12TH HIV Nursing Network Conference

May 20,2016

35 years of HIV

Nursing Diane Jones RN

Bay Area and North Coast

AIDS Education and Training

Center

Disclaimer

Socio—political

context

• Race/Poverty

• Politics of Sex and

Gender

• Politics of Drugs

• Status of Women and

Girls

• Immigration

Health Disparities

“Epidemics do not announce themselves but enter on cat’s paws”

The Global Epidemic

37 million persons living with HIV

2 million new infections each year

1.2 million deaths

2015: Global HIV epidemic at a glance

Source: Global mapper

5,600 new HIV infections each day

2 out of 3 new HIV infections in Sub-Saharan Africa

1 out of 3 new HIV infections are in youth (15-24yr)

Overview of the HIV Pandemic

• There is…

UNAIDS. Global Report: UNAIDS Report on the Global AIDS Epidemic 2010. UNAIDS: Geneva, Switzerland;2010. Available at: http://www.unaids.org/documents/20101123_globalreport_em.pdf. Accessed April 10, 2012. 16

• Every 12 seconds in the world

• Every 9 minutes in the United States

• Every day in San Francisco

One new infection...

Impact of HIV in San Francisco

and Beyond

Cumulative

HIV Cases

Cumulative

HIV Deaths

Living HIV

Cases

New HIV

Cases per

year

San Francisco 35,397 19,738 15,662 392

17

1 in 4 Gay Men in SF is HIV-positive

>50% in the Castro

Highest rate of new infections is

among transgender injection drug

users (6% per year)

HIV Prevalence

El-Sadr WM, Mayer KH, Hodder SL. AIDS in America--forgotten but not gone. N Engl J Med. 2010 Mar 18;362(11):967-70. 18

VISION

The US will become a place where new HIV infections are rare and when they do occur, every person, regardless of age,

gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to

high quality, life-extending care, free from stigma and discrimination.

Strategy URL: http://www.whitehouse.gov/administration/eop/onap/nhas

Strategy Goals and Targets for 2020

Reducing New HIV Infections

Increasing Access to Care and Improving Health Outcomes for People Living with HIV

Reducing HIV-related Health Disparities and Health inequities

Achieving a more coordinated national response

Strategy URL: http://www.whitehouse.gov/administration/eop/onap/nhas

Good News First…(in the US)

Slide courtesy of Dr. Joanna Eveland

21

Preventing Perinatal HIV: A Success Story!

Components of care • Universal maternal

HIV testing and treatment

• Intrapartum AZT, C-section if high viral load

• PEP for exposed infant

US HIV Demographics

HIV and Healthcare Reform

Getting to Zero: Will San

Francisco be the first city to

succeed?

And what is our role to make this happen?

Getting to Zero San Francisco:

The Power of Collective Impact

Zero new HIV infections

Zero HIV deaths

Zero stigma and discrimination

Strategic Plan: Signature Initiatives

1. City wide coordinated PrEP program

2. Rapid ART start with treatment hubs

3. Patient centered linkage, engagement,

retention in care

Committee for each initiative + stigma

committee has action plan, metrics

and milestones. City of San Francisco

provided additional funding 2015-6 for

new initiatives

We have been heading toward zero New HIV diagnoses and deaths in SF

2010: ART at

diagnosis; HIV test scale-up

2012: PrEP

2006: HIV test w/o

written consent 2011:

LINCS

HIV Prevention Toolkit

• Treatment as prevention

• Serosorting/ seropositioning • Condoms • Syringe

exchange and drug treatment

• PrEP

First Initiative: PrEP

Pre-Exposure Prophylaxis

Estimated SF PrEP eligibles and users Bob Grant: Abstract 25

Group People

HIV negative at substantial risk:

MSM with 2+ ncAI partners1

MSM with 0 ncAI and an STI in the last year2

Female partners of HIV+ MSM3

Trans women4

12,589

2,325

653

522

TOTAL estimated PrEP eligibility 16,089

TOTAL reporting PrEP in past year 5,059

Percent of eligible people using PrEP in past year 31%

1. SF City Clinic 2014 survey x HIV negative MSM population of 50,000;

2. SF NHBS self report of STI among MSM with 0 ncAI in 2014 x HIV negative MSM population of 50,000;

3. SF NHBS MSM reporting female partners in 2014 x HIV positive MSM population of 14638.

4. IDU and ncRAI in est. 923 HIV negative trans women in SF adapted from Wilson BMCID 2014 14:430.

5. SF NHBS 2014, data on file.

Grant CROI Abstract 25 Seattle 2015.

Cascade among HIV diagnosed:

San Francisco

Second Initiative: RAPID: Treatment on Diagnosis

1. Concept of “Collapsing the cascade” or “Treatment Upon Diagnosis” --being evaluated here in San Francisco and in Africa

2. Treatment on Diagnosis • Reduce risk of HIV complications • For acute/early HIV decrease the size of the HIV

reservoir • Reduce HIV transmission • May help empower patient • May increase retention

RAPID: Rapid ART Program Initiative for HIV Diagnoses

• Expedited initiation of antiretroviral therapy and linkage to HIV care at the time of HIV diagnosis (same day if possible)

• Piloted since 2013 at SFGH/HIV clinic and embraced by patients and providers

– All acute/recent diagnoses (within 6 months of infection)

– Newly diagnosed with chronic infection

0 30 60 90 120 150 180 210 240 270 300 330 360

Referral 1st Clinic

Visit

1st PCP

Visit

ART

Prescribed

Viral load

suppressed

2006-2009

CD4-guided

ART

2010-2013

Universal ART

Days since

Referral

Milestones of care: SFGH, 2006-2013

132

37

218

128

Pilcher, IAS, 2015

The SFGH RAPID Model

RAPID visit: ART start • Disclosure, counseling • Registration • Insurance • Housing/SU/MH • Labs • Counseling • Medical eval

PCP Visits • VL monitoring • ART mgment • Adherence • Retention

HIV+ Diagnosis • Disclosure • Referral • Scheduling

1st Clinic Visit • Registered • Insured • Housing/SU

/MH • Counseling • Labs

1st PCP Visit • Medical

evaluation • ART criteria

met

ART start • Pills taken

Viral load suppressed • VL

monitoring • Adherence • Retention

Pilcher, IAS, 2015

RAPID

Time to VL suppression by ART initiation strategy: SFGH 2006-2014

RAPID vs.

universal

ART

P<0.001

Universal ART

CD4-guided ART

Proportion

<200 copies

Pilcher, IAS, 2015

San Francisco: New HIV Diagnosis, Living

HIV cases and Deaths

• 15,979 living

with HIV

• 302 new

diagnosis

• 177 deaths

Characteristics of New Diagnosis

• 55%

persons of

color

• 93% male

• 75% MSM

• 12% <24

years of

age

• 17% >50

years of

age

• 36% >50

among

women

Characteristics of Persons Living

with HIV • 92% Male

• 39%

Persons

of Color

• 4% <24

years of

age

• 58% >50

years of

age

Causes of Death

• 44% HIV

related

• 14% non-

AIDS

cancer

• 9% heart

disease

• 11% drug

overdose

Summary

1. The number of new diagnosed cases of

HIV in San Francisco is decreasing, but we

still have hundreds of new HIV infections

every year

2. New diagnosis are being recognized in all

adult age groups, and are

disproportionately effecting persons of

color

3. We have an aging population of persons

living with HIV

Median CD4 at time of HIV

Diagnosis in San Francisco

YEAR CD4 cells/mm3

at Diagnosis

2008 394

2009 409

2010 411

2011 438

2012 422

2013 443

ART in San Francisco by CD4 Nadir

Summary

• Nearly 95% affected persons know their

HIV status – but there are still gaps!

• HIV diagnosis is occuring much earlier in

the disease course– but there are still late

presenters!

• ART is being initiated earlier

• Linkage, Retention and re-engagement in

care still has major gaps

Thank you Susan Scheer and team for leading SF Epi report!

Third Initiative: Retention --

Achilles Heal of the Cascade • Barriers: socioeconomic, unstable housing,

addiction, stigma, denial, fragmented health

system, mental health

• We don’t understand enough about motivations of

our clients and where and how we might make a

difference – need research

• We need to act while waiting for the research by

expanding and evaluating innovative city

programs

Getting to Zero: Will San Francisco Be

the first city to succeed?

Test, PreP and Treat, “San Francisco style”

Universal ART

PrEP

Getting to Zero

Wish List

• New generation of nurses who will get us

to Zero

– Expertise in clinical care

– Passionate advocates for social justice and

fighting disparities and stigma

• Research: Qualitative (stigma, retention in

care)

• Systems of care

Thanks

• Dr. Joanna Eveland PAETC

• Dr. Diane Havlir UCSF

• San Francisco Getting to Zero Consortium

• DPH HIV Nursing Network

• Colleagues at SFGH, Ward 86 and HAH

• AETC, especially Amanda Newstetter