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1 O NEILL INSTITUTE PRESENTATION TITLE GOES HERE 1 Preventing Infectious Disease O NEILL INSTITUTE Transmission Among People who PRESENTATION TITLE GOES Inject Drugs: HERE Observations and Lessons from Scott County, Indiana CITYNAME, STATE, COUNTRY JANUARY 30, National Latino HIV and Hepatitis C Conference San FIRSTSPEAKERS Antonio, Texas NAMEGOESHERE May The Title 19, of the 2018 First Speaker Goes Here, O Neill Institute for National Global Health Law name@law.reorgetown.edu FIRSTSPEAKERS NAMEGOESHERE Jeffrey S. Crowley The Title of the First Speaker Goes Here, O Neill Institute for National Global Health Law name@law.reorgetown.edu Distinguished Scholar/Program Director, Infectious Disease Initiatives O Neill Institute for National Global Health Law Jeffrey.Crowley@law.georgetown.edu

2 O NEILL INSTITUTE PRESENTATION TITLE GOES HERE Preventing Infectious Disease Transmission Among People who Inject Drugs: 2 2 O NEILL INSTITUTE Starting in late 2014, Scott County, a rural county in southern PRESENTATION Indiana, experienced TITLE an HIV outbreak GOES tied to HERE injection of the opioid oxymorphone. Whereas the county had experienced about 5 HIV diagnoses CITYNAME, STATE, per year COUNTRY prior to this outbreak, 181 cases JANUARY 30, 2016 were diagnosed from November 2014 through November FIRSTSPEAKERS NAMEGOESHERE The Title of the First Speaker Goes Here, O Neill Institute for National Global Health Law name@law.reorgetown.edu 157 of 159 cases on which phylogenetic testing was performed FIRSTSPEAKERS were NAMEGOESHERE linked to one HIV-infected person The Title of the First Speaker Goes Here, O Neill Institute for National Global Health Law who name@law.reorgetown.edu was introduced into the network of people who inject drugs (PWID).

3 O NEILL INSTITUTE PRESENTATION TITLE GOES HERE Preventing Infectious Disease Transmission Among People who Inject Drugs: 3 3 O NEILL INSTITUTE PRESENTATION TITLE GOES OVERVIEW HERE 1. What happened in Scott County? 2. What was the response? CITYNAME, STATE, COUNTRY JANUARY 30, What are the broader policy implications of this outbreak? FIRSTSPEAKERS NAMEGOESHERE The Title of the First Speaker Goes Here, O Neill Institute for National Global Health Law 4. name@law.reorgetown.edu Has there been much policy change since the Scott County outbreak? FIRSTSPEAKERS NAMEGOESHERE The Title of the First Speaker Goes Here, O Neill Institute for National Global Health Law name@law.reorgetown.edu

4 4 SECTION 1 What happened in Scott County?

5 5 SECTION 1: What happened in Scott County? Surge of HIV diagnoses was the first sign of trouble January 23, 2015, Indiana State Department of Health began an outbreak investigation after 11 cases were confirmed in Scott County As of April 21, patients identified: years; 74 (55%) = male; median age = 32 Small number of pregnant women diagnosed and started on ART; no infants diagnosed Of 135: 108 (80%) reported IDU; 4 (3%) reported no IDU; and 23 (17%) had not been interviewed Of 108, all reported dissolving and injecting oxymorphone as their drug of choice 114 (85%) were co-infected with Hepatitis C Reported daily injections ranged from 4-15; reported injection partners ranged from 1-6 per injection event Source: Community Outbreak of HIV Infection Linked to Injection Drug Use of Oxymorphone Indiana, 2015, MMWR, 2015;64(16):443 4.

6 6 SECTION 1: What happened in Scott County? County and state were quickly overwhelmed by the number of cases Public health officials were surprised by the size of the network of people who inject drugs and the extent of syringe sharing, given the small size of the community (~4,300 residents in the town of Austin and <24,000 residents in the county) From November 14, 2014-November 1, cases identified over this period:104 (57%) = male and 77 43%) = female; 179 were white) Most (88%) reported having injected the extended release formulation of oxymorphone 92% were co-infected with Hepatitis C Among 159 cases where gene sequencing was performed, 157 (99%) had sequences that were highly related by phylogenetic analyses Source: HIV Infection Linked to Injection Use of Oxymorphone in Indiana, , NEJM, 2016;375(3):

7 7 SECTION 1: What happened in Scott County? Scott County is not unique The CDC conducted a county-level vulnerability assessment for rapid dissemination of HIV and HCV infection, finding 220 US counties at high risk for a future outbreak

8 8 SECTION 2 What was the response?

9 Sources: Mike Pence s defining moment as governor Enabling an HIV Outbreak, by Erin Schumacher, updated October 6, 2016, Huffington Post and HIV Infection Linked to Injection Use of Oxymorphone in Indiana, , NEJM, 2016;375(3): Preventing Infectious Disease Transmission Among People who Inject Drugs: 9 SECTION 2: What was the response? State mobilized and CDC provided extensive support Governor Pence declared a public health emergency on March 26, 2015 In Congress and as governor, Mike Pence championed defunding Planned Parenthood. In 2013, his 1 st year as governor, the Planned Parenthood clinic in Scott County closed (only free HIV testing site in the county), following state cuts in public health funding Response included rapid expansion of free HIV/HCV testing and partner services, establishment of local HIV treatment services, provision of substance use disorder treatment, and immediate access to health insurance and immunization services Number of HIV tests increased from 23 in November 2014 to 1,838 in March-May 2015 (>600/month) Between April 4-November 1, 2015, of 176 patients who could be monitored, 152 (86%) attended an HIV medical appointment and 107 (61%) initiated ART By April 5, 2015, 1 st SSP in state established in Scott County; from April 4-October 31, 2015, 277 persons enrolled and 97,000 syringes were distributed and returned; participants reported median of 5 injections per day

10 10 SECTION 2: What was the response? And, the response made a difference The CDC conducted a detailed transmission network analysis following the outbreak Predicted infection dates suggest that transmission began in 2011, underwent explosive growth in mid-2014, and slowed after the declaration of a public health emergency The majority of infections likely already had occurred when the investigation began Early transmission may have been associated with sexual activity and injection drug use Contact tracing yielded a network of 1,060 high-risk linkages among 411 individuals: 839 (79%) were injection drug users only, 84 (8%) were sex partners only, and 137 (13%) were sex partners and injection drug users In 2017, only 8 new HIV cases were reported in Scott County Sources: Detailed Transmission Network Analysis of a Large Opiate-Driven Outbreak of HIV Infection in the United States, JID, 2017;216: and Indiana Persons Living with HIV/AIDS as of December 31, 2017, Indiana State Department of Health.

11 11 SECTION 3 What are the broader policy implications of this outbreak? All slides in this section build on policy lessons identified in the Editorial: Crowley JS and Millett GA, Preventing HIV and Hepatitis Infections Among People Who Inject Drugs: Leveraging an Indiana Outbreak Response to Break the Impasse, AIDS Behav, 2017 Apr;21(4):

12 12 SECTION 3: What are the broader policy implications of this outbreak? Bolster state and local public health systems Indiana often ranks last among states in terms of public health capacity; Scott County is one of the poorest counties in the state with among the worst health outcomes Federal funding for public health largely has been flat funded in recent years Adjusting for inflation, CDC s budget has declined by about $580 million since 2010 Within public health, investing in infectious disease control is not always a top priority in states Politicization of key program operators and services (i.e. Planned Parenthood, contraception, PrEP, etc.) often weakens support for critical programs Source: A Funding Crisis for Public Health and Safety: State-by-State Public Health Funding and Key Health Facts, 2017, Trust for America s Health, April 2017.

13 13 SECTION 3: What are the broader policy implications of this outbreak? Develop integrated approaches to prevention, treatment, and support for recovery A notable feature of the Scott County outbreak was its intergenerational nature often three generations of family members were using drugs together Family support is often critical to recovery. This is challenged when drug using patterns change so that women household members and younger and older family members also are using drugs. This calls for new approaches to prevention and treatment We may need new engagement with child welfare and new models for family-based treatment Needed focus is currently being generated on the need for expanded access to overdose reversal and medication assisted therapy (MAT), but we still seem to lack fully integrated approaches to prevention and treatment of substance abuse and control of infectious diseases

14 14 SECTION 3: What are the broader policy implications of this outbreak? Protect Medicaid s ability to respond to the opioid crisis Medicaid is the nation s largest purchaser of behavioral health services and was critical to Indiana s response to the Scott County outbreak In 2016, 1.9 million nonelderly adults in the United States had an opioid addiction. Medicaid covers 4 in 10 nonelderly adults with opioid addiction. Among nonelderly adults with opioid addiction, those with Medicaid were twice as likely as those with private insurance or no insurance to have received treatment in 2016 Medicaid facilitates access to treatment by covering numerous inpatient and outpatient treatment services, as well as medications prescribed as part of medication-assisted treatment Contrary to popular assertions, Medicaid expansion did not fuel the opioid crisis: expansion population no more likely to be prescribed opioids than traditional Medicaid population and expansion states expanded access to MAT more significantly than non-expansion states Sources: The Opioid Epidemic and Medicaid s Role in Facilitating Access to Treatment, Henry J. Kaiser Family Foundation, April 2018 and Sharp A et al, Impact of Medicaid Expansion on Access to Opioid Analgesic Medications and Medication-Assisted Treatment, AJPH, 2018; 108(5):

15 15 SECTION 3: What are the broader policy implications of this outbreak? Expanding Medicaid to all States will Strengthen the Response to the Opioid Crisis Medicaid is the critical base upon which to build a comprehensive financing system for substance use services and recovery supports

16 Despite Federal legal uncertainty, cities such as New York, Philadelphia, San Francisco and Seattle are trying to move forward to implement SCS programs. But, these models may not work in Scott County or southern Texas. How long must we wait to test innovative and often controversial ideas in these places? Preventing Infectious Disease Transmission Among People who Inject Drugs: 16 SECTION 3: What are the broader policy implications of this outbreak? Push the envelope to deliver innovative services that further minimize the harm from drug abuse while increasing treatment uptake The Vice President (former Governor of IN) and the Surgeon General (former IN Health Commissioner) had originally opposed syringe services programs (SSPs), but changed their views in the face of the crisis Health professionals need to be fearless in offering their best evidenceinformed policy recommendations SSPs have come a long way, but they remain controversial to some. Even where they exist, penetration is limited SSPs alone are insufficient, we need to keep testing new ideas including models for safe consumption services (SCS) and drug user health

17 Source: Opioid & Health Indicators Database, amfar, the Foundation for AIDS Research, Preventing Infectious Disease Transmission Among People who Inject Drugs: 17 SECTION 3: What are the broader policy implications of this outbreak? Limited capacity to delivery syringe services programs is a nationwide problem Only an estimated 309 SSPs operate nationally in 2018

18 18 SECTION 3: What are the broader policy implications of this outbreak? Foster local responses based on community engagement and support Public health leadership was important, but insufficient. Law enforcement, religious, and other community leaders were critical to changing the law to permit SSPs and begin to take steps to curb the outbreak Scott County sheriff was a local leader that played a critical role in building support for SSPs; Faith leaders and others are critical Since Indiana changed its laws to permit SSPs, at least two counties, Lawrence and Madison, have disbanded their SSPs. While health officials and hospital executives supported the continuation of these programs, local prosecutors and county commissioners have said that they cannot condone facilitating illegal drug use and have offered Biblical objections to these programs Local opposition remains a barrier to implementation and expansion of effective programs in many communities across the US See Leigh Hedger, 2 nd Indiana county ends needle exchange, with 1 official citing moral concerns, IndyStar, October 26, 2017 and Josh Katz, Why a city at the center of the opioid crisis gave up a tool to fight it, New York Times, April 27, 2018.

19 19 SECTION 4 Has there been much policy change since the Scott County outbreak?

20 20 SECTION 4: Has there been much policy change since the Scott County outbreak? Policy change has begun In some sense, Scott County has tangibly changed the policy debate In the Obama years, the Congress modified the ban on federal funds for SSPs, reinstated it, and then modified it again Recent policy was supported by congressional leaders from Appalachia who had been staunchest opponents of these programs Currently policy permits federal funds for all, but purchase of actual syringes; state, local, tribal, and territorial health departments must consult with CDC and provide evidence that their jurisdiction is experiencing or at risk for significant increases in hepatitis infections or an HIV outbreak due to injection drug use Opana, the extended release form of oxymorphone that was responsible for the Scott County outbreak, has been removed from the market in the United States Indiana changed its law to permit SSPs to operate in the state under specified criteria

21 HIV and HCV diagnoses are increasing among PWID: CDC recently reported a 4% increase in new HIV diagnoses among PWID nationally, the first such increase in two decades. CDC reported a 21% increase in HCV in infections between 2015 and 2016, driven by the opioid crisis Preventing Infectious Disease Transmission Among People who Inject Drugs: 21 SECTION 4: Has there been much policy change since the Scott County outbreak? The opioid crisis is worsening New funding is being provided and policy makers are responding, but it still feels like it is too little and too late Opioid deaths increasing: According to the CDC, in the 12-month period preceding September 2017, overdose deaths were 13 percent higher than over the prior 12 months which had already been the highest on record Infectious diseases are being overlooked: While the President s Commission on Combating Drug Addiction and the Opioid Crisis brought much-needed attention to the opioid epidemic, the resulting report of nearly 70 policy recommendations did not mention the resurgence of infectious diseases associated with injection drug use, much less offer a plan for addressing them

22 22 SECTION 4: Has there been much policy change since the Scott County outbreak? The HIV and HCV communities must do more to lead this fight Our roots in advocacy and our community connections give us unique capacity to achieve better approaches to drug user health We need to learn new ways to address drug use: Many medical providers have had to rethink how they engage with patients on questions such as condom use in the PrEP era. Similarly, our society often has taught us harmful notions about people who use drugs and addiction that need to be rethought We need to change the narrative: Common perceptions that people cannot recover from substance abuse hold us back. We need to lead the way to teach our larger communities how to have a more constructive dialogue around drug use The spotlight on the opioid crisis in an opportunity: New funding and the recognition that we need more services and new approaches to drug use prevention and treatment create new opportunities to create more comprehensive solutions that will help us end the HIV epidemic

23 O NEILL INSTITUTE PRESENTATION TITLE GOES HERE Preventing Infectious Disease Transmission Among People who Inject Drugs: O NEILL INSTITUTE PRESENTATION TITLE GOES HERE QUESTIONS? CITYNAME, STATE, COUNTRY JANUARY 30, 2016 FIRSTSPEAKERS NAMEGOESHERE The Title of the First Speaker Goes Here, O Neill Institute for National Global Health Law name@law.reorgetown.edu THANK YOU! FIRSTSPEAKERS NAMEGOESHERE The Title of the First Speaker Goes Here, O Neill Institute for National Global Health Law name@law.reorgetown.edu