getting to zero: will san francisco be the first city to succeed? diane havlir, md, professor of...
TRANSCRIPT
Getting to Zero: Will San Francisco be the first city to
succeed?
Diane Havlir, MD, Professor of Medicine, UCSF, Chief HIV San Francisco General Hospital
Susan Buchbinder, SF Department of Public Health, Director of Bridge Professor UCSF
Outline
• San Francisco epidemic
• Key aspects of the response
• Getting to Zero
New HIV diagnoses & deaths, San Francisco
Characteristics of new HIV diagnoses,San Francisco
• 93% male• 86% MSM or
MSM/IDU• Total of 14
new dx’es in women 2014
• 71% 25-49 yo• 12% <25 yo• 17% >50 yo
Total # new HIV diagnoses by race/ethnicity, San Francisco
*
Significant decline*
Characteristics of persons living with HIV, San Francisco
• 92% Male
• 39% Persons of Color
• 4% <25 years of age
• 58% >50 years of age
HIV and Non-HIV Deaths in PWA, SF
Non-HIV Causes of Death, SF
Summary1. The number of new HIV diagnoses has
decreased in San Francisco, but we still have hundreds of new HIV infections every year
2. New diagnosis are being recognized in all adult age groups, and are disproportionately affecting persons of color
3. We have an aging population of persons living with HIV and continue to have preventable deaths
HIV testing in San Francisco
• HIV testing is the gateway to treatment and prevention• 93% of persons with HIV in San Francisco are aware of
their HIV status• Key lesson learned: Multi-pronged approach to HIV
testing scale up successful in San Francisco– 2010 18,000 tests
– 2014 25,000 tests
Median CD4 at time of HIV Diagnosis, San Francisco
Year CD4 cells/mm3 at diagnosis
2008 394
2009 409
2010 411
2011 438
2012 422
2013 443
HIV Care Cascade, San Francisco compared with CA and USA
Summary 1. HIV diagnosis is occurring earlier after
infection, but 18% are “late presenters” (develop AIDS within 3 months of first HIV diagnosis)
2. ART is being initiated earlier after diagnosis
3. Linkage, retention and viral suppression still have major gaps
SF Response: Key components
• Political will and financial support– Ryan White essential, SF City backfills federal cuts in
funding
• Innovation at program level– HIV testing access– Treat on diagnosis– first in world 2010– San Francisco Model of Care
• Innovation comes from NIH and state funded research– PrEP, care delivery (US and global), cure, vaccine
“Getting to Zero” in San FranciscoConsortium
Zero new HIV infectionsZero HIV deathsZero stigma and discrimination
Photo by Jim Herd Photo by Rich Niewoski
www.gettingtozerosf.org
How it began….
“This is all interesting, but are you working
together?”
--Community member
Getting to Zero SF: What are we?
• Multi-sector independent consortium– operates under principles of collective impact: “Commitment of groups from different sectors to a common agenda to solve a specific problem.”
• Vision –Become the first municipal jurisdiction in the United States to achieve the UNAIDS vision of “Getting to Zero”
90% reduction in new HIV infections by 2020
Strategic Plan: Signature Initiatives
1. City wide coordinated PrEP program
2. Rapid ART start with treatment hubs
3. Patient centered linkage, engagement, retention in care
Committee for each initiative + stigma committee has action plan, metrics
and milestones. City of San Francisco provided additional funding 2015-6 for
new initiatives
PREP use in Kaiser San Francisco
• July 2012-Feb 2015
• 1035 referrals
• 677 initiations
• 20 re-starters
Volk, Hare, CID, 2015
Second Initiative: RAPID: Treatment on Diagnosis
1. Concept of “Collapsing the cascade” or “Treatment Upon Diagnosis” --being evaluated here in San Francisco and in Africa
2. Treatment on Diagnosis• Reduce risk of HIV complications • For acute/early HIV decrease the size of the HIV
reservoir • Reduce HIV transmission • May help empower patient• May increase retention
Third Initiative: Retention -- Achilles Heal of the Cascade
• We know many of the barriers: socioeconomic, unstable housing, addiction, stigma, denial, fragmented health system, mental health
• We don’t understand enough about motivations of our clients and where and how we might make a difference – need research
• We need to act while waiting for the research by expanding and evaluating innovative city programs
Getting to Zero: Will San Francisco Be the first city to succeed?
Test, PreP and Treat, “San Francisco style”
Universal ART
PrEP
Getting to Zero