San Francisco continues to make progress in reducing new HIV infections and expanding early access to treatment, but stubborn disparities remain, according to a World AIDS Day update on the city's Getting to Zero consortium, held November 29.
Effective antiretroviral therapy that suppresses HIV viral load not only prevents disease progression, but is also a crucial tool for preventing transmission. Getting out the message that "undetectable equals untransmittable" - or U=U - would encourage HIV-positive people to start and stay on treatment, as well as reducing stigma, according to a panel of people living with HIV and service providers.
"It is absolutely clear that treatment as prevention, or U=U, is working and is an incredibly sound public health intervention," Getting to Zero steering committee member Mike Shriver told the Bay Area Reporter.
"Gay men are quite capable of staying adherent to our treatment regimens and we deserve to have healthy sex lives," added Shriver, himself a gay man and co-chair of the San Francisco HIV Community Planning Council.
The Getting to Zero initiative aims to make San Francisco the first city to achieve the UNAIDS goals of eliminating new HIV infections, deaths due to HIV/AIDS, and stigma against people living with HIV. It relies on a three-prong strategy of expanded access to PrEP, rapid initiation of antiretroviral therapy, and retaining HIV-positive people in care.
The San Francisco Department of Public Health's latest HIV epidemiology report, released in September, shows that new HIV infections fell to 223 in 2016, a new all-time low. The city outdoes the country as a whole when it comes to helping people get tested, start treatment as soon as possible after diagnosis, and stay on therapy to achieve viral suppression.
But the latest data show that some groups, including young gay and bisexual men, trans women (there are hardly any data about trans men), people of color, and homeless people, have higher rates of infection and poorer treatment outcomes.
"We lost 165 people living with HIV in San Francisco last year," said Dr. Susan Buchbinder, director of DPH's Bridge HIV research program. "We still have a long way to go."
The way forward may become more challenging in the years ahead due to policy changes at the federal level.
Courtney Mulhern-Pearson of the San Francisco AIDS Foundation gave an overview of pending tax reform legislation that could lead to millions more people without health insurance and steep cuts of Medicaid and Medicare.
San Francisco will see substantial cuts to its HIV budget next year, as funds from the Centers for Disease Control and Prevention are reallocated to jurisdictions with more new infections. But Mayor Ed Lee and the Board of Supervisors have agreed to "backfill" these cuts, keeping funding near its current level. [See related story.]
At the state level, a new PrEP assistance program is expected to start in 2018, which will cover out-of-pocket costs for Truvada (tenofovir/emtricitabine) and associated lab work, according to Mulhern-Pearson.
Dr. Albert Liu of the DPH, giving an update on behalf of the Getting to Zero PrEP committee, noted that an estimated 40 percent of eligible men who have sex with men - or around 12,300 gay and bi men - have started PrEP. Although disparities remain, "we're starting to see some improvement in the gaps," he said.
Dr. Susan Coffey of UCSF, reporting for the RAPID committee, said that the median time from HIV diagnosis to entering care in the city has dropped to five days, and the time from starting care to initiating antiretroviral therapy has fallen to zero days, meaning most people are prescribed treatment during or soon after their first care visit.
U=U
Dr. Matt Spinelli of UCSF outlined the research supporting the concept that people with viral suppression do not transmit HIV, and the history of the movement around it. In September, the CDC for the first time officially acknowledged that U=U.
"Scientists are conservative," Spinelli told the forum. "This was driven by the community."
Two large studies - the PARTNER study, which included mostly heterosexual participants, and Opposites Attract which focused on gay men - saw zero cases of HIV transmission in around 75,000 sex acts between serodiscordant partners when the HIV-positive partner was on treatment with an undetectable viral load.
Panel members living with HIV spoke of the stigma, fear of infecting partners, and fear of rejection that resulted from the persistent belief that HIV-positive people could not safely have sex without condoms no matter how well they adhered to treatment or how low their viral load fell.
"[U=U] gives people a reason to be on meds and it's a tool for engagement in care," said Rob Newells of the AIDS Project of the East Bay. "PrEP let HIV-negative people relax during sex and not worry about transmission. U=U plays the same role for HIV-positive people."
U=U can be a great organizing tool, but the real goal is overcoming disparities and getting people into care, according to Shriver.
"The fact remains that the benefit from HIV treatment is not equal across all the impacted communities and this has to be rectified if we are to see an end to new HIV infections in San Francisco," he told the B.A.R. "Now more than ever, we need to listen to and address the needs of those individuals and those communities that are still experiencing disparities in terms of access to care and culturally appropriate, community-specific services."
Wrapping up the forum, gay founding consortium member and openly HIV-positive San Francisco Supervisor Jeff Sheehy sounded a similar theme.
"We're probably at the most challenging time I've seen in Getting to Zero," Sheehy said. "We have claimed the low-hanging fruit. The challenge is to do something really innovative to reach the people who are missing. In the epidemic all along there have been disparities, but we can again be a model in San Francisco."