San Francisco Stakeholders Flesh Out 'Getting to Zero' HIV Plan

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Public health officials, healthcare providers, and community advocates provided more details and raised more questions about San Francisco's Getting to Zero plan for eliminating new HIV infections at a recent Board of Supervisors hearing. Attendees emphasized that funding for the new initiative should not come at the expense of existing HIV services.

The Getting to Zero plan aims to make San Francisco the first city to eliminate HIV infections through a combination of pre-exposure prophylaxis (PrEP), prompt antiretroviral therapy (ART), and efforts to retain people with HIV in care and treatment. The name refers to UNAIDS' triple goal of zero new infections, zero AIDS deaths, and zero stigma for people living with HIV.

City supervisors Scott Wiener and David Campos, both of whom are openly gay and have been active in efforts to expand access to PrEP, attended the January 21 Budget and Finance Committee hearing in lieu of regular committee members Eric Mar and John Avalos.

"We know that if we're able to get people tested regularly so that they know their status, if when people do become positive they're immediately connected with treatment, [and] if we are able to keep people consistently on treatment so they're healthy and have a suppressed viral load, that will reduce new infections," said Wiener. "If we can get it right here in San Francisco, it will spread to other the parts of the country and other parts of the world."

"To the extent San Francisco has been a sanctuary for so many different people and issues, I think that we should aim to be a sanctuary where there are no new HIV/AIDS infections here in San Francisco," Campos added.

Coalition steering committee member Jeff Sheehy from UCSF explained that idea for Getting to Zero arose after a World AIDS Day forum in December 2013 where participants asked why the many HIV organizations and stakeholders in the city were not working together more closely. A second World AIDS Day forum last month presented the basics of the plan and gathered community feedback.

The coalition, which has grown to more than 3 dozen members, includes representatives from the Board of Supervisors and the mayor's office, the SF Department of Public Health, the University of California San Francisco (UCSF), the San Francisco AIDS Foundation, Project Inform, other local AIDS service organizations, Kaiser Permanente, private HIV care providers, and community advocates.

Good Progress to Date

San Francisco was an epicenter of the early AIDS epidemic and has consistently been a leader in providing new models of care and treatment.

The city has seen a steady decline in new HIV infections, reaching 359 in 2013. The number has fallen in all demographic groups except for young people age 25 to 29, and there have been no HIV infections among newborn babies since 2006, noted steering committee member Neil Giuliani of the San Francisco AIDS Foundation. The number of deaths attributable to HIV has fallen to 182, and there has been an increase in the number of people living with HIV as they survive longer, now nearing 16,000.

Looking at the cascade of care, San Francisco already does better than the U.S. as a whole. In 2012, 94% of people with HIV in San Francisco had been tested and knew their status, compared with 86% nationwide in 2011. Among people diagnosed with HIV in the city in 2012, 89% were linked to care and 68% started treatment and achieved viral suppression. The CDC estimates that 30% of all people with HIV nationwide have achieved viral suppression, but this is not comparable to the San Francisco figure, which only looks people who were diagnosed.

Three-Part Program

The first prong of the three-part Getting to Zero plan involves expanding access to PrEP. Gilead Sciences' Truvada (tenofovir plus emtricitabine) taken once daily has been shown to reduce the risk of HIV infection by more than 90%. In 2014 both the CDC and the World Health Organization advised that at-risk people should consider PrEP.

"I want to emphasize that PrEP is really a game changer," said Susan Buchbinder, director of Bridge HIV at the SF DPH. "We have been in the same place for HIV prevention for the last 30 years [and] have not had any other real new tools to prevent infections."

The latest estimates suggested that fewer than 1000 people in San Francisco are receiving PrEP -- including more than 500 at Kaiser Permanente alone -- though a recent surge in interest has likely increased this number. According to PrEP researcher Robert Grant from the Gladstone Institutes, as many as 6000 city residents could potentially benefit from PrEP.

But cost is a barrier for many people, with a price tag of approximately $1200 per month. This fall the Board of Supervisors passed legislation, introduced by Campos, that allocates approximately $300,000 to hire "navigators" to help people obtain PrEP through existing channels such as private insurance, Medi-Cal, or Gilead's patient assistance programs.

Noting that the Getting to Zero plan relies heavily on PrEP, Campos suggested that $300,000 "is a drop in the bucket" and "may not necessarily reflect the level of commitment that is needed."

The second prong is rapid antiretroviral treatment as soon as people find out they are infected. In 2010 San Francisco was the first city to recommend that all people diagnosed with HIV should start treatment regardless of CD4 T-cell count, which is now reflected in national treatment guidelines.

"During the early phases of HIV, when patients appear to be asymptomatic, levels of virus in the blood are causing inflammation and affecting their organs," explained Diane Havlir, chief of the division of HIV/AIDS at San Francisco General Hospital. "Now we know that at all stages of HIV disease the virus is more toxic than medications, therefore we should be starting treatment immediately."

Havlir added that there is a "2-for-1 benefit" of early therapy because people who start treatment and achieve undetectable viral load dramatically reduce their risk of transmitting HIV -- by 96% in one major study.

Under San Francisco's RAPID ART program, people who are diagnosed with HIV are "offer[ed] treatment on the spot," Havlir said. Getting to Zero seeks to expand this initiative from San Francisco General Hospital and SF DPH clinics to all providers citywide.

The third prong involves retention in care, for example when someone loses their job, their housing, or their health insurance.

"For many diseases, having a short interruption in therapy isn't devastating," Havlir said. "That is not the case for HIV. "When people [stop] taking HIV therapy the virus levels immediately surge and it's very unhealthy for the patient and also puts the community at risk for transmission."

Campos emphasized the existing disparities in access to PrEP and HIV treatment and the many factors that affect outcomes, including lack of housing. Mental health issues and substance use are also barriers facing many people living with or at risk for HIV.

"There are still many disparities in certain communities including the African-American community, the Latino community, and the transgender community," he said. "You can't talk about serving those living with HIV without talking about the other issues that impact their lives."

Campos suggested that the Getting to Zero coalition "doesn't really reflect the diversity of San Francisco," and emphasized the importance of people from the most heavily affected communities "hav[ing] a role in being part of the solution."

More Funding Needed

SF DPH chief financial officer Greg Wagner explained that over past 5 years San Francisco has seen more than $14.6 million in cuts to state and federal HIV funding, with more expected for the coming year. In fiscal year 2014-21015 the city will spend about $36 million for HIV health services, about $15 million for prevention, and about $5 million for epidemiology and research.

The Getting to Zero effort will require additional funding over and above the current HIV budget, although the exact amount has not yet been determined.

"Getting to Zero's first year initiatives are costed out at a bit over 2 million," said Sheehy. "[The coalition] is hoping the city can cover roughly half and is actively seeking funding from foundations, private industry, and other sources for the remainder. We want this to be a public-private initiative."

"We do have a pretty comprehensive plan for PrEP and for RAPID ART, and for retention, and we do believe that all 3 are required to get to zero," Buchbinder concurred. "We believe it needs to be a public and private partnership, so we are approaching both foundations as well as private industry, including Gilead. This is really going to be a very broad consortium."

Several speakers emphasized that funding for the Getting to Zero initiative must not replace existing HIV services and programs.

"This is not a replacement program to replace funding for existing supports and programs," Giuliano stressed. "We're here to talk about a new commitment, a commitment to getting us to zero, that we believe will enable San Francisco to be the first city that ends HIV transmission."

"Our future success in getting to zero is going to be built on the existing foundation of HIV services that we want to make sure does remain intact," said Stephanie Goss from the Asian and Pacific Islander Wellness Center. "We have to ensure we don't leave the most vulnerable and hardest to reach communities behind."

1/29/15