u Syringe Exchange: RURAL CENTER FOR SIDSISTO PREVENTION Indicators of Need & Success iVercle] US 2 The recent outbreak of HIV in southern Indiana among injection drug users brings attention to the lack of a strong public health system in these communities, ond the need for syringe. exchange programs (SEPs}. SEPs are part of a comprehensive public health response fo HIV and Hepatitis C.' Key indicators of need for SEPs include reported Hepatitis C, and injection drug use. Hepatitis C & Heroin Us: Surrogate Indicators Hepatitis C virus (HCV) has increased in indiana since 2011. There have SEP are cost been 15,709 reported cases of acute and chronic HCV from 2011-20132 effective, because they Hepatitis C is the strongest indicator of need for syringe exchange reduce Hepatitis C because 50-80% of people who inject drugs become infected within 5 \ and HIV among years of initiating injection drug use.? According to CDC, 50-90% of |") injection drug users. People with HCV are co-infected with HIV. Evidence-based programs link SEPs Heroin Use or Dependence at Substance Abuse Treatment Admission. tightly wich HIV Hoosier use and dependence on heroin increased significantly from 2001 testing, antiretroviral to 2012 (most recent data). Of those admitted for substance abuse treatment and treatment, 9% reported heroin dependence and 11.1% reported heroin substance abuse Use in 2012.3 These data are supplemental and conservative indicators of reamment, need for syringe exchange because they do not represent the total Gi : 1. Beth Meyerson, population of injection drug users, and only include admissions for state- ‘Binal Céuter or funded substance abuse treatment. AIDS/STD Prevention, Indiana Univers Prescription Drug Overdose Morality. Nationally, there is evidence of an sang aati increase of HCV omong young, heroin-injecting drug users who first used Alstinigion oral prescription opioid drugs. Prescription overdose mortality rates can further inform communities where prescription drugs are injected. Public Health System: Necessary for SEP Success HIV Testing, Case Management and Preventive health services such as HIV/HCV _ ie ae f Treatment Resources in Region screening, HIV/HCV treatment, and substance abuse treatment are necessary ‘components to SEPs, SEP workers can be on critical ‘bridges’ between injection drug rove, users and the health system. See System investment is necessary for SEP ae success. Southern Indiana counties have teprncmoae jed access lo HIV testing, HIV treatment Gnd affordable substance abuse treatment "=" (see inset). Temporary HIV testing and td fe treatment services are now available in Scott County; however, sustainability is unclear. Page 1 of 5Acute and Chronic Hepatitis C in indiana Counties 2011-2013 An analysis of publicly available reported cases of acute and chronic HCV by county, as well as supplemental indicators of heroin and prescription drug overdose mortality suggests the following: + HCV is the most robust surrogate indicator of need for syringe exchange programming (SEP): Both rural and urban communities are affected by HCV. Those in quartile 4 merit attention to their public health systems to assure early HCV and HIV screening; and linkage fo HIV, HCV and substance abuse treatment. (See attached table) — Rates of HCV (cases per 100,000 population) indicate more about the impact of HCV in communities than case counts do; and they allow comparison between ‘and among communities. + Supplemental indicators also indicate need for SEP. While not as strong as HCV cases and rates, these indicators include: 1) reported heroin use and dependence at admission to state-funded substance abuse treatment, and 2) decth rates from prescription drug overdose. They do not represent the population of injection drug users, but can point to emerging need; particularly in communities aware of injection drug use or, ike Scott County, when community members inject prescription drugs. (Supplemental indicators by county are available from the Rural Center for AIDS/STD Prevention at Indiana University). + Early Warning Potential: Surrogate and supplemental indicators can be used to guide prevention and treatment planning for greatest health protection. — Scott County, the center of the current HIV. outbreak, ranks among the top 3 counties for rates of acute ond chronic hepatitis C. — Wayne, Fayette and Henry counties, also in-quartile 4, experienced a rapid increase of acute HCV among young injection drug users in early in 2011.3 Methodology The state of Indiana publishes combined reported cases for acute and chronic HCV by year for each county. While HCV case rates are usually calculated for acute HCV, both types are associated with HIV. Thus, rates for the combined acute and chronic reported cases were calculated per 100,000 population to allow for county comparison. Thresholds for supplemental indicators were identified for reported heroin use or dependence at substance abuse freaiment admission for 2014. Counties with >100 (count) or >20% of total substance abuse treatment admissions reporting heroin use or dependence were recommended for SEP consideration. In many cases, quartile ranking for these counties was lower because of county population size. e RURAL CENTER FOR References: ASST PREVENTION 1. Centr for Disease Contol and Prevention. Syringe Exchange Programe United Sites 2008, Morbiy and a Morty Weekly Report 20105945) 1488-1491 ater 2, Tiana Sate Deparment of Heath, Chronic and Acute Hepa Crates by county (Ms) 2011, 2012, 2013, 3. Cote for Heats Ply, IUPUI. The Consunpton and Conequcnces of Alcohol, Tobacco and Drags in Indiana: A State Epdeniolgie Profi 20 4, Klevens RM, Ha DI, ies, Holmberg SD. Evolving epidemiology of hepattiC vin in he United States, Ci Infect Dis 2012;55S1:82 5. Gross BM, Einergence of Acute Hepatis in Voung injection Drug Uses Presentation al he 2013 Hepa Teenical Assistance Mectng honed by ie National Alliance of State and Tents AIDS Director. Page 2 of 5(set and Rates of Acute and Cronic Hepatitis Cby Ineiana County 2011-2013 (Quarts based on 3-year county median rate) zon 2012 2013, Sermedioncase_Caetate ‘oserate coments ‘ate (pr 10090 Iper100,009 Reported (per 300,000. 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Joseghe ax] sea] oe) en of Neal aa] a Prorter sey aya Saal lauareio2 frie jos] 392| sf aol gags Iancack ‘aia]a1a 35) saa] 3a 2.4] IFauntain ars] 467s] __ 35] —aas]_—_7] lasper ES] DES) RR RE ENTE] sertholomew aa] ss4l aa] Sa] ae) asa Daviess aia] 68a 9a] San] un aa.n) 1] Verein as] 5[ 7] aa] 7] a7] | knox aay] 46a] a] 4a7] a7] 34a] 75} fippecsnes [aus] 393] a9] so] 2a] a5] [orange 2735217] asa] ___ sf soe] a0] [cinson aa[ | is] 389] ial a7] a Ispencer aol sa2i til ssf 7] aso a ukon 2837] [af of sf w -AIbWSTO PRETO Page 3 of 5anes and ates of ete a chon pots by das cont 20142013 (Guns aceon 3a cuny med ate) ‘on ton nn Pipes toa one oct ‘helpusono® (pi09to Moet (p00 Mage ortod eed SEES Comat “toe” GORGE OCS | teaver toe ouarte2 comin ha ae an $oal—a05] 5. —son] ig — fe Stal Tenaga ah en Sia] sag) sa ea sia —eeal egal ts Seo sa seal isa wer acer aa et reeaiae a Bae Sea) a ana aaa fare $ea]—s9g] 36] sus] 1] ses Conard eel——sea—-s] —s09]| 1) see] — ures assce 3a ea ra 7 arn tana] — 39] 70] ag sos leak 63: B59] 305) gaa] aa] Sis 253i Ste sar eos lela es ual ena nit ptalal—sf at ace [7 Seb ere ene] 3] 8] 3] ats — 0 fa 703| 0a 1.53 13a rege 7is| sexy] yas] — al al ey 7s] sia ass sy ‘aa — ra] | oa] ao] “res — a ta Ea | ET | Deer 7a] ena ta] 50 ug! sat ea eae aes Eater aa es iow 5) EE | Fe 7 4 em ag) ata) eles ala inte a9] ea] | 173] ers] a Iswrenc ‘alta —w] reo] 3 —stel —a issn 73] sal eel aya] or ses TT Soe oni [= EE u EASA Page 4 of 5‘Cases and Rates of Acute and Chronic Hepatitis C by indiana County 2011-2013, (Quatles bated on 3-year county mean rate) 201i 2012 2013, ‘Srearmefian cte! 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