Getting to Zero: How San Francisco is Making Progress
On World AIDS Day, the Getting to Zero (GTZ) consortium in San Francisco held a meeting to update community members on progress made toward goals last year. The GTZ consortium aims to make San Francisco the first municipal jurisdiction in the U.S. to achieve zero new HIV infections, zero AIDS-related deaths and zero HIV stigma by the year 2020.
The GTZ consortium is a multifaceted group with representatives from the San Francisco Department of Public Health, community health clinics, nonprofits, hospitals and other community agencies. “In many cities, there’s all sorts of politics and lack of cooperation. And here, we’re really and truly all working together,” said Diane Havlir, MD, chief of the HIV/AIDS division at San Francisco General Hospital.
Here’s what the consortium presented at the December 1 meeting.
RAPID start of antiretroviral therapy
With evidence that early HIV treatment is best for immune system recovery and helps reduce infectiousness, one component of GTZ is focused on getting people who are newly diagnosed into HIV care and on medication. Their goal is to get people with acute or early infection and those with evidence of an advanced infection (i.e., with an opportunistic infection) on antiretroviral therapy (ART) within 48 hours of diagnosis, and all others on ART after five days.
By establishing navigators at sites where people are diagnosed with HIV to help them sort through insurance coverage options, establishing RAPID “hubs” at medical centers and educating providers by producing reference materials and doing trainings, the RAPID committee is making an impact.
Oliver Bacon, MD, shared preliminary data on the RAPID program through the first quarter of 2015. Although data are still being collected for 2015, the median times between diagnosis and starting ART, and between starting ART and reaching viral suppression have decreased. The median number of days to get someone into care after diagnosis went down from 12 in 2014 to 8 in 2015. The median number of days for people to reduce their viral loads to less than 200 copies/mm3 after being linked to care went down from 67 days in 2014 to 50 days in 2015.
“These are all really encouraging numbers and we hope to update you every six months with additions,” said Bacon.
Pre-exposure Prophylaxis (PrEP)
Increasing knowledge and access to PrEP for people who may be at risk of HIV is a central goal of GTZ. The PrEP GTZ committee shared that PrEP knowledge and uptake has increased in the past year, and Brad Hare, MD, a PrEP physician at Kaiser Permanente said that interest in PrEP has “exploded” in San Francisco.
“One of the most common questions is, ‘How many people are on PrEP?’” said Susan Buchbinder, MD, director of Bridge HIV. “Every city is struggling with this. Trying to figure out how to do it [measure PrEP use]. Because it’s not entirely clear exactly how many people are taking PrEP in San Francisco, so one effort of the PrEP GTZ committee is to estimate how many people are on PrEP.
Susan Scheer, PhD, MPH shared news of the PrEP Metrics subcommittee’s progress in measuring PrEP’s uptake in San Francisco with findings from surveys, clinical encounters and reports from providers and medical facilities.
Data from San Francisco City Clinic indicates that about 20% of people knew about PrEP in 2012, and that jumped to about 80% in 2014 and 85% in 2015. A survey of San Francisco City Clinic patients found an increase in PrEP use over time with about 15% reporting PrEP use in 2014 and 20.5% in 2015. Scheer reported that a Stop AIDS Project street-based survey with HIV-negative men who have sex with men found that 15.5% of men reported using PrEP in 2014, and this went up to 23% in 2015.
With data from San Francisco hospitals and providers including Kaiser Permanente, University of California San Francisco and San Francisco AIDS Foundation and others, the GTZ group counted 3,854 people in San Francisco taking PrEP. But Scheer said that these data are subject to limitations including that some providers of PrEP may not have reported their patients on PrEP.
After the event, the PrEP Metrics subcommittee co-chair Jen Hecht, MPH of San Francisco AIDS Foundation said that, after factoring in the limitations of provider data and information from ongoing community-based surveys, she estimates the number of people taking PrEP in San Francisco to be as high as 10,000 but likely somewhere between 7,000 and 8,000. “The PrEP Metrics subcommittee is also actively looking at this data as part of its work,” she said.
Looking forward, the PrEP committee will increase access to populations of people that are currently underserved by expanding and diversifying a PrEP Ambassador Program. “We have this explosion happening, and we want to capitalize on it. We recognize that there are key populations that are not being reached. We want to identify those, and that is one thing the ambassador program is really designed to do is to reach into communities, communities where there isn’t that explosion happening yet and create that fire,” said Hare.
Retention and Reengagement
The Retention and Reengagement committee is focusing on improving navigation and outreach services to meet the needs of people who have fallen out of care, and improve processes to reach people more quickly and efficiently.
“Retention and reengagement is a huge monster. It takes research, coalition building, community and provider buy-in and collaboration. It takes a lot of investment in many, many ways,” said Andy Scheer, as he introduced the issue of efforts to retain people with HIV in medical care.
“We’re seeing a lot of blossoming of navigation programs out there in the city. LINCS (the department of public health’s linkage and navigation program) is working with those programs so there’s collaboration across those navigation programs,” said Scheer.
Navigation services will continue to improve thanks to a $500,000 MAC AIDS Fund grant, which was announced late in October. The grant will fund retention and reengagement support and research at three sites in the city including Ward 86, Tom Waddell and the Castro-Mission Health Center. The committee also will work to expand support services such as mental health and harm reduction services.
The challenge, noted Scheer, is that San Francisco’s housing affordability crisis and shortage of mental health and substance use services hinders efforts to get and keep high-needs people with HIV in care, on medication and virally suppressed.
Austin Padilla presented a progress report for the Ending Stigma committee. The group “was just an idea” last year, said Padilla, and now includes 22 members. Padilla highlighted two main goals for 2016: to find out more about stigma in San Francisco and to engage people affected by stigma.
A city-wide needs assessment, with community member surveys, focus groups and web-based surveys will be used to direct the Ending Stigma committee’s efforts. The committee will advocate against stigma by holding a “speaker’s bureau” with 30 people speaking about issues such as HIV decriminalization. They will also conduct a social marketing campaign centered on a digital storytelling project.
“I did a digital storytelling myself as a poz person, and it was incredible helpful to me,” said Padilla. He said that the films people submit about stigma will live online, and that people will be encouraged to submit their own video-based stories to the site.
Find out how to get involved with the Getting to Zero consortium and read the latest updates on progress toward goals at www.gettingtozerosf.org.
Slides from the World AIDS Day presentation are available at gettingtozerosf.org/world-aids-day-report-back/.