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HomeMy WebLinkAboutMINUTES - 12172013 - C.77RECOMMENDATION(S): ACCEPT the annual HIV Prevention/Needle Exchange update for 2013 from the Health Services Department, Public Health Division, as recommended by the Family and Human Services Committee. FISCAL IMPACT: None - informational only. BACKGROUND: The HIV Prevention/Needle Exchange program was referred to the Family and Human Services Committee in October 2002. The issue was discussed four times during 2003 and was subsequently closed. The referral was then re-opened on January 4, 2005. Since that time the Family and Human Services Committee has discussed the surrounding issues eight times. This is the ninth report. CONSEQUENCE OF NEGATIVE ACTION: The public and the Board of Supervisors will not have current information. APPROVE OTHER RECOMMENDATION OF CNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE Action of Board On: 12/17/2013 APPROVED AS RECOMMENDED OTHER Clerks Notes: VOTE OF SUPERVISORS AYE:John Gioia, District I Supervisor Candace Andersen, District II Supervisor Mary N. Piepho, District III Supervisor Karen Mitchoff, District IV Supervisor Federal D. Glover, District V Supervisor Contact: Denice Dennis, 925-313-6825 I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown. ATTESTED: December 17, 2013 David Twa, County Administrator and Clerk of the Board of Supervisors By: Stephanie L. Mello, Deputy cc: C. 77 To:Board of Supervisors From:FAMILY & HUMAN SERVICES COMMITTEE Date:December 17, 2013 Contra Costa County Subject:Annual HIV Prevention/Needle Exchange Updae CHILDREN'S IMPACT STATEMENT: Not applicable. ATTACHMENTS HIV/Needle Exchange Update HIV/Needle Exchange PowerPoint November 2013 Prepared for the Contra Costa Board of Supervisors by Contra Costa Health Department Needle Exchange Update NEEDLE EXCHANGE •In 1999, the Contra Costa Board of Supervisors endorsed a State of Emergency with respect to HIV and AIDS to allow for the provision of needle exchange services. •Subsequent legislation replaced the State of Emergency with a written report. •This report satisfies the legislative requirement to maintain needle exchange services in Contra Costa County. HIV/AIDS in Contra Costa County As of December 31, 2012, 1983 individuals were reported living with AIDS or HIV in Contra Costa. Approximately 81% are male and 19% are female. African Americans are 30.6% of those living with HIV or AIDS, Whites 44.5% and Hispanics 20%. Predominant transmission among those living with HIV or AIDS remains men who have sex with other men (MSM). Injection Drug Use (IDU) (only) is 11.4% and IDU/MSM is 4.5%, totaling about 16% of the caseload attributed to injection drug use. All People Currently Living with HIV and AIDS Compared to Newly Reported HIV (Two year block: Jan 2011 – December 2012) 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% Male African American White Hispanic MSM IDU MSM/IDU Heterosexual PLWA / H New HIV Children with HIV and AIDS Infant Exposure has not been tracked by Stanford University since 2009. Of the 3,102 AIDS cases ever reported in Contra Costa, 24 have been pediatric cases (1-12 years of age). Seventeen of those pediatric cases were born to women with HIV/AIDS, and six were infected through blood/blood products. Of 737 HIV cases ever reported in Contra Costa, there were eight pediatric cases. Five were born to women with HIV/AIDS, and three have undetermined transmission. Reported Chronic Hepatitis C Cases Over Time Law Enforcement and First Responder Exposures Needle Exchange Services Services are provided by HIV Education Prevention Project of Alameda County (HEPPAC) One-for-one exchange offered in East and West County: services which had been declining over time are now increasing. Approximately 48% of participants are White, 35% African American, and 16% Latino. This past fiscal year 97 referrals were provided to health care, substance abuse treatment, and other services. Reported Contacts (Individuals) at Needle Exchange Sites Over Time Number of Syringes Distributed Over Time Secondary Exchanges Reported By HEPPAC Over Time AODS Service Enrollment FY 12-13 n=3829 (765 IDUs and 3064 non IDU) AODS IDU Service Enrollment IDU/Non IDU AODS Service Enrollment By Gender Other Prevention Strategies to Reduce Transmission of HIV in IDUs HIV and STD testing services in community and in Alcohol and Other Drugs Services programs; Clinical Risk Reduction services which include Partner counseling and Anonymous Partner notification and counseling services; Hepatitis C testing for highest risk IDUs; Evidence-based interventions in prevention agencies; Outreach services to link new positives to care; Cross training of staff and agencies. Syringe Disposal Options Adults anywhere in California may now purchase up to 30 syringes without a prescription. A number of locations for safe disposal of syringes are now available in Contra Costa. A link to the full list is maintained by the Contra Costa Environmental Health Program, as is a list of frequently asked questions on syringe and needle disposal and links to syringe disposal mail back services. More information on disposal is located at http://www.cchealth.org/eh/medical_waste/ CONCLUSIONS 1. Access to clean needles is making a difference in Contra Costa and remains an important component of the strategy to reduce transmission of blood borne diseases. The number of infections attributed to injection drug use has declined dramatically over time and the availability of needle exchange and pharmacy syringe sales has played a role in this trend. 2. Reported local law enforcement exposure to potential blood borne pathogens via needle stick injury remains at the same level as prior to implementation of needle exchange and pharmacy sales. Materials for Law Enforcement to document potential exposure and request assistance remain available on the website. 3. There is no evidence of increased maternal transmission of HIV to unborn children. 4. Change in Needle Exchange service provider has not adversely affected the service. The number of referrals to health and support services has increased under the new provider. Contra Costa Health Services Needle Exchange Update Report to Family & Human Services Committee November 2013 - 1 - RECOMMENDATIONS 1) Accept this report on needle exchange as part of the comprehensive HIV Prevention Program. 2) Direct the Health Services Department to continue supporting and monitoring needle exchange services and reporting at least biennially as required by law. SUMMARY This report satisfies State regulatory requirements to maintain needle exchange services in Contra Costa. Last year’s legislative changes allowing pharmacies to dispense up to 30 syringes without a prescription have had no apparent negative effect on Contra Costa. Currently, 1983 individuals are living with HIV or AIDS in Contra Costa. The percentage of new infections attributed to Injection Drug Use has been decreasing over time. While the distribution of combined HIV and AIDS cases remains largely similar to previous years, among People Living with HIV (PLWH) and people newly diagnosed with HIV (not AIDS), the percentages attributed to Injection Drug Use (IDU) are dramatically reduced. Management of needle exchange services has successfully transitioned to HIV Education and Prevention Project of Alameda County (HEPPAC) and services which had been dropping off over time have stabilized. The Health Department continues to provide $54,000 in County general funds annually to support the operation of Needle Exchange services. Services are provided in West and East County on a weekly basis and are reaching those in need. There has been a sharp uptick in referrals for health and supportive services this past fiscal year. There is no evidence that needle exchange services and the increased accessibility of syringes for purchase at pharmacies have negatively impacted law enforcement in terms of exposure to blood borne pathogens. The availability of needle exchange as part of a comprehensive continuum of services for injection drug users is a necessary Public Health measure to continue to reduce transmission of blood borne diseases, and as such should remain available in Contra Costa County. Contra Costa Health Services Needle Exchange Update Report to Family & Human Services Committee November 2013 - 2 - BACKGROUND Multiple studies have demonstrated the efficacy of needle exchange in reducing transmission of blood borne pathogens. In a 2008 study in New York, researchers reported that an expenditure of $502 per client produced a gain of 0.01 quality adjusted life years per client. The same study reported that needle exchange reduced HIV treatment costs by $325,000 per case of HIV averted, and averted 4–7 HIV infections per 1000 clients.1 A comprehensive review of international studies on syringe access programs, including both syringe exchange and nonprescription pharmacy syringe sales concluded, “There is compelling evidence that increasing the availability, accessibility, and both the awareness of the imperative to avoid HIV and utilization of sterile injecting equipment by IDUs reduces HIV infection substantially.”2 Needle exchange has been a formal component of Contra Costa’s comprehensive HIV risk reduction strategy to reduce the transmission of HIV attributed to Injection Drug Use (IDU) since 1999. Existing State statutes at that time required a monthly declaration of a State of Emergency to authorize needle exchange services. In 2005 the authorization process was simplified by replacing the continuous declaration of a local state of emergency with a written report. Additional legislation in 2012 reduced reporting requirements to a biennial report. On January 10, 2006, the Contra Costa Board of Supervisors: • TERMINATED the local State of Emergency first declared on December 14, 1999; • AUTHORIZED the Health Services Department to administer a clean needle and syringe exchange project pursuant to Health and Safety Code section 121349 et seq; and • DIRECTED the Health Services Director to annually report to the Board on the status of the clean needle and syringe exchange project, with a focus on reducing transmission among women to their unborn children, reducing HIV and Hepatitis C transmission, ensuring access to treatment services, and not increasing risk to law enforcement. In 2012 the Family and Human Services Committee directed the Health Department to continue to provide annual reports on the status of needle exchange activities in Contra Costa County. REDUCING TRANSMISSION OF DISEASE As of December 31, 2012, 1290 individuals were reported living with AIDS (PLWA) and an additional 693 living with HIV (PLWH) in Contra Costa. The number of newly reported AIDS cases has declined over time while the number of newly reported HIV cases has increased by about 45% since the two year period of 2006-2007. HIV reporting by name was instituted in 1 Hrishikesh K. Belani, Peter A. Muennig. Journal of HIV/AIDS & Social Services, Vol. 7(3) 2008. Available online at http://www.haworthpress.com. # 2008 by The Haworth Press. 2 Wodak A, Cooney A. Do needle syringe programs reduce HIV infection among injecting drug users: a comprehensive review of the international evidence. Subst Use Misuse. 2006;41(6-7):777-813. Contra Costa Health Services Needle Exchange Update Report to Family & Human Services Committee November 2013 - 3 - 2005. The distribution of major demographics in the total number of people living with HIV and AIDS is largely unchanged over the past several years with some shifts noted in those newly diagnosed and living with HIV. People Living with HIV and AIDS. N= 1983 People Living with AIDS N=1290 People Living with HIV N=693 New HIV infections January 2011 – December 2012 N=116 (subset of PLWH) Male 81.4% 80.2% 83.8% 88.8% African American 30.6% 30.3% 31% 34.5% White 44.5% 44.8% 44% 30.2% Hispanic 20% 19% 21% 25% Similar shifts are seen in transmission risks. While Injection Drug Use (IDU) and Men who have Sex with other Men and also inject drugs (MSM/IDU) together comprise 19.4% of those living with AIDS, they are 10% of those living with HIV and only 4.3% of the new HIV infections occurring in the most recent two year interval. People Living with HIV and AIDS. N= 1983 People Living with AIDS N=1290 People Living with HIV N=693 New HIV infections January 2011 – December 2012 N=116 (subset of PLWH) MSM 61.2% 58.3% 67% 71.6% IDU 11.4% 14.4% 6% 2.6% MSM/IDU 4.5% 5% 4% 1.7% Heterosexual 12.5% 13% 12% 4.3% These figures demonstrate a remarkable change from earlier years, when injection drug users comprised about 25% of all People Living with AIDS in Contra Costa 3. While Contra Costa continues to have a higher percentage of individuals living with HIV or AIDS who attribute their infection to injection drug use than the State, the figures are now more closely aligned than in the past. The most recent published California data (for 2009) shows that statewide about 8 percent of living and 6 percent of newly diagnosed cases report injection drug use as their primary risk. Injection drug users (IDUs) who also report MSM activity account for about 8 percent of living and 5 percent of newly diagnosed cases.4 The City of Richmond continues to report the largest number of indviduals living with HIV or AIDS in Contra Costa. Currently, 36% of all PLWH/PLWA are residents of West County, 40% are residents of Central County, and 24% are residents of East County. Cities with five or more 3 Contra Costa Public Health Division report, July 2006. http://cchealth.org/health-data/pdf/hiv_2006_07.pdf 4 California HIV/AIDS Epidemiological Profile, 2009. August 2012. http://www.cdph.ca.gov/programs/aids/Documents/RSEpiProfileUpdate2009.pdf Contra Costa Health Services Needle Exchange Update Report to Family & Human Services Committee November 2013 - 4 - cases are included in the chart below. Because the higher numbers of people attributing their infections to injection drug use remain in the West and East areas of Contra Costa, there are no plans to modify needle exchange site locations at this time. Maternal Transmission There is no comprehensive tracking of maternal transmission since the Stanford project was defunded in 2009. Locally, because of their small numbers, the impact of the epidemic among children is tracked by cumulative (ever diagnosed and reported) numbers: of 3,102 cumulative AIDS cases reported through 12/31/12, 24 are attributed to pediatric transmission (15 male and 9 female). Seventeen were born to women with HIV/AIDS, and six were exposed through blood/blood products. One has no identified risk. Additionally, of 737 cumulative HIV cases reported through 12/31/12, eight are pediatric (5 male and 3 female). Five were born to women Contra Costa Health Services Needle Exchange Update Report to Family & Human Services Committee November 2013 - 5 - with HIV/AIDS, and three have no identified risk. The decrease in maternal transmission is attributed to earlier diagnosis and treatment of HIV positive women to interrupt the transmission of HIV to their unborn children. Hepatitis C In Contra Costa, the number of chronic Hepatitis C carriers continues to decline from a high of 1,400 cases reported in 1999. However, reporting data for Hepatitis C is generally not considered reliable due to considerable variation in medical provider reporting capacities. New technologies in lab reporting are helping to clarify the picture, and efforts are underway to promote electronic reporting of all communicable diseases. Please note: Fiscal Year 1011 was grossly under-reported due to transitioning to a new database. Data for fiscal year 1213 contains one full year of data from the new database. Exposure Impact on Law Enforcement and First Responders The Public Health Communicable Disease Control Program reviews reported exposures to ensure that law enforcement and first responders have access to the information, care and treatment needed to ensure their health and wellbeing following any exposure. Prepackaged kits containing all necessary paperwork and blood collection tubes are provided to CML, the lab company under contract with the Sherriff’s Department, to ensure the correct process is followed and proper documentation provided. Printed materials are also available on our website at http://cchealth.org/aids/syringe-exchange.php. Contra Costa Health Services Needle Exchange Update Report to Family & Human Services Committee November 2013 - 6 - The number of needlestick exposures (occurring outside a medical context) compared to all exposures reported by first responders remains very small, with 3 incidents out of 81 potential exposures reported between July 1, 2012 and June 30, 2013 which were attributed to needle sticks not associated with the provision of medical care 5 . Needle Exchange Services, Fiscal Year 12/13 Needle exchange services in the region rely on a combination of county general funds and other funding secured through foundations and other organizations. An RFP for provision of needle exchange services in Contra Costa was issued this year and the contract was awarded to HIV Education and Prevention Project of Alameda County (HEPPAC). The agency had assumed interim service delivery responsibility following the passing of long time needle exchange provider Bobby Bowens last year, and has gradually increased performance over the last several months. HEPPAC’s mission is to stop the spread of HIV and Hepatitis C among injection drug users and their families and to reduce the impact of drug related harm to the community. The agency adheres to a Harm Reduction model and provides health education as well as condoms and other risk reduction materials to participants. Their services in Alameda include a drop in center, training, access to STD and Hepatitis C testing, health and wellness support as well as other services. The agency is a registered 501(c) 3 and is certified to offer HIV testing. They conduct surveys among their clientele and offer staff education and support. Between August 2012 and June 2013 (the period of transitional exchange services) they provided 97 referrals to health care, substance use treatment and other resources. The county general funds portion of the budget supports an outreach worker, a site supervisor, staff training, and supplies. 5 Contra Costa Health Department Communicable Disease Program Contra Costa Health Services Needle Exchange Update Report to Family & Human Services Committee November 2013 - 7 - The following data on FY 12/13 needle exchange services was provided by HEPPAC. The percentage of African Americans and Hispanics served has increased since the previous year. Ethnicity Totals African American 382 34.7% European American 534 48.5% Latino/Hispanic 177 16.1% Native American 1 Asian/Pacific Islander 5 Other 1 Total 1100 Of the 1100 contacts served in the year, 676 (approx. 62%) were male. Detailed data for one quarter was not delineated by region of the county served, but for the quarters which were delineated, 25% of the reported contacts were in East County and 75% in West County. One-for-one syringe exchange continues to be the core operating principle of needle exchange. While the number of individuals attending needle exchange, as well as the number of individuals doing secondary exchange for others, has decreased over the past 5 years, services have stabilized under the management of HEPPAC, and there is a modest increase in the number served over the previous year. Individuals bringing in syringes for others, referred to as a secondary exchange, are the “Reported Number of People Reached by Needle Exchange Services”, below. These figures are duplicated. Contra Costa Health Services Needle Exchange Update Report to Family & Human Services Committee November 2013 - 8 - Finally, the total number of syringes distributed over time has also decreased, but as with clients served, the numbers have stabilized and modestly increased over the past year. The agency is performing above expectations for the first contract period and will be continuing to provide the service in both East and West County sites on a weekly basis. Alcohol and Other Drug Services (AODS) Of the 3,829 admissions to AODS services last fiscal year, 765 were injection drug users. A review of data from AODS treatment sites shows a nearly 20% decline in enrollment since fiscal year 0809. Several factors may reflected in this decline: the loss of Proposition 36 funding for Contra Costa Health Services Needle Exchange Update Report to Family & Human Services Committee November 2013 - 9 - services for nonviolent drug offenses, the loss of a major substance abuse provider agency in FY 1112, and transitioning of BASN case management funding all may contribute to a reduction in services. While the drop in enrollment is reflected across all demographics, African Americans and women show the greatest decline (37.2% and nearly 30% respectively) in service utilization since 0809. Additionally, the ratio of injection drug users as a percentage of overall population served, while increasing marginally over the previous year, has decreased by approximately 9% over the last 5 years. Contra Costa Health Services Needle Exchange Update Report to Family & Human Services Committee November 2013 - 10 - More than 32% of all AODS enrollees indicated that they were homeless at entry into the AODS program. Most participants identify as having a “dependent” living condition (reliant on someone else or some other institution for their housing), with only about 4.5% of all enrollees indicating that they were independently housed at time of entry into AODS services. While 23% of all enrollees have had three or more prior AODS treatment admissions, more than 38% claim no prior enrollment in AIDS treatment services. The Public Health HIV/AIDS and STD Program continues to provide Education, HIV rapid testing, HCV testing, and STD testing at selected AODS residential and detox centers in Contra Costa. We serve both adult and youth facilities. In FY 1213, 819 adults and 203 youth received comprehensive HIV and STD health education services. Of these, 143 adults elected to receive HIV testing and 355 youth were tested for a range of STDs including HIV. One HIV positive adult was linked to care and treatment. The Program also continues to offer limited Hepatitis C testing to approximately 35-50 of the highest risk individuals per year. Pharmacy Syringe Sales Adults anywhere in California may now purchase and possess up to 30 syringes for personal use without a prescription when acquired from an authorized source.6 http://cchealth.org/aids/syringe- sales.php The pharmacy must ensure that syringes are stored in a manner that makes them inaccessible to unauthorized persons and providers must offer consumers information on options for disposal. While the Health Department no longer provides registration or oversight of this program, Health Education resources for consumers are available on our website at and additional resources are located on the state website: 6 CA State Senate Bill 41, in effect January 2012 – January 2015. Contra Costa Health Services Needle Exchange Update Report to Family & Human Services Committee November 2013 - 11 - http://www.cdph.ca.gov/programs/aids/Pages/OASyringeAccess.aspx. We have received no complaints from law enforcement, business, pharmacies, or community members regarding discarded syringes this year. Disposal Contra Costa Environmental Health (CCEH) is responsible for administering the State's Medical Waste Management Program for Contra Costa County, and is the local enforcement and regulatory agency for Medical Waste Generators. CCEH issues permits and registers generators of medical waste, responds to complaints of abandoned medical waste on public property, and implements the Medical Waste Management Act (Part 14, C. 1-11 of the California Health and Safety Code). CCEH maintains a list of frequently asked questions on syringe and needle disposal, a list of disposal sites in Contra Costa, and links to syringe disposal mail back services. More information on disposal is located at http://www.cchealth.org/eh/medical_waste/. A number of locations for safe disposal of syringes are now available in Contra Costa, including: • Alamo Sheriff’s Substation – 150 Alamo Plaza, Suite C. • Lafayette Fire Station – 3338 Mt. Diablo Blvd. • Moraga Fire Station – 1280 Moraga Way • Orinda Police Department – 22 Orinda Way • San Ramon Fire District – 1500 Bollinger Canyon Road • Walnut Creek Fire Station - 1050 Walnut Avenue • Walnut Creek City Hall - 1666 N. Main Street • Rossmoor - Gateway Building, 1001 Golden Rain Road • Danville Police Department - 510 La Gonda Way • Household hazardous waste facility- 101 Pittsburg Ave., Richmond, • Delta Household Hazardous Waste Collection Facility- 2550 Pittsburg/Antioch Highway • Sutter Regional Medical Foundation- 4053 Lone Tree Way, Antioch, Several companies also are listed as State-sanctioned mail in systems. More information on medical waste mail-back services can be found at: http://www.cdph.ca.gov/certlic/medicalwaste/Documents/MedicalWaste/SharpsMailBackList.pdf. OTHER PREVENTION ACTIVITIES FOR INJECTION DRUG USE The Contra Costa HIV Prevention plan, aligned with the State HIV Prevention strategy, targets highest risk populations including men who have sex with other men and injection drug users, for HIV prevention services. We anticipate continuing County General Funds for needle exchange services to support the downward trend in HIV infections attributed to injection drug use. The full plan can be found on the Public Health website at: http://cchealth.org/aids/pdf/HIV-Prevention-Plan-Update-2012-2015.pdf Contra Costa Health Services Needle Exchange Update Report to Family & Human Services Committee November 2013 - 12 - While the Prevention program has received numerous budget reductions over the years, we continue to offer specialty services including:  HIV testing services at community sites and in Alcohol and Other Drugs Services programs, reaching approximately 2000 people per year. More than 99% of Public Health HIV testing uses a rapid test, providing preliminary results in 20 minutes.  Clinical risk reduction services targeting high risk men through incremental behavior change plans is available county wide through a subcontracted mental health provider serving HIV positive individuals.  Partner Counseling services providing support for notification to partners of potential exposure and testing available to HIV positive individuals and their providers.  Tighter linkages for making follow up medical appointments for new positives to reduce the number of individuals falling out of care and increase adherence to HIV medications is offered county wide.  Training to increase community capacity to provide prevention services in Contra Costa is provided annually.  Of the three Evidenced Based Interventions prevention subcontracts initiated in the previous fiscal year, two remain in operation, promoting HIV testing among highest risk communities.  Hepatitis C testing is offered to the highest risk individuals in conjunction with HIV testing of injection drug users and has been expanded in the new fiscal year.  Cross training between HIV, STD and HIV Surveillance staff is done to increase the pool of individuals available to meet community demand for education services CONCLUSIONS: 1. Access to clean needles is making a difference in Contra Costa and remains an important component of the overall strategy to reduce transmission of blood borne diseases. The number of infections attributed to injection drug use has declined dramatically over time and the availability of needle exchange and pharmacy syringe sales has played a role in this trend. 2. Reported local law enforcement exposure to potential blood borne pathogens via needle stick injury has not increased with the implementation of needle exchange and pharmacy sales. Materials for Law Enforcement to document potential exposure and request assistance remain available on the website. 3. There is no evidence of increased maternal transmission of HIV to unborn children. 4. The change in the Needle Exchange service provider has not adversely affected the service. The number of referrals to health and support services has increased under the new provider.