hiv in southeastern indiana: lessons learned from an unprecedented outbreak jennifer walthall, md...
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HIV in Southeastern Indiana: Lessons Learned from
an Unprecedented Outbreak
Jennifer Walthall, MD MPH
Deputy Health Commissioner and Director of Health Outcomes
Indiana State Department of Health
August 17, 2015
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Unusual Features
• Number of cases (175)• Rural setting (most are urban)• Percentage of injection drug use
(96% vs 3%)
Outbreak Notification
• In late 2014, 3 new HIV diagnoses in Austin• DIS learned 2 had shared needles--contact tracing • Identified 8 more new infections in jurisdiction with <5
new HIV infections annually• All cases report injection of the opioid analgesic
oxymorphone (Opana® ER and generic ER)• ISDH HIV/STD Division creates contact maps,
determines cluster description and cause • Rural injection of oral opiate = only HIV cluster of
its kind, largest HIV outbreak in Indiana
Why Austin? Expanding epidemic of injection drug use heralded
by dramatic increase in acute HIV infections
Suryaprasad Clin Infect Dis; 2014, 59(10):1411-1419
2006 2012
Why Austin? Expanding epidemic of injection drug use heralded
by dramatic increase in acute HIV infections
Suryaprasad Clin Infect Dis; 2014, 59(10):1411-1419
2006 2012
Why Austin? Expanding epidemic of injection drug use heralded
by dramatic increase in acute HCV infections
MMWR Morb Mortal Wkly Rep 2015, 64(17): 444-448, “Increases in Hepatitis C Virus Infection Related to Injection Drug Use Among Persons Aged ≤30 Years — Kentucky, Tennessee, Virginia, and West Virginia, 2006–2012”
* Among person reporting known risk: 138 urban, 127 non-urban
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Scope of Response
OutbreakCommunity
Capacity Building
Media and Messaging
Syringe Exchange
One-Stop Shop
Addiction Treatment
Medical Care
Laboratory Testing
Epidemiology
Timeline
• February 10 – ERC, ISDH leadership notified• February 20 – incident command system
activated• February 24 – local partners identified and
communication plan initiated • February 25 – IHAN message issued• February 27 – CDC Epi-Aid requested
Timeline
• March 2 – DIS blitz • March 3 – FSSA meeting for HIP 2.0 support• March 9 – Addiction services added • March 10 – Scott County Community meeting• March 13 – Media campaign begins• March 18 – 55 cases• March 23 – DOC added to response
Timeline
• March 25 – Executive order declared • March 26 – Incident command in Austin
deploys mobile ground center (76 cases)• March 30 – HIP 2.0 PE goes live• March 31 – HIV clinic begins in Austin • April 1 – Community Outreach Center has
fully operational “One Stop Shop” (83 cases)
Timeline
• April 3 – Limited syringe exchange approved • April 11 – Community Clean-Up Day, national
media on site (99 cases)• April 20 – Executive order extension allows
for recovery phase to begin (129 cases)• April 22-24 – NPR onsite• April 24 – MMWR and CDC telebriefing • April 27-28 – Visit from CDC, SAHMSA, HHS,
HRSA (138 cases)
Timeline
• April 29 – Syringe exchange bill (SEA 461) passes general assembly
• April 30 – Cascade of care blitz begins• May 5 – Governor Pence signs SEA 461• May 24 – Executive order expires• June 8 – Time article issued• June 12 – LHD tour of one-stop shop• June 16 – CDC debriefing in Austin• June 25 – Last day of COC operations
Epidemiology Update: 8.10.15
• Total cases: 175• Total co-infections with hepatitis C: 146 (86%) • Total COC services: 1679 (as of 6/9)• Total needle exchange participants: 182• Contacts remaining to trace: 3• Positivity rate among tested contacts: 40%• All patients requesting inpatient detox placed
Demographics of Cases• Median age 32 years, range 19-56• Male 55%• 100% non-Hispanic white• Of 112 interviewed:
– 108 (96%) injected drugs– 10 (7.4%) commercial sex work, all female
• High poverty (19.0%) and unemployment (8.9%)• Low educational attainment (21.3% no high school)• High proportion without health insurance
• Early Release, MMWR Morb Mortal Wkly Report 2015, April 24, 2015; U.S. Census http://quickfacts.census.gov/qfd/states/18/18143.html
Laboratory Results
• HIV specimens– Almost all analyzed specimens are one cluster– Most infections acquired within past 6 months
• HCV specimens– Multiple strains and clusters– HCV has been repeatedly introduced over years to
decades– Many infections are recent
HIV Outbreak Diagnoses by Week
Drug Use Among HIV+ Cases
• Multigenerational sharing of injection equipment (insulin syringe)
• Daily injections: 4-15• Number of partners: 1-6 per injection event
• Early Release, MMWR Morb Mortal Wkly Report 2015, April 24, 2015
OPANA® ER – crush-resistant formulation: half-life 7-9 hours
Outbreak Control Interventions• Very few insured: established “one-stop shop”• No HIV/HCV care: state provided resources (IU), HRSA• Little HIV awareness: multiple educational efforts including
billboards, infographics, webinars, TV/radio, newspaper, Jeannie White Ginder community event at Austin HS
• Syringe exchange illegal: executive orders followed by new law• Limited addiction services (methadone moratorium): raise
awareness of MAT, train and accredit providers to prescribe Suboxone®, local mental health provider designated as a FQHC, SAMHSA collaboration
• Most focus on HIV infection: HCV effort gaining momentum as extent of HIV epidemic better defined and addressed
Incident Command Structure
Incident Command Structure
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One-Stop Shop
Initial Objectives
• Implement ICS and Command Structure
• Establish Local Executive Policy Group– Local policy group identified through local
collaboration and input; meetings began first day ISDH Command Staff on ground
• Establish Community Outreach Center (One Stop
Shop)– One Stop Shop operational in temporary/mobile
location within 3 hours of arriving on scene– Community Outreach Center/ One Stop Shop
operational within 48 hours of deployment
Initial Objectives• Implement Needle Exchange Program
(SCHD)– Provided technical expertise in development of
Scott County Needle Exchange Program – SCHD submitted and received approval from local
officials and State Health Commissioner on 4/4/15
• Coordinate Licensing, Records and Insurance Registration at One Stop Shop– Partner State Agencies reported to Scott County
on 3/30/15 and operational at mobile site 3/30/15; set up and fully operational in Community Outreach Center by 4/1/15
Initial Objectives
• Coordinate HIV Testing, Treatment and Prevention – Working with ISDH HIV/STD Division; establish
goals and outcomes for HIV Contact Tracings, Testing, Care Coordination and Treatment
– Clark County DIS led the DIS efforts
• Develop long-term strategy for continued care and recovery– Foundations Family Medicine providing care and
prevention– Expansion of Mental Health/ Substance Abuse
Treatment, Services and Programs locally
Scott County Health Department
• Provided HIV testing training, needed testing supplies, arranged for volunteer testers from around the state to cover their testing hours, technical assistance in the development and implementation of their NEP
• Supported hiring of additional PHN (candidate started June 15, 2015)
• Provided a full time HIV tester (contract employee) for continuation at SCHD, Needle Exchange/OSS site and other community testing events
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Scott County HD SEP
• Community Outreach Center and mobile unit
• Donations accepted for needles, supplies--no state or federal funds
• ID cards issued• One-for-one model• Partnership for disposal
Syringe Exchange Program
169 persons amongestimated 500 PWID
• The following LHDs, Hospitals and Organizations have received training on HIV testing since beginning of response.– Scott County Health Dept– Jefferson County Health Dept– Jackson County Health Dept– Switzerland County Health Dept– Floyd County Health Dept– St Vincent Salem Hospital– Scott County School District 2– Foundations Family Medicine
*the Miami County Police Dept also received training on HIV and HCV basic facts
HIV Testing
Continuum of HIV care in Austin, Indiana August 17, 2015
Total diagnosed=175 (175 confirmed). Persons were ineligible if deceased (n=1) or outside of the jurisdiction (n=5); estimates are based on the number of eligible persons (n=169); ** Patients engaged in care if have at least one VL or CD4 *** Percent on ARVs increases to 65% and virally suppressed increases to 30% when denominator changed to number engaged in care. Clinical services were initiated 3/31/15. ART data updated through 8/17/15.
N=169 N=141 N=125 N=92 N=43
Eligible* Engaged in Care** Care coordination Prescribed ARV's*** Virally suppressed***0
10
20
30
40
50
60
70
80
90
100 N=169
N=141
N=125
N=92
N=43
Scott County Jail
• Created and implemented HIV testing procedures and protocol– Performed testing on 60 inmates; returning 15 +/-
positive results equating to approximately 10% jail population
– Completed HIV treatment protocolo Through coordination with ISDH HIV/STD Division
provided HIV related services for all HIV positive inmates
o Identified all cost associated with HIV testing and care and provided funding to cover identified gaps in care for inmates
Community Support
• Provided Sharps Containers to local Police, Sheriffs Dept, Volunteer Organizations, EMA
• Supplied Police, Fire, EMS with safety gloves and supplies for Community Clean Up efforts and protection– 145 pairs of needle-nose pliers– 92 pairs of puncture proof gloves
• Community Outreach Center designated as Sharps Collection and Disposal Site– Total number of needles collection through community efforts at
COC 4,204– Provided training for Opioid overdose treatment, Narcan, and
supplies to Scott County first responders (EMS, Fire and Police)
• Initial HIV specialty service gap in Scott County
• During emergency response: partnership with Foundations Family Medicine, AIDS Healthcare Foundation, IU Health Physicians, and MATEC
• Long-term within Scott County at Foundations Family Medicine/AHF
Clinical Care Services
• LifeSpring established satellite location in Austin in OSS
• Dual Diagnosis clinic in partnership with IUSM
• Partnership with HRSA to designate Scott County as a HPSA for mental health
Mental Health Services
Challenges:Gaining Local Trust
• Media not permitted at COC– Press briefings held weekly at City Hall
• Information and messaging distributed through volunteers embedded in community– Had two sites staffed with COC flyers including
transportation information and phone number for first four weeks
• Community Outreach Center flyers sent to EVERY Scott County resident
Challenges:Gaining Local Trust
Challenges:Gaining Local Trust
Indiana Syringe Exchange Law• Local health officer declares to county/municipality:
– There is an epidemic of hepatitis C or HIV;– The primary mode of transmission is IV drug use;– Syringe exchange is medically appropriate as part of the
comprehensive public health response.
• The executive/legislative body of county/municipality:– Conducts a public hearing– Votes to adopt the declaration of the local health officer
• The county/municipality notifies the ISDH Commissioner and:– Requests the Commissioner to declare a public health emergency– Other measures to address the epidemic have not worked
Additional Policy Supports
• Community Bystander Naloxone law• HIP 2.0 Medicaid waiver
Communications
Communications
Communications
COC Service Summary
Community Outreach Center Service Summary
COC Service Running Total through 6/11
Total Services1761
Visitors1085
Insurance Enrollments397
Drivers License/State ID137
Vital Records247
Immunizations378
Mental Health106
Care Coordination116
HIV Testing331
Department of Workforce Development49
COC Service Summary
Lessons Learned
1. Expect the unexpected– Promptly report new HIV and HCV cases
for surveillance – Look for possible clusters of HIV and HCV – Become familiar with local data so any
increases are easily identified– County profiles and SEP toolkit located at
http://www.in.gov/isdh/26680.htm
Lessons Learned
2. Be prepared– Know who to contact for assistance and
appropriate health services– Identify your community partners and
leadership for assistance in response– If you see something, say something!
Lessons Learned
3. Escalation– Activate incident command– Identify your mission, goals and indicators
of success– Keep everyone informed– Monitor your resources carefully– Plan your de-escalation at the same time
Moving Forward
• HIV/Hepatitis C co-infection care• Hepatitis C eradication model• Needle exchange evaluation• Sustainability planning – partnerships
and transition from incident command• Telling the story
Moving Forward• Expand HIV/HCV testing efforts and capacity to
detect early signals– Routine HIV testing at “sensitive” venues (e.g., jails,
addiction services, ERs)– Active outreach testing to at-risk population (e.g., PWID)
• Develop systems to keep uninfected uninfected– Systematic retesting and education of high-risk persons– Repeat offer and provision of SSP and HIV PrEP
• Decrease opioid over-prescribing and increase addiction treatment services, including MAT
• Long-term solutions to improve public health infrastructure and socioeconomic disparities
Health Impact Pyramid
