HIV&HCVinTN:StateoftheState

VanderbiltCCCHIVSymposiumNashville,TN/November3,2017

CarolynWester,MD,MPH|TDHHIV/STD/VHProgram

Outline

• HIVEpidemiology

• “Neutralizing”theHIVCoC

• HCVEpidemiology

• HIVVulnerability

• OutbreakDetection&Response

• HIV&HCVMolecularSurveillance

HIV&AIDSinTN(1982-2015)

HIVdiseasebystatusandyearofdiagnosis(TN,2005-2015)

954 939972

996

712753

923

784

865861 852

Male-to-malesexualcontact

Heterosexualcontact

Injectiondruguse

NewlyDiagnosedHIVintheU.S.byTransmissionCategory(U.S.,2005– 2014)

Diagno

ses,n

YearCDCNationalHIVSurveillanceSystemdata

2020HIVContinuumofCareGoals: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*• 85% newly diagnosed “linked” to care < 1 month diagnosis• 90% prevalent diagnosed engaged in care

• 90% engaged virally suppressed

TennesseeHIVContinuumofCare:2010,2015,2020Goals)

*2020linkagegoalrelatestolinkagewithin1monthofdiagnosis;whereasfor2010&2015,linkageiswithin3monthsofdiagnosis.

64%

29% 35%

71%

53% 52%

*85% 90%

81%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Linked Engaged VirallySuppressed

2010

2015

2020

TennesseeHIVContinuumofCare:LinkagetoCare< 3MonthsofDiagnosis(2012– 2015)

72% 80% 76%

71%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

2012 2013 2014 2015

%new

lydiagnosed

linkedto

care

Linkagetocare:individualsnewlydiagnosedwithHIVin2015andhaving≥1CD4orVLresultreported<3monthsofdiagnosis.Datasource:TennesseeeHARS,accessedJune30,2017.Provisionaldata,donotdistribute.

TennesseeHIVContinuumofCare:LinkagetoCarebyTimefromDiagnosis(2015)

47%

71% 79%

86%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

1Month 3Months 6Months 1Year

0

20

40

60

80

100

120

%personsate

pide

miologicrisk

TheHIVNeutral HIVContinuumofCare

Undiagnosed

Diagnosed

HIVCAREANDPREVENTIONARETHESAME=GETTINGTOHIVNEUTRAL

SlidecourtesyofDr.DemetreDaskalakis(NYCDOH)

WorkingtheNeutralCoC:WhatWeHave

• Testing– HDs– CBOs

• Prevention• Treatment• PrEP• SSP• MAT

• Treatment• Linkage(delinquent)• Re-engagementutilizingD2C

WorkingtheNeutralCoC:WhatWeNeed

• RapidAccesstoTreatment– “Rapid-Rapid”testingalgorithms– “Test&Treat”initiatives

• AugmentedPrevention• PrEP• nPEP• SSP

• ExpandedRe-EngagementActivities• D2C(Re-engagement)

WhatThisMightLookLike:Test&Treat,PrEP,nPEP

• Who(identify)• HIVtesting(rapid– rapid)andSTDscreening

• High-risknegatives(historysyphilis,rectalGC/Chl)• Positives(newlydiagnosed,priorsOOC)

• Services– Treatment:MCM,labs,treatment(newdx,priorsARTnaïve)– Prevention:PrEP,nPEP(?)

• Where– CloseproximitytoHDactivities

• How• Costumerfocused:Hoursofoperation,limitedwait,stigma-freeenvt• On-sitestaff:MCM,nurse,APN/PA/physician• On-siteservices:Labs,casemanagement,start-upmeds• Referraltolocalprovidersforon-goingcare

WhatThisMightLookLike:Test&Treat,PrEP,nPEP

• Funding• StateHIVfunding??

• Staff• Pre-RyanWhiteregistration

– Casemanagement– Laboratorytesting– Medications

» 2weeksofARVs» 1monthofPrEP» 1monthnPEP

• Operationalizing• ProviderswithHIVexpertise• HDco-location• Accesstomedicationsat340bprices(STDFormulary?)• Test&Treat:NOTappropriatefortreatmentexperiencedclients• nPEP:GatewaytoPrEP,butdemandmayoverwhelmotheractivities

NextSteps

v SecureFunding

v PilotTest&Treat,PrEP,nPEP

v Establishandscale-upSSPs

v Outbreakpreparednessandresponse

IntersectionofEpidemics

OpioidAbuse

HepatitisC HIV

DistributionofAcuteHCV&NewHIVCaseRatesinTN(2016)

TennesseeNBS,accessedFebruary10,2017TennesseeeHARS,accessedJune30,2017

PopulationSource,AmericanCommunitySurvey2011-2015CountyAverages

AcuteHCVCases

NewlyDiagnosedHIVCases

ReportedCasesofAcute HCVinTN

2011 2012 2013 2014 2015

US caserate 0.4 0.6 0.7 0.7 0.8

cases 1,229 1,778 2,138 2,194 2,436

TN caserate 1.3 2.0 1.5 1.9 2.6

cases 83 129 98 123 173

rank 4th 4th 6th 5th 4th

http://www.cdc.gov/hepatitis/statistics/2015surveillance/pdfs/2015hepsurveillancerpt.pdf*per100,000population

NewlyReportedCasesofChronic HCVinTN

*CentralofficechronicHCVsurveillanceeffortsaugmentedbeginning7/1/15

CaseClassification

2013 2014 2015* 2016

Confirmed 1,782(44%)

3,385(50%)

7,394(59%)

10,442(50%)

Probable 2,234 3,421 5,244 10,496

Total(C+P) 4,016 6,806 12,628 20,938

Confirmed&ProbableCasesofChronicHCVinTN(2016)(n=20,938)

HCVPrevalenceAmongWomenwithLiveBirths(TN&U.S.,2009– 2014)

3.84.7

5.4

7.07.8

10.0

1.8 2.0 2.22.6

3.03.4

0

2

4

6

8

10

12

2009 2010 2011 2012 2013 2014

Per 1

,000

Liv

e Bi

rths

Year

Tennessee US

PatrickSetal,MMWR2017

EstimatingtheTotalBurdenofHCVinTN

v StatelevelHCVPrevalenceEstimatesUsingNHANESDatao TNpopulation=6,651,194o EstimatedrateHCV(+)inU.S.=1.3%

o EstimatedcasesHCVAb(+)inTN=86,466o Past5yrs,acuteHCVrateTN2.1– 3.3xhigherthanU.S.

o Initialweighted estimatedcasesHCVAb(+)inTN=233,456

v Accountfor#HCV Ab(+)casesinTN’snon-civilianpopulationo ~23%HCVAb(+)individualsintheU.S.arenotaccountedforinNHANES*

o Incarcerated,homeless,hospitalized,nursinghomes,military,reservationso Adjustingforestimatesamongnon-civilianpopulation…

FinalestimateHCVAb(+)casesinTN=303,189

*EdlinBR,etal.TowardamoreaccurateestimateoftheprevalenceofhepatitisCintheUnitedStates.Hepatology2015;62:1353–1363.

ContextforOutbreak Planning

TNCountiesHighlyVulnerabletoHIV/HCVOutbreakAmongPWID

VanHandelMMetal,JAIDS,2016

HCVTesting&GHOSTPilotinTN

• June1– October31,2016

4,753ptstestedforHCV• 8.4%Ab(+)

• 73.2%RNA(+)

HCVTesting:HDPilotResults(cont’d)

RiskFactor Totaln(%)

N=4753

HCVAb(+)n(%)N=397

HCVAb(-)n(%)

N=4356

PValue

Injectiondruguse 425(8.9) 276(64.9) 149 (35.1) <0.0001

Intranasaldruguse 967(20.3) 295(30.5) 672(69.5) <0.0001

Tattoo/piercing 1092(23.0) 188(17.2) 904(82.8) <0.0001

Incarceration 1309(27.5) 303(23.1) 1006(76.9) <0.0001

Transfusion 62(1.3) 13(21.0) 49(79.0) 0.0003

Noriskfactors 2598(54.7) 39(1.5) 2559(98.5) <0.0001

v 4,753personstestedo 8.4%Abpositive

§ 74.1%RNApositive

OutbreakResponseWorkgroup

DevelopedTools

Outbreak Response Plan

Outbreak Response Form

REDCap Database

SNA R Code

Specimen Collection and Transport

RegionalClusterInvestigation(Apr2017)

OnApril21,2017• NotifiedofuptickinnewHIVdiagnosesin2PHRs

– 1pairlinkedPWID (namedascontacts)

• PromptedaninvestigationintoapossibleclusterofHIV/HCV

ActionItems• MobilizedOutbreakResponseFormandREDCapDatabase• DevelopedHIVClusterCaseDefinition• Developed“SituationReport”• EstablishedICSroles&regularcallschedule(CO,PHRs,Lab)• Distributedspecimencollectiontransportguidelines

“SituationReport”Elements• CurrentSituation

– Definitions– #HIVCases/#Contacts

• #InterviewedwithOBRF• #Specimenscollected

• EpiCurve

• LineLists– Cases:HIVDx,RiskFactors,HCVstatus– Contacts:ContactType(P1,P2,P3),HCVstatus

• LaboratoryTestResults– HIV,HCV,HBVtesting

• ActionSteps

“EpiCurve”(HIVClusterInvestigation)

HIV&HCVMolecularTesting• Goal

– Focusoncasesandcontacts• Intervieww/OBRF• Collectspecimens

– HIVtesting(HIVmolecularsurveillance)– HCVtesting(GHOSTtesting)– HBVscreening

• Reality– “Outreach”testingconductedfirstweekendofinvestigation– Manycontactswithlimitedinfoorsimplydidnotwanttobefound– Importanttoembedphlebotomyinoutreach– OftennotenoughspecimenforbothHIVandHCVmoleculartesting

SocialNetworkAnalysis

SocialNetworkAnalysis

HIVMolecularTesting

• ToidentifyexistingHIVtransmissionnetworks

• HIVMolecularTesting– 16casestested

• 9 “recent” and 4 “prevalent” HIV infections (3 unknown)• 3clustersidentified

– 2personcluster(MSM,MSM)– 2personcluster(MSM,NIR)– 4personcluster(MSM/PWIDx3,MSMx1)

IdentifyingLinkages:HIVMolecularTesting

HCVMolecularTesting(GHOST)

• ToidentifyexistingHCVtransmissionnetworksasaharbingerofpotentialHIVtransmissionnetworksamongPWID

• Builtlabcapacityduring2016HCVtestingpilotinEasternTN

HCVTesting&GHOSTPilotinTN

• June1– October31,2016

4,753ptstestedforHCV• 8.4%Ab(+)

• 73.2%RNA(+)(n=291forGHOST)

GHOST-identifiedtransmissionnetworks

TNPilotcases291samples

8transmissionclusters(19cases)

Unrelatedcases

Linkagebytransmission(>96.3%seq.identity)

0.037

GHOST:HIVClusterInvestigation

• 22HCVRNA(+)positivepersonsidentified– 7fromHIVclusterinvestigation– 15from“outreach”testing

• 4linkagesidentified(allfrom“outreach”testing)– 2personcluster…..bothHIV(-)– 1personlinkedto2016pilot– 1personlinkedto2016pilot

# #HCVTested(PWID)

#HCVAb(+)(PWID)

#HCVRNA(+)

HIVCases 33 15(5) 3(3) 1

PriorHIVPositives 12 0 0 0

Contacts 95 10(8) 8 (8) 6

“Outreach” 22 22 15 15

OngoingTNHCVsurveillance

0.037

(291)Pilotcases+

(7)Clustercases+

(15)Outreachcases

3additionalclusters(totalof11)

LessonsLearned/NextSteps

LessonsLearned• Betterintegrationofteams(PHEP/CO/PHRs)• Missedalotoftestingopportunities

– Ensureadequatesamplecollection– DBtocapturemoleculartestingresults

NextSteps• Securesoftwaretoincorporate

moleculartestingintoSNA• SecureEpiforoutbreaksurgecapacity• Intelligentresourceallocation

– GHOST(outbreaksvs.vulnerablecounties)• Develop“One-Stop-Shops”

ThankYou!

TDHHIV/STD/VHShanellMcGoyLindseySizemoreMichaelRicklesJenniferBlackMeredithBrantleySamanthaMathiesonMelissaMorrison

TDHCEDEPMary-MargaretFillRendiMurphreeCorinneDavisJuliaSchaffner

NYCDOHDemetreDaskalakis

CDCYuryKhudyakovSumathiRamachandranPhilPetersBillSwitzer

TDHStateLaboratoryRickSteeceJimGibsonPaulaGibbsLindaThomas