5/2/2016. Dr Brooks has no relevant financial affiliations to disclose. (Update 04/15/16) Learning Objectives

Transcription

1 Persistent Challenge of HIV Transmission Control in Injection Drug Use: The Indiana Outbreak John T. Brooks, MD Senior Medical Advisor, Division of HIV/AIDS Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention Atlanta, Georgia FINAL: 04/11/2016 Washington DC: April 15, 2016 Financial Relationships With Commercial Entities Dr Brooks has no relevant financial affiliations to disclose. (Update 04/15/16) Slide 2 of 52 Learning Objectives After 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 Slide 3 of 52 1

2 Diagnoses, n 5/2/2016 In 2014, what fraction of new HIV diagnoses were estimated as attributable to injection drug use: 25% % 36% 29% % % 11% % Slide 4 of 52 In the last 5 years, the number of new HIV diagnoses estimated as attributable to injection drug use has been: 21% 1. Stable 25% 2. Declining 43% 3. Rising 11% 4. All over the place Slide 5 of 52 Slide 6 of 52 Number of HIV Infections Diagnosed among Adults and Adolescents, by Transmission Category, United States and 6 Dependent Areas 30,000 Male-to-male sexual contact 25,000 20,000 15,000 Heterosexual contact 63% decline over 10 years 6% of all HIV infections in ,000 5,000 6,408 Injection drug use 2, Year 2

3 Slide 7 of 52 Indiana HIV Outbreak: Geography Scott County pop. 24,000; Austin city pop. 4,200 Slide 8 of 52 Rural southeastern region of state Scott County ranked 92 nd 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 Summary Slide 9 of 52 In early 2015, 11 new HIV infections diagnosed in Scott County, IN Over past decade, <1 HIV new infection in Scott County per year As of February 1, new HIV diagnosis >90% coinfected with hepatitis C virus Response required a large and intensive 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 3

4 Slide 10 of 52 Demographics of HIV-infected Cases (N=181) Median age 34 years, interquartile range % male 99% non-hispanic white 96% injected drugs in past 12 months Peters P et al., in press Slide 11 of 52 Diagnoses of HIV Infection Among Persons Who Inject Drugs by Sex and Race/Ethnicity, 2014 United States and 6 Dependent Areas 4% Males N = 1,672 Females N = 1,060 4% 27% 41% 34% 43% Historical demography Mostly urban Male > female Mostly non-white 28% 19% Black, African-American Hispanic/Latino a White Other 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. Slide 12 of 52 Diagnoses of HIV Infection Among Persons Who Inject Drugs by Sex and Race/Ethnicity, 2014 United States and 6 Dependent Areas Males N = 1,672 Females N = 1,060 69% 62% Historical demography Mostly urban Male > female Mostly non-white Black, African-American Hispanic/Latino White Other 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

5 HIV Diagnoses per Week 16-Nov 23-Nov 30-Nov 7-Dec 14-Dec 21-Dec 28-Dec 4-Jan 11-Jan 18-Jan 25-Jan 1-Feb 8-Feb 15-Feb 22-Feb 1-Mar 8-Mar 15-Mar 22-Mar 29-Mar 5-Apr 12-Apr 19-Apr 26-Apr 3-May 10-May 17-May 24-May 31-May 7-Jun 14-Jun 21-Jun 28-Jun 5-Jul 12-Jul 19-Jul 26-Jul 2-Aug 9-Aug 16-Aug 23-Aug 30-Aug 6-Sep 13-Sep 20-Sep 27-Sep 4-Oct 11-Oct 18-Oct 25-Oct 1-Nov 8-Nov 15-Nov 22-Nov 29-Nov 6-Dec 13-Dec 20-Dec 27-Dec 3-Jan 10-Jan 17-Jan 24-Jan 31-Jan 5/2/2016 Slide 13 of 52 Demographics of HIV-infected Cases (N=181) Median age 34 years, interquartile range % male 99% non-hispanic white 96% injected drugs in past 12 months 92% oxymorphone 27% heroin, 23% methamphetamine, 9% cocaine Peters P et al., in press Slide 14 of 52 Drug Use among HIV-infected Cases (N=108) Multigenerational users Daily injections: 4-15 Number of needle-sharing partners per injection event: 1-6 Sharing of injection equipment common Oxymorphone ER with INTAC Tablet Images* GENERIC oxymorphone ER Tablet Images* Early Release, MMWR Morb Mortal Wkly Report 2015, April 24, 2015 HIV Diagnoses by Week, Indiana HIV Outbreak (N=188) Slide 15 of Detect and confirm Peters P et al., in press and Indiana State Department of Health Week Ending 5

6 HIV Diagnoses per Week HIV Diagnoses per Week HIV Diagnoses per Week 16-Nov 23-Nov 30-Nov 7-Dec 14-Dec 21-Dec 28-Dec 4-Jan 11-Jan 18-Jan 25-Jan 1-Feb 8-Feb 15-Feb 22-Feb 1-Mar 8-Mar 15-Mar 22-Mar 29-Mar 5-Apr 12-Apr 19-Apr 26-Apr 3-May 10-May 17-May 24-May 31-May 7-Jun 14-Jun 21-Jun 28-Jun 5-Jul 12-Jul 19-Jul 26-Jul 2-Aug 9-Aug 16-Aug 23-Aug 30-Aug 6-Sep 13-Sep 20-Sep 27-Sep 4-Oct 11-Oct 18-Oct 25-Oct 1-Nov 8-Nov 15-Nov 22-Nov 29-Nov 6-Dec 13-Dec 20-Dec 27-Dec 3-Jan 10-Jan 17-Jan 24-Jan 31-Jan 16-Nov 23-Nov 30-Nov 7-Dec 14-Dec 21-Dec 28-Dec 4-Jan 11-Jan 18-Jan 25-Jan 1-Feb 8-Feb 15-Feb 22-Feb 1-Mar 8-Mar 15-Mar 22-Mar 29-Mar 5-Apr 12-Apr 19-Apr 26-Apr 3-May 10-May 17-May 24-May 31-May 7-Jun 14-Jun 21-Jun 28-Jun 5-Jul 12-Jul 19-Jul 26-Jul 2-Aug 9-Aug 16-Aug 23-Aug 30-Aug 6-Sep 13-Sep 20-Sep 27-Sep 4-Oct 11-Oct 18-Oct 25-Oct 1-Nov 8-Nov 15-Nov 22-Nov 29-Nov 6-Dec 13-Dec 20-Dec 27-Dec 3-Jan 10-Jan 17-Jan 24-Jan 31-Jan 16-Nov 23-Nov 30-Nov 7-Dec 14-Dec 21-Dec 28-Dec 4-Jan 11-Jan 18-Jan 25-Jan 1-Feb 8-Feb 15-Feb 22-Feb 1-Mar 8-Mar 15-Mar 22-Mar 29-Mar 5-Apr 12-Apr 19-Apr 26-Apr 3-May 10-May 17-May 24-May 31-May 7-Jun 14-Jun 21-Jun 28-Jun 5-Jul 12-Jul 19-Jul 26-Jul 2-Aug 9-Aug 16-Aug 23-Aug 30-Aug 6-Sep 13-Sep 20-Sep 27-Sep 4-Oct 11-Oct 18-Oct 25-Oct 1-Nov 8-Nov 15-Nov 22-Nov 29-Nov 6-Dec 13-Dec 20-Dec 27-Dec 3-Jan 10-Jan 17-Jan 24-Jan 31-Jan 5/2/2016 HIV Diagnoses by Week, Indiana HIV Outbreak (N=188) Slide 16 of Detect and confirm Deploy emergency command, HIV testing, contact tracing, services 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 0 Peters P et al., under review and Indiana State Department of Health Week Ending HIV Diagnoses by Week, Indiana HIV Outbreak (N=188) Slide 17 of Detect and confirm Deploy emergency command, HIV testing, contact tracing, services Consolidate case management, HIV treatment, prevention services Peters P et al., under review and Indiana State Department of Health Week Ending HIV Diagnoses by Week, Indiana HIV Outbreak (N=188) Slide 18 of Detect and confirm Deploy emergency command, HIV testing, contact tracing, services Consolidate case management, HIV treatment, prevention services Retesting blitz Peters P et al., under review and Indiana State Department of Health Week Ending 6

7 HIV Diagnoses per Week HIV Diagnoses per Week 16-Nov 23-Nov 30-Nov 7-Dec 14-Dec 21-Dec 28-Dec 4-Jan 11-Jan 18-Jan 25-Jan 1-Feb 8-Feb 15-Feb 22-Feb 1-Mar 8-Mar 15-Mar 22-Mar 29-Mar 5-Apr 12-Apr 19-Apr 26-Apr 3-May 10-May 17-May 24-May 31-May 7-Jun 14-Jun 21-Jun 28-Jun 5-Jul 12-Jul 19-Jul 26-Jul 2-Aug 9-Aug 16-Aug 23-Aug 30-Aug 6-Sep 13-Sep 20-Sep 27-Sep 4-Oct 11-Oct 18-Oct 25-Oct 1-Nov 8-Nov 15-Nov 22-Nov 29-Nov 6-Dec 13-Dec 20-Dec 27-Dec 3-Jan 10-Jan 17-Jan 24-Jan 31-Jan 16-Nov 23-Nov 30-Nov 7-Dec 14-Dec 21-Dec 28-Dec 4-Jan 11-Jan 18-Jan 25-Jan 1-Feb 8-Feb 15-Feb 22-Feb 1-Mar 8-Mar 15-Mar 22-Mar 29-Mar 5-Apr 12-Apr 19-Apr 26-Apr 3-May 10-May 17-May 24-May 31-May 7-Jun 14-Jun 21-Jun 28-Jun 5-Jul 12-Jul 19-Jul 26-Jul 2-Aug 9-Aug 16-Aug 23-Aug 30-Aug 6-Sep 13-Sep 20-Sep 27-Sep 4-Oct 11-Oct 18-Oct 25-Oct 1-Nov 8-Nov 15-Nov 22-Nov 29-Nov 6-Dec 13-Dec 20-Dec 27-Dec 3-Jan 10-Jan 17-Jan 24-Jan 31-Jan 5/2/2016 HIV Diagnoses by Week, Indiana HIV Outbreak (N=188) Slide 19 of Detect and confirm Deploy emergency command, HIV testing, contact tracing, services Consolidate case management, HIV treatment, prevention services Retesting blitz Adult prevalence as of February 1, 2016 Scott County (18,264*): 1.0 % Austin, if home for 80% of cases (3,143*): 4.6 % 5 0 Week Ending Peters P et al., under review and Indiana State Department of Health *estimated population age >18 years, U.S. Census HIV Diagnoses by Week, Indiana HIV Outbreak (N=188) Slide 20 of Detect and confirm Deploy emergency command, HIV testing, contact tracing, services Consolidate case management, HIV treatment, prevention services Retesting blitz Declined earlier testing Finally came in for testing or diagnosed at incarceration Peters P et al., under review and Indiana State Department of Health Week Ending Laboratory Investigation, 2015 Indiana HIV Outbreak Phylogenetic Analysis of pol Sequences and Recency Testing* Slide 21 of 52 SOURCE OF SAMPLE Indiana outbreak investigation Indiana reference sample (non-outbreak related) GenBank reference 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* *Poster 215: Campbell et al., Infer and characterize a transmission network in an opioid-driven HIV-1 outbreak 7

8 Laboratory Investigation, 2015 Indiana HIV Outbreak Phylogenetic Analysis of pol Sequences and Recency Testing* Slide 22 of 52 SOURCE OF SAMPLE Indiana outbreak investigation Indiana reference sample (non-outbreak related) GenBank reference 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) * Recency testing was performed using a Modified BioRad 1/2 Plus O Assay with avidity index cutoff set at 30%, corresponding to approximately 221 days Major Logistical Challenges Responding to Outbreak Slide 23 of 52 Very few affected persons were employed or insured Lacked documents* to enroll in state-supported program ( One-Stop 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 Emergency Declaration and New Law Permitted Syringe Exchange in Response to Outbreak Slide 24 of

9 Slide 25 of 52 Slide 26 of 52 Federal funds can be used for syringe service programs (except purchase of needles and syringes) if 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) Slide 27 of 52 p <0.001 p <0.001 p < % 20% 18% 19% 24% 10% 0% 2% Sharing syringes to inject Sharing syringes to divide drugs 4% 5% Sharing other injection equipment First visit Most recent visit (median 10 weeks after first visit) Patel et al. IDWeek 2015, abstract: Open Forum Infect Dis (Fall 2015) 2 (supplement 1): S69-S70 9

10 Slide 28 of 52 Why Did this Event Happen? Slide 29 of 52 What Had Changed? Time Magazine, June 15, 2015 Slide 30 of 52 10

11 Slide 31 of 52 Rates of motor vehicle traffic and drug overdose deaths, United States Source: DHHS, Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities, September 2013 * Slide 32 of 52 Rates of motor vehicle traffic and drug overdose deaths, United States ,055 * 32,675 ** Source: DHHS, Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities, September 2013 * MMWR Wkly Rep 2016, 64(50): ** Slide 33 of 52 Rates of motor vehicle traffic and drug overdose deaths, United States : Opioids involved: 30% of drug overdoses Source: DHHS, Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities, September 2013 * 11

12 Slide 34 of 52 Rates of motor vehicle traffic and drug overdose deaths, United States : Opioids involved: 60% of drug overdoses 1999: Opioids involved: 30% of drug overdoses Source: DHHS, Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities, September 2013 * Slide 35 of 52 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 Slide 36 of 52 Rates of opioid overdose deaths, opioid sales, and opioid substance abuse treatment admissions, United States Increasing opioid use Increasing injection of drugs Source: DHHS, Addressing Prescription Drug Abuse in the United States Current Activities and Future Opportunities, September

13 Number of cases per 100,000 population 5/2/2016 Rapid expansion of injection drug use heralded by epidemic of new HCV infections in areas with historically low rates of HIV infection Slide 37 of Acute HCV infections incidence per 100,000 population 0-1 >1-10 >10-20 >20-40 >40 Acute HCV infections incidence per 100,000 population 0-1 >1-10 >10-20 >20-40 >40 Suryaprasad Clin Infect Dis; 2014, 59(10): Rapid expansion of injection drug use heralded by epidemic of new HCV infections in areas with historically low rates of HIV infection Slide 38 of Acute HCV infections incidence per 100,000 population 0-1 >1-10 >10-20 >20-40 >40 Acute HCV infections incidence per 100,000 population 0-1 >1-10 >10-20 >20-40 >40 Suryaprasad Clin Infect Dis; 2014, 59(10): Rapid expansion of injection drug use heralded by epidemic of new HCV infections in areas with historically low rates of HIV infection Kentucky, Tennessee, Virginia, West Virginia Slide 39 of Incidence nonurban more than twice urban, and increasing faster Nonurban areas Urban areas Zibbell J et al. MMWR Morb Mortal Wkly Rep 2015, 64(17): , 13

14 Needle and Syringe Programs Reduce HIV Incidence 56% reduction in risk of HIV infection Slide 40 of 52 Aspinall E J et al. Int J. Epidemiolog. 2014, Courtesy of Richard Needle Opioid Substitution Therapy Reduces HIV Transmission 64% reduction in risk of HIV infection Slide 41 of 52 MacArthur G J et al. BMJ 2012, Courtesy of Richard Needle Explosive Increases in HIV Prevalence among PWID, HIV prevalence (%) 40% and higher prevalence may be reached within 1-2 years 100 New York, USA 80 Edinburgh, Scotland Bangkok, Thailand 60 Chiang Rai, Thailand Ruili, China 40 Manipur, India Ho Chi Minh, Vietnam 20 Kathmandu, Nepal Nikolaev, Ukraine 0 Odessa, Ukraine Slide 42 of UN Reference Group on HIV/AIDS Prevention and Care among IDU in Developing and Transitional Countries, Courtesy of Richard Needle 14

15 What can we do? Assess and reduce vulnerability to an outbreak Determine if unsafe injection of drugs is occurring Employ syringe service programs Diagnose and treat substance use disorder Slide 43 of 52 Enhance capacity to detect a change in HIV and HCV infections Test at drug treatment service sites, jails/prisons, hospitals Prepare an action plan in the event of an outbreak Delineate landscape of HIV/HCV prevention and treatment Establish relationships with local law enforcement Lessons from Indiana Slide 44 of 52 The U.S. is experiencing an expanding prescription drug and heroin epidemic that is driving increases in injection drug use Lessons from Indiana Slide 45 of 52 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 15

16 Lessons from Indiana Slide 46 of 52 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 Slide 47 of 52 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 Slide 48 of 52 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 Other communities are at risk 16

17 Lessons from Indiana Slide 49 of 52 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 Other communities are at risk and the number could grow Lessons from Indiana Slide 50 of 52 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 Other communities are at risk and the number could grow It could happen again Lessons from Indiana Slide 51 of 52 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 Other communities are at risk and the number could grow It could happen again but it doesn t have to 17

18 Acknowledgments Scott and Clark County Health Departments Scott County Sheriff s Office Foundations Family Medicine Scott Memorial Hospital Indiana State Department of Health Indiana Family and Social Services Administration Indiana University School of Medicine School of Public Health Louisville 550 Clinic Centers for Disease Control and Prevention Division 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 Slide 52 of 52 18