San Francisco Determined to Get to Zero When It Comes To HIV

A FDA-approved medication that reduces the risk of HIV by more than 90 percent is a new tool San Francisco’s Department of Public Health is using to help get the city’s HIV infection and HIV deaths to zero.

Taken once daily, the new pre-exposure prophylaxis (PrEP), Truvada®, does not come without controversy. Some suggest Truvada can diminish the public health message of protected sex and could potentially increase sexually transmitted diseases.

“We think the community has embraced PrEP and we have demonstrated evidence” of its effectiveness, says Susan Buchbinder, director of the department’s Bridge HIV, Population Health Division.

The city is expanding its PrEP studies and access to the medication. In doing so, it is training primary care providers to offer PrEP to at-risk patients, creating systems to link at-risk persons to prevention services, helping patients obtain PrEP cost coverage, providing information about PrEP and monitoring the impact of PrEP.

San Francisco is on a mission to be the first city in the nation to reduce HIV infection and HIV/AIDS deaths to zero. Yes, zero. To achieve that lofty goal, the San Francisco Department of Public Health and a broad-based coalition of over 35 organizations launched the San Francisco Getting to Zero Consortium in 2014. To that end, the consortium set a short-term goal of reducing HIV infections and HIV/AIDS deaths by 90 percent by 2020.

From the very beginning of the HIV epidemic, San Francisco has been a leader in its response and in setting standards for prevention, care and treatment. The city has a strong HIV surveillance system, plentiful testing services, syringe access programs, comprehensive care in the public and private sectors, and robust linkages between community organizations and scientists. To see where San Francisco is headed, it’s valuable to understand how far the city has come in combatting the epidemic.

“We would not be where we are without the leadership of the department of health,” says Jeff Sheehy, communications director of the University of California (UCSF), San Francisco’s AIDS Research Institute. The San Francisco Department of Public Health is the only health department with its own clinical trials unit, Bridge HIV, which has been working to find innovative ways to fight HIV/AIDS since the start of the epidemic. In 2011, the department refocused HIV prevention on increasing testing—resulting in more than doubling the number of HIV tests performed annually. About five years ago, the widely respected, health department-run San Francisco General Hospital was the nation’s first to recommend treatment for all persons living with HIV, and the department was the first in the nation to make the recommendation city wide, a policy which has since been adopted nationally.

Such efforts have helped to reduce the number of new HIV diagnoses in the city; for example, in 2013, there were 359 new diagnoses, fewer than half the number in 2002. HIV death rates have dropped by nearly half. The numbers of those with HIV who don’t know they have it have plunged by two thirds—from 18% to 6%. Nine of 10 patients are linked to medical care within 90 days of their diagnosis, while about 65 percent of all HIV-infected residents have achieved undetectable viral loads with antiretroviral therapy, according to the San Francisco Department of Public Health. Patients who have undetectable virus levels are 96 percent less likely to transmit HIV to their uninfected partners.

Still, to achieve the UNAIDS vision of “Zero new HIV infections, Zero HIV deaths and Zero HIV Stigma,” more needed to be done. That message came during a city-wide gathering on World AIDS Day 2013, where a variety of stakeholders said even more could be done if efforts were better integrated with community partners. The city listened. “The community has changed this epidemic from the start,” says Susan Buchbinder, director of the department’s Bridge HIV, Population Health Division, and Getting to Zero represents a “renewed effort” to battle HIV/AIDS in the city. “This really is a collective effort; there is no one entity in charge or owning it,” says Buchbinder, addingthat a steering committee representing multiple institutions helps guide the work.

“Stigma still is a really important issue,” says Buchbinder. Nationally, HIV diagnoses are increasing among those aged 25 to 29, and the highest rate of new infections are among African Americans and Latinos. “It’s an important reason why people don’t get tested, why they don’t get or stay in treatment,” says Buchbinder, adding, “it’s difficult to get the care you need when care is lower on your list of priorities than getting housing or food.”

In order to get to zero, the effort has taken on three elements. “Focusing just on prevention or just on treatment will never be enough,” notes Buchbinder. The three-pronged Getting to Zero effort aims to reduce the number of new HIV infections, cut HIV transmission and preserve health via early treatment and care retention. The initiative includes:

  • PrEP expansion: Pre-exposure prophylaxis (PrEP) has been shown to reduce the risk of HIV infection by more than 90 percent among individuals who are considered high risk. The use of anti-HIV medications by HIV-negative individuals to prevent infection is a fairly new promising prevention method, and the department is expanding its ongoing studies of—and access to—the medication, called Truvada®, which is FDA approved and recommended by the U.S. Centers for Disease Control and Prevention (CDC).
  • RAPID ART: Early diagnosis and treatment of HIV prevents further transmission during the highest-risk period—when a newly infected person is most contagious but unaware of their infection. So the Getting to Zero Consortium is expanding the SFGH/UCSF-based Rapid ART Program Initiative for HIV Diagnosis, which aims to facilitate the start of antiretroviral therapy (ART) and counseling the same day someone is diagnosed with HIV, as well as help transition clients to sustainable long-term HIV care.
  • Retention in HIV Care: Consistent, reliable medical care is critical in Getting to Zero. People with lower incomes, mental health or substance abuse and other vulnerable populations face more acute challenges in receiving consistent care. The consortium is convening HIV providers, service organizations, community advocates and government to identify gaps and coordinate new outreach and retention strategies to keep people in HIV care.

“With one of the highest prevalence levels, San Francisco is dramatically reducing community viral load, and thus incidence,” says Dr. Jeff Levi, executive director of the Trust for America's Health, a non-partisan public health non profit. The city “has fully embraced PrEP. They are the model for making HIV a winnable battle.”