NJ HIVLinks Winter 2018 edition by NJ AIDSLine

HIVLinks Winter

2018

HIV, STD, and TB news and information for health professionals

Post-Exposure Prophylaxis (PEP) for Sexual and Injection Drug Use Exposure to HIV Continuing Education • P ost-Exposure Prophylaxis (PEP) for Sexual and Injection Drug Use Exposure to HIV........2

Feature Ar ticle • S ynergistic Effects of HIV, Hepatitis C, and Opioid Epidemics: The NJ Response............. 13 • S tate Seeks to Apply Population Health Goals to Opioid Addiction............................................. 16

Practice Tips • Test and Treat Strategy: It Makes Sense....... 19 • B ack with a Vengeance: Increasing STDs in New Jersey and the United States.................23 Published by the FXB Center, School of Nursing, Rutgers, The State University of New Jersey and the New Jersey Department of Health, Division of HIV, STD, and TB Services

• T he New Jersey AIDS STD Hotline: A Resource New Jersey HIVLinks, Winter 2018 / Page for Your Patients. .................................................. 261

Continuing Education

Post Exposure Prophylaxis (PEP) for Sexual and Injection Drug Use Exposure to HIV Release date: January 1, 2019-Expiration Date: December 31, 2020- Course Code 19HH02 PROVIDERS Jointly provided by François-Xavier Bagnoud (FXB) Center, School of Nursing, Rutgers, The State University of New Jersey and the New Jersey Department of Health (NJDOH) - Division of HIV, STD and TB Services. FUNDING This activity is supported by an educational grant from the New Jersey Department of Health (NJDOH)—Division of HIV, STD and TB Services, through an MOA titled “Education and Training for Physicians and other Healthcare Professionals in the Diagnosis and Treatment of HIV/AIDS.” STATEMENT OF NEED The CDC has recommended and provided guidelines on the use of non-occupational post-exposure prophylaxis (nPEP) for the prevention of HIV infection since 2005 and has subsequently updated in 2016. Studies have shown inconsistent adoption of these guidelines in emergency departments (EDs) across the United States (U.S.) as well as disparities in nPEP counseling to those at risk. Even in metropolitan areas with a high prevalence of HIV infection, nPEP has been shown to be underused. While no large, formal studies of nPEP use in rural emergency departments in the U.S. have been carried out, it is presumed that patients in these areas likely find it difficult to access appropriate and comprehensive nPEP services. One reason for underuse may be a lack of straightforward and easily accessible nPEP guidance and protocols at the point of care. This activity will assist healthcare providers with implementation of post-exposure prophylaxis (nPEP) for patients cared for following a possible HIV exposure. TARGET AUDIENCE This activity is designed for physicians, physician assistants, advanced practice nurses, nurses, health educators, and other health care professionals in New Jersey who are involved in the care of people infected with HIV and their non-HIV infected partners. METHOD OF PARTICIPATION Participants should read the learning objectives, review the activity in its entirety, and then complete the self-assessment test, which consists of a series of multiple-choice questions. Upon completing this activity as designed and achieving a passing score of 70% or more on the self-assessment test, participants will receive a CE certificate 4 weeks after receipt of the self-assessment test, registration, and evaluation materials. This activity may also be completed online at https://rutgers.cloud-cme.com/19HH02. LEARNING OBJECTIVES Upon completion of this activity, participants should be better able to: 1. Identify the appropriate use of non-occupational post-exposure prophylaxis (nPEP) for patients cared for following a possible HIV exposure. 2. Identify patient treatment recommendations for sexually transmitted infections following a sexual exposure (assaultive and non-assaultive). FACULTY Activity Director/CE Academic Advisor Jihad Slim, MD, Medical Director NJDOH-Division of HIV, STD and TB Services and Assistant Professor of Medicine at New York Medical College in Valhalla, N.Y. Darcel Reyes, PhD, ANP-BC, Assistant Professor, Director, HIV Specialization School of Nursing, Rutgers, The State University of New Jersey PLANNING COMMITTEE Loretta Dutton, Director, HIV Care and Treatment, NJ Department of Health Greta Anschuetz, MPH, Director of STD Services, NJ Department of Health Michelle Thompson, Program Manager, FXB Center, Rutgers University Nahid Suleiman, PhD, Quality Assurance Coordinator, NJ Department of Health Amelia Hamarman, MSEd, MS, STD Services, NJ Department of Health Macsu Hill, PhD, MPH, CHES, Program Manager, FXB Center, Rutgers University Elizabeth Ward, MSJ, Executive Director, Rutgers Center for Continuing and Outreach Education ACTIVITY AUTHORS John A. Nelson, PhD, CNS, CPNP, AETC NCRC, Program Director, Rutgers School of Nursing Sara Wallach, Program Specialist, Division of HIV, STD and TB Services, NJ Department of Health ACCREDITATION In support of improving patient care, this activity has been planned and implemented by Rutgers Biomedical and Health Sciences. and the New Jersey Department of Health-Division of HIV, STD and TB Services. Rutgers Biomedical and Health Sciences is jointly accredited by the Accreditation Council for Continuing Medical Edu-

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cation (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. PHYSICIANS Rutgers Biomedical and Health Sciences designates this enduring material for a maximum of .75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NURSES This activity is awarded .75 contact hours. (60 minute CH) Nurses should claim only those contact hours actually spent participating in the activity. PHYSICIAN ASSISTANTS AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. PAs may receive a maximum of .75 Category 1 credits for completing this activity. PEER REVIEW In order to help ensure content objectivity, independence, and fair balance, and to ensure that the content is aligned with the interest of the public, CCOE has resolved all potential and real conflicts of interest through content review by a non-conflicted, qualified reviewer. This activity was peer-reviewed for relevance, accuracy of content and balance of presentation by Andrea Norberg, DNP, MS, RN. Field Test: This activity was field tested for time required for participation by Shobha Swaminathan, MD, Diana Finkel, MD, Amesika N. Nyaku, MD, Laura Bogert, BSN, RN, Virginia Lynch, BSN, RN, and Lisa Monti, RN DISCLOSURE DISCLAIMER In accordance with the disclosure policies of Rutgers University and to conform with Joint Accreditation requirements and FDA guidelines, individuals in a position to control the content of this educational activity are required to disclose to the activity participants: 1) the existence of any relevant financial relationship with any entity producing, marketing, re-selling, or distributing health care goods or services con sumed by, or used on, patients, with the exemption of non-profit or government organizations and non-health care related companies, within the past 12 months; and 2) the identification of a commercial product/device that is unlabeled for use or an investigational use of a product/device not yet approved. DISCLOSURE DECLARATIONS Jihad Slim, MD: Grant/Research Support: Gilead Sciences, Merck; Speakers Bureau: AbbVie, Gilead Sciences, Janssen, Merck Shobha Swaminathan, MD: Grant/Research Support: Gilead Sciences; Consultant: Gilead Sciences; Other Financial Support: ViiV Healthcare (lecturer) All other authors, planning committee members, peer reviewers and field testers have no relevant financial relationships to disclose. OFF-LABEL/INVESTIGATIONAL USAGE DISCLOSURE This activity does not contain information of commercial products/devices that are unlabeled for use or investigational uses of products not yet approved. Content Disclaimer: The views expressed in this activity are those of the faculty. It should not be inferred or assumed that they are expressing the views of NJDOH – Division of HIV, STD and TB Services, any manufacturer of pharmaceuticals or devices, or Rutgers University. It should be noted that the recommendations made herein with regard to the use of therapeutic agents, varying disease states, and assessments of risk, are based upon a combination of clinical trials, current guidelines, and the clinical practice experience of the participating presenters. The drug selection and dosage information presented in this activity are believed to be accurate. However, participants are urged to consult all available data on products and procedures before using them in clinical practice. Copyright ©2018 Rutgers University. All rights reserved including translation into other languages. No part of this activity may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval systems, without permission in writing from Rutgers University. Privacy Policy: To review CCOE’s privacy policy, please see: http://ccoe.rbhs.rutgers.edu/general/privacypolicy. html. Please direct CE related or technical questions to CCOE at 973-972-4267 or email ccoe@ca.rutgers.edu.

HIVLinks Winter

2018

HIV, STD, and TB news and information for health professionals

Post-Exposure Prophylaxis (PEP) for Sexual and Injection Drug Use Exposure to HIV

O bj ec t ives 1. I : den exp tify th ea a osu 2. I fter a re pro pprop phy riat den po sex tify p ssible laxis ( e use o a exp ually tr tient HIV ex nPEP) f non pos osu trea -occ ans trea u t re ( m tme upa ass itted ment re. nt f tion ault infe reco or p al p ive m atie ostand ctions men nts non follo datio -ass win ns f o ault g a ive) sexu r . al

John A. Nelson, PhD, CPNP, Franรงois-Xavier Bagnoud Center, Rutgers School of Nursing, Program Director, AETC National Coordination Resource Center Sara Wallach, PrEP Coordinator and Program Specialist, New Jersey Department of Health, Division of HIV, STD and TB Service straightforward and easily accessible some providers may still be reluctant Introduction nPEP guidance and protocols at the to offer nPEP to those at highest risk Since 2005, the US Centers for Dispoint of care.7 Because nPEP is one of of HIV acquisition following a possiease Control and Prevention (CDC) several CDC-recommended intervenble HIV exposure. In addition, studies has recommended and provided tions used to get to zero new HIV show inconsistent adoption of nPEP guidelines about the use of noninfections in the US, knowledge of apguidelines in emergency departments occupational post-exposure prophy7-10 and disparities propriate nPEP use and integration of (EDs) across the US laxis (nPEP) for the prevention of HIV 11 in nPEP counseling for those at risk. nPEP use into clinical practices across 1 infection. Subsequently, updated Even in metropolitan areas with a high the US is essential. 2 guidelines were published in 2016. prevalence of HIV infection, nPEP is Because of side effects and complexWho Needs nPEP? underused.10 Although no large, formal ity of nPEP regimens, many people studies of nPEP use in rural EDs in the In EDs, urgent care centers, and other prescribed nPEP prior to the newest US have been carried out, it is prewalk-in acute care sites (high school guidelines did not complete the sumed that patients are likely to find 3,4 based clinics, college/university stuprescribed nPEP 28-day regimen. it difficult to access appropriate and dent health centers, community health The revised recommended regimens 12-14 comprehensive nPEP services. One have been shown to be highly effecreason for underuse may be a lack of continued on next page tive and better tolerated.5,6 However,

New Jersey HIVLinks, Winter 2018 / Page 3

Continuing Education

centers, and other primary care sites), identifying who is appropriate for nPEP, getting that person tested for HIV, and initiated on the first dose as soon as possible is essential. Ideally, the first dose of the 28-day nPEP regimen is taken within the first 1-2 hours after the possible HIV exposure. Despite having up to 72 hours after the exposure to initiate nPEP, it is more effective the sooner it is taken after an exposure. nPEP should be prescribed only for HIV-negative persons “substantially” exposed (see Figure 1 and Table 1) to HIV less than or equal to 72 hours before. If the person is HIV-positive or the HIV risk exposure occurred more than 72 hours ago, nPEP should NOT be prescribed. The CDC defines a “substantial risk for HIV acquisition” as the exposure of the vagina, rectum, mouth, eye, nonintact skin, other mucous membrane, or percutaneous

contact with the blood, semen, vaginal fluids, breast milk, rectal secretions, or other body fluid with visible blood contamination of a “source” person living with HIV. If the source person is HIV-negative at the time of exposure, nPEP is not needed. However, in most cases of possible non-occupational HIV exposure (including sexual assault, injection drug use, and consensual sex), the HIV status of the source person(s) is not known. In this case, nPEP SHOULD be provided for HIV-negative persons after a substantial HIV risk (eg, vaginal or rectal intercourse, injection drug use).

What Laboratory Tests are Needed? For the person possibly exposed to HIV within the past 72 hours, it’s essential to make sure they are not already living with HIV. An HIV test, preferably a 4th generation HIV anti-

Figure 1: Algorithm for evaluation and treatment of possible non-occupational HIV exposures2

body/antigen test, must be conducted to assess current HIV status before starting nPEP. If a person is HIV antibody and/or antigen reactive (positive), then nPEP should not be used. nPEP should only be used for people who are HIV-uninfected. If HIV seroconversion occurs during or after nPEP (HIV test is “reactive” or positive after a baseline “non-reactive” or negative test), or the person is HIV-positive and not in care, contact an HIV expert or ID provider immediately and provide guidance to the person as recommended by the expert. Immediate linkage to care for antiretroviral therapy and HIV primary care is essential. Alanine transaminase (ALT), aspartate aminotransferase (AST), serum creatinine and estimated glomerular filtration rate (eGFR), should be assessed at baseline if the person will be prescribed a tenofovir disoproxil fumarate (TDF)-based regimen. A pregnancy test should be done, along with documentation of last menstrual period and any contraception use, if appropriate. Because the behaviors associated with substantial HIV risk (ie, condomless/PrEPless vaginal or rectal intercourse, and injection drug use) are also associated with high risk of acquiring other sexually transmitted infections and viral hepatitis, the following laboratory tests should be performed as appropriate: • Hepatitis C virus (HCV) antibody; • H epatitis B virus (HBV) surface antigen, HBV core antibody, and HBV surface antibody; • Syphilis serology (usually RPR); • U rine (or genital swab) gonorrhea/ chlamydia (GC/CT) nucleic acid amplification test (NAAT); • Pharyngeal GC/CT swab NAAT; • Rectal GC/CT swab NAAT. It is recommended that all individuals be tested for the presence of chronic HBV before initiating medications that are active against HBV. This would include several medications that may

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Post-Exposure Prophylaxis (PEP) for Sexual and Injection Drug Use Exposure to HIV

Table 1. Estimated per-act risk for acquiring human immunodeficiency virus (HIV) from an infected souce, by exposure acta

HIVLinks Winter

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HIV, STD, and TB news and information for health professionals

and arrange for follow-up within 24 hours to further discuss the indications for nPEP. Preferred nPEP regimen for adolescents and adults (≥ 13 years old) with normal renal function (creatinine clearance >59 mL/min): • T DF/FTC 300/200 mg, 1 tablet by mouth daily + dolutegravir 50 mg, 1 tablet PO daily for 28 days** OR • T DF/FTC 300/200 mg, 1 tablet by mouth daily + raltegravir 400 mg, 1 tablet by mouth BID for 28 days OR • T DF/FTC 300/200 mg, 1 tablet once by mouth daily + darunavir 800 mg, 1 tablet daily + ritonavir 100 mg, 1 tablet by mouth daily for 28 days. Preferred nPEP regimen for adults and adolescents aged ≥ 13 years with renal dysfunction (creatinine clearance ≤59mL/min): • z idovudine and lamivudine with both doses adjusted to the degree of renal function + raltegravir 400 mg, 1 tablet by mouth twice a day for 28 days OR

be used in nPEP regimens: TDF, tenofovir alafenamide (TAF), emtricitabine (FTC), and lamivudine. Severe acute exacerbations of HBV (including decompensated liver disease and liver failure) have been reported in patients who discontinue HBV-active medications. Patients with HBV should be closely monitored with both clinical and laboratory follow-up for at least several months after stopping (TDF/ FTC) or other HBV-active medications. If appropriate, initiation of chronic anti-hepatitis B therapy may be warranted.15 Testing for GC/CT (NAAT swab and/ or urine testing) may be performed if requested by patient, but is not necessary because empiric treatment should be given, and results will not reflect the current possible exposure. Syphilis

serology should be ordered with other blood tests.

What nPEP Medications should the Clinician Prescribe? EARLY treatment of the exposed patient is the PRIORITY and should NOT be delayed while waiting for lab results. START nPEP if the patient has a substantial risk for infection, and the HIV test is negative (“non-reactive”). INITIATE nPEP within 1-2 hours of exposure or as soon as possible prior to 72 hours post-exposure and continue for 28 days.2 If a significant exposure occurred but the patient is too distraught (eg, following an overdose or a sexual assault) to engage in a discussion about the nPEP regimen at the initial assessment, the clinician should offer a first dose of the medications

• z idovudine and lamivudine with both doses adjusted to degree of renal function + dolutegravir 50 mg, 1 tablet by mouth daily for 28 days OR • z idovudine and lamivudine with both doses adjusted to degree of renal function + darunavir 800 mg, 1 tablet by mouth daily + ritonavir 100 mg, 1 tablet by mouth daily, all taken at the same time, with food, for 28 days.2 * If the patient is a woman who may conceive while on the medication, or is in the early stages of pregnancy, do not prescribe dolutegravir.16,17 ** If pharmacist will not dispense less than a 30-day supply of nPEP medications (because of cost to pharmacist of removing tablets from a 30-day bottle), then a prescription for a 30-day supply should be given continued on next page New Jersey HIVLinks, Winter 2018 / Page 5

Continuing Education

and patients should be instructed to only take medications for 28 days. For women of childbearing age, document the last menstrual period, and perform rapid urine pregnancy test. If the pregnancy test is negative, and vaginal exposure to semen occurred, offer emergency contraception on site. Pregnancy should not preclude nPEP use, but if the patient is in the early stages of pregnancy (ie, < 12 weeks post-conception) or at risk of conceiving while on nPEP, dolutegravir should not be used.16,17 If the woman is < 12 weeks pregnant or reports wanting to become pregnant and has normal renal function (creatinine clearance >59 mL/min), the recommended nPEP regimen is: TDF/FTC 300/200 mg, 1 tablet by mouth daily + raltegravir 400 mg, 1 tablet by mouth twice a day for 28 days. Counsel about the risk of breastfeeding after a possible HIV exposure (there is a risk of transmission to the infant through breastfeeding if the mother becomes infected with HIV).18

What other Medications should the Clinician Consider? GC, CT, and trichomonas (for women) should be treated presumptively if oral, vaginal, and/or anal sex occurred.19 For adolescents (≥ 13 years) and adults, treat for GC and CT with ceftriaxone 250 mg intramuscular injection once, and azithromycin 1 gram by mouth once, preferably at the same time and under directly observed therapy to ensure completion of treatment.19 For women with vaginal exposure, treat empirically for trichomonas with metronidazole 2 grams taken orally once OR tinidazole 2 grams taken orally once (have her take it after discharge from the emergency department/clinical site) if alcohol has been consumed in the prior 24 hours or if emergency contraception was taken, to minimize potential side effects and drug interactions.19 For pediatric patients (≤ 12 years), consult CDC guidelines.2 In addition, because the most common nPEP regimen side effect is nausea, Page 6 / New Jersey HIVLinks, Winter 2018

ondansetron 8 mg, 1 tablet by mouth 30 minutes before taking the nPEP medications may be prescribed.

and 3 months and assist with referring/appointment making with the patient prior to discharge.

For patients 9-45 years old who have not completed human papillomavirus (HPV) vaccinations, offer the HPV vaccine.20 Administer the vaccine at the initial examination, and follow-up dose(s) according to the usual vaccination schedule. Clinicians in EDs, urgent care centers, and walk-in acute care sites may need to provide the patient with a referral for completion of the HPV vaccine series.

• Counsel on naloxone administration – provide overdose response education to any family members or friends available to provide naloxone if overdose occurs. Naloxone may be injected (intramuscular, intravenous, subcutaneous) or sprayed intranasally. Injectable naloxone comes in a lower concentration (0.4mg/1ml given by auto-pen injection once, then repeated after 2-3 minutes if not responding) than intranasal naloxone (2mg/2mL). Intranasal naloxone is administered by giving one spray in one nostril, then repeating after 2-3 minutes if not responding. A naloxone auto-pen or nasal spray prescription should be provided and once prescription is filled, the pen or spray bottle kept on the person or by family/friends who may use it if needed.

Post-exposure hepatitis B vaccination without Hepatitis B immune globulin (HBIG) should be given if the hepatitis B status of the source person is unknown and the patient has not been vaccinated previously. If the source person is known to be HBV surface Ag-positive, unvaccinated exposed patients should receive both hepatitis B vaccine and HBIG. The vaccine and HBIG, if indicated, should be administered at the time of the initial evaluation, and follow-up doses of vaccine should be administered as per the usual vaccination schedule. Patients who previously vaccinated who did not have a post-vaccination test confirming immunity should receive a single vaccine booster dose.19

What Patient Education should be Provided?21 • Counsel on the need to use condoms during vaginal and/or anal sex or to abstain from sex until HIV transmission has been ruled out (with negative testing 3 months after the possible exposure) or the source person has been found to be HIV negative. • Counsel on possible nPEP side effects to improve adherence (nausea, GI upset, headache, and myalgias are the most common) and consider prescribing an anti-emetic at the same time as HIV nPEP. • Reinforce the need for follow-up appointments within 24-72 hours of the initial assessment, 4-6 weeks,

• C ounsel against mixing drugs, sharing needles, syringes (for injection drugs as well as needleless syringes for administering intrarectal drugs such as crystal methamphetamine), and other injection equipment. Provide information on syringe access or needle exchange programs in the community if available. • A ssess for readiness for substance use treatment services and refer/ initiate treatment as appropriate. • S chedule a follow-up referral appointment for getting hepatitis A, B, and C titer results, and hepatitis A and B vaccines if titers are negative. Refer for follow-up monitoring and treatment if the patient is found to be hepatitis C antibody positive. • T he clinician should ensure that the patient and/or support person(s) understands the following discharge information: ° n PEP is most effective if started as soon as possible (within 1-2 hours after the exposure or as soon as possible if), but no later than 72

Post-Exposure Prophylaxis (PEP) for Sexual and Injection Drug Use Exposure to HIV

hours after the exposure. nPEP should be taken for 28 days to decrease the likelihood of becoming infected with HIV. ° I t is very important to take the nPEP medicines every day, without interruption. ° S ometimes the medicines can cause unpleasant side effects like nausea and fatigue as well as diarrhea, headaches and rashes. ° T he most common medication side effect is nausea. Counsel the patient to take the prescribed anti-nausea

medicine ½ hour before taking the nPEP medications. ° S ome nPEP medications can interact with other prescriptions, street drugs, or over the counter medications, so patients should inform their healthcare provider if they are using any other medicines or drugs in addition to the nPEP medicines. ° Patients should call their healthcare provider if any side effects become concerning, because these medications SHOULD NOT be discontinued once started unless side effects are severe or life threatening.

Table 2. Recommended Baseline and Follow-up Labs2

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What Follow-up is needed? Identify a follow-up nPEP provider(s) in your institution or community who is familiar with the recommended follow-up management. Follow-up on lab work adherence, answers to questions the patient may have, and supportive counseling is essential. For those with ongoing HIV risk, start the patient on pre-exposure prophylaxis (PrEP) immediately (day 29) after successful completion of the 28-day nPEP regimen. The follow up provider should confirm that the latest HIV test is negative and renal function is normal, prior to starting PrEP. The follow-up provider will need to know which nPEP regimen was prescribed, when the patient started it, and if the patient has enough medicine (nPEP regimen and anti-nausea medication, if needed). There should be an assessment of nPEP regimen adherence, side effects, and the need for potential changes in the nPEP regimen because of adverse reactions or intolerance. The follow-up provider should enquire about patient concerns. It is important for the follow up provider to determine if there is a plan for review of the laboratory results and ensure that appointments are set for follow-up at 4-6 weeks, 3 months, and 6 months if necessary.

What is happening in New Jersey? In New Jersey, nPEP is not readily or uniformly available at all the locations individuals seeking nPEP search –EDs, urgent care centers, and local clinics. The NJ Department of Health (NJDOH) receives reports from patients who have gone from one health center to another during the 72-hour window period unable to get treatment because of providers’ lack of knowledge about how to provide nPEP. Several pharmacy chains provide nPEP; however, patients do not typically go to pharmacies for nPEP. Unfortunately, there is no set stancontinued on next page New Jersey HIVLinks, Winter 2018 / Page 7

Continuing Education

dard for “starter-packs,” or the initial nPEP dose administered to a patient upon presentation at one of these non-pharmacy locations. According to information reported from some of these sites, starter-packs vary from one to three to five pills. In addition, there is no consistent or universally accepted protocol for follow-up after nPEP initiation; some centers provide patients with a prescription for the remainder of the regimen at the time of the visit, while other centers refer patients to another provider or clinic for the remaining nPEP doses. Many patients may not have the financial resources or insurance coverage required for nPEP. However, some pharmaceutical manufacturers have payment assistance programs to help uninsured patients pay for the nPEP prescription, but patients may need assistance accessing these programs.

Moreover, it is unclear whether patients are receiving the correct lab work and/or the CDC’s recommended follow-up across the state. This is especially important now that we have more tools in our biomedical prevention toolbox. A patient who seeks out nPEP on a consistent basis, and does not seroconvert, may benefit from linkage to PrEP, which is highly effective at preventing HIV infection. The NJDOH, specifically the Division of HIV, STD and TB Services, has systems and infrastructure to take on the task of connecting people to nPEP and PrEP services. There is an existing HIV/AIDS Hotline (1-800-624-2377) patients could call to connect with HIV Patient Navigators and PrEP Counselors who can potentially guide patients through the process and assist with follow-up and insurance navigation. The HIV Patient Navigators and PrEP

Counselors can provide harm reduction counseling; ensure that patients are assessed in 72 hours, at 3-4 weeks, and then 3 months after the initiation of nPEP. More importantly, they can link these patients to care, regardless of HIV status. There are other barriers to full access to nPEP. Standardized starter-packs, support services to secure funds or a prescription for the complete 28-day nPEP regimen, more pharmacies willing to provide less than a 30-day supply of nPEP medications, and more knowledgeable healthcare providers to provide and follow-up with nPEP care have been identified as ways of reducing the barriers.

Conclusion We can stop new HIV infections in New Jersey. nPEP, along with PrEP and U=U (undetectable means untransmittable) are effective biomedical HIV prevention tools. Patients exposed to HIV are aware that there is treatment to prevent HIV infection and are seeking resources for nPEP treatment, as evidenced by accounts from our NJ PrEP Counselor programs. However, many have had difficulty accessing it. Every second counts in initiating nPEP. We encourage providers to read and share the CDC nPEP guidelines reviewed in this article with collogues. To download or order free clinician nPEP pocket guides and

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HIVLinks Winter

Post-Exposure Prophylaxis (PEP) for Sexual and Injection Drug Use Exposure to HIV

nPEP policy and procedure templates to use at your clinical site, visit the AIDS Education & Training Center National Coordinating Resource Center’s nPEP toolkit. To learn more about nPEP or to get further guidance about prescribing, providers can contact the National Clinician Consultation Center’s PEPline (see below).

Acknowledgement: The AETC Rural Health Committee:

References: 1.

DC. Antiretroviral postexposure prophyC laxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the US Department of Health and Human Services. MMWR. 2005. 54(No. RR-2). https://aidsinfo.nih.gov/contentfiles/NonOccupationalExposureGL.pdf.

2. Updated Guidelines for Antiretroviral Postexposure Prophylaxis after Sexual,

adherence. HIV Med. 2014.15(1):13-22. doi:10.1111/hiv.12075. McAllister JW, Towns JM, Mcnulty A, Pierce AB, Foster R, Richardson R, Carr A. Dolutegravir with tenofovir disoproxil fumarate-emtricitabine as HIV postexposure prophylaxis in gay and bisexual men. AIDS. 2017.31(9):1291-1295. doi:10.1097/ QAD.0000000000001447. Ende AR, Hein L, Sottolano DL, Agins BD. Nonoccupational postexposure prophylaxis for exposure to HIV in New York State emergency departments. AIDS Patient Care and STDs. 2008. 22(10). https://doi. org/10.1089/apc.2007.0157. Krause KH, Lewis-O’Connor A, Berger A, et al. Current practice of HIV postexposure prophylaxis treatment for sexual assault patients in an emergency department. Women’s Health Issues. 2014. 24(4):e407-12. https://doi.org/10.1016/j. whi.2014.04.003. Mccausland JB, Linden JA, Degutis LC, et al. Nonoccupational postexposure HIV prevention: emergency physicians’ current practices, attitudes, and beliefs. Annals of Emergency Medicine. 2003.42(5):651-

HIV, STD, and TB news and information for health professionals

13.

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For Clinician-to-Clinician Assistance with nPEP, Contact: AETC National Clinician Consultation Center’s Post-Exposure Prophylaxis Hotline (PEPline):

17.

888-HIV-4911 (888-448-4911) 9 a.m. – 8 p.m. ET Monday – Friday 11 a.m. – 8 p.m. ET on Saturday, Sunday, & holidays http://nccc.ucsf.edu/clinician-consultation/PEP-post-exposure-prophylaxis/

Injection-Drug Use, or Other Nonoccupational Exposure to HIV — United States, 2016. MMWR. 2016. 65:458. http://dx.doi. org/10.15585/mmwr.mm6517a5. 3. Mayer KH, Mimiaga MJ, Cohen D, Grasso C, Bill R, Van Derwarker R, Fisher A. Tenofovir DF plus lamivudine or emtricitabine for nonoccupational postexposure prophylaxis (NPEP) in a Boston Community Health Center. JAIDS. 2008. 47(4):494-9. doi:10.1097/QAI.0b013e318162afcb. 4. Scannell M, Kim T, Guthrie BJ. A meta-analysis of HIV postexposure prophylaxis among sexually assaulted patients in the United States. JANAC. 2018. 29(1):60-69. 5. McAllister J, Read P, McNulty A, Tong WW, Ingersoll A, Carr A. Raltegravir-emtricitabine-tenofovir as HIV nonoccupational post-exposure prophylaxis in men who have sex with men: safety, tolerability and

6. https://doi.org/10.1016/ S019606440300338X. 10. Rodriguez AE, Castel AD, Parish CL, et al. HIV medical providers’ perceptions of the use of antiretroviral therapy as nonoccupational postexposure prophylaxis in two major metropolitan areas. JAIDS. 2013.1;64 Suppl 1:S 68-79. https://doi.org/10.1097/ QAI.0b013e3182a901a2. 11. Misra K, Udeagu C. Disparities in awareness of HIV postexposure and preexposure prophylaxis among notified partners of HIV-positive individuals, New York City 2015–2017. JAIDS. 2017. 76(2):132–140. https://doi.org/10.1097/ QAI.0000000000001473. 12. C row A, Ahmed T, Kumar R, Katner HP. Statewide survey of emergency department practice for prophylaxis of sexually trans-

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19.

20.

mitted infections in rape victims. Infectious Diseases Society of America. 2013. Session 137: Presentation 1138. Djelaj V, Patterson D, Romero CM. A qualitative exploration of sexual assault patients’ barriers to accessing and completing HIV prophylaxis. Journal of Forensic Nursing. 2017.13(2), 45-51. doi:10.1097/ jfn.0000000000000153. McKenney J, Sullivan PS, Bowles KE, et al. HIV risk behaviors and utilization of prevention services, urban and rural men who have sex with men in the United States: results from a national online survey. AIDS and Behavior. 2018. 22(7):2127-2136. Terrault NA, Lok ASF, McMahon BJ, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 Hepatitis B. Hepatology. 2018. 67(4). https://www.aasld.org/sites/default/files/ HBVGuidance_Terrault_et_al-2018-Hepatology.pdf. US Department of Health and Human Services Centers for Disease Control and Prevention. Update: Interim Statement Regarding Potential Fetal Harm from Exposure to Dolutegravir – Implications for HIV Post-exposure Prophylaxis (PEP). Attachment to Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV—United States, 2016. Downloaded from https://www.cdc. gov/hiv/pdf/programresources/cdc-hivnpep-guidelines.pdf on 7/10/2018 Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. Department of Health and Human Services. Available at http:// aidsinfo.nih.gov/contentfiles/lvguidelines/ AdultandAdolescentGL.pdf. US Department of Health and Human Services. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Downloaded from https://aidsinfo.nih.gov/guidelines on 7/10/2018. US Department of Health and Human Services Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR. 2015. 64(3). https://www.cdc.gov/std/tg2015/ sexual-assault.htm. XX. https://www.cdc. gov/std/tg2015/default.htm. Expanded use of Gardasil: https://www. fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm622715.htm

21. https://aidsetc.org/resource/

non-occupational-post-exposure-prophylaxis-npep-toolkit

New Jersey HIVLinks, Winter 2018 / Page 9

Continuing Education

Post Exposure Prophylaxis (PEP) for Sexual and Injection Drug Use Exposure to HIV

Questions refer to article content. To receive CME/CNE credit, complete the post test, registration and evaluation forms on-line at https://rutgers.cloud-cme.com/19HH02 or fill in the forms below and on the following pages and mail or fax to CCOE at the address on the registration form. 1. A ll are considered substantial risk for HIV EXCEPT:

ritonavir xe200/50 mg, 2 tablets PO twice/day for 28 days

a. A man not on PrEP has condomless receptive anal intercourse with a man of unknown HIV status

4. F or a patient presenting for treatment following a rape, all the following statements are true EXCEPT:

b. A woman not on PrEP has condomless vaginal intercourse with a man of unknown HIV status

a. P rophylactic gonorrhea and chlamydia treatment should be provided

b. F or women at risk of pregnancy, emergency contraception should be offered

c. F or persons testing HIV Ab/Ag positive on screening, they should be started on nPEP

d. F or persons testing HIV Ab/Ag positive on screening, an infectious disease or other HIV specialist should be contacted immediately and nPEP not started

c. A man taking PrEP has condomless insertive rectal intercourse with a man living with HIV who is virally suppressed d. A woman has shared a needle and syringe for injecting heroin with another person of unknown HIV status

2. W hen is the MOST optimal time to take the first dose of nPEP following a substantial exposure?

a. W ithin the first 1-2 hours or as soon as possible after the exposure

b. A ny time within 72 hours after the exposure

c. After 72 hours

d. A ny time 24-48 hours after the exposure

3. A woman who was rectally and vaginally raped 8 hours earlier by a man of unknown HIV status is being evaluated in the emergency department (ED). She reports her last menstrual period was “about a month ago”, and her urine pregnancy test in the ED is positive. She tests HIV Ab/Ag negative in the ED, and you start her on nPEP. Based on current CDC guidelines, which regimen would be the BEST choice if her renal function is normal?

a. T DF/FTC 300/200 mg, 1 tablet PO daily + dolutegravir 50 mg, 1 tablet PO daily for 28 days

5. F or a 22 year-old patient who tests HIV Ab/Ag negative, has normal renal function, and is being evaluated for nPEP following a repeated substantial sexual HIV exposure, what would you recommend?

a. C omplete the 28-day nPEP regimen, and start taking PrEP on day 29

b. C omplete the 28-day course of nPEP and abstain from sex after that

c. D o not prescribe nPEP but treat prophylactically for gonorrhea/chlamydia d. P rescribe nPEP but do not treat prophylactically for gonorrhea/chlamydia

6. W here do persons looking for nPEP typically present?

b. When they present for nPEP and test HIV-negative, in addition to initiating nPEP

c. A fter they have completed their 28day nPEP regimen, test HIV-negative, and have normal renal function

d. Patients seeking nPEP would not benefit from PrEP

8. I f rapid HIV testing is not available and blood is sent for HIV Ab/Ag, a patient needing nPEP should:

a. Not start nPEP until a definite HIV negative result is back in 24-48 hours

b. Should start nPEP, and follow-up within 24 hours (when HIV results are available)

c. n PEP should not be given unless rapid HIV testing is done

d. Not start nPEP unless it’s certain that the source of sexual exposure is living with HIV

9. W hich of the time periods for follow-up lab testing of persons after initiating nPEP are recommended?

a. 1 month, 3 months, 6 months, 9 months, 12 months

b. 1 month, 3 months, 6 months

c. 2 months, 4 months, 6 months

d. 1 week, 2 weeks, 1 month, 2 months

10. W hich of the following blood tests should be done at baseline when assessing for nPEP initiation?

a. HIV Ab/Ag or HIV Ab, syphilis serology, hepatitis B surface Ag, surface Ab, core Ab, hepatitis C AB, creatinine, alanine transaminase (ALT), aspartate aminotransferase (AST)

b. HIV Ab, HIV genotype, BUN, creatinine, syphilis serology, ALT, AST

a. Emergency departments

b. Urgent care centers

b. T DF/FTC 300/200 mg, 1 tablet PO daily + raltegravir 400 mg, 1 tablet PO BID for 28 days

c. Acute care sites

d. All of the above

c. T DF/FTC/efavirenz 300/200/600 mg, 1 tablet PO daily for 28 days

7. W hen is it appropriate to recommend a patient start PrEP?

c. H epatitis panel, BUN, creatinine, CBC, syphilis serology, ALT, AST

d. L amivudine/zidovudine 150/300 mg, 1 tablet PO daily + lopinavir/

d. Hepatitis panel, CBC, BUN, syphilis serology, ALT, AST

Page 10 / New Jersey HIVLinks, Winter 2018

a. W hen they present for nPEP and test HIV-negative, instead of initiating nPEP

Post Exposure Prophylaxis (PEP) for Sexual and Injection Drug Use Exposure to HIV

Continuing Education

REGISTRATION FORM In order to obtain continuing education credit, participants are required to:

(1) Read the learning objectives, review the activity, and complete the post-test. (2) Complete this registration form and the activity evaluation form on the next page. Record your test answers below. (3) Send the registration and evaluation forms to: Rutgers Center for Continuing & Outreach Education • VIA MAIL: 30 Bergen St., ADMC 7, Newark, NJ 07103 • VIA FAX: (973) 972-7128 (4) Retain a copy of your test answers. Your answer sheet will be graded and if you achieve a passing score of 70%or more, a CE certificate will be mailed to you within four (4) weeks. Online option: This activity will be posted at https://rutgers.cloud-cme.com/19HH02 where you may obtain a CE certificate upon successful completion of the online post-test and evaluation. Please note: CE credit certificates will only be issued upon receipt of completed evaluation form.

SELF-ASSESSMENT TEST

Circle the best answer for each question.

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

– PLEASE PRINT – First Name

M.I.

Profession

Last Name

Degree

Specialty

Company/Affiliation Preferred Mailing Address:  Home  Business Address City

State

Phone

Zip Code

Country

Indicate the type of continuing education credit you wish to obtain as a result of your participation in this activity.  Nurses: .75 CNE Contact Hour. Contact Hours Claimed: —  Physicians .75 AMA PRA Category 1 Credit™. Credits Claimed: —  Other Healthcare Providers: All other healthcare providers will receive a letter of attendance documenting their participation in this activity. One credit/contact hour for each hour of participation I attest that I have completed this activity as designed. I will report the number of credits/contact hours claimed during my filing of continuing education credit with professional organizations, licensing boards, or other agencies. Signature

Date

Release date: January 1, 2019 • Expiration date: Credit for this activity will be provided through December 31, 2020. A CE credit letter will be mailed to you in approximately 4 weeks. Rutgers Center for Continuing & Outreach Education 30 Bergen St . ADMC 7 • Newark, New Jersey 07107 • Phone: 973-972-4267 or 1-855-482-1843 • Fax: 973-972-7128

CE Activity Code: 19HH02 — This form may be photocopied.

New Jersey HIVLinks, Winter 2018 / Page 11

The planning and execution of useful educationally sound(PEP) continuing education activities Drug are Use Exposure to HIV Post and Exposure Prophylaxis for Sexual and Injection guided in large part by input from participants. To assist us in evaluating the effectiveness of this Continuing activity and toEducation make recommendations for futureFORM educational offerings, please take a few moments EVALUATION The planningthis andevaluation executionform. of useful educationally are to complete Your and response will help sound ensurecontinuing that futureeducation programs activities are informaguided in large part by input from participants. To assist us in evaluating the effectiveness of this tive and meet the educational needs of all participants. activity and to make recommendations for future educational offerings, please take a few moments Please note: CE letters will only be issued upon of completed evaluation form.are informato complete thiscredit evaluation form. Your response willreceipt help ensure that future programs tive and meet the educational needs of all participants. PROGRAM completed this activity, you are better ableactivities to: The planningOBJECTIVES: and executionHaving of useful and educationally sound continuing education areStrongly Agree Strongly Disagree Please note: CE credit letters will only be issued upon receipt of completed evaluation form. The planning and execution of useful and educationally sound continuing education activities are guided in large part by input from participants. To assist us in evaluating the effectiveness of this The planning execution useful and educationally continuing education activities are guided in large part by inputof participants. To assistsound us in evaluating the effectiveness of this 4 3 2 1 The planning and execution offrom useful and educationally sound continuing education activities are 5 activity and toand make recommendations for future educational offerings, please take a few moments PROGRAM OBJECTIVES: Having completed this activity, you are better able to: guided in large part by input from participants. To assist us in evaluating the effectiveness of this Strongly Agree Strongly Disagree activity and to make recommendations for future educational offerings, please take a few moments guided in large by inputform. fromYour participants. us in evaluating the effectiveness of this to complete thispart evaluation response To willassist help ensure that future programs are informaactivity to make recommendations for educational offerings, please take to complete form. Yourofresponse will help ensure that future programs aremoments informaactivity and tothis make recommendations for future educational offerings, please take aa few few moments tive andand meet theevaluation educational needs allfuture participants. Objective 2: 5 4 3 2 1 to complete this evaluation form. Your will that programs tive and meet the educational needs all participants. to complete this evaluation form. Yourofresponse response will help help ensure ensurecontinuing that future futureeducation programs are are informainforma- 5 The planning execution of useful educationally 4 3 2 1 The planning and execution ofneeds useful and educationally sound continuing education activities are are Please note: CEand credit letters will only beofand issued upon receiptsound of completed evaluation form.activities tive and meet the educational all participants. tive andinmeet the educational needs of all participants. guided large part by input from participants. To assist us in evaluating the effectiveness of this Please note: CE credit letters willfrom only participants. be issued upon of completed evaluation form. guided in 2: large part by input To receipt assist us in evaluating the effectiveness of this Objective Please note: credit letters only be issued upon receipt of evaluation Objective Recognize risk will factors common comorbidities in you PLWH 5 4 3 2 1 activity and to make for educational offerings, please take aa few moments activity and3:CE to make recommendations for future future educational offerings, please takeform. fewto: momentsStrongly PROGRAM OBJECTIVES: Having completed this activity, are better able Please note: CE creditrecommendations letters will onlyfor be issued upon receipt of completed completed evaluation form. 5 Agree 4 3Strongly2Disagree 1 to complete this evaluation form. Your response will help ensure that future programs are informaPROGRAM OBJECTIVES: Having completed this activity, are better ableare to:informa-Strongly Agree to complete this evaluation form. Your response will help ensure you that future programs Strongly Disagree Objective 1:OBJECTIVES: Identify the appropriate use of non-occupational post-exposure prophylaxis Objective 4: Identify approaches to prevent and manage comorbidities and PROGRAM Having completed this activity, you are better able to: tive and meet the educational needs of all participants. Strongly Agree Strongly 2Disagree tive and meet the educational needs of all participants. 5 4 3 1 PROGRAM OBJECTIVES: Having completed this activity, you are better able to: Strongly Agree Objective 3: Recognize factorstocared for common comorbidities in PLWH 5 4 3Strongly2 2Disagree 1 (nPEP) forrisk patients forchronic following a possible HIV exposure. coinfection in order control inflammation 5 4 3 1 5 4 3 2 1 Please note: note: CE CE credit credit letters letters will will only only be be issued issued upon upon receipt receipt of of completed completed evaluation evaluation form. form. Please 55 44 33 22 11 patient treatment recommendations for sexuallyand transmitted infecObjective 2: 4: Identify Identify approaches to prevent and manage comorbidities OVERALL EVALUATION: This activity: Strongly Agree Strongly Disagree following a sexual exposure (assaultive andyou non-assaultive). coinfection in order to control chronic inflammation 5 Agree 4 3Strongly 1 PROGRAM OBJECTIVES: Having completed this activity, are Objective 2: tions Strongly Agree Strongly2Disagree Disagree PROGRAM OBJECTIVES: Having completed this activity, you are better better able able to: to: Strongly Objective 2: Increased my understanding of the subject 5 4 3 2 1 Objective 2: 55 44 33 22 11 Objective 3: Recognize risk factors for common comorbidities in PLWH OVERALL EVALUATION: This activity: Strongly 5 Agree 4 3Strongly2Disagree 1 Objective 3: Recognize risk factors for common comorbidities in PLWH 5 4 3 2 1 Increased 3: myRecognize understanding of the subject Objective risk factors for common comorbidities in PLWH 55 44 33 22 11 Objective 4: Identify approaches to prevent and manage comorbidities and 3: Recognize risk factors for common comorbidities in PLWH 5 4 3 2 1 Objective 2: Objective 2: Objective 4: Identify approaches preventchronic andprofessionals manage comorbidities and Will help me collaborate with other coinfection in order to healthcare control inflammation 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 Objective 4: approaches and comorbidities coinfection inscientifically order to to prevent control chronic inflammation 5 4 3 2 1 Objective 4: Identify Identify approaches prevent and manage manage comorbidities and and Was evidence based and balanced 5 4 3 2 1 coinfection in order to control chronic inflammation 5 4 3 2 1 coinfection in order to control chronic inflammation 5 4 3 2 1 OVERALL EVALUATION: This activity: Strongly Agree Strongly Disagree Objective 3: Recognize risk factors for common comorbidities in PLWH 5 4 3 2 1 Will help collaboraterisk with other healthcare Objective Recognize factors for commonprofessionals comorbidities in PLWH Was free me of3:commercial bias or influence 5 4 3 2 1 Strongly Agree Strongly Disagree OVERALL EVALUATION: This activity: Increased my understanding of the subject 5 Agree 4 3Strongly 2 2Disagree 1 Was evidence based approaches and scientifically balanced Met my expectations 5 4 3 1 Strongly OVERALL EVALUATION: This activity: Objective 4: Identify to subject prevent and manage manage comorbidities comorbidities and and Strongly OVERALL EVALUATION: This activity: Objective 4: Identify approaches to prevent and Increased my understanding of the 5 Agree 4 3Strongly2Disagree 1 Was free of commercial bias or influence Increased my understanding of the subject 5 4 3 2 1 coinfection in order to control chronic inflammation 5 4 3 2 1 coinfection in order to control chronic inflammation 5 4 3 2 1 Based onmy theunderstanding content of the activity, you do differently in the care of your (Check patients regarding your Increased of the subject What impact will this activity have onwhat yourwill interprofessional collaborative practice? alland/or that apply) Met my expectations 5 4 3 2 1 professional responsibilities? Having completed this activity, you are better able to: OVERALL EVALUATION: This activity: Strongly Agree Strongly Disagree Will help me collaborate with other healthcare professionals 5 4 3 2 1 OVERALL EVALUATION: This activity: Strongly Agree Strongly Disagree  acontent change in practice/workplace ofDo nothing differently; Content was not4 convincing □ Implement Work with individuals ofmy other professions toprofessionals maintain a climate mutual respect and shared values Based on the of the activity, what will you do differently in the care of your patients and/or regarding your Will help me collaborate with other healthcare 5 3 2 1 Increased my understanding of the subject Was evidence based and scientifically balanced Increased myknowledge understanding of thethis subject 5 4the 3 change 2 needs 1 Will help me collaborate other healthcare professionals 55 44 33 22 11 professional responsibilities? □ Seek U se the ofwith your own role and those of other professions tonothing appropriately assess and address health care  additional information on topic  Do differently; System barriers prevent Will help me collaborate with other healthcare professionals 5 4 3 2 1 Was free evidence based andbias scientifically balanced 5 4 3 2 1 Was of commercial or influence 5 4 3 2 1 of patientsbased Was evidence and scientifically balanced 44 convincing 33 22 11  abased change my practice/workplace  Do nothing differently; Content 5 was Was evidence andin scientifically balancedresponsibilities reflects 5 not  Implement Do nothing differently; current practice/job activity recommendations Was free of commercial bias or influence 5 4 3 2 1 Met my expectations 5 4 3 2 □ Cfree ommunicate with patients, families, and other health professionals in a responsive and responsible that supports Was of commercial bias or influence 55 manner 44prevent 33 change 22 a11  Seek additional information on this topic  Do nothing differently; System barriers Was free of commercial bias or influence 1 Met my expectations 4 3 2 1 Will help me collaborate with other healthcare professionals 5 4 3 2 1 team approach to theof promotion and maintenance ofyour health and the and/or prevention and treatment of55 Will help me collaborate with other healthcare professionals 5disease 4 3 2briefly 1 If you anticipate changing one or more aspects of practice professional responsibilities please Met my expectations 4 3 2 1 Based on the content the activity, what will you do differently in the care of your patients and/or regarding your Met mynothing expectations 5 4 3 2 1  Do differently; current practice/job responsibilities reflects activity recommendations □ Perform effectively on teams to plan, deliver, and evaluate patient/population-centered care describe how you plan to do so. Was evidence based and scientifically balanced 5 4 3 2 1 Based on the content of the activity, what will you do differently in the care of your patients and/or regarding your professional responsibilities? Was evidence based and scientifically balanced 5 4 3 2 1 Based on the content of the activity, what will you do differently in the care of your patients and/or regarding your professional responsibilities? □ Other: specify __________________________________ Based on the content of the activity, what will you do differently in the care of your patients and/or regarding your Was free of commercial bias or influence 5 4 3 2 1  Implement a change in my practice/workplace  Do nothing differently; Content was not convincing Was free of commercial bias orone influence 5 4 3 2briefly 1 If you anticipate changing or more aspects of your practice and/or professional responsibilities please professional responsibilities? professional □ Implement No impact; this activity diddo notso. address interprofessional collaborative practice differently; Content was  aresponsibilities? change in to my practice/workplace  Do nothing not4 convincing describe how you plan Met my expectations 5 3 2 1 Met my expectations 5 4 3 2 1  Implement Seek additional information on this topic  Do Do nothing nothing differently; differently; Content System barriers prevent change  aa change in  was convincing  change in my my practice/workplace practice/workplace  was not notprevent convincing  Implement Seek additional information on this topic  Do Do nothing nothing differently; differently; Content System barriers change Based on thedifferently; content of theonactivity, activity, whatresponsibilities will you you do do differently differently in the the care of your your patients and/or regarding your  Do nothing current practice/job reflects activity recommendations Based on the content of the what will in care of patients and/or regarding  Seek additional information this topic  Do nothing differently; System barriers prevent change  Seek additional information onpractice/job this topic responsibilities reflects  Do nothing differently; System barriers prevent change your  Do nothing differently; current activity recommendations professional responsibilities? professional responsibilities?  Do nothing differently; current practice/job responsibilities reflects activity recommendations  Do nothing differently; practice/job responsibilities activity recommendations If anticipate changing or more aspects of yourreflects practice and/or professional responsibilities please briefly  you Implement change incurrent my one practice/workplace  Do Do nothing differently; Content Content was not not convincing convincing  Implement aa change in my practice/workplace  nothing differently; was If you anticipate one describe how youchanging plan to do so.or more aspects of your practice and/or professional responsibilities please briefly  Seekissues additional information onso. this topic  Do Doand/or nothing responsibilities differently; System System barriers prevent change If you anticipate changing one or aspects of practice professional responsibilities briefly What you experiencing in your practice and/or professional that could beplease addressed in  Seek additional information on this topic  nothing differently; barriers prevent change describe howare you plan to do If you anticipate changing one or more more aspects of your your practice and/or professional responsibilities please briefly describe how you plan to do so. future programming? describe how you plan to do so.  Do nothing differently; current practice/job responsibilities reflects activity recommendations  Do nothing differently; current practice/job responsibilities reflects activity recommendations What issues are you experiencing in your practice and/or professional responsibilities that could be addressed in If changing future programming? If you you anticipate anticipate changing one one or or more more aspects aspects of of your your practice practice and/or and/or professional professional responsibilities responsibilities please please briefly briefly describe how you plan to do so. describe how you plan to do so. CE Activity Code: 19HH02 — This form may be photocopied.

What issues are you experiencing in your practice and/or professional responsibilities that could be addressed in What issues are you experiencing in your practice and/or professional responsibilities thatform could in future programming? CE Activity Code: 19HH02 — This maybebeaddressed photocopied. What are future programming? What issues issues are you you experiencing experiencing in in your your practice practice and/or and/or professional professional responsibilities responsibilities that that could could be be addressed addressed in in future future programming? programming? What issues issues are are you you experiencing experiencing in in your your practice practice and/or and/or professional professional responsibilities responsibilities that that could could be be addressed addressed in in What CE Activity Code: 19HH02 — This form may be photocopied. future programming? programming? future CE Activity Code: 19HH02 — This form may be photocopied. CE Activity Code: 19HH02 — This form may be photocopied. Page 12 / New Jersey HIVLinks, Winter 2018 CE Activity Code: 19HH02 — This form may be photocopied.

Feature Article

Synergistic Effects of the HIV, Hepatitis C, and Opioid Epidemics: The New Jersey Response Loretta Dutton, MPA, Director, HIV Care and Treatment, NJDOH- Division of HIV, STD, and TB Services Kulpreet Kaur, MS, MPH, Syringe Access Program Coordinator, NJDOH- Division of HIV, STD and TB Services Laura Taylor, PhD, MCHES, Viral Hepatitis Coordinator, NJDOH- Communicable Disease Service Adam Bucon, LSW, State Opioid Treatment Authority, NJDOH- Division of Mental Health and Addiction Services Darcel Reyes, PhD, ANP-BC, Assistant Professor/Director of HIV Specialization, Rutgers University School of Nursing

Introduction

he synergistic effects of Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) on the opioid epidemic is increasingly recognized as a public health problem.1-3 It is estimated that of the 10 million people who inject drugs (PWID) worldwide, 67% are infected with HCV.1 In comparison, an estimated 3 million PWID are infected with HIV.2 In the United States (US), according to the Centers for Disease Control and Prevention (CDC), the reported cases of acute HCV infection increased about 3.5-fold from 2010 to 2016.4 These new infections are associated with rising rates of injection drug use. Fifty percent of PWID will become infected with HCV within the first 5 years of injecting drugs.5 Among those who inject drugs for more than 6 years, HCV prevalence ranges from 64% to 94%.6 The mortality among HCVinfected persons is now higher than that of HIV-infected persons.7.8 The opioid epidemic has also affected rates of HIV infection; PWID accounted for 9% of newly diagnosed HIV cases in 2016, an increase from 6% in 2015.4

often sold as Spice, K2 or fake weed, and crack are linked to risk behaviors, further fueling the opioid epidemic and increasing the risk of HCV and HIV transmission.9 This article discusses the intersection of the opioid crisis, HCV infection, and HIV infection.

Background As opioid and heroin use increases, the number of cases of HCV in PWID younger than 30 years of age has also increased.10 Analysis of New Jersey Communicable Disease Reporting and Surveillance System (CDRSS) data revealed that in 2017, the majority (45.6%) of acute cases of HCV were in individuals aged 17-30; followed by individuals aged 31-49 (35.4%) and 19% of acute cases were in individuals over 50 years of age.10 CDRSS data indicates that the highest rates of new or acute HCV cases linked to injection drug use in New Jersey (NJ) occurred in the Northwest region (Warren,

Sussex, Morris, and Passaic counties), a part of the state with a large proportion of non-urban and rural areas.10 A recent Morbidity and Mortality Weekly Report (MMWR) reviewed trends in emergency department (ED) visits. The MMWR noted increased ED visits for opioid overdoses across the country, and of the three blood borne pathogens associated with injecting drugs (HBV, HCV, and HIV), only HCV rates are trending upward.11

HCV and HIV Transmission among PWID HIV and HCV infections are transmitted efficiently via shared syringes or other injection equipment. Unsafe injection practices and lack of knowledge about HCV and HIV transmission increases the risk of PWID acquiring these infectious viral diseases. National estimates suggest that more than 60% of new cases of HCV infection are

Other substances that contribute to the opioid epidemic include strong synthetic opioids such as fentanyl, its analogues, and methamphetamine. These drugs are mixed into heroin, cocaine, or benzodiazepines. In addition, synthetic cannabinoids, continued on next page New Jersey HIVLinks, Winter 2018 / Page 13

Feature Article

associated with injection drug use.12 HCV prevalence levels are 70%-90% among long term PWID.12 According to CDC, approximately 196,300 PWID are living with HIV and 7% are unaware of their status.4 Some characteristics of HCV contribute to increased rates of infection in PWID. First, parental transmission of HCV is 10-fold more efficient than that of HIV.13 HCV transmission occurs through percutaneous exposure from injection drug use. This is the greatest risk factor for infection because microscopic amounts of blood infected with HCV remains viable in dried blood for as long as six weeks.13 Second, HCV has a stronger tendency towards chronicity compared to other forms of viral hepatitis. Approximately 85% of persons acutely infected with HCV develop persistent viremia.14 Third, people may be unaware that they are infected with HCV because it is often asymptomatic and a blood test is the only way to determine HCV infection.14 These characteristics result in HCV infected PWID with the potential to spread the virus by sharing needles and injection equipment (cookers, tourniquets, cotton) and “backloading” (the practice of using one syringe to squirt doses of dissolved drug solution into other syringes).15 Social and economic factors contribute to HIV transmission among PWID. More than half (56%) of HIV positive PWID are homeless, 25% experience incarceration, and 16% lack health insurance.4 HIV related stigma and mistrust of the health care system may prevent HIV positive PWID from engaging in care.4

Responses to the Opioid Epidemic PWID and those thinking about using drugs need unbiased, non-judgmental, reliable information about the anticipated effects and unanticipated harms of the drug(s) they are using or considering using. Some of these harms, such as HIV or HCV infection, Page 14 / New Jersey HIVLinks, Winter 2018

may be associated with the effects of the drug on the body, mind, and behavior. Drug related harms might also be the result of social, economic, legal, cultural, and political factors that shape the way illicit drugs are available and conditions under which they are used.17 Poverty, racism, social isolation, past trauma, sex-based discrimination, and other social inequities affect people’s capacity to deal with drug-related harm. Harm reduction programs are one way to address the social determinants of health that contribute to drug use.18 Harm reduction counseling and overdose prevention strategies play a significant role in reducing risky injection behaviors and decreasing the spread of HIV and HCV infection. Syringe access program (SAPs) are evidence-based harm reduction programs that provide clean syringes and injection equipment, education about safe injection practices and safe sex practices, and overdose reversal.18 SAPs also provide access to fentanyl strips to test for its presence in illicit drugs.19 SAPs are effective in communicating “one shot, one syringe,” an important message for younger PWID given the social aspects of injecting.18 In addition, access to clean injecting equipment and safe disposal of needles and syringes reinforces harm reduction behaviors and reduces transmission of bloodborne pathogens. SAPs also serve as an entry point for PWID to access medical, social, and mental health services.18 Implementation of SAPs has led to reductions in injecting risk behaviors and thus, reductions in HIV and HCV transmission among PWID.20,21 For example, when New York City expanded its syringe exchange programs from 250,000 syringes per year to 3,000,000 syringes per year, the rate of new HIV infections among PWID fell from 4% per year to 1% per year.22,23 SAPs combined with medication assisted treatment of substance misuse and substance use disorders are linked to a greater than 60% reduction in the transmission of HCV among PWID.24

Reduction of HCV transmission among PWID prevents new infections and reduces the number of people with endstage liver disease who require liver transplantation.7 Supervised Injection Facilities (SIFs), also known as supervised consumption spaces (SCSs), are evidence-based, harm reduction programs that play a significant role in reducing overdose and preventing transmission of HCV and HIV.25 SIFs are medically supervised facilities where PWID can use legal or illicit drugs. SIFs prevent overdose among PWID and provide education about safe drug injection practices that reduce the risk of HCV and HIV. SIFs also link participants to preventive care, testing, treatment, and social services. The American Medical Association, American Public Health Association, HIV Medicine Association, and the Infectious Disease Society of America, all endorse the implementation of SIFs.25

Expanded HCV Testing in New Jersey The New Jersey Department of Health (NJDOH) has created partnerships and provided harm reduction education and outreach to address the rising HCV prevalence in the state. A plan to expand HCV testing is gaining traction as funding permits. Testing sites include SAPs, health departments, opioid treatment programs (OTPs), and community organizations. Rapid HCV testing currently exists at most of the Access to Reproductive Care and HIV Services (ARCH) nurse locations with SAPs (Camden, Atlantic City, Paterson, Newark, and Jersey City). In 2019, HCV testing will be expanded to seven new ARCH nurse sites without SAPs. Identification and linkage to treatment of individuals who test positive for HCV is an integral part of the testing and counseling process, the first step in reducing the spread of HCV in NJ.26 With federal funding for HCV surveillance, NJDOH was able to identify and fund 5 licensed OTPs.26

HIVLinks

Synergistic Effects of HIV, Hepatitis C, and Opioid Epidemics: The New Jersey Response

The funding pays for testing, linkage to care resources, and staff time to collect HCV surveillance data. Early analysis of the data from OTPs indicates that a little more than half of the clients identify as PWID (54%). Approximately 41% of clients were aware of their positive HCV status upon entering the OTP and 91% of clients were tested for HCV upon admission to the OTP. Of those who were tested, 16% were newly diagnosed with HCV. Eighty-nine percent of clients newly diagnosed with HCV or HCV positive upon admission to the OTP were linked to care.26

Conclusion The Surgeon General characterized HCV and HIV as “hidden casualties” of the opioid crisis.27 Governor Murphy has assured the citizens of NJ that he is serious about addressing the opioid crisis by providing prevention, care, and treatment services.28 The NJDOH has responded to the synergistic effects of these epidemics with a grounded approach that addresses the intersection of HIV, HCV, and the opioid crisis through analyzing surveillance data to determine the need for services, increasing the number of SAPs, OTPs, HCV testing centers, and linking PWID who are infected with HIV or HCV to on-going treatment.

References 1. Nelson PK, Mathers BM, Cowie B, et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: Results of systematic reviews. Lancet. 2011; 378:571-583. 2. Mathers B, Degenhardt L, Phillips B, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: A systematic review. Lancet. 2008; 372:1733-1745. 3. Zibbell JE, Asher AK, Patel RC, et al. Increases in Acute Hepatitis C Virus Infection Related to a Growing Opioid Epidemic and Associated Injection Drug Use, 2004 to 2014. Amer J Public Health. 2018 Feb;108(2):175-81. doi: 10.2105/ AJPH.2017.304132. Epub 2017 Dec 21. 14. 4. Centers for Disease Control and Prevention. HIV Among People Who Inject Drugs. h t t p s : // w w w . c d c . g o v / h i v / g r o u p / h i v idu.html. Updated February 22, 2018. Accessed September 17, 2018.

5. P age K, Morris MD, Hahn JA, Maher L, Prins M. Injection drug use and hepatitis C virus infection in young adult injectors: using evidence to inform comprehensive prevention. Clin Infect Dis. 2013;57(suppl_2): S32-S38. 6. Des Jarlais DC, McKnight C, Arasteh K, et al. Transitions from injecting to non-injecting drug use: potential protection against HCV infection. Journal of Substance Abuse treatment. 2014; 46(3), 325-331. 7. Salmon-Ceron D, Lewden C, Morlat P, et al. Liver disease as a major cause of death among HIV infected patients: role of hepatitis C and B viruses and alcohol. Journal of Hepatology. 2005; 42(6): 799-805. 8. Van MH, Rose CE, Hallisey EJ, et al. Countylevel vulnerability assessment for rapid dissemination of HIV or HCV infections among persons who inject drugs, United States. J Acquir Immune Def Syndr. 2016;) 73(3): 323-331. 9. National Institute of Health, National Institute on Drug Abuse (NIDA), Drugs of Abuse, March 2018. https://www.drugabuse.gov/ drugs-abuse. Accessed September 14, 2018 New Jersey Communicable Disease 10. Reporting and Surveillance System (CDRSS) report (2017), New Jersey Department of Health. https://www.state.nj.us/health/cd/ reporting/cdrss/ Accessed September 14, 2018. 11. ivolo-Kantor V AM, Seth P, Gladden RM, et al. Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses — United States, July 2016– September 2017. MMWR. 2018; 67:279– 285. DOI: http://dx.doi.org/10.15585/ mmwr.mm6709e1 12. Williams IT, Bell BP, Kuhnert W, Alter MJ. Incidence and transmission patterns of acute hepatitis C in the United States, 1982-2006. Arch Intern Med. 2011; 14; 171(3): 242–248. doi: 10.1001/archinternmed.2010.511 13. age P K, Morri MD, Hahn J.A, Maher L, Prins M. Injection drug use and hepatitis C virus infection in young adult injectors: Using evidence to inform comprehensive prevention. Clin Infect Dis. 2013; 57(Suppl 2): S32–S38. http://doi.org/10.1093/cid/ cit300 14. Villano SA, Vlahov D, Nelson KE, Cohn S, Thomas D L. Persistence of viremia and the importance of long-term follow-up after acute hepatitis C infection. Hepatology. 1999; 29(3): 908-914. 15. Averhoff FM, Glass N, Holtzman D. Global burden of hepatitis C: Considerations for healthcare providers in the United States. Clin Infect Dis. 2012; 55(suppl_1): S10-S15. 16. ahn H J, Page-Shafer K, Lum PJ, et al. Hepatitis C virus seroconversion among young injection drug users: Relationships and risks. J Infecti Dis. 2002; 186:1558-64 17.Spooner C, Hetherington K. Social determinants of drug use. National Drug

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18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

and Alcohol Research Centre, University of New South Wales: Sydney; 2005. Harm Reduction Coalition. Principles of Harm Reduction. https://harmreduction. o r g /a b o u t - u s /p r i n c i p l e s - o f - h a r m reduction/. Accessed September 14, 2018 Harm Reduction Coalition. Fentanyl. https:// har mr e du c t i o n .o r g / i s su e s/fe n t any l/. Accessed September 14, 2018. Hagan H, Pouget ER, Des Jarlais DC. A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs. J Infect Dis. ,2011; 204(1): 74-83. doi: 10.1093/ infdis/jir196 Van Den Berg C, Smit C, Van Brussel G, Coutinho R, Prins M. Full participation in harm reduction programmes is associated with decreased risk for human immunodeficiency virus and hepatitis C virus: Evidence from the Amsterdam Cohort Studies among drug users. Addict. 2007; 102(9): 1454-1462. Center for Drug Use and HIV Research. Syringe Service Programs Reduce HIV and HCV Infections in People Who Inject Drugs (Research for Implementation Brief #4). New York, NY; 2017. http://www. cduhr.org/wp-content/uploads/2017/04/ CDUHR-Syringe-Service-ImplementationBrief-May2017.pdf. Accessed September 17, 2018. Des Jarlais DC, Arasteh K, McKnight C, et al. What happened to the HIV epidemic among non-injecting drug users in New York City? Addict. 2017; 112 (2): 290-298. doi: 10.1111/add.13601 Turner KM, Hutchinson S, Vickerman P, et al. The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: pooling of UK evidence. Addict, 2011; 106(11): 1978-1988. NASTAD Issue Brief: The Intersection of Hepatitis, HIV and the Opioid Crisis: The Need for a Comprehensive Response. July 2018. Centers for Disease Control and Prevention. Strengthening Surveillance in Jurisdictions with High Incidence of Hepatitis C Virus and Hepatitis B Virus Infections (CDCRFA-PS17-1703). https://www.cdc.gov/ hepatitis/policy/StrengtheningSurveillance. htm. Updated May 3, 2017. Accessed September 17, 2018. Wolitski R. Three Medical Societies Identify Specific Infections of Concerns in Relation to the Opioid Crisis. U.S. Department of Health and Human Service. Published June 13, 2018. State of New Jersey, Office of the Governor. Governor Murphy Advances $100 Million Commitment to Tackle New Jersey’s Opioid Crisis, Strategy Provides Multi-Pronged, Coordinated Approach. Published April 2018.

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Feature Article

State Seeks to Apply Population Health Goals to Opioid Addiction Lilo H. Stainton | June 6, 2018 Reprinted with permission from NJ Spotlight: www.njspotlight.com/stories/18/06/05/state-seeks-to-apply-population-health-goals-to-opioid-addiction

reatment and recovery are a start, but more is needed, including investing in wellness and building safer communities New Jersey must focus more on population health and prevention — not just treatment and recovery — by collaborating across government and with community partners to invest in wellness and build safer neighborhoods to make a real dent in the deadly opioid epidemic. That was the takeaway from the state Department of Health’s third annu-

al population health summit, which focused on an integrated approach to addressing opioid addiction, and drew hundreds of healthcare providers, community leaders, and recovery advocates to the Bridgewater Marriott on Tuesday. The event featured federal and state officials — including five cabinet members; state Sen. Joseph Vitale, the chair of the health committee; and former Gov. Jim McGreevey, an advocate for prisoner re-entry services — as well as a wide range of ad-

diction specialists, plus a pastor and family members who have personal experience with drug abuse. Speakers agreed that while the state has made significant progress reducing access to prescription opioids and expanding access to treatment, more must be done to tackle the underlying social determinants of health — issues like safe housing, healthy food, and easy access to care for mental health and medical concerns. The DOH is committed to using this approach to reduce health disparities and address chronic health issues like addiction, health commissioner Dr. Shereef Elnahal said.

A disease of the poor and vulnerable While opioid addiction has exploded in middle- and upper middle-class communities in recent years, Dr. David B. Nash, founding dean of the Jefferson College of Population Health, in Philadelphia, said the disease still predominantly impacts poor, vulnerable people. One half of addicts are unemployed, one-quarter permanently disabled, and six in 10 below the federal poverty line, he said, and combating the disease will require us to invest in poor communities and prevention, not just focus on treatment options.

Former Gov. Jim McGreevey

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“This is a disease of despair. It’s also a disease of racism,” Nash said in his keynote address, stressing the need to address the underlying fac-

State Seeks to Apply Population Health Goals to Opioid Addiction

HIVLinks Winter

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HIV, STD, and TB news and information for health professionals

more comprehensive, much more strategic approach,” said Michael Santillo, executive director of operations at John Brooks Recovery Center, a leading network of care in the state, and a former addict who has been in recovery for nearly three decades. “We need to have pre-treatment services, recovery services, and ways to help (patients) navigate the treatment system,” he added.

Joe Vitale

tors. “We need to shut off the faucet before we start mopping up the floor.” More than 2,000 Garden State residents died of drug-related issues last year and more than 1,200 have been logged so far this year, according to state data compiled by the attorney general’s office. Roughly 76,000 people were admitted to substance-abuse treatment in 2016, Elnahal said, including 33,000 heroin addicts — some 7,000 more than received care the previous year. The epidemic is also taking a growing toll on the next generation; nearly 700 babies were born addicted in 2016, twice the number that tested positive in 2008. “These deaths of despair” — which include addiction deaths and suicide — “are actually changing the epidemiology of the lifespan in our country, with the opioid epidemic at the center of the storm,” Nash said, warning that in some parts of the country population is now shrinking as a result of these overdoses.

Revealing the full scope of the problem In addition to a greater focus on un-

derlying social factors, Nash said solving this problem requires better data to illustrate the full scope of the epidemic and standardized interventions and treatments based on best practices. In addition, he said, reimbursement systems must pay for prevention programs and long-term care for those who are addicted, including medically assisted treatment — the use of prescribed medications to ease addictive behavior — when appropriate. Elnahal said the state is now moving in this direction. Former Gov. Chris Christie, a Republican, made the opioid epidemic a signature cause and called for hundreds of millions of dollars to be spent on programs to expand treatment and recovery options. But Gov. Phil Murphy, a Democrat who took office in January, has reassessed these efforts and redirected $100 million to fund specific evidence-based programs, support community providers, address social determinants, and improve the quality of the state’s data on addiction. “I don’t think we’re going to get out of this problem just by providing more treatment beds. It has to be a much

Efforts to protect and strengthen atrisk youth are particularly important, according to Pam Capaci and Morgan Thompson of Prevention Links, a nonprofit that helped found the Raymond J. Lesniak Experience Strength and Hope Recovery High School in 2014 — one of two, soon to be three, such facilities statewide. Nine out of 10 addicts begin using drugs as adolescents, they said, and 12 percent of youngsters live with a parent facing substance-use issues. Ensuring that these kids have a safe school environment, with counseling and support services in addition to academics, is essential to keeping them healthy.

Earlier intervention Attorney General Gurbir S. Grewal said more could also be done to intervene earlier when drug users come in contact with law enforcement — even before they are charged with a crime that makes them eligible to access treatment through the state’s drug-court system, designed to divert nonviolent offenders from the criminal justice system. He launched such an effort as Bergen County prosecutor and plans to roll out structured municipal drug-court programs in the months to come. “Why do we have to wait until someone is charged with an indictable (criminal) offense to get them the treatment that they need?” Grewal asked. “A warm handoff from a cop to a (addiction) professional can be very successful.” When it comes to treatment, presenters agreed clinicians can also do better continued on next page New Jersey HIVLinks, Winter 2018 / Page 17

Feature Article

vision of Mental Health and Addiction Services from the Department of Human Services to DOH, which regulates most aspects of medical care.

One-stop treatment At the Henry J. Austin Health Center, a federally qualified heath clinic in Trenton, leaders have sought to create a one-stop facility where patients can get screened and treated for substance-use or mental health issues, while also visiting their family doctor for routine care, explained Dr. Rachael Evans, the chief medical officer.

State Attorney General Gurbir Grewal

in addressing addiction. Unlike protocols for stroke or heart attack, which are documented and standardized, doctors don’t always work from the same playbook when it comes to detoxing and treating opioid abuse, Nash and others said, resulting in a wide variety of outcomes. Stigma remains a problem, even for providers, several speakers noted. Dr. Louis Baxter, an assistant medical professor at Rutgers New Jersey Medical School who heads the Professional Assistance Program of New Jersey, which works with addiction professionals, said that, for example, too many doctors still treat diabetics differently from opioid addicts, although both are suffering from a chronic health condition. “We don’t say, ‘See you later, get sugar free,’” when we discharge a diabetes patient from the emergency room, Baxter said. While some addiction proPage 18 / New Jersey HIVLinks, Winter 2018

viders try to limit a patient’s access to medically assisted treatment — which involves prescribed drugs designed to curb withdrawal symptoms and addictive behaviors — “No one ever says, ‘hurry up and get that (diabetic) patient off insulin,’” he added. “If we did the same for people with chronic substance abuse we would go a long way toward addressing the crisis.” Caring for those with substance-use issue requires well-coordinated, truly integrated care, panelists noted. Many addicts struggle with other chronic health conditions as well, mental illness in particular, which often get overshadowed by drug use and left untreated by clinicians. Seton Hall Law School Professor John V. Jacobi talked about his research on integration and the work he is doing to assist state officials, including reforms to the licensing process that is part of the state’s shift of the Di-

While there is a greater need for clinical standards, connecting addicts with treatment often requires the touch of someone who has shared their experience, several speakers noted. That’s where Adrienne Petta, a peer-recovery specialist in Mercer County, a former drug user who now works for a state program that dispatches her to the emergency room to visit with overdose victims. Petta sits at their bedside, sharing her story and listening to theirs, and, if they are willing, helping them — in big and small ways — advance toward treatment. She also checks back regularly for at least eight weeks and said nothing is more rewarding than the simple text messages she gets thanking her for being there when they needed help the most. “The proof is in the messages I get from people and family members,” she said. “You’re not some doctor that just read something out of a book. You’ve lived that experience.”

Practice Tips

Test and Treat Strategy: It Makes Sense Jihad Slim, MD

Introduction

ver the past three decades of using antiretroviral therapy (ART), our knowledge about

Human Immunodeficiency Virus (HIV) pathophysiology and transmission has improved. Along with the evolution of ART to fewer daily pills that are better tolerated and have a higher genetic barrier, it has become clear that individuals newly diagnosed with HIV could benefit from early initiation of treatment. This article discusses the theoretical reasons a test and treat strategy should become the new standard of care and presents the current data that support this practice.

Historical Background Zidovudine (AZT) was the first antiretroviral drug approved by the FDA in 1987 for treatment of HIV.

The initial dosing schedule was 2 tablets every 4 hours around the clock. It was a major challenge for patients to adhere to therapy with AZT because of its related nausea, headache, anemia, and myriad of adverse events. Ten years later, after we were able to measure viral load (VL) and resistance testing was available, most patients still required multiple pill ART regimens, taken several times a day, with frequent and severe adverse events, in order to maintain an undetectable VL. It is only in this last decade that most people living with HIV (PLWH) are able to take fewer pills or one pill once a day with minimal side effects to maintain good viral suppression and disease control. continued on next page

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Practice Tips

In the early years of the epidemic, concerns about resistant HIV and patients’ ability to adhere to therapy led to a cautious approach. It took multiple visits to a clinician and review of a patient’s genotype test for possible resistance to HIV medications prior to initiation of ART. It was standard practice at that time to delay ART until the CD4 count dropped to 200 cells/mm3. During this period, many patients were lost to care.1 Two large randomized trials in 2015, START and TEMPRANO, demonstrated an approximate 50% reduction in morbidity and mortality among PLWH and CD4 counts >500 cells/mm3 who had an immediate initiation of ART.2, 3 As a result, guidelines for HIV treatment recommended ART for all PLWH regardless of CD4 cell count.2, 3

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There is no longer a need to wait weeks for the result of genotype testing prior to initiating ART because HIV resistance to protease inhibitors (PI) or second generation integrase strand transfer inhibitors (INSTI) in ART-naïve individuals is very unusual. This was demonstrated in the DIAMOND trial, a multicenter study in the US that assessed the safety and efficacy of Cobicistat/Darunavir/Emtricitabine/Tenofovir alafenamide (COBI/DRV/FTC/ TAF) co-formulated in a single tablet regimen.4 COBI/DRV/FTC/TAF was given to 109 newly diagnosed HIV-1 infected patients within 14 days of diagnosis, prior to HIV resistance testing.4 Results of the trial indicated that none of the patients discontinued treatment because of lack of efficacy, no patients

met the resistance stopping rule, and 90% of those treated had a VL<50 copies/ml at week 24.4 Because current recommendations are to treat all PLWH, it seems logical to start treatment as soon as possible using regimens containing either a PI or second generation INSTI if resistance testing is not available at the time of the visit.

Potential Benefits There are at least two theoretical reasons to initiate ART as soon as patients are diagnosed with HIV disease. The first theoretical reason is that ongoing replication of the virus is never beneficial to an infected individual. Replicating HIV virus can only destroy more CD4 cells, disrupt the immune system,

HIVLinks Winter

Test and Treat Strategy: It Makes Sense

enrich the reservoir, and cause organ damage. The second theoretical reason is that decreasing the community VL could lead to an overall decrease in HIV transmission.

some patients, clinicians may need to provide counseling and education prior to the initiation of ART.

The benefits of immediate ART initiation are apparent in many categories of HIV infection:

Current evidence indicates the efficacy of initiating therapy at the time of diagnosis. Although randomized controlled trials have not been performed in the US, a pilot study of 39 individuals in San Francisco suggested that initiating ART on the same day of HIV diagnosis would shorten the time to achieving viral suppression, which may have some impact on community VL and could decrease HIV transmission.14 Our own work, a retrospective study of patients seen in Newark, New Jersey between 2014 and 2017 demonstrated that immediate initiation of ART after an HIV diagnosis decreased the median time of the first medical visit from 14 to 4 days and this was associated with a decrease in viral suppression median time from 124 to 80 days (p<0.05).15 At least 4 randomized controlled trials (Haiti, South Africa, Uganda, and Lesotho)16-19 and 11 observational studies carried out across 8 countries (China, Ethiopia, Malawi, South Africa, Swaziland, Thailand, the United Kingdom, and the US)20-30 investigated same day ART initiation. Most of the research found evidence of benefit from same day ART initiation with respect to all clinical outcomes, including increased viral suppression and retention in care at 12 months; some studies showed a trend toward reduced mortality. Another study found that earlier treatment initiation results in faster decline of HIV incidence and transmitted resistance.31 In a study at a Ryan White funded clinic in New Orleans, a test-and-start strategy (ART started within 72 hours of diagnosis) not only achieved viral suppression faster (98% had VL<200 copies/ml at 120 days), but insurance coverage increased from a baseline of 47 % to 82 % during the study period.32

• I n pregnancy, the use of ART has reduced the rate of perinatal transmission of HIV from approximately 20% to 30% to 0.1% to 0.5%.5 A study from South Africa reported that 75.8% of pregnant women who started ART the same day they were diagnosed were virally suppressed at the time of delivery.6 • I n acute HIV infection, earlier ART initiation increases the probability of restoring normal CD4 counts, a normal CD4/CD8 ratio, and lower levels of immune activation and inflammation.7 Studies in samples of men who have sex with men (MSM) from Thailand, the United Kingdom, and the US reported higher levels of viral suppression at 6 months (>90%) following same day ART initiation. 8-10 • I n advanced HIV disease, people with CD4 < 200 cells/mm3 who start ART are at less risk of developing opportunistic infections (OI). • A RT alone has proven effective in preventing progression of Kaposi Sarcoma secondary to human herpesvirus-8 (HHV-8), microsporidiosis, or progressive multifocal leukoencephalopathy secondary to John Cunningham virus (JC Virus).11,12 • H IV Dementia is reversible once ART is started and HIV nephropathy can be halted by achieving an undetectable HIV VL.13 On the other hand, deferred ART could be a better strategy in patients infected with Tuberculosis, or Cryptococcus Meningitis because of the high risk of immune reconstitution syndrome. Clinicians also need to consider psychosocial issues along with patients’ readiness and willingness to start ART. With

Current Evidence

Conclusion At the 2017 International Antiretroviral Society conference, the World Health

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HIV, STD, and TB news and information for health professionals

Organization (WHO) launched guidelines on rapid initiation of ART. The WHO guidelines recommend that all PLWH should be offered ART within 7 days of their diagnosis. ART initiation should be offered on the same day as diagnosis for people who are ready to start. Test and treat strategy in the US would be resource-intensive, requiring the availability of clinicians, (physicians, nurse practitioners, physician assistants), social workers, nurses, and laboratory staff to coordinate clinical evaluation of patients, and provide appropriate counseling and education. Not all patients will be ready to start treatment on the same day as diagnosis for a variety of reasons, including privacy, disbelieve of the diagnosis, distrust of the medical care, and medication phobia. Finally, the Department of Health and Human Services (DHHS) guidelines recommend prompt ART initiation as soon as the diagnosis is made, stating that it reduces morbidity and mortality in PLWH and decreases HIV transmission. The DHHS guidelines acknowledge that there are certain clinical and psychosocial factors that may occasionally necessitate a brief delay in ART, but ART should be started as soon as possible.33

References: 1. R osen S, Fox MP. Retention in HIV care between testing and treatment in sub-Saharan Africa: A systematic review. PLoS Med. 2011; 8:e1001056. 2. Lundgren JD, Babiker AG, Gordin F, et al. INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. 2015; 373:795–807. 3. Danel C, Moh R, Gabillard D, et al. TEMPRANO ANRS 12136 Study Group. A trial of early antiretrovirals and isoniazid preventive therapy in Africa. N Engl J Med. 2015; 373:808–822. 4. Huhn GD, Crofoot G, Ramgopal M, et al. Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) in a tes-andtreat model of care for HIV-1 infection: interim analysis of the Diamond study. Poster presented at the 22nd International AIDS Conference; July 23-27, 2018; Amsterdam, The Netherlands.

continued on next page New Jersey HIVLinks, Winter 2018 / Page 21

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5. Townsend CL, Cortina-Borja M, Peckham CS, de Ruiter A, Lyall H, Tookey PA. Low rates of mother-to-child transmission of HIV following effective pregnancy interven-tions in the United Kingdom and Ireland, 2000-2006. AIDS. 2008;22(8):973-981. Available at: https:// www.ncbi.nlm.nih.gov/pubmed/18453857. 6. Black S, Zulliger R, Myer L, et al. Safety, feasibility and efficacy of a rapid ART initiation in pregnancy pilot programme in Cape Town, South Africa. S Afr Med J. 2013; 103:557–562. 7. Le T, Wright EJ, Smith DM, et al. Enhanced CD4+ T-cell recovery with earlier HIV-1 antiretroviral therapy. N Engl J Med. 2013;368(3):218-230. Available at: http:// www.ncbi.nlm.nih.gov/pubmed/23323898. 8. De Souza MS, Phanuphak N, Pinyakorn S, et al. RV254SEARCH 010 Study Group. Impact of nucleic acid testing relative to antigen/ antibody combination immunoassay on the detection of acute HIV infection. AIDS. 2015; 29:793–800. 9. Girometti N, Nwokolo N, McOwan A, Whitlock G. Outcomes of acutely HIV-1-infected individuals following rapid antiretroviral therapy initiation. Antivir Ther. 2017; 22:77–80. 10. Hoenigl M, Chaillon A, Moore DJ, et al. Rapid HIV viral load suppression in those initiating antiretroviral therapy at first visit after HIV diagnosis. Sci Rep. 2016; 6:32947. 11. Goguel J, Katlama C, Sarfati C, Maslo C, Leport C, Molina JM. Remission of AIDS-associated intestinal microsporidiosis with high-ly active antiretroviral therapy. AIDS. Nov 1997;11(13):1658-1659. 12. Clifford DB, Yiannoutsos C, Glicksman M, et al. HAART improves prognosis in HIV-associated progressive multifocal leukoenceph-

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alopathy. Neurology. 1999; 52(3): 623-5. 13. B etjes MG, Verhagen DW. Stable improvement of renal function after initiation of highly active anti-retroviral therapy in patients with HIV-1-associatednephropathy. Nephrol Dial Transplant. 2002;17:1836–9 14. Pilcher CD, Ospina-Norvell C, Dasgupta A, et al. The effect of same-day observed initiation of antiretroviral therapy on HIV viral load and treatment outcomes in a US public health setting. J AcquirImmune Defic Syndro. 2017;74(1):44-51. Available at: https:// www.ncbi.nlm.nih.gov/pubmed/27434707. 15. Mohammed DY, Martin E , Babyants Y, Slim J. Same-day medical visit in newly diagnosed HIV patients decreases time to viral suppression Center, Newark, United States. Poster presented at the 22nd International AIDS Conference; July 23-27, 2018; Amsterdam, The Netherlands. 16. Rosen S, Maskew M, Fox MP, et al. Initiating antiretroviral therapy for HIV at a patient’s first clinic visit: the RapIT randomized controlled trial. PLoS Med. 2016; 13:e1002015. 17. Koenig SP, Dorvil N, Devieux JG, et al. Sameday HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV: A randomized unblinded trial. PLoS Med. 2017; 14:e1002357. Amanyire G, Semitala FC, Namusobya J, 18. et al. Effects of a multicomponent intervention to streamline initiation of antiretroviral therapy in Africa: a stepped-wedge cluster-randomised trial. Lancet HIV. 2016; 3:e539–e548. Labhardt ND, Ringera I, Lejone TI, et al. 19. Same day ART initiation versus clinic-based pre-ART assessment and counselling for individuals newly tested HIV-positive during community-based HIV testing in rural Lesotho: a randomized controlled trial (CAS-

CADE trial). BMC Public Health. 2016; 16:329. 20. Black S, Zulliger R, Myer L, et al. Safety, feasibility and efficacy of a rapid ART initiation in pregnancy pilot programme in Cape Town, South Africa. S Afr Med J. 2013; 103:557–562. 21. Chan AK, Kanike E, Bedell R, et al. Same day HIV diagnosis and antiretroviral therapy initiation affects retention in option B+ prevention of mother-to-child transmission services at antenatal care in Zomba District, Malawi. J Int AIDS Soc. 2016; 19:20672. 22. Kerschberger B, Mazibuko S, Zabsonre I, et al. Outcomes of patients initiating ART under the WHO Test & Treat Approach [Abstract TDPEB060]. 21st International AIDS Conference, Durban. 23. Langwenya N, Phillips T, Zerbe A, et al. Immediate initiation of antiretroviral therapy in PMTCT programmes is not associated with nonadherence during pregnancy: a cohort study [Abstract WEPED866]. 8th IAS Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, 19–22 July 2015. 24. Mitiku I, Arefayne M, Mesfin Y, Gizaw M. Factors associated with loss to follow-up among women in option B+ PMTCT programme in northeast Ethiopia: a retrospective cohort study. J Int AIDS Soc. 2016; 19:20662. 25. Pilcher CD, Ospina-Norvell C, Dasgupta A, et al. The effect of same-day observed initiation of antiretroviral therapy on HIV viral load and treatment outcomes in a US public health setting. J Acquir Immune Defic Syndr. 2017; 74:44–51. 26. De Souza MS, Phanuphak N, Pinyakorn S, et al. RV254SEARCH 010 Study Group. Impact of nucleic acid testing relative to antigen/ antibody combination immunoassay on the detection of acute HIV infection. AIDS. 2015; 29:793–800. 27. Wilkinson L, Duvivier H, Patten G, et al. Outcomes from the implementation of a counselling model supporting rapid antiretroviral treatment initiation in a primary healthcare clinic in Khayelitsha, South Africa. S Afr J HIV Med. 2015; 16:1–7. 28. Wu Z, Zhao Y, Ge X, et al. Simplified HIV testing and treatment in China: analysis of mortality rates before and after a structural intervention. PLoS Med. 2015; 12:e1001874. 29. Kostaki E.G, et al. Earlier Treatment Initiation Correlates with a Decreased Incidence of Transmitted Drug Resistance in Greece; poster presented at EACS 2017, Milan, Italy. 30. Halperin J, Holm P, Butler I, et al. Linkage and Anti-Retroviral Therapy Within 72-hours at a Ryan White-Funded FQHC in the Deep South; poster presented at IDweek 2017, San Diego, CA 31. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV at https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/0

Practice Tips

Back with A Vengeance: Increasing STDs in New Jersey and the United States Amelia Hamarman, MS., MS.Ed., Assistant Manager, STD Education and Special Projects Greta Anschuetz, MPH, Director, STD Services & Prevention Studies School of Public Health, Rutgers University

recent analysis from the Centers for Disease Control and Prevention (CDC) shows continuous, sharp increases in rates of sexually transmitted diseases (STDs) across the United States (US) from 2013 to 2017. During this four year period, there were reported rate increases of 67% in gonorrhea, 76% in syphilis, and 22% in chlamydia.1 In addition, chlamydia remains the number one reported infection to the CDC with more than 1.7 million cases reported in 2017.1 In New Jersey (NJ), STDs are increasing at rates similar to those nationwide. Between 2013 and 2017, NJ saw STD rate increases of 35% in gonorrhea, 77% in early syphilis, and 24% in chlamydia.2 These increases are both surprising and concerning, be-

cause almost 20 years ago, elimination of syphilis in the US was considered possible given the historic low rates of infection.3 So what is causing these unprecedented resurgences across the US and in NJ? As with most public health concerns, there is no single cause for this resurgence in STDs. Rather, multiple factors contribute to a climate that may facilitate disease transmission with fewer opportunities for disease disruption. This article explores some possible explanations for the rise in reported STDs.

Are We Just Catching More STD Cases? NJ data suggests a possible overall increase in STD screening over the past five years. For example, one major

commercial laboratory showed an increase of about 20% in the number of chlamydia tests performed between 2013 and the first half of 2018.4 Similarly, the total number of chlamydia tests conducted in NJ family planning clinics increased by 34% between 2013 and 2017. Although the positivity rate remained stable (~3.2%), the actual number of positive results for NJ family planning clinics increased by 38% during this period.5 It stands to reason that more STD screening will find more cases of STDs. However, increasing STD rates are not simply a matter of better detection because the positivity rate remains unchanged while the overall number of cases continues to rise. continued on next page New Jersey HIVLinks, Winter 2018 / Page 23

Practice Tips Are Dating and Hook-up Sites and Apps to Blame? Many believe online hook-ups and dating apps facilitate increased numbers of sexual partners, leading to a surge in STDs.6 Dating, hook-up websites, and apps such as Tinder, Jackâ&#x20AC;&#x2122;d and Grindr have made it easier and speedier for people to meet sexual partners. One study of men who have sex with men (MSM) attending an STD clinic found that 75% of those who tested positive for an STD met a partner through an app, including 100% of those diagnosed with gonorrhea.7 Another study found

that MSM who met partners through hook-up apps were more likely to test positive for gonorrhea or chlamydia compared with their counterparts who met partPage 24 / New Jersey HIVLinks, Winter 2018

ners through in-person venues.8 Conclusions regarding the relationship between online hook-ups and increased STD rates are mixed.

no clear association among these variables.9

Surmising that all dating apps and websites lead to an increased risk of STD infection may be too broad a conclusion. One study of multiple hook-up and dating apps found that although an increase in STDs was associated with certain websites (eg, Match.com, OKCupid, Down Dating, etc.), lower numbers of STDs were associated with

The increased use of dating and hookup apps presents barriers for disease intervention activities. Partner notification, aimed at intervening in the spread of disease by locating those at-risk of STD exposure and referring them for evaluation and treatment, is more difficult when sexual partners meet through websites. Lack of identifying information about partners met online make it difficult to contact or

other websites (eg, Our Time, Ashley Madison, Adult Friend Finder, Tinder, Grindr, etc.).8 Furthermore, a systematic review that explored correlations between meeting sex partners online and condomless sex or STD status found

locate them. For example, often location specific apps such as Grindr do not allow Disease Intervention Specialists to find a profile for notification purposes because the identified partner is not logged onto the website or in the specified geographic area.

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Back with A Vengeance: Increasing STDs in New Jersey and the United States Are Biomedical Advances in HIV Prevention Leading to More Condomless Sex? The growing use of biomedical interventions, such as pre-exposure prophylaxis (PrEP), may also contribute to condomless sex. Some studies show a relationship between PrEP use and condomless sex as well as rectal chlamydia and other STDs.10,11 However, the relationship between PrEP and STD screening may also be a factor. In NJ, PrEP use requires close monitoring by healthcare providers, which includes regular screening for syphilis and other STDs. Although some PrEP users may be more inclined to skip using a condom, regular screening reduces the chances of spreading undetected STDs. Therefore, the question emerges, are we seeing actual increases in STDs among PrEP users, or are we just more successful in detecting existing STDs before the appearance of signs and symptoms? Again, the answer to this question appears to be a combination of multiple factors including increased number of sexual partners, less condom use, and better STD detection.12

What Populations are Experiencing Increases in STDs? Although the majority of syphilis cases in the US and NJ are found in MSM, there is evidence that the epidemic is increasing in other populations.2 In 2017, almost 70% of primary and secondary syphilis infections in the US and about 55% of primary and secondary syphilis cases in NJ were among MSM.1,3 However, increasing numbers of syphilis cases are reported in women, leading to increased rates of congenital syphilis. In NJ, between 2012 and 2015, primary and secondary syphilis increased by 37% among women. In the past 2 years, NJ Department of Health (NJDOH) reported 25 cases of congenital syphilis, a significant increase from the 5 cases reported in 2011.2 In the US, congenital syphilis cases were 458 in 2014; in 2017, the number doubled to 917.13,14

HIV, STD, and TB news and information for health professionals

Is Decreased STD Funding to Blame? Nationally, federal STD funding has decreased by approximately 40% since 2003.13 NJ has experienced decreases of approximately 26% in federal grant funding for STDs, the primary funding source for STD prevention activities conducted by the NJDOH. This has detrimental effects on public health efforts to prevent the spread of disease, including decreases in the work force to follow-up on STD cases and the provision of needed technical assistance to local STD programs. In addition, a survey of local public health programs throughout the nation revealed that the majority have experienced budget cuts; the most common effect of these cuts were fewer clinic hours and reduced partner services.14 Thus, decreased funding leads to missed opportunities, which means many STDs go undetected and untreated, further exacerbating the spread of infection.

Conclusion STDs are at unprecedented levels throughout the US and NJ. Changes in screening practices, sexual behavior, social culture, and declining public health resources interact to exacerbate this rise. While resources remain limited, it is incumbent upon public health officials and health care professionals to use all possible resources and tools at our disposal to slow this increase and eventually reverse it.

References 1. C enters for Disease Control and Prevention (2018). New CDC analysis shows steep and sustained increases in STDs in recent years. https://www.cdc.gov/nchhstp/newsroom/2018/press-release-2018-std-prevention-conference.html. Updated August 28, 2018. Accessed September 11, 2018 2. New Jersey Department of Health STD Surveillance Data. Communicable Disease Reporting and Surveillance System. https:// w w w.state.nj.us/health/cd/repor ting / cdrss/. Accessed September 11, 2018. 3. Belluz J. 5 reasons why STDs are roaring back in America. Vox Media. h t t p s: // w w w .v o x . c o m /s c i e n c e - a n d health/2017/9/27/16371142/stds-syphilis-gonorrhea-chlamydia. Accessed September 11, 2018. 4. Laboratory Data Regional Health Depart-

2018

10.

11.

12.

13.

14.

15.

ment Collaboration. New Jersey Department of Health, Division of HIV, STD and TB Services. STD Services. https://www. nj.gov/health/hivstdtb/. Accessed September 11, 2018. New Jersey Department of Health. New Jersey Family Planning League Screening Data. Accessed September, 14, 2018. Chan P, Crowley C, Rose J, et al. A network analysis of sexually transmitted diseases and online hookup sites among men who have sex with men. Sex Transm Dis. 2018; 45(7):462-468. Beymer MR, Weiss RE, Bolan RK, et al. Sex on demand: Geosocial networking phone apps and risk of sexually transmitted infections among a cross-sectional sample of men who have sex with men in Los Angeles county. Sex Transm Infect. 2014; 90:567572. Enomoto C, Noor S, Widner B. Is social media to blame for the sharp increases in STDs? Soc Sci. 2017; 6(3), 78; doi:10.3390/ socsci6030078 Tsai JY, Sussman S, Pickering TA, et al. Is online partner-seeking associated with Increased risk of condomless sex and sexually transmitted infections among individuals Who Engage in Heterosexual Sex? A systematic narrative review. Arch Sex Behav. 2018; 1-23. https://doi.org/10.1007/ s10508-018-1235-2. Accessed September 11, 2018. Traeger MW, Schroeder SE, Wrigh tEJ, et al. Effects of pre-exposure prophylaxis for the prevention of human immunodeficiency virus on sexual risk behavior in men who have sex with men: A systematic review and meta-analysis. Clin Infect Dis. 2018; 67(5): 676-686. Nguyen VK, Greenwald ZR, Trottier H, et al. Incidence of sexually transmitted infections before and after preexposure prophylaxis for HIV. AIDS. 2018; 32:523-530. Kojima N, Davey D, Klausner J. Pre-exposure prophylaxis for HIV infection and sexually transmitted infections among men who have sex with men. AIDS. 2016; 30 (14):2251-2252 Bowen V, Su J, Torrone E, Kidd S, Weinstock H. Increase in Incidence of Congenital Syphilis — United States, 2012–2014. MMWR. 13 Nov 2015; 64(44):1241-1245. ht tps://w w w.cdc .gov/mmwr/preview/ mmwrhtml/mm6444a3.htm Centers for Disease Control and Prevention. Sexually transmitted disease surveillance, 2017. https://www.cdc.gov/std/stats17/ default.htm. Updated September 24, 2018. Accessed September 11, 2018. National Coalition of STD Directors . STDs hot record highs again, threatening millions of American lives. http://www.ncsddc.org/ stds-hit-record-highs-again-threatening-millions-of-american-lives/ . Accessed September 11, 2018.

16. L eichliter J, Heyer K, Peterman M. U.S. public STD clinical services in an era of declining public health funding: 2013–14. Sex Transm Dis. 2017; 44(8):505–509.

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Practice Tips

The New Jersey AIDS STD Hotline: A Resource for Your Patients Diane P. Calello, MD, Executive and Medical Director, New Jersey Poison Control Center, Rutgers NJ Medical School’s Department of Emergency Medicine Alicia Gambino, MS, MCHES Bruce Ruck, Pharm.D., Managing Director, New Jersey Poison Control Center, Rutgers NJ Medical School’s Department of Emergency Medicine

re you a healthcare provider who takes care of sexually active New Jersey (NJ) residents with questions and concerns about sexual health? Besides providing information as a healthcare provider, you can refer patients to the NJ AIDS/HIV/STD hotline, a free health service for all state residents. The AIDS/HIV/STD hotline is one of the ways NJ is addressing the STD (sexually transmitted disease) epidemic. According to the NJ Department of Health (NJDOH), 1 in 2 sexually active people will contract an STD by age 25.1 The NJ hotline is a free, multilingual, confidential sexual health service that provides information to the public about Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS), and other STDs, such as gonorrhea, chlamydia, syphilis, and hepatitis. Hotline staff also refer callers to state-funded HIV and STD services and programs. Your patients can call, text, or chat with the medical professionals (physicians, nurses, and pharmacists) 24 hours a day, 7 days a week. For individuals’ whose primary language is not English or Spanish, hotline staff can access translation services in real time and provide assistance in over 150 languages. In addition, the hotline promotes sexual health education through press releases and social media outreach. In recent years, the hotline has worked closely with the NJDOH Division of HIV, STD, and TB Services to connect callers with additional health services. If a caller is a person living with HIV Page 26 / New Jersey HIVLinks, Winter 2018

(PLWH) and not receiving medical treatment, the hotline connects him or her to a state Linkage-to-Care Coordinator. Once confirmed as HIV-positive, hotline staff strive to get the PLWH into HIV care within 24 hours of diagnosis or on the next business day. Hotline staff are able to link PLWH in need of housing to a housing coordinator as well as provide locations and hours of operation for the NJ Syringe Access Program. Since January 2018, the hotline has helped over 2,500 callers. Hotline staff referred over 500 individuals for emergency housing assistance. Approximately 150 individuals were referred for counseling, and testing; over 60 callers were referred for medical care or to a Linkage to Care Coordinator for assistance accessing HIV treatment. Here are some reasons people call the hotline: • Unsure of HIV/STD status • Looking to get tested for HIV or other STDs • HIV-positive and no longer receiving medical care • In need of clean syringes • Think they may have HIV or another STD • Uncomfortable speaking to health care professionals about high risk sexual behaviors • Thinking about pre-exposure prophylaxis (PrEP) • Have an untreated STD • Unsure of when to get an HIV or STD test • Have a tattoo or piercing and are worried about HIV or hepatitis infection

• E xperiencing side effects from an HIV or STD medicine • Wish to discuss treatment information for HIV and other STDs • At high risk for STD infection • Shared needles or injecting equipment “works” (cookers, cotton, and water) • Had unprotected sex recently and now worried about possible infection • Diagnosed with HIV and need to know the next steps • Unsure of how to lower their risk for getting and spreading STDs • Taking HIV medicine while pregnant or breastfeeding • Need information about partner notification or the AIDS Drug Distribution Program (ADDP) If you are a healthcare provider taking care of patients who may at risk of contracting an STD, having unprotected sex, or sharing needles or drug works, you may want to consider telling your patients about the hotline. The NJ HIV/ AIDS/STD Hotline can be reached by dialing 1-800-624-2377 or through the website, www.njhivstdline.org

References 1. N ew Jersey Department of Health. Sexually Transmitted Diseases (STDs). https://www. state.nj.us/health/hivstdtb/stds/. Accessed September 20, 2018.

The New Jersey AIDS STD Hotline: A Resource for Your Patients

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2018

HIV, STD, and TB news and information for health professionals

New Jersey HIVLinks, Winter 2018 / Page 27

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FranÇois-Xavier Bagnoud Center, School of Nursing, Rutgers, The State University of New Jersey 65 Bergen Street, 8th floor, Newark, NJ 07101-1709

HIV, STD, and TB news and information for health professionals

New Jersey HIVLinks is published by FXB Center, School of Nursing, Rutgers, The State University of New Jersey with the New Jersey Department of Health, Division of HIV, STD, and TB Services (NJDOH-DHSTS) through a Memorandum of Agreement titled “Education and Training for Physicians and Other Healthcare Professionals in the Diagnosis and Treatment of HIV/AIDS”. FXB Center Executive Director Andrea Norberg, DNP, MS, RN Editor of NJ HIVLinks Darcel M. Reyes, PhD, ANP-BC FXB Center NJ HIVLinks Editorial Team Macsu Hill, PhD, MPH, CHES and Michelle Thompson FXB Center Graphic Designer Jersey Printing Associates NJ HIVLinks Medical Advisor Shobha Swaminathan, MD FXB Center 65 Bergen Street, Stanley S. Bergen Building, 8th Floor, Newark, NJ 07101-1709 Tel: (973) 972-5644 • Fax: (973) 972-0397 FXBCenter@sn.rutgers.edu Division of HIV, STD and TB Services Christopher Menschner Assistant Commissioner New Jersey HIV Links Planning Committee

Division of HIV, STD, and TB Services • Jihad Slim, MD, Medical Director

• Shobha Swaminathan, MD, Medical Director

• Loretta Dutton, Director, HIV Care & Treatment

• Darcel M. Reyes, PhD, ANP-BC

• Greta Anschuetz, MPH Director, STD Services • Nahid Suleiman, PhD, Quality Assurance Coordinator

save the date…coming soon HIV Clinical Update 2019 Thursday, June 6, 2019 ◆ APA Hotel Woodbridge, Iselin, NJ

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For more information contact: Michelle Thompson at ccthomps@sn.rutgers.edu or (973) 972-1293.

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NJDOH-DHSTS The New Jersey AIDS Drug Distribution Program (ADDP) and Social Media for Agencies, Centers and Academic Institutions http://hpcpsdi.rutgers.edu/training/main.php

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New Jersey Department of Health–Division of HIV, STD, and TB Services (NJDOH-DHSTS) (609) 984-5874 • www.state.nj.us/health/aids ¡¡ NJ HIV/AIDS statistical reports, regulations, forms, and links to HIV care, prevention programs, and training ¡¡ New Jersey rapid testing site: www.state.nj.us/ health/aids/rapidtesting ¡¡ New Jersey AIDS/STD Hotline: (800) 624-2377 François-Xavier Bagnoud (FXB) Center, School of Nursing, Rutgers, The State University of New Jersey (973) 972-5644 • Fax: (973) 9720397 • http://www.fxbcenter.org/about.html ¡¡ HIV/AIDS conferences, training ¡¡ Free online continuing education (CE) credits for healthcare professionals ¡¡ HIV/AIDS MEDICAL UPDATE SERIES: with funding from NJDHSS ¡¡ Free on-site HIV medical education for healthcare sites.Jersey Contact Michelle Thompson Page 28 / New HIVLinks, Winter 2018 at (973) 972-1293 or ccthomps@sn.rutgers.edu

HIV/AIDS Training & Information Resources AIDS Education and Training Center (AETC) Program ¡¡ National Coordinating Resource Center: www.aidsetc.org ¡¡ Northeast/Caribbean AETC: www.nynjaetc.org ¡¡ National Clinician Consultation Center: http://www.nccc.ucsf.edu/ HIV Warmline: (800) 933-3413 Post-Exposure Prophylaxis Hotline/PEPline: (888) 448-4911 Perinatal HIV Hotline: (888) 448-8765 Pre-Exposure Prophylaxis Hotline (PrEPline): 888-HIV-PREP Substance Use Warmline: (855) 300-3595 Hepatitis C Warmline: 844-437-4636 AIDSinfo: a service of the US Department of Health and Human Services, offers access to the latest, federally approved HIV/AIDS medical practice guidelines, HIV treatment and prevention clinical trials, and other research information. http://www.aidsinfo.nih.gov/

US National Institutes of Health: a registry and results database of publicly and privately supported clinical studies conducted around the world. http://clinicaltrials.gov US Centers for Disease Control and Prevention (CDC): http://www.cdc.gov/hiv/ default.html Health Resources and Services Administration (HRSA): http://www.hrsa.gov FDA MedWatch: (800) FDA-1088; Subscribe to e-bulletin: www.fda.gov/medwatch/elist.htm Center for Quality Improvement and Innovation: no-cost, technical assistance for Ryan White funded grantees to improve the quality of HIV care nationwide. www.nationalqualitycenter.org TARGET Center: technical assistance and training resources for the Ryan White community. www.careacttarget.org

Keep up to date via email. If you would like to be added to our electronic mailing list, visit our website at www.fxbcenter.org. To confirm your email address, or be deleted from the mailing list, please contact FXBCenter@sn.rutgers. edu. You will receive an e-mail when New Jersey HIVLinks is posted on the website.