Foundations Family Medicine's HIV, HCV, Opioid and Substance Use Disorder Services

Description

Fueled by the worsening opioid crisis, Austin, Indiana, a rural town in Scott County, experienced the largest concentrated outbreak of HIV in rural America's recent history. The state also had a 400% increase in hepatitis C (HCV) cases from 2010 to 2015, with some of the highest rates coming from southeastern Indiana. Scott County was anticipating an HIV outbreak, but not at the 5% infection rate in which it came. Since 2015, over 200 residents have been diagnosed with the virus.

The dire situation led Austin's only medical doctor at the time, Dr. William Cooke, to respond. Cooke is the medical director and founder of Foundations Family Medicine, a Rural Health Clinic and the only location for medical services in Austin. Within his clinic, Cooke established HIV, HCV, substance use disorder (SUD), and opioid use disorder (OUD) services, reserving 6 of their 15 exam rooms to free and confidential testing, treatment, education, and care coordination. This was the first clinic in Scott County to respond to the crisis by integrating these services into primary care.

To spread the word about Foundations Family Medicine's new services, the staff took to the streets, personally inviting people through door-to-door invitations and phone calls. Initiating these unconventional methods of medical outreach influenced the decline in the number of HIV cases by the end of 2015.

Because of the limited amount of professionals qualified to test and treat HIV in the state, Cooke was the first family practice doctor in Indiana who became a certified HIV specialist. Several of his staff also became certified HIV testers. When Cooke started this service, primary care doctors were restricted from prescribing HCV medication, due to its high cost. He and the Indiana University School of Public Health worked with state departments to get permission to become certified to administer HCV medication through Project ECHO. Cooke was the first primary care provider in Indiana to prescribe medication to treat HCV, but has since worked with partners to expand the certification to the rest of the state.

The urgency of the situation and media attention brought local, state, national, and international organizations to partner with the HIV Clinic to assist in the efforts. Austin's success is also largely due to the collective partnership between Foundations Family Medicine and the groups listed below, as well as many others:

National Partners:

• Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention – Provided funding and established universal HIV testing guidelines used by Foundations Family Medicine.
• AIDS Healthcare Foundation – A global nonprofit organization that supplied mobile testing units, HIV treatment, and outreach services.
• New York City Health Department, The Chicago Recovery Alliance, and Midwest AIDS Training + Education Center – Offered harm reduction and HIV training in Austin.
• TeamHealth – Donated money for HIV services.
• The Great Lakes Addiction Technology Transfer Center Network (ATTC Network)

State Partners:

• Rural Center for AIDS/STD Prevention Project Cultivate – Offered assistance and training for launching the county's syringe service program.
• Indiana Recovery Alliance – A harm reduction program that mobilizes former drug users to help reduce drug use and the stigma that surrounds it.
• Overdose Lifeline, Inc. – Offers advocacy, education, harm reduction, prevention, resources, and support for those affected by OUD/SUD.
• Indiana University School of Medicine – Experts helped establish HIV services at Foundations Family Medicine and an infectious disease doctor commutes to the clinic every week to treat HIV and hepatitis C patients.
• Indiana University School of Public Health and Marian University College of Osteopathic Medicine – Students helped clean Austin's streets, yards, and parks during syringe cleanup events.
• LifeSpring Health System – A psychiatrist visits once a week to provide behavioral health and addiction services to Scott County.
• Indiana State Department of Health – Funds some of Foundations Family Medicine's operations, coordination, and technical assistance surrounding HIV, HCV, and SUD/OUD services. Initially provided care coordinators, a disease intervention specialist, a counselor, a certified HIV tester, and a public health nurse.
• Indiana Department of Mental Health and Addiction – Helped Foundations Family Medicine develop an outpatient MAT program.
• Family and Social Services Administration's Division of Mental Health and Addiction

Local Partners:

• Scott County Health Department – Hosts a county-wide syringe exchange service.
• Centerstone Behavioral Health – Housed within Foundations Family Medicine and offers inpatient treatment for patients with opioid and substance use disorder.
• Community Health Center of Jackson County – Helped Cooke become certified to prescribe HCV medication through Project Echo.
• Norton Scott Hospital – The emergency room implemented CDC's HIV testing guidelines. Patients with SUD and OUD are admitted to the hospital and are referred to needed services.
• Austin pharmacies – Carry an adequate supply of HIV medication for Foundations Family Medicine patients and provides education for patients regarding treatment plans.
• Get Healthy Scott County Coalition – Brings local agencies together to provide care coordination, recovery support, and education for HIV patients and the community.
• Todd's Place – A transitional housing and detox center for men in nearby Seymour that sends residents to Foundations Family Medicine for treatment.
• Together for Scott County: from Darkness to Deliverance – United 34 churches in providing spiritual support and multiplying addiction ministries.
• Hope to Others Church, Inc. – Offers faith-based recovery support services.
• Food 4R Souls and Oasis of Hope Missions – Offer free meals for people in need.
• City of Austin

Services offered

Although Foundations Family Medicine is open to patients every weekday for testing, Cooke sees patients Mondays and Wednesdays for HIV and HCV testing and treatment for those ages 13 and older. Through a gum swab (results take 20 minutes) or prick of the finger (results take 1 minute), results and plans are discussed with the patient during the visit. Although there is still no cure for HIV, treatment through medication can make it undetectable in the body, reducing the risk of passing it to another person and increasing the patient's life expectancy.

Foundations Family Medicine is a fully-integrated clinic, offering rheumatology, sports medicine, advanced diabetes care, primary care, prenatal, behavioral health, case management, and school-based services. When patients come in for HIV, HCV, SUD, or OUD services, they are connected with the following additional services as needed:

• Medication for pre- and post-HIV exposure
• HIV and hepatitis C treatment
• Medication-Assisted Treatment for OUD
• Women's health program, including contraceptive care and STD screening
• Wellness exams
• Infectious disease consultations
• Addiction counseling
• Insurance enrollment assistance
• Consultation about social decisions affecting health
• Care coordination
• Outreach through community health workers
• Job counseling
• Referrals to drug treatment services

Although the Clinic offers outpatient treatment, they also refer patients to Centerstone Recovery Center for Women, a service housed within their building. Centerstone offers inpatient addiction care, SBIRT (Screening, Brief Intervention, and Referral Treatment), Medication-Assisted Treatment (MAT), and other detox treatment and recovery methods for opioid and heroin dependency.

Foundations Family Medicine refers patients to the Scott County Health Department syringe service. This service allows those injecting opioids and other substances to exchange their used needles for new ones with no fear of being arrested.

Cooke sends out their four community health workers to connect with patients who are uncomfortable or unable to visit the clinic. Cooke also tests, treats, and follows up with patients at the Jackson County Jail. Through telehealth services, he can connect with patients seen by community health workers, at the jail, or in other situations. Mobile testing units, supplied by the AIDS Foundation and based in Austin, visit surrounding counties to offer hepatitis C and HIV testing on a regular basis.

Many patients who have made progress in their recovery have become peer recovery coaches. Using a Recovery-Oriented Systems of Care (ROSC) philosophy created by SAMHSA, these coaches are examples of creating a community where recovery is possible for every person.

Results

Although the virus continues to spread throughout Scott County, the rate of infection has significantly decreased, outdoing national suppression rates by a large margin (76% compared to national average of 49%).

As of June 2015:

• 172 new HIV cases discovered (89% co-infected with HCV)
• 126 engaged in treatment
• 25 virally suppressed
• 114 enrolled in care coordination in 2015
• 4 support groups

As of April 2018:

• 222 new HIV cases were discovered (most co-infected with HCV)
• 222 engaged in treatment
• 168 virally suppressed (76% rate)
• 120 enrolled in care coordination in 2018
• 15+ support groups (700% increase in participation)

In addition, Scott County has experienced:

• A decrease in overdose deaths (from 17 in 2016 to 6 in 2017)
• A decrease in chronic HCV cases (from 247 in 2015 to 102 in 2017), while most surrounding counties were experiencing increases
• A decrease in the sharing of used syringes (from 78% to now 22%)
• An increased use of syringe service program (86% of those who inject, 98% of those who inject and have HIV)
• Over 200 women enrolled in Centerstone Recovery Center for Women in 2017 (13 pregnant, 4 had HIV, about 80% diagnosed with HCV)
• Over 30 people have graduated from a local peer recovery coach program

Efforts from Foundations Family Medicine and their partners have also helped to decrease stigma, reunite families, and secure jobs for patients.

Publications:

• Peters et al. (2016). HIV Infection Linked to Injection Use of Oxymorphone in Indiana, 2014-2015. The New England Journal of Medicine, 375(3), 229-239. Article Abstract
• Patel et al. (2018). Reduction of Injection-Related Risk Behaviors After Emergency Implementation of a Syringe Services Program During an HIV Outbreak. Journal of Acquired Immune Deficiency Syndrome, 77(4), 373-382. Article Abstract
• Fraser et al. (2018). Scaling-Up HCV Prevention and Treatment Interventions in Rural United States-Model Projections for Tackling an Increasing Epidemic. Addiction, 113(1), 173-182.

In the news:

• Responding to the HIV Crisis in Scott County, Indiana: Q&A with Dr. William Cooke, the RHIhub Rural Monitor, 2018
• 2019 Family Physician of the Year: Compassion, Faith Drive FPOY to Help Patients, Community, American Academy of Family Physicians, 2018
• Mobile HIV and Hep C testing offers free resources, treatment, News and Tribune, 2018
• Courier Journal Series:
  • Part 1: Healing Austin: How a lone doctor saw drug-fueled HIV plague looming, Courier-Journal, 2017
  • Part 2: Healing Austin: Town races to stop America's worst rural HIV plague, Courier-Journal, 2017
  • Part 3: Healing Austin: Faith lifts small town from depths of HIV plague, Courier-Journal, 2017
• Searching for solutions: Revisiting Austin, Indiana, WHAS11, 2017
• HIV clinic may help Southern Indiana 'win the battle', IndyStar, 2015
• Rural Indiana struggles with drug-fueled HIV epidemic, PBS, 2015
• HIV clinic opens at epicenter of Indiana health crisis, MSNBC, 2015
• First HIV Clinic Set to Open in Indiana Town Beset by Epidemic, ABC News, 2015
• Indiana Races to Fight H.I.V. Surge Tied to Drug Abuse, The New York Times, 2015

Challenges

Although Foundations Family Medicine has seen much success, there have been challenges of many kinds along the way:

Portrayal

• Because of the extreme rise in HIV cases in Austin, extensive media coverage that put the town in a negative light did not sit well with residents. However, the attention also motivated outside supporters and rallied local groups to put resources and energy into the crisis.

Partnerships

• The influx of aid coming in to Scott County started out as disjointed and uncoordinated. While state and national programs offered valued training and funding, local health commissioners were scrambling to get a handle on the HIV problem while local service communities needed to connect to resources. Efforts from the Get Healthy Scott County Coalition helped everyone get on the same page.

Structural

• At the beginning of the epidemic, Medication-Assisted Treatment was offered only through a program 40 minutes away from Austin. At first, those who qualified would have to enroll in a residential treatment facility for at least 60 days before starting treatment. For outpatient services, patients were required to meet with a therapist for several weeks before beginning treatment. Multiple navigation steps also delayed access to care.
• The Indiana Department of Mental Health and Addiction helped Foundations Family Medicine develop an outpatient MAT program. Even so, outpatient MAT requires a detoxification period. Only patients who are highly motivated, have strong family and social support, and stable housing can qualify for this program.

Financial

• Those who are uninsured cannot get coverage for their HIV medical treatment (upwards of $20,000 annually per patient).
• Foundations Family Medicine started offering insurance enrollment assistance for Medicaid and the state insurance plan. Dr. Cooke worked with the State Department of Health to have the county federally designated as medically underserved, which increased the clinic's reimbursement for services and covered some of the cost of treatment for HIV, HCV, and opioid/substance treatment. However, their community health worker program and other public health services still do not receive insurance reimbursement.

Legal

• Because HIV was believed to have entered Austin through needle sharing between opioid users, the county proposed permission from Governor Mike Pence for a needle exchange program. Prior to the request, needle exchange programs were banned by Indiana law. Cooke advocated for the Governor to sign an executive order in 2015, which declared a public health emergency for Scott County and allowed a needle exchange program to operate under state supervision at the Scott County Health Department.
• Since needle exchange services had been illegal in Indiana, there was initial distrust about the newly legalized program. Many with OUD and SUD avoided the exchanges, pinning it as a tactic that police used to arrest offenders and to enforce paraphernalia laws. This misconception died down once patients began using the syringe services and understood the intent behind them.
• The fear of being caught with a syringe is also a reason behind discarding used needles into a yard or ditch so they cannot be used as evidence against them.
• People with OUD who are arrested and placed in jail for other actions sometimes have to wait weeks until they can continue their medication regimen. Because of that, getting patients who are released from prison back into treatment is often difficult.

Cognitive

• Those with OUD or SUD in Scott County are also at greater risk of cognitive barriers, which can affect public health literacy and harm reduction understanding.
• There was also stigma around needle exchange services, which led some to turn a blind eye to a practice they didn't agree with while others blamed the clinic for condoning a drug habit.
• At the beginning, there was a significant lack of understanding that HIV can only be spread through the sharing of needles and sexual intercourse. Misconceptions that HIV can be contracted from shopping carts, drinking fountains, and the exchange of money continued to justify the need for community education. Sessions taught by the sheriff's department and local health department, along with the CDC, have helped in this effort.

Social

• Adverse childhood experiences can contribute to a person's susceptibility to drug use and their risk of contracting HIV. Leading up the HIV outbreak, child abuse cases also increased in Scott County.
• Perceived stigma, the consequences of addiction, guilt, and a sense of hopelessness are common barriers to patients seeking treatment and recovery services. Social determinants of health, like untreated mental illness, homelessness, and poverty have also added to the barriers to getting appropriate care. By working with faith-based and other community services in Austin, Foundations Family Medicine has helped meet these needs.

Replication

Making their services sustainable was one of the large focuses of the HIV Clinic. Through trial and error, their key principles for replicating a similar program have already been used by other communities attempting to stop viruses from spreading:

• Listening to patients about their needs, barriers to care, and treatment methods that work can change the trajectory and speed at which communities, clinics, and agencies respond to a crisis.
• Because someone's environment can significantly affect their health, it is important to invest in social services and care coordination efforts while also addressing the patient's health and substance use dependency. Partnering with local agencies and groups also prevents you from duplicating services and can stretch grant funds.
• Be innovative in reaching out to your community. Engage in nontraditional methods of advertising, including personal invitations through phone calls and door-to-door visits.
• Healthcare services that partner with child-based programs and schools can help build resiliency in children so that a harmful cycle of intergenerational trauma can be broken.
• Contact local churches, your city government, social service agencies, and other local groups to build referral sources. Utilize community health workers to meet with the patients who are not comfortable or are unable to come to the clinic for services. Visit patients in jails to continue treatment, and engage in telehealth methods to extend your reach.
• There is less fear of stigma if a patient's appointment is within a primary care clinic as opposed to a treatment or behavioral health center. Locating HIV, HCV, and SUD/OUD services in a primary care clinic helps maintain patients' anonymity.
• It's important to decrease the structural barriers to medication and care. This involves creating easy access and multiple locations for screenings, local access to HIV treatment, direct access to a medical provider, and streamlining systems and services.

Additional Resources:

• The Rural Health Information Hub's Rural HIV/AID Prevention and Treatment Toolkit includes tips for programs addressing HIV and AIDS.
• The Centers for Disease Control and Prevention created the Outbreak of Recent HIV and HCV Infections among Persons Who Inject Drugs resource based on the Austin epidemic. It includes recommendations for healthcare providers and health departments based on their findings.

Contact Information

Dr. William Cooke, Medical Director
Foundations Family Medicine
812.794.8100
Dad.Cooke@yahoo.com