San Francisco's "Getting to Zero" Initiative and HIV Pre-exposure Prophylaxis (PrEP)

San Francisco's 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; (see below for a description)  rapid initiation of antiretroviral therapy, or ART; and engaging and retaining HIV-positive people in care. At a report presented on World Aids Day, December 1, 2016, progress was celebrated, along with a recognition that San Francisco still has far to go, particularly since there are still significant disparities between populations.

"HIV Pre-exposure Prophylaxis , or PrEP , is a critical component of the Getting to Zero strategy for ending the HIV epidemic in San Francisco. PrEP is a co - formulated pill (emtricitabine/tenofovir[Truvada®]) taken daily and can reduce the risk of HIV transmission by over 90 %. PrEP complements other proven HIV prevention options, such as reducing the number of partners , consistent use of condoms, needle and syringe exchange, and suppressing viral load through use of HIV medication among those who are HIV infected. Current surveillance data estimates 12,500 SF residents on PrEP." (www.sfdph.org).

The San Francisco Department of Public Health has published a handy two page information sheet regarding PrEP.  Please see the link here https://www.sfdph.org/dph/files/newsMediadocs/2016PR/AskAboutPrEPandHelpSFGettoZero12012016.pdf as well as Project Inform's detailed chart about how to get PrEP, which can be found at http://www.projectinform.org/pdf/PrEP_Flow_Chart.pdf. 

 

 

 

 

 

 

 

 

 

 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."

LEARN MORE ABOUT VACCINATIONS FROM THE CDC "YOU CALL THE SHOTS"

The Center for Disease Control has free, on line learning modules regarding the latest science on vaccines.  On

http://www.cdc.gov/vaccines/ed/youcalltheshots.html   You Call the Shots is an interactive, web-based immunization training course. It consists of a series of modules that discuss vaccine-preventable diseases and explain the latest recommendations for vaccine use. Each module provides learning opportunities, self-test practice questions, reference and resource materials, and an extensive glossary where you can learn about:

 

Wanted: More Physicians to Serve in Community Health Centers

A recent article in "Modern Health Care" summed up the urgent problems of recruiting physicians for community health centers:

 "The limited supply of primary-care doctors and other clinical staff dedicated to the field has increased competition among healthcare providers to attract these key personnel. Federally qualified health centers often lose out in the scramble.

The larger health systems and hospitals have the wherewithal to offer lucrative signing bonuses and financial incentives to prospective employees. Community health centers do not.

“In any given market, whether it be small or large, there are at least 10 different delivery systems a family practitioner can practice in,” said Travis Singleton, senior vice president at physician search firm Merritt Hawkins. “That wasn't the world that we had 10 years ago.”

Many factors fuel the trend. One of the largest came with the implementation of the Affordable Care Act, as millions of newly insured Americans gained access to routine healthcare. Other causes include population growth, an increased elderly population and the likelihood that as many as one-third of the current physician workforce will retire over the next decade.

The confluence of factors has raised the possibility of a shortage of primary-care providers over the next decade. The Association of American Medical Colleges estimates the shortfall will reach between 14,900 and 35,600 physicians by 2025, according to a recent report.

A recent survey on physician recruiting by Merritt Hawkins showed family physicians are the most sought-after specialty for the 10th straight year. Urgent-care physicians, a growing alternative, have moved from 20th most requested in 2015 to ninth in 2016. Average starting salaries rose 13% to $225,000 in 2016 from a year earlier.

The nation's 1,200 community health centers are expected to be hit hardest by the shortage, experts say. The 10,000 primary-care physicians now at community health centers will need to be supplemented by an additional 15,000 providers over the next 10 years."

Here in San Francisco, recruitment is made more difficult because of the high cost of living and the fact that the scoring that is used to provide Federal Loan Repayment, traditionally a strong recruiting tool for doctors coming out of medical school with thousands of dollars in debt, disadvantages high cost, high density urban areas.

SFCCC is working with local, state and national partners on a series of initiatives to ameliorate this problem.  The California Primary Care Association (CPCA) has laid out the following priority recommendations and we will be adding local priorities and projects to address these issues.

CPCA Overarching Priority Recommendations

1. EDUCATE the public and key stakeholders about growing primary care access, quality, and cost challenges

2.  IMPROVE documentation and communication of emerging primary care workforce problems and consequences.

3. SECURE additional investment and partnerships to accelerate primary care transformation within CCHCs including pilot projects, training, technical assistance, and shared learning.

4.INCREASE the number of primary care residencies in California with a priority focus on residencies in community health centers and medically underserved regions.

5. EXPAND loan repayment funds and provisions to incentivize new and existing providers to practice in CCHCs.

6. ADVOCATE for funds to expand medical schools targeting candidates committed to primary care practice in underserved areas

7. DEVELOPformal ongoing relationships between CPCA and other key advocacy organizations and build an inclusive broad-based coalition to focus explicitly on primary care access and workforce-related policy solutions.

8. DEVELOP state level public-private entity with the necessary expertise, capacity, and relationships to advance collaborative primary care workforce solutions. Convene a process for development of a multi-year strategic plan for California to strengthen primary care capacity and access.

9. ACCELERATE and expand payment reform and pilot projects that align financial incentives and regulations with new team-based primary care models.

 

Facts About HIV/AIDS in San Francisco

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San Francisco has an estimated 15,979 people living with HIV.  In 2014, there were 302 newly diagnosed HIV cases, a decrease in number from recent years.

86% of new HIV diagnoses are among gay and bisexual men. In the past five years, the proportion of Latinos ( 27% in 2014) and Asian/Pacific Islanders ( 13% in 2014) who make up new HIV diagnoses has increased.   African-Americans are disproportionately represented among new HIV infections, with 11% of new diagnoses among African-Americans in 2014, while only 6% of San Francisco’s population is African-American.  Survival after AIDS diagnosis is worse for African-Americans than for other racial/ethnic groups.

The proportion of new diagnoses among people ages 25 to 29 years dropped from 21% to 17% between 2013 and 2014.  In 2014, more than 58% of those living with HIV in San Francisco were over fifty years old.

On average, 62% of people newly diagnosed with HIV achieve viral suppression within a year of diagnosis in San Francisco.  Among all people living with HIV—whether diagnosed or not—60% have their virus under control (are virally suppressed) compared to 30% nationally.

(Statistics and graphic from SF AIDS Foundation: http://sfaf.org/hiv-info/statistics/)