“Dream big, take risks”: How NYC is on the way to ending its AIDS epidemic
On the final day of CROI 2017, Demetre Daskalakis, MD, MPH, delivered an inspirational plenary session presentation about how New York City has re-imagined its HIV prevention, treatment and care services—to get on track with ending its epidemic in the coming years.
“HIV is the symptom, not the disease,” Daskalakis emphasized, as he explained the reasoning behind why the city has ramped up services related to housing, post-exposure prophylaxis, PrEP, rapid antiretroviral start and other health services. “It should not be the main message for priority populations. Address their priority needs first.”
The end of STD clinics
“As of last week, STD clinics are dead,” said Daskalakis.
Which isn’t to say that NYC isn’t providing testing and treatment for sexually transmitted infections and HIV. Instead, STD clinics have been re-imagined in NYC—as sexual health “destination centers” that focus on health instead of disease. These health clinics now feature expanded hours to improve access, screening services for asymptomatic clients, modern STD diagnostics, enhanced HPV-related services and quick-start contraceptives for women.
Curious about how another U.S. city is making strides to end their HIV epidemic? San Francisco’s Getting to Zero consortium is working towards zero new HIV infections, zero HIV stigma and zero AIDS-related deaths. Read an update on the epidemic in San Francisco and what the Getting to Zero consortium has accomplished in three years.
The improved model of care places HIV at the forefront of services offered—for both people living with HIV and those who are HIV-negative.
This is important, said Daskalakis, because STD clinics see the population of people who could benefit the most from improved HIV prevention and treatment services. They’re where many Black and Latino men who have sex with men (MSM) and transgender people receive their sexual health care, said Daskalakis. One study estimated that one out of every 42 MSM who visit a New York City STD clinic seroconvert within a year—so the need for improved HIV services at these clinics has been demonstrated.
The demand for those services is there too. “Thousands and thousands” of potential pre-exposure prophylaxis (PrEP) candidates are seen at the clinics every year, said Daskalakis. One survey of NYC STD clinic clients revealed that 65% of people were willing to start PrEP at those clinics.
“The dialogue of, ‘You’re being treated for your syphilis, thank you for coming, come back for testing in three to six months’ is over. Now, the dialogue is, ‘Thank you for coming to our sexual health clinic. We’re treating you for syphilis. Do you want to start PrEP today?’ That’s the change,” said Daskalakis.
Increasing access to PrEP, PEP and HIV treatment
Sexual health centers are now focused on being efficient gateways for PrEP, post-exposure prophylaxis (PEP), and antiretrovirals (ARVs) for HIV treatment. People are able to access same-day start of PEP (which can prevent HIV infection if the medications are started as soon as possible after a potential HIV exposure), PrEP and HIV treatment.
The same-day start of ARVs, for people who newly test positive for HIV or are re-engaging with their care, is called “JumpstART,” and is modeled after the RAPID Program established at Ward 86 in San Francisco. People starting ART (and PrEP or PEP), are also linked to a social worker who helps them figure our insurance options and work through barriers to continued care. They are then linked to longer-term care and services.
PEP, which can prevent seroconversion if taken immediately after an HIV exposure, is a “really important” service, said Daskalakis, but “a mess in every jurisdiction, including ours.”
Ramping up the provision of PEP, given to people after a suspected HIV exposure, is a big part of NYC’s plan. To improve PEP delivery, Daskalakis said NYC has established a 24-hour PEP hotline, which people can call for information on where to receive services. People stopping in to sexual health centers will be provided with the first dose of PEP immediately, then linked to a navigation for longer-term care.
“We’re trying to fix PEP, and I think we’ll be able to,” said Daskalakis.
Increasing access to PrEP is also a priority. As of October 2016, PrEP navigation has been offered at every sexual health clinic in NYC. In one clinic only, reported Daskalakis, there have been 61 PrEP starts so far—62% among people who are Black and Latino.
“It’s going to be very exciting as we get all these interventions to scale,” he said.
Supporting priority populations
“Men who have sex with men and transgender individuals continue to be over-represented in our epidemic,” said Daskalakis, a statement which is true not only in NYC, but in other places in the U.S. as well. “We have significant disparities in our jurisdiction. You can’t just change the HIV epidemic in one population—it needs to be a population-wide strategy.”
To support transgender people in reducing risk for HIV and improving the health of transgender people living with HIV, Daskalakis reported that NYC is helping transgender-led and transgender-focused organizations increase their reach with funding and infrastructure support. “Some of our organizations increased their funding by 100-fold,” he said.
Supporting people who are homeless or marginally housed is also part of NYC’s plan, since inadequate housing is associated with higher viral loads and failure to attain viral suppression in people living with HIV. Daskalakis said that NYC has changed the HIV/AIDS Service Administration program’s qualification criteria—so that people living with HIV can qualify for housing support independent of disease state. Since the Fall of 2016, 1,000 clients have been housed who would not have previously qualified under the previous set of rules.
Dream big, and take risks
Daskalakis ended the plenary talk by encouraging audience members to “dream big, and take risks,” and work together to enact lasting change. “Government and community advocates must work together and create a unified narrative. One voice is stronger.”
“It seems pretty clear that we’re heading in the right direction. If we accelerate, I bet we can get below 600 new infections by 2020. So we’re really on the right track.”
Daskalakis, D. If you can make it there: Ending the HIV epidemic in New York. CROI 2017 Plenary Session. Watch the webcast.