Getting to Zero: Will San Francisco be the first city to

succeed?

Diane Havlir, MD, Professor of Medicine, UCSF, Chief HIV San Francisco General Hospital

Susan Buchbinder, SF Department of Public Health, Director of Bridge Professor UCSF

Outline

• San Francisco epidemic

• Key aspects of the response

• Getting to Zero

New HIV diagnoses & deaths, San Francisco

Characteristics of new HIV diagnoses,San Francisco

• 93% male• 86% MSM or

MSM/IDU• Total of 14

new dx’es in women 2014

• 71% 25-49 yo• 12% <25 yo• 17% >50 yo

Total # new HIV diagnoses by race/ethnicity, San Francisco

*

Significant decline*

Characteristics of persons living with HIV, San Francisco

• 92% Male

• 39% Persons of Color

• 4% <25 years of age

• 58% >50 years of age

HIV and Non-HIV Deaths in PWA, SF

Non-HIV Causes of Death, SF

Summary1. The number of new HIV diagnoses has

decreased in San Francisco, 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 affecting persons of color

3. We have an aging population of persons living with HIV and continue to have preventable deaths

HIV testing in San Francisco

• HIV testing is the gateway to treatment and prevention• 93% of persons with HIV in San Francisco are aware of

their HIV status• Key lesson learned: Multi-pronged approach to HIV

testing scale up successful in San Francisco– 2010 18,000 tests

– 2014 25,000 tests

Median CD4 at time of HIV Diagnosis, San Francisco

Year CD4 cells/mm3 at diagnosis

2008 394

2009 409

2010 411

2011 438

2012 422

2013 443

HIV Care Cascade, San Francisco compared with CA and USA

Summary 1. HIV diagnosis is occurring earlier after

infection, but 18% are “late presenters” (develop AIDS within 3 months of first HIV diagnosis)

2. ART is being initiated earlier after diagnosis

3. Linkage, retention and viral suppression still have major gaps

SF Response: Key components

• Political will and financial support– Ryan White essential, SF City backfills federal cuts in

funding

• Innovation at program level– HIV testing access– Treat on diagnosis– first in world 2010– San Francisco Model of Care

• Innovation comes from NIH and state funded research– PrEP, care delivery (US and global), cure, vaccine

“Getting to Zero” in San FranciscoConsortium

Zero new HIV infectionsZero HIV deathsZero stigma and discrimination

Photo by Jim Herd Photo by Rich Niewoski

www.gettingtozerosf.org

How it began….

“This is all interesting, but are you working

together?”

--Community member

Getting to Zero SF: What are we?

• Multi-sector independent consortium– operates under principles of collective impact: “Commitment of groups from different sectors to a common agenda to solve a specific problem.”

• Vision –Become the first municipal jurisdiction in the United States to achieve the UNAIDS vision of “Getting to Zero”

90% reduction in new HIV infections by 2020

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

PREP use in Kaiser San Francisco

• July 2012-Feb 2015

• 1035 referrals

• 677 initiations

• 20 re-starters

Volk, Hare, CID, 2015

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

Third Initiative: Retention -- Achilles Heal of the Cascade

• We know many of the 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