San Francisco's Getting to Zero effort is making good progress toward ending the city's HIV epidemic, consortium members reported at a recent quarterly update. But the new Republican administration in Washington threatens to reverse gains, and more work is needed to reach underserved groups such as people who use drugs.
The Getting to Zero initiative aims to make San Francisco the first city to eliminate 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 (ART), and engaging and retaining HIV-positive people in care.
Federal policy changes
Dana van Gorder, executive director of Project Inform, opened the March 23 meeting with an update on national policy relevant to people with HIV/AIDS and its potential implications for San Francisco and California.
While some federal agencies involved in HIV/AIDS policy and funding have seen a change of leadership, others still have the same heads in place, Van Gorder said. The White House Office of National AIDS Policy is currently unstaffed and its future is unknown. The Ryan White Treatment Modernization Act, which funds many services for people with HIV, appears to be protected for now, but could be affected by overall Health and Human Services cuts.
Van Gorder outlined the Republican effort to repeal and replace the Affordable Care Act, which he said would have "effectively wiped out Medicaid," which covers more than 40 percent of people with HIV. On March 24 House Speaker Paul Ryan (R-Wisconsin) announced that the Republicans' proposed replacement, the American Health Care Act, did not have enough votes to pass.
"You can tell everything is a nightmare �" the only good news is they can't seem to get anything through the House," Van Gorder concluded. But one possible positive point is President Donald Trump's stated desire to bring down drug prices.
San Francisco progress
Reporting for the Getting to Zero PrEP committee, Dr. Albert Liu from the Department of Public Health said that four PrEP programs have now been funded at the San Francisco AIDS Foundation, Mission Neighborhood Health Center/Instituto Familiar de La Raza, Asian and Pacific Islander Wellness Project, and the Lavender Youth Recreation and Information Center.
A new program at Mission Wellness Pharmacy will have pharmacists play a larger role in providing PrEP, and a PrEP emergency fund for youth has been established. DPH has provided PrEP trainings to more than 80 clinical providers and 190 front-line staff since last December, Liu said.
The Getting to Zero RAPID committee has developed a protocol for accelerated antiretroviral treatment, ideally starting the day someone is diagnosed with HIV. Studies have shown that people who start treatment early have better health outcomes and those with undetectable viral load do not transmit HIV to others.
Dr. Oliver Bacon from UCSF reported that 27 office practices and health care organizations in the city are now using RAPID, in addition to Zuckerberg San Francisco General Hospital, where it was initially piloted.
The median time from HIV diagnosis to starting care fell from eight days in 2013 to five by mid-2016. The time from care to treatment initiation dropped from 27 to zero days (that is, ART starts at the first care visit), and the time from diagnosis to reaching undetectable viral load decreased dramatically from 133 to 51 days.
But the news is not all good. About 15 percent of people with HIV in the city are not on antiretroviral treatment, Bacon said. And Andy Scheer, LCSW, from San Francisco City Clinic, reporting from the retention and re-engagement committee, said that among homeless and marginally housed individuals, only 33 percent have achieved viral suppression.
Substance use and HIV
The consortium meeting also featured a panel discussion on substance use, HIV, and stigma.
Kyriell Noon from Glide Harm Reduction Services described his organization's work in the Tenderloin, including clean syringe distribution, safe disposal, rapid HIV and hepatitis C testing and linkage to care, and referral to drug addiction treatment if desired.
"We provide naloxone training for roughly 50 people a month and there have been something like 827 citywide overdoses that have been reversed as a result of this program [in 2016], which is pretty amazing," Noon said, referring to the city's collaborative Drug Overdose Prevention and Education (DOPE) Project.
For crack users, Isaac Jackson from the Urban Survivors Union described his group's harm reduction work, which includes providing new pipes, as old glass pipes can cause burns and cuts on the lips that raise the risk of HIV and hepatitis C transmission.
Dr. Edwin Charlebois from UCSF described PACE �" the Pacing Alcohol Consumption Experiment �" a harm reduction study for gay bar patrons.
Alcohol is considered a driver of HIV infection in San Francisco because while its effect may be small compared to, for example, methamphetamine or injection drug use, heavy drinking is much more common, Charlebois said. Of the 357 liquor licenses in San Francisco, 57 are for gay- or queer-identified bars �" matching the 58 total liquor licenses for all of Oakland �" and gay and bi men are estimated to consume 2.7 million alcoholic drinks per month.
The PACE intervention involved a bar media campaign about pacing the amount of alcohol consumed by alternating alcoholic drinks with water, providing free filtered water, and on-the-spot blood alcohol content testing using an iPad app attached to a breathalyzer.
Researchers compared two bars in the Castro that implemented the intervention and two that did not. They found that the intervention reduced both blood alcohol levels and the likelihood of hazardous drinking.
Finally, Laura Thomas from the Drug Policy Alliance gave an overview of state and city drug policy. At the state level there have been some recent legislative and ballot victories, including expanded access to clean syringes and naloxone, and propositions in November that changed drug possession to a misdemeanor and legalized adult use of marijuana. Advocates are currently supporting Assembly Bill 186, which would allow supervised drug consumption facilities.
At the city level there has been a drop in drug-related arrests and prosecutions and strong support for alternatives to incarceration, but there are still major racial disparities in arrests and in the jail population.
"Overall, California is going in the right direction when it comes to drug policy and harm reduction," Thomas said. "San Francisco is also going in the right direction, but when you look at some of the most basic measures we're failing horribly. The African-American population in the city is 3-6 percent, and yet over half the people in jail are African-American, and that's driven significantly by drug charges."