Officials flesh out 'Getting to Zero' HIV plan
by Liz Highleyman
Public health officials, health care providers, and community advocates provided more details and raised more questions about the city's "Getting to Zero" plan for eliminating new HIV infections at a recent Board of Supervisors Budget and Finance Committee hearing.
Attendees emphasized that funding for the new initiative should not come at the expense of existing HIV services.
Gay supervisors Scott Wiener and David Campos, both of whom have been active in efforts to expand access to pre-exposure prophylaxis, or PrEP, attended the January 21 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, who publicly disclosed last fall that he is taking PrEP. "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."
As previously reported, the Getting to Zero plan aims to make San Francisco the first city to eliminate HIV infections through a combination of PrEP, prompt antiretroviral therapy, and efforts to retain people with HIV in care and treatment. The name reflects UNAIDS' triple goal of zero new infections, zero AIDS deaths, and zero stigma for people living with HIV.
The coalition, which has grown to more than three-dozen members, includes representatives from the Board of Supervisors and the mayor's office, the Department of Public Health, 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 Giuliano, SFAF CEO. 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 percent of people with HIV in San Francisco had been tested and knew their status, compared with 82 percent nationwide. While 72 percent of people diagnosed with HIV in the city were linked to care and 63 percent started treatment and achieved viral suppression, the corresponding nationwide figures were 66 percent and 25 percent, respectively.
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 percent.
"I want to emphasize that PrEP is really a game changer," said Susan Buchbinder, director of Bridge HIV at 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 1,000 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 6,000 city residents could potentially benefit from PrEP.
But cost is a barrier for many people, with a price tag of approximately $1,200 per month. Last 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 therapy 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, but this 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 "two-for-one benefit" of early therapy because people who start treatment and achieve undetectable viral load dramatically reduce their risk of transmitting HIV – by 96 percent 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, referring to quick access to antiretroviral therapy. Getting to Zero seeks to expand this initiative from SFGH and 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 having a place at the table.
Need for more funding
DPH chief financial officer Greg Wagner explained that over the past five 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 2014-2015 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," steering committee member Jeff Sheehy told the Bay Area Reporter. "[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."
Several speakers emphasized that funding for the Getting to Zero initiative must not replace existing HIV services and programs.
"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."