS in TN (1982-2015)

Demographics of HIV in Tennessee (2016)Characteristic Population Diagnosed & Living Newly Diagnosed

6,346,113 15,251 710Gender• Male 49% 74% 82%• Female 51% 26% 18%Race / Ethnicity• Black (NH) 17% 57% 59%• White (NH) 76% 37% 34%• Hispanic 5% 4% 5%Transmission Category• MSM -- 50% 56%• HRH -- 25% 30%• IDU -- 6% 3%• MSM/IDU -- 3% 3%• NIR -- 16% 6%Age (years)• 15-24 14% 3% 27%• 25-34 13% 17% 33%• 35-44 13% 22% 18%• >44 41% 57% 21%

Distribution of Newly Diagnosed HIV in TN (2016)

Tennessee eHARS, accessed June 30, 2017Population Source, American Community Survey 2011-2015 County Averages

Newly Diagnosed HIV Cases

Current Status of HIV in TN • In 2017…

~17,530 Persons living with HIV

713 Persons newly diagnosed with HIV

298 Deaths among persons living with HIV

Data source: Tennessee eHARS, accessed July, 20 2018

Number of Persons Newly Diagnosed with HIVBy stage at diagnosis, 2013-2017

520 579 590 568 581

264 185 153 141 132

n=784 n=764 n=743n=709 n=713

2013 2014 2015 2016 2017

HIV only HIV & stage 3 concurrent

Data source: Tennessee eHARS, accessed July, 20 2018

Number of Males Newly Diagnosed with HIVBy transmission risk, 2013-2017

0

50

100

150

200

250

300

350

400

450

500

2013 2014 2015 2016 2017

MSM IDU MSM and IDU Heterosexual

Data source: Tennessee eHARS, accessed July, 20 2018

Rates of Males Newly Diagnosed with HIVBy race/ethnicity, 2013-2017

0

10

20

30

40

50

60

70

80

2013 2014 2015 2016 2017

Non-Hispanic White Non-Hispanic Black Hispanic

Rates per 100,000 population

Data source: Tennessee eHARS, accessed July, 20 2018

Number of Females Newly Diagnosed with HIVBy transmission risk, 2013-2017

0

20

40

60

80

100

120

140

160

2013 2014 2015 2016 2017

Heterosexual IDU Unknown

Data source: Tennessee eHARS, accessed July, 20 2018

Rates of Females Newly Diagnosed with HIVBy race/ethnicity, 2013-2017

0

2

4

6

8

10

12

14

16

18

20

2013 2014 2015 2016 2017

Non-Hispanic White Non-Hispanic Black Hispanic

Rates per 100,000 populationData source: Tennessee eHARS, accessed July, 20 2018

Rates of Deaths Among Persons Living with HIVBy race/ethnicity, 2012-2016

0

2

4

6

8

10

12

14

16

18

2012 2013 2014 2015 2016

Non-Hispanic White Non-Hispanic Black Hispanic

Data source: Tennessee eHARS, accessed July, 20 2018

HIV CoC

HIV Continuum of Care Definitions

Where the evaluation year is referred to as “x”v Diagnosed: Number of individuals living with diagnosed HIV by Dec 31, “x-1” & alive and living in TN Dec 31, “x”

v Linked to Care: Individuals newly diagnosed with HIV in “x” and having ≥ 1 CD4 or VL result reported < 3 months of diagnosis*Note: This uses a different denominator than the other categories.

v Engaged in Care: Diagnosed individuals having > 2 CD4 and/or VL measurements > 3 months apart in “x”

v Virologically Suppressed: Diagnosed individuals having ≥ 1 VL measurement in “x” & the last VL measure < 200 copies/mL

TN HIV CoC: 2010 Baseline & 2015 Goals

80%

64%

51%

64%

29%35%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Diagnosed Linked Retained Achieved ViralSuppression

Pers

ons

wit

h H

IV

Engagement in HIV Care

TN Goal (2015) TN (2010)

Viral Suppression & Special Considerations: 2010 Status vs. 2015 Goals

47%

37% 36%34%

39%

31% 30%28%

0%

10%

20%

30%

40%

50%

60%

MSM Blacks Hispanics 25-34 yr olds

Pers

ons

wit

h H

IV A

chie

ving

Vir

al S

uppr

essi

on

Disproportionately Impacted Populations

TN ↑20% (2015) TN (2010)

2015 Statewide Goal = 51%

Tennessee’s HIV/AIDS Strategy Progress Report (2015)

Goal 2010 2015 2015 Goal Status (2015)

Increase Access to Care & Improve Health Outcomes Among Persons Living with HIV Infection

Reduce Late Stage Diagnosis 27% 18.1% < 20.3%

Increase Linkage to HIV Medical Care < 3 Months of Diagnosis

64% 71% > 80%

Increase Retention in HIV Medical Care

29% 53% > 64%

Increase Viral Suppression 35% 52% > 51%

Reduce HIV-Related Disparities

Increase Viral Suppression Among MSM by 20%

39% 55% > 47%

Increase Viral Suppression Among NH Blacks by 20%

31% 49% > 37%

Increase Viral Suppression Among Hispanics by 20%

30% 44% > 36%

Increase Viral Suppression Among 25 – 34 year olds by 20%

28% 44% > 34%

Tennessee HIV Continuum of Care: Linkage to Care by Time from Diagnosis (2015)

47%

71%79%

86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 Month 3 Months 6 Months 1 Year

Linkage to HIV Care Has Not Improved Over Time

0

10

20

30

40

50

60

70

80

90

100

30-day 60-day 90-day

2012 2013 2014 2015

47%55%

51%47%

65%71% 69%

64%

73%77% 76%

72%

2020 target2015 target

% Li

nked

to C

are

Slide Source: A Ahonkhai

Black Patients in the Highest Burdened Counties Have Persistently Low Linkage to Care

Slide Source: A Ahonkhai

2020 HIV Continuum of Care Goals: NHAS, 90-90-90, & Tennessee

• NHAS– Reduce new infections by 25%– 85% linkage < 1 month of diagnosis

• 90-90-90• 90% diagnosed

• 90% on treatment– 90% virally suppressed

• TN Goals• Reduce new infections by 25%• 85% newly diagnosed linked to care < 1 month diagnosis• 90% prevalent diagnosed engaged in care

• 90% engaged virally suppressed (= 81% of diagnosed)

Tennessee HIV Continuum of Care: 2016 Progress, 2020 Goals

*2020 linkage goal relates to linkage within 1 month of diagnosis

46%

55% 54%50%

62% 60%

85%90%

81%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Linked (1-mo) Engaged Virally Suppressed

2016 (TN)

2016 (RW)

2020 (Goal)

Recap: HIV Epi & CoC

Progress• Decreasing numbers of people with newly diagnosed HIV• Decreasing rates of AIDS within 1 year of diagnosis• Significant improvements along HIV CoC (2010 – 2015)

Challenges• Racial ethnic disparities • New HIV diagnoses• Timely linkage to care (engagement, viral suppression)• Death among PLHW

• Robust 2020 Goals• Loss of some progress along CoC

VulnerabilitiesSlide Source: A Ahonkhai

Opioid & HCV Syndemic

U.S. Opioid Prescribing Rates per 100 U.S. Residents by State (2016)

(https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html)

Drug Overdose Deaths & Death Rates(TN, 2013 – 2017)

(https://www.tn.gov/health/health-program-areas/pdo/pdo/data-dashboard.html)

The Syndemic of Acute HCV and Opioid Abuse(< 30 year olds in 4 Appalachian States)

(MMWR, May 2015)

Intersection of Epidemics

Opioid Abuse

Hepatitis C HIV

HIV Vulnerability

Number of Males Newly Diagnosed with HIVBy transmission risk, 2013-2017

0

50

100

150

200

250

300

350

400

450

500

2013 2014 2015 2016 2017

MSM IDU MSM and IDU Heterosexual

Data source: Tennessee eHARS, accessed July, 20 2018

Context for Outbreak Planning

HIV Risk Vulnerability Assessment, TN, County Level (CDC, TDH)

Rickles et al, CID 2018

Van Handel et al, JAIDS 2016

Outbreak Planning: Early Detection & Rapid Response

Outbreak Response Plan

Outbreak Response Form

REDCap Database

SNA R Code

Specimen Collection and Transport

“Epi Curve” (HIV Cluster Investigation)

Social Network Analysis

HIV / HCV Molecular Surveillance• HIV Molecular Surveillance

– Identify existing HIV transmission networks– Lab reportable in TN (2018)

• HCV Molecular Surveillance– Identify existing HCV transmission networks as a proxy for

• PWID networks, and• Potential HIV transmission networks

– TDH State Laboratory Capacity

HCV

Increasing HCVSurveillance, Testing and Navigation to Care

• Surveillance– Outbreak Planning, Detection and Response– Chronic HCV– Perinatal HCV

• Testing– Health Department STD Clinics– Community Based Partners

• Navigation to Care– Treatment (MH, SUD, HCV, HIV)– Prevention (SSPs, OD, Vaccinations, Family Planning)

Surveillance for Chronic HCV in Tennessee

*TDH Central office chronic HCV surveillance efforts augmented beginning 7/1/15.

Case Classification

2013 2014 2015* 2016 2017

Confirmed 2,070 (50%)

3,771 (55%)

7,782 (64%)

11,063(54%)

10,709(50%)

Probable 2,111 3,095 4,431 9,450 10,555

Total (C + P) 4,181 6,866 12,213 20,513 21,264

TDH NEDSS Based System (NBS), 2017 Frozen Data Set

Newly Reported Chronic HCV in TN by Age & Gender

TDH NEDSS Based System (NBS), 2017 Frozen Data Set

Perinatal HCV Exposure 2013-2017

HCV Perinatal Exposure per Live Birth: 2013 to 2017

Year No RNA RNA Total

ExposedTotal Live

BirthsHCV exposed per

1,000 birthsAB (+) RNA (+) Only RNA (-)2013 307 329 57 636 79,954 8.0

2014 312 503 101 815 81,609 10.0

2015 351 632 148 983 81,374 12.1

2016 477 777 227 1,254 80,755 15.5

2017* 429 844 258 1,273 81,013 15.7

Total 1,876 3,085 791 4,961 404,705 12.3Source: Tennessee Department of Health (TDH) National Electronic Surveillance System (NEDSS) Based System (NBS), TDH Birth Statistical File 2013-2017*As 2017 data has not been finalized, a provisional data set from August 8, 2018 was used

Rates of Perinatal HCV Exposure per 1,000 Live Births in TN, 2017

HCV Testing in HD STD Clinics in TN (4/1/17 – 3/31/18)

Risk Factor Total

n (%)

N = 27,261

HCV Ab (+)

n (%)

N = 3,407

HCV Ab (-)

n (%)

N = 23,854

Injection Drug Use 3,495 (12.8) 2,188 (62.6) 1,307 (37.4)

Intranasal Drug Use 6,032 (22.1) 2,123 (35.2) 3,909 (64.8)

Incarceration 7,781 (28.5) 2,206 (28.4) 5,575 (71.7)

Non-Professional Tattoo 6,804 (25.0) 1,542 (22.7) 5,262 (77.3)

Baby Boomers 2,949 (10.8) 768 (26.0) 2,181 (74.0)

No Risk Factors Reported 13,019 (47.7) 321 (2.5) 12,698 (97.5)

v 27,261 people tested o 12.5% Ab (+)

§ 69.8% RNA (+)

Note: Risk factors are not mutually exclusive; and total %’s are by column, whereas HCV Ab+ and Ab- %’s are by row.

(TDH PTBMIS, Knox County Electronic Health Records)

TDH Navigation to Treatment(7/3/17 – 3/31/18)

• VH Case Navigators (1 in each of 13 PHRs)

• 2,042 HCV RNA+ clients ID’d through HDs for follow-up– 1,991 clients (98%) had reported RFs

• 69% -- IDU • 66% -- INDU • 68% -- Incarceration

– 1,134 (56%) clients were verbally contacted and referred• 80% -- HCV treatment (n=912), • 21% -- Substance use disorder treatment (n=241),• 5% -- Mental health services (n=60), • <1% -- HIV care (n=9)

Harm Reduction

SSPs in TN: Legislation• May 18, 2017: Signed into law (TCA, Title 68, Ch 1, Pt 1)

• Who– Non-governmental organizations

– Approved by TDH (initial application, annual reporting)

• What– Provision of needles, hypodermic syringes, and other injection supplies at no

cost

– Disposal of used needles and hypodermic syringes

– Educational materials

– Access or referral to naloxone

– Availability of on-site consultation for MH and substance use disorder treatment

– (Provision of SSP participant cards)

SSPs in TN: Legislation• Restrictions

– No public funds can be used to purchase needles, hypodermic syringes, or other injection supplies

– Written security plan (site, equipment, personnel) required to be shared with local law enforcement, updated annually

– No SSP operations within 2000 feet of schools or public parks

• Protections / Exceptions (TCA, Title 39, Ch 17, Pt 4)– No charges for possession of needles, hypodermic syringes, injection supplies

or residual substance contained within these devices (as long as they were obtained from or being returned to an approved SSP)

– Exception only applies to possession for participants with written verification of participation in an approved SSP while either at the SSP or in transit to or from the SSP

– Equipment possession exception also applies to operators of verified SSPs

SSPs in TN: Application & Annual Reporting• Application

– Organization name, areas and populations to be served, and methods for achieving program requirements

• Annual Reporting (w/in 1 year of approval and annually thereafter)

– Number of individuals served, types of supplies dispensed and disposed, and naloxone kits distributed

– Number and types of other services and referrals provided

• Education, counseling, testing, treatment

• How / Where– Form

– Direct online entry or traditional forms

– https://www.tn.gov/health/health-program-areas/std0/std/syringe-services-program.html

SSPs in TN: 2018• Amendments

– 2000 ft restriction (schools & public parks) â to 1000 ft in 4 metros

– LHDs can establish & operate SSPs … if… approved & funded by county Commission

• Progress– 3 organizations approved (7 sites) – 1 Middle TN, 2 Eastern TN

– Partner with MHSA Regional OD Prevention Specialists (ROPS)

– Feb 2018 – June 2018

• > 125,000 needles & syringes distributed

• > 36,000 needles & syringes collected

• > 1,600 referrals made for SUD and MH treatment

• 672 naloxone kits supplied

Navigation Services• TDH

– HCV Navigators (x 13)

– Substance Use Resource Navigators (6 county pilot)

• TDMHSAS

– Regional Overdose Prevention Specialists (x 17)

• Narcan trainings & distribution

– TN Recovery Navigators (x 11)

• Meet with patients seen in EDs due to OD

• Provide information & navigate clients to treatment (30 days)

– Lifeline Peer Project (x 10)

• Provide recovery trainings,

• Refer people to SUD treatment

• Establish recovery meetings

TDH: lindsey.sizemore@tn.govTDMHSAS: monty.burks@tn.gov

Recap: Opioid / HCV Syndemic & HIV Vulnerability

Progress• Enhanced surveillance (HCV, opioid, ODs)• Established HCV testing• Variety of navigation services • Augmented HCV treatment capacity• Established 3 SSPs• Established molecular surveillance (HIV, HCV)

Challenges• Extremely high rates of HCV (including WoCBA)• Vulnerability of HIV Among PWID• Limited number of SSPs• Limited access to treatment for PWID (SUD, HCV)• Determining best use of molecular surveillance• Coordinating navigation services

Next Steps: 2019• PrEP Clinics • Shelby County HD (1/1/19)• Metro Nashville HD (1/1/19)

• SSP Funding Opportunity ($1 million)• Non-governmental organizations (4/1/19)

• Augment LTC / D2C Capacity• 2 new central office positions• Accelerate LTC & D2C through collaboration w/

testing agencies, MCMs & providers

Thank You!

TDH - HIVMeredith BrantleyRandi RosackSamantha Mathieson

TDH – Viral HepatitisLindsey SizemoreJennifer BlackHeather WingateCathy GoffKim Gill

TDH – Harm ReductionAllison SandersSarah Cooper

VUMCAima AhonkhaiCody ChastainJennifer BurdgeClare Bolds