HIV & HCV in TN: State of the State

HIV & HCV in TN: State of the State Vanderbilt CCC HIV Symposium Nashville, 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 15,251 710 Gender 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) Newly Diagnosed HIV Cases Tennessee ehars, accessed June 30, 2017 Population Source, American Community Survey 2011-2015 County Averages

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 HIV By stage at diagnosis, 2013-2017 n=784 n=764 n=743 n=709 n=713 264 185 153 141 132 520 579 590 568 581 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 HIV By transmission risk, 2013-2017 500 450 400 350 300 250 200 150 100 50 0 2013 2014 2015 2016 2017 Data source: Tennessee ehars, accessed July, 20 2018 MSM IDU MSM and IDU Heterosexual

Rates of Males Newly Diagnosed with HIV By race/ethnicity, 2013-2017 80 70 60 50 40 30 20 10 0 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 HIV By transmission risk, 2013-2017 160 140 120 100 80 60 40 20 0 2013 2014 2015 2016 2017 Data source: Tennessee ehars, accessed July, 20 2018 Heterosexual IDU Unknown

Rates of Females Newly Diagnosed with HIV By race/ethnicity, 2013-2017 20 18 16 14 12 10 8 6 4 2 0 2013 2014 2015 2016 2017 Rates per 100,000 population Data source: Tennessee ehars, accessed July, 20 2018 Non-Hispanic White Non-Hispanic Black Hispanic

Rates of Deaths Among Persons Living with HIV By race/ethnicity, 2012-2016 18 16 14 12 10 8 6 4 2 0 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 100% 90% 80% 80% TN Goal (2015) TN (2010) 70% 64% 64% Persons with HIV 60% 50% 40% 30% 29% 51% 35% 20% 10% 0% Diagnosed Linked Retained Achieved Viral Suppression Engagement in HIV Care

Viral Suppression & Special Considerations: 2010 Status vs. 2015 Goals Persons with HIV Achieving Viral Suppression 60% TN 20% (2015) TN (2010) 50% 47% 2015 Statewide Goal = 51% 39% 40% 37% 36% 34% 31% 30% 30% 28% 20% 10% 0% MSM Blacks Hispanics 25-34 yr olds Disproportionately Impacted Populations

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 64% 71% > 80% < 3 Months of Diagnosis Increase Retention in HIV Medical 29% 53% > 64% Care Increase Viral Suppression 35% 52% > 51% Reduce HIV-Related Disparities Increase Viral Suppression Among MSM by 20% Increase Viral Suppression Among NH Blacks by 20% Increase Viral Suppression Among Hispanics by 20% Increase Viral Suppression Among 25 34 year olds by 20% 39% 55% > 47% 31% 49% > 37% 30% 44% > 36% 28% 44% > 34%

Tennessee HIV Continuum of Care: Linkage to Care by Time from Diagnosis (2015) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 86% 79% 71% 47% 1 Month 3 Months 6 Months 1 Year

Linkage to HIV Care Has Not Improved Over Time 100 90 80 70 2020 target 65% 71% 69% 64% 73% 2015 target 77% 76% 72% % Linked to Care 60 50 40 30 20 47% 55% 51% 47% 10 0 30-day 60-day 90-day 2012 2013 2014 2015 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 TN Goals 90% on treatment 90% virally suppressed 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 100% 90% 80% 85% 90% 81% 70% 60% 50% 46% 50% 62% 55% 54% 60% 2016 (TN) 2016 (RW) 40% 2020 (Goal) 30% 20% 10% 0% Linked (1-mo) Engaged Virally Suppressed *2020 linkage goal relates to linkage within 1 month of diagnosis

Progress Recap: HIV Epi & CoC 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 Vulnerabilities Slide 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

Context for Outbreak Planning

HIV Risk Vulnerability Assessment, TN, County Level (CDC, TDH) Van Handel et al, JAIDS 2016 Rickles et al, CID 2018

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 HCV Surveillance, 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 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 Central office chronic HCV surveillance efforts augmented beginning 7/1/15. 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 Year HCV Perinatal Exposure per Live Birth: 2013 to 2017 No RNA RNA Total AB (+) RNA (+) Only RNA (-) Exposed Total Live Births HCV exposed per 1,000 births 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 12.3 Source: 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) v 27,261 people tested o 12.5% Ab (+) 69.8% RNA (+) 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) 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-servicesprogram.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.gov TDMHSAS: 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 - HIV Meredith Brantley Randi Rosack Samantha Mathieson TDH Viral Hepatitis Lindsey Sizemore Jennifer Black Heather Wingate Cathy Goff Kim Gill TDH Harm Reduction Allison Sanders Sarah Cooper VUMC Aima Ahonkhai Cody Chastain Jennifer Burdge Clare Bolds