San Francisco continues to make progress in reducing new HIV infections and expanding access to early treatment, according to a World AIDS Day update on the city's Getting to Zero initiative. But some groups are not benefitting as much as others and need greater focus.
"We have done a lot of good things, but we cannot pat ourselves too much on the back because we have not made a big dent in the disparity statistics," said Dr. Diane Havlir, chief of the Division of HIV/AIDS at Zuckerberg San Francisco General Hospital.
In the wake of the recent election, many in the city's HIV/AIDS community are worried about the consequences of President-elect Donald Trump's incoming administration, including dismantling of the Affordable Care Act and cuts to federal funding of the Ryan White HIV/AIDS program.
But San Francisco is likely to fare better than many other cities.
"I refuse to go backward and I think all of you are with me on that," city Health Director Barbara Garcia, a lesbian, said at the December 1 forum. "You are very fortunate to live in San Francisco and to have the kind of political support that says health is one of the top concerns and needs of our community."
Scott Wiener, a gay man who was on the Board of Supervisors but was sworn in as the city's state senator earlier this month, vowed to advocate for people with HIV in the Legislature.
"It could not be a more scary yet opportune time" to go to Sacramento, Wiener said at the event, held at UCSF's Mission Bay campus. "You can do things [in San Francisco] that you can't do elsewhere. We need to take that statewide. We need to make sure that Getting to Zero is being replicated everywhere, that we're expanding PrEP access everywhere, and we're making sure that everyone with HIV has access to their meds at all times."
Progress in 2015
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 by 2020. It relies on a three-prong strategy of expanded access to PrEP; rapid initiation of antiretroviral therapy, or ART; and engaging and retaining HIV-positive people in care.
The latest San Francisco Department of Public Health HIV epidemiology report, released in September, shows that the number of new HIV diagnoses fell 17 percent in 2015, to 255, the lowest level since the start of the epidemic. The total number of deaths due to all causes among people living with HIV also fell, by about 10 percent, to 197. About 40 percent of those deaths were due to HIV/AIDS-related causes.
And San Francisco continues to do a better job than the U.S. as a whole in moving people through the continuum of care, from HIV testing to linkage to care to initiation of treatment to viral suppression.
But there are still notable disparities. African-Americans are the only group for whom new HIV diagnoses are stable or rising rather than declining, and blacks are more likely to be diagnosed late and less likely to be promptly linked to care. African-Americans accounted for 17 percent of all new HIV diagnoses in San Francisco in 2015, despite making up about 6 percent of the city's population.
Dr. Albert Liu of the DPH reported on behalf of the Getting to Zero PrEP committee that the city recently launched a social marketing campaign – "Our Sexual Revolution" – to encourage gay and bisexual men of color and transgender women to consider daily Truvada (tenofovir/emtricitabine) for HIV prevention.
San Francisco has taken the lead on access to PrEP. Informal estimates suggest that 6,000 to 10,000 people in the city may be taking Truvada for PrEP. However, to date major PrEP providers, including the San Francisco AIDS Foundation's Magnet program at Strut and Kaiser Permanente, have primarily served white and Latino gay men.
Rapid treatment
Dr. Oliver Bacon of UCSF and the HIV Division at SFGH gave a progress report from the Getting to Zero Rapid committee, which aims to get people newly diagnosed with HIV on antiretroviral treatment as soon as possible – ideally the same day.
Currently the median time from diagnosis to initiation of care is seven days and the time from starting care to treatment initiation is six days. Altogether, the time from diagnosis to reaching an undetectable viral load is 69 days – down from 131 days in 2013.
"Physicians around the city are quite willing to do rapid ART," Bacon said. "One of the major barriers to [rapid ART] is insurance status. If you have Medi-Cal or public insurance it's very easy to get rapid ART in San Francisco, but if you're eligible for commercial insurance or are uninsured, it's actually much more difficult."
The city has created the first directory of Rapid providers who can start ART right away, as well as an insurance navigation guide.
Reporting from the retention and re-engagement in care committee, Edwin Charlebois, Ph.D., from UCSF's Center for AIDS Prevention Studies, said that the city has received renewed funding from the MAC AIDS Fund for a linkage demonstration project. A pharmacy working group is exploring whether pharmacists can help identify people at risk of falling out of care.
Stigma is harder to measure than the number of people on PrEP or the length of time to viral suppression, but Austin Padilla from the stigma committee said the goal for the next year is to establish metrics.
HIV among young and old
A member of the audience asked where young people fit into the Getting to Zero plan.
According to the latest HIV Surveillance Report from the Centers for Disease Control and Prevention, young adults age 25-29 are the only age group to see an increase in new HIV diagnoses in 2015. In San Francisco this age group accounts for 23 percent of new diagnoses, while those age 18-24 account for 13 percent.
Liu said that the PrEP committee has identified youth as a high priority and the city is talking about establishing a fund to provide PrEP for young people. Oliver noted that Larkin Street Youth Services was one of the first to sign on to the rapid ART program.
The Getting to Zero meeting concluded with a discussion of HIV and aging. According to the DPH annual report, 60 percent of people living with HIV in San Francisco are age 50 and older.
"We quit our jobs, went on disability, and prepared to die – but some of us didn't," said long-term survivor Hank Trout. "Our golden years are turning into tin."
Vince Crisostomo, manager of SFAF's 50-Plus Network, said that housing is the biggest concern of older people living with HIV in San Francisco.
Dr. Monica Gandhi, medical director of the HIV clinic at SFGH, described a new program – dubbed Golden Compass – that will launch in early January at Ward 86. The program will centralize services for HIV-positive people age 50 and older, including cardiology and neuropsychiatric care, exercise and fitness for bone strength, vision and hearing services, and peer support groups.
"So much in HIV started in San Francisco and we need to be on the forefront of HIV and aging," Gandhi said. "As we work toward the [Getting to Zero] goal, we need to make sure people living with HIV are living better."