6,000 people on PrEP in San Francisco
by Liz Highleyman
The San Francisco AIDS Foundation's Strut sexual health program celebrated its 1,000th PrEP prescription at a party last Friday, May 26. Along with other large PrEP programs and private providers in the city, the number of people on PrEP is now thought to exceed 6,000, a majority of them gay and bisexual men.
"Hitting 1,000 enrollments in our PrEP health program has highlighted the tremendous demand for PrEP in San Francisco," Strut nursing director Pierre-Cédric Crouch told the Bay Area Reporter . "Our clients have been returning to the clinic with happier and healthier relationships and sex lives. We're delighted to share that experience with them."
The U.S. Food and Drug Administration approved Gilead Science's Truvada (tenofovir/emtricitabine) for HIV pre-exposure prophylaxis in July 2012. Adoption was initially slow, but took off in San Francisco starting in late 2013 as gay men began to promote PrEP within their communities.
Studies of gay and bisexual men and transgender women have shown that Truvada reduces the risk of HIV infection by more than 90 percent if used consistently, with no new infections among people who take it at least four times a week.
Standing over a cake in the shape of a blue Truvada pill, Crouch said that when he first heard about PrEP he thought people would come into Magnet, learn about PrEP, and then get it from their providers, "but it didn't work out that way."
PrEP was initially expected to account for 20 percent of clients at Magnet, which became part of the Strut health and wellness center in January. Now about half of Strut's daily clients come for PrEP, according to former director of sexual health services Steve Gibson, who is now HIV prevention branch chief at the State Office of AIDS in Sacramento.
At the National HIV Prevention Conference last December Gibson reported that adherence to PrEP remained high among Magnet's clients and there were no new infections among those who took Truvada regularly.
As of last week the total number of PrEP clients at Strut, which focuses on gay and bi men, was "just shy of 1,100," Crouch said. In addition, there are 60 PrEP clients currently enrolled at SFAF's Market Street headquarters, which receives referrals from Glide (which sees a diverse population of homeless and low-income clients in the Tenderloin) and St. James Infirmary (which serves sex workers of all genders).
Crouch said that Strut's nurse-led clinic has been able to safely and effectively provide PrEP, while navigators are on hand to help figure out how to pay for it.
"Most clients making less than $58,000 annually pay nothing out of pocket for Truvada," navigator Jayne Gagliano told the B.A.R. "Our goal is helping uninsured and insured people access this powerful prevention tool for little or no cost to them, and we've been very successful."
"As a partner in San Francisco's Getting to Zero consortium, we are helping lead the way to zero new HIV infections by empowering people to proactively protect their health – with our PrEP health program as an integral part of that strategy," said SFAF's new CEO Joe Hollendoner. "We are delighted to reach this significant milestone of 1,000 enrolled clients and look forward to seeing our program continue to grow and meet the sexual health needs of the community."
PrEP elsewhere in San Francisco
It is difficult to estimate how many people have used PrEP, since this information is not centrally collected. But experts estimate that upwards of 40,000 people in the U.S. are taking it, with San Francisco being ahead of the curve.
Strut's sexual health program is not the largest PrEP program in the city – that distinction goes to Kaiser Permanente San Francisco, which serves approximately 225,000 patients, or roughly a quarter of the city's population.
Dr. Brad Hare, Kaiser's director of HIV care and prevention, told the B.A.R. that his program sees about 90 PrEP clients a month – a majority of them men who have sex with men – and expects to reach 1,800 prescriptions this week.
Hare's team reported in a medical journal last fall that there had been no new HIV infections among the first 650 people who received PrEP at Kaiser SF since 2012.
Turning to city-run facilities, just over 500 people have started PrEP at San Francisco City Clinic since February 2015, according to Robert Wilder Blue, the clinic's coordinator of HIV prevention services.
Prior to that, City Clinic enrolled 300 people in one of the country's first PrEP demonstration projects, some of whom may have gone on to receive regular ongoing prescriptions. Dr. Albert Liu from the SF Department of Public Health reported last year that no one who used PrEP consistently became infected with HIV during the demo project.
In addition, SF DPH's Dr. Hyman Scott told the B.A.R. that there were approximately 220 people on PrEP within the department's primary care clinics.
Finally, at a World AIDS Day update on San Francisco's Getting to Zero initiative last December, the consortium's PrEP committee reported that as of November 2015 roughly 700 people were receiving PrEP at hospitals (including SF General Hospital, UCSF Medical Center, and the SF Veterans Affairs Medical Center) and more than 1,700 were known to be receiving PrEP through private providers and medical groups – numbers that have no doubt risen.
Altogether, this brings the total number of people receiving PrEP in the city to over 6,000, though this is likely an underestimate due to missing sources including the rest of the UCSF health system, other hospitals, and non-DPH-affiliated health centers.
"I think about half of people in San Francisco get their PrEP from primary care providers," said PrEP researcher Dr. Robert Grant from the UCSF Gladstone Institutes, noting that UCSF's PrEP service sees between 100 and 200 people. "While we should celebrate the big services, we should also highlight how primary care providers have stepped up."
Others pointed to the challenges that remain.
"Seeing such a significant interest in PrEP is very encouraging," Hare told the B.A.R. "But we have to remember that PrEP isn't right for everyone, and not everyone who could benefit from PrEP has access to it. There is still much work to be done."