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