Getting to Zero in San Francisco
At a town hall meeting one year ago, the San Francisco Getting to Zero idea took root. As explained by Diane Havlir, MD, chief of the HIV/AIDS division at San Francisco General Hospital, members of the Getting to Zero consortium have a simple, yet ambitious goal: to have San Francisco be the first jurisdiction in the U.S. to get to zero new HIV infections, zero HIV deaths, and zero HIV stigma.
This year, on December 1, 2014—World AIDS Day—Havlir, along with Neil Giuliano, CEO of San Francisco AIDS Foundation, co-convened a town hall meeting at San Francisco Department of Public Health to provide an update on the Getting to Zero consortium’s progress over the past year.
Members of this consortium form a powerful, knowledgeable, and passionate group. This independent group operates with the understanding that collective action—across public and private sectors—will ultimately hold the key to significant change. At the meeting, a core group of consortium members joined Havlir and Giuliano to present highlights from the Getting to Zero update and draft strategy.
Here’s what they shared.
Where We Are Now
Compared to the nation, San Francisco is doing well to care for people along the HIV continuum of care, but there’s still significant work to be done. Supervisor Scott Weiner shared data from the Applied Research, Community Health, Epidemiology, and Surveillance unit at San Francisco Department of Public Health. Ninety-four percent of people living with HIV in San Francisco have been diagnosed, 72% have been linked to care, and 63% are virally suppressed. Viral suppression is critical to ensuring the best possible individual health outcomes in addition to preventing subsequent transmission. The fact that nearly two-thirds of those in SF are virally suppressed—compared to less than a third of people nationwide—is encouraging.
Over the last seven years, San Francisco has achieved a 30% decline in the number of new HIV cases—there were a total of 359 new HIV diagnoses in 2013. The number of AIDS deaths has also been on the decline, with a 50% reduction in the number of deaths attributed to AIDS in the last seven years. Last year, 182 San Franciscans died of AIDS. We have also seen improved survival rates for homeless people living with HIV. Even though new HIV cases overall are declining, new HIV diagnoses among young adults (25 to 29 years old) are on the rise. And race-based disparities are evident, with higher numbers of new infections occurring among African Americans and Latinos.
HIV Prevention Including PrEP
The first part of the consortium’s program will be to invest in HIV prevention programming including increasing awareness, education, and access to Truvada-based pre-exposure prophylaxis (PrEP) in order to curb further HIV transmission. “San Francisco has always been the leader in PrEP, and we need to continue to be there.” sums Havlir.
Susan Buchbinder, MD, director of Bridge HIV at San Francisco Department of Public Health, shared evidence of PrEP’s effectiveness in preventing HIV infections. “PrEP does work, and it works really well. But you have to take it in order for it to work. The good news is that PrEP has some forgiveness. Meaning that you can skip a pill here and there and it still seems to work for rectal transmission,” she explained. But at this point, there’s not enough information about how effective intermittent dosing works, so only daily dosing is recommended by CDC.
Since Truvada for PrEP was approved in 2012, Kaiser Permanente has kept track of referrals and prescriptions to document demand and uptake. Brad Hare, MD, a PrEP provider at Kaiser, shared data from Kaiser’s PrEP program to demonstrate the demand for PrEP in San Francisco over the past two years.
He explained that earlier this year, new referrals for PrEP took off. “There’s an incredible demand for PrEP in the city,” explained Hare. Kaiser has had over 800 PrEP referrals and has thus far provided PrEP for over 500 people—the majority of which, Hare says, are high-risk men who have sex with men with multiple partners or in serodiscordant relationships. But, he notes that there are fewer women, transgender people, and injection drug users taking PrEP—all who may benefit from PrEP, so there is still room for more advocacy and education among other at-risk communities.
Hare explained that he’s seen a shift in why people are coming in to access PrEP. “What we’re seeing now from people who are referred is that it’s become a norm. Word is really getting around, so we’ve really seen demand skyrocket.”
There haven’t been any HIV infections among Kaiser patients started on PrEP. And adherence to PrEP, inferred from pharmacy refill data, seems to be high.
One substantial barrier for people interested in accessing PrEP is cost. It’s especially challenging for people who are uninsured but have higher incomes—Truvada can cost $1250/month in addition to costs for lab work and office visits without coverage from government assistance programs like Medi-Cal. To help people figure out how to pay for PrEP, the consortium aims to establish a program that will link prospective PrEP patients to navigators who help identify public and private insurance coverage and assistance programs.
The consortium will focus their work on PrEP on three main areas: users and potential users, providers, and outcomes measurement. Their goals are to launch a wide-spread education campaign and establish a hotline so that people can continue to learn about PrEP. They’d also like to increase and diversify the clinicians who are providing PrEP, to include specialties such as OB/GYNs, adolescent medicine providers, and mental health professionals. A “warmline” for providers will provide consultation help.
Rapid Linkage and Treatment
The Rapid Antiretroviral Program Initiative for new Diagnoses (RAPID) program has been in place at San Francisco General Hospital for a little over a year. This program eliminates some of the logistical barriers that prevent people who are newly diagnosed with HIV from getting into care and starting antiretrovirals.
Tim Patriarca, of San Francisco AIDS Foundation, explained RAPID this way. “Right before Thanksgiving we had an acute infection at Magnet. The links coordinator who’s embedded at Magnet made a referral to the RAPID program. The person who tested positive about an hour later was in a cab to general hospital—met with one of [Dr.] Hatano’s colleagues, and literally within another hour had taken their first dose of antiretrovirals. Then they met with a social worker to figure out how to pay for the drugs.”
About 50 people have been a part of the RAPID program, and Patriarca notes that most people who are approached to participate want to start treatment right away. Right now the only place RAPID operates is at San Francisco General Hospital. “We’d like to build on the program—that’s already working—and put it on steroids,” Patriarca explained. The consortium plans to do this by creating “hubs” providing immediate access to antiretroviral medications across the city. To do this, they’ll need more navigators, better provider awareness, clinical standards of care that providers can follow to start ART rapidly, emergency supplies of antiretrovirals on hand, and a way to share program practices with other cities.
Retention in Care
Being able to keep people engaged in care—ensuring that they see HIV providers on a regular basis—is a big part of the consortium’s focus. Dana Van Gorder, of Project Inform, shared some of the challenges associated with retaining HIV patients in care. For one, providers don’t have a system, or lack the capacity, to keep track of patients who miss appointments and fall out of care.
“I don’t want to be trite, but my dentist—and probably your dentist—makes sure that I never miss an appointment. And if I do miss an appointment, it’s rescheduled, and somehow I can’t manage to go without dental care. But I sure can go without making all my HIV appointments. I can go for lengthy periods of time without getting my labs done,” Van Gorder explained.
In addition to this, surveillance data and medical record information can make it difficult to see why patients are missing appointments. In addition to being truly lost to follow up, people may move, or otherwise transfer their care to another clinic. Mental health issues, addiction, homelessness, and poverty can also be barriers to continuous care.
Diane Jones, RN, a long-time nurse at SFGH’s Ward 86, expanded on these barriers to retention in care, by explaining how stigma, shame, and loss of insurance can prevent people from getting the medical care they need.
“Say I’m a 62-year-old white lesbian, I’m virally suppressed, and Brad Hare is my doctor at Kaiser. The standard of care is that maybe I come in once every 6 months, maybe even once a year. He knows me, he trusts me, but maybe I lose my job, and I lose my Kaiser. And who pays attention or notices—how am I going to deal with my life falling apart? And I have shame because I lost my job, and lost my insurance. Where do I go to get the help I need? And this is for a white, 62-year old person. Now imagine I’m an 18-year-old African American gay man, who is in the closet, who’s still dependent on my parents who don’t know that I’m HIV positive. How do I stay in care?”
To keep people in care, the consortium is proposing a patient assistance hotline, that can help people navigate care options if they’re not currently in care. In addition, the consortium aims to strengthen the role of case managers so that they can collaborate and communicate about patient visits, to improve surveillance systems to increase awareness of when patients truly fall out of care, and to increase support services such as affordable housing, mental health, and substance abuse treatment services.
“The consortium’s proposals are a good first step towards addressing the retention challenges but we know that ultimately we won’t be successful in our goals unless we are able to meaningfully address the mental health, substance use and housing issues that so many of our clients face. I am excited about the momentum this group is gaining and look forward to working together to tackle these larger systemic issues,” notes Courtney Mulhern-Pearson, MPH, a Getting to Zero Consortium member and director of state and local affairs at San Francisco AIDS Foundation.
The Way Forward
The consortium’s short-term, measurable goal is to reduce the number of new HIV infections and HIV deaths by 90% from their current levels by the year 2020. To do that, the support of providers, patients, public health officials, foundations, private corporations, and community members will be needed. The strategic plan—still in draft form—will guide efforts.
“This is a draft. We really need input from the community for us to take this to the public sector and those in the private sector who we may want to talk to about this plan, as well. We need input, and we want to hear your ideas,” said Giuliano.