hiv prevention - sfdph...focus area #1: hiv status awareness • what will be emphasized? • new...
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HIV Prevention HIV Prevention UpdateUpdateGrant Colfax, MD
Director of HIV PreventionSan Francisco Department of Public Health
Community and Public Health CommitteeMarch 16, 2010
HIV Prevention: from the Plan to PracticeOur vision is to end new HIV infections in San FranciscoOur goal is to reduce new HIV infections by 50% by 2015
We will focus efforts in populations at the greatest HIV risk: men who have sex with men, injection drug users, and transfemales who have sex with malesWe will focus efforts in populations with large HIV disparities: African‐American MSM, transfemales who have sex with males
HIV Prevention SectionKey tasksPartners with 37‐member HIV Prevention Planning Council
Emphasis on community‐based input and feedback to set prioritiesContracts with CBOs and other agencies to provide prevention programs
Allocates funding in accordance with distribution of HIV epidemicMonitors and evaluates who we are reaching with prevention servicesRuns condom distribution program (1 million/year)
Supports agencies in delivery of prevention workOversees testing, counseling, and linkages to care (17,000 HIV tests annually)Assists agencies in delivery of interventionsCoordinates and implements health education initiatives
Conducts prevention researchDevelops and tests new prevention interventionsPerforms needs assessments of specific populationsDisseminates research findings to prevention providers and community members
Advocates for improved HIV prevention and treatment policyInvolves local, state, national stakeholdersAddresses both fiscal and legislative issues
Adapted from: El‐Sadr, et al., NEJM 2010
HIV Prevalence, by region and subgroup
0500
10001500200025003000350040004500
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2007
2008
Our endemics
Gay men: Endemic
Injection drug users: Endemic
Heterosexuals: Neither epidemic nor endemic
McFarland, 2009
Relentless inevitability of infection among San Francisco MSM
Age-Specific HIV Prevalence
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
20 25 30 35 40 45 50 55 60
Age
HIV
Pre
vale
nce
Blue line = probability of infection for white MSM; red = AA MSM; McFarland 2007
Community Viral Load
Das et al., CROI 2010
Transm
ission R
ate p
er 10
0 Person‐Years
HIV-1 RNA (copies/ml)
Quinn et al., NEJM 2000
Charlebois et al., CROI 2010
New Directions for HIV PreventionHPS will focus on priority areas in plan
In order to reduce new HIV infections by 50% by2015, the HIV Prevention Plan prioritizes five areas:
• HIV status awareness• Prevention with positives (PWP)• Syringe access• Drivers of HIV• Structural change
Source: HPPC, 2010 San Francisco HIV Prevention Plan
Example of the need for more HIV testing among high‐risk groupsBehavioral Risk Populations (BRPs)
At risk pop. size*
% not tested past 6 mos.**
Testing deficit, 6 mos.
MSM 48,329 54% 26,098
IDU 14,609 58% 8,473
TFSM 1880 UNK UNK
Min. total additional tests needed every 6 months 34,571
*Based on Consensus Estimates, 2010 San Francisco HIV Prevention Plan
**Source: National HIV Behavioral Surveillance (NHBS) study, San Francisco data
Focus Area #1: HIV Status Awareness• What will be emphasized?
• New testing models, including those addressing fear, stigma, andother barriers to testing
• More partner notification by DPH• More detection of early infection by using advanced testing technology
• Indicators of success:• Positivity rate and number of new positives identified• Frequency of testing among high‐risk populations• Linkage to medical care for HIV‐positive individuals
• Goals: • All persons at high‐risk for HIV are tested every 6 months• 90% of HIV‐positive persons are in care within 3 months of diagnosis
Focus Area #2: Prevention with Positives (PWP)
What will be emphasized?Results that measure positive health outcomesIncreased PWP in HIV medical care settingsFocus on persons at high‐risk for transmitting HIVModels that address barriers to care, including stigma, fear, discrimination, etc.
Indicators of success:Engagement and retention in careTreatment adherenceViral load suppression
Goal:All HIV‐positive persons in care are offered treatment90% of those on treatment have undetectable viral loads
We are doing well, but we can do better…
Of 15,757 known HIV cases in SF21% not in routine care28% have detectable viral loadIn 2008, 329 in SF known to have viral load >100k
Correlates of higher viral load are: Transgender, homeless, IDU, African‐American, MSM‐IDU; four neighborhoods w/lowest median incomes
Source: HIV/AIDS Annual Report, 2008
Focus Area #3: Syringe Access
What will be emphasized?Harm reductionProvision of support services with syringe access
Indicators of success:Number of syringes/sterile equipment distributedNumber of contacts made
Goal: All injectors in SF will have access to syringe access programs
Focus Area #4: Drivers of HIVPlan definition of a driver:
Prevalence of 10% or greater in highest‐risk populationsIndependently associated with a minimum 2‐fold increase in risk for HIV infection
What will be emphasized? Drivers in the Plan: ‐ Cocaine/crack ‐ Gonorrhea‐Methamphetamine ‐ Heavy alcohol use‐ Poppers ‐Multiple partners
Indicators of success for programs focusing on drivers:Linkage to HIV testingLinkage to careReduction in drivers
Goal: HPS‐supported programs will focus on one or more drivers
Focus Area #5: Structural Change• Plan definition: “New or modified programs, practices, or policies that
are logically linkable to HIV transmission and acquisition and that can be sustained over time even when key actors are no longer involved.”
• What will be emphasized?
• HIV and STI screening and referral as standard of care in medical settings for persons at risk for HIV
• Universal healthcare coverage for PLWHA• Non‐harassment policies for drug paraphernalia • Client‐level linkages to Healthy SF for comprehensive
healthcare across all our HIV prevention program
• Goal: Successful implementation of structural changes that positively influence one of the other focus areas, or that are associated with declines in HIV incidence
Next steps…Community and provider meetings to discuss and get input on these directions Continued collaboration with colleagues in HIV Health Services, Surveillance, and other DPH programsRFP release in 2010, new contracts in 2011Refinement of data systems to collect programmatic outcome dataContinued research on HIV prevention interventions, including new testing strategies and technologies, pharmacotherapies for stimulant dependence, and more…