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HIV ResearchSan Francisco Department of Public Health
Health CommissionAugust 2, 2011
HIV Epidemiology
Susan Scheer, PhD, MPH
AIDS cases, deaths, and prevalenceSan Francisco, 1980-2010
0
2,000
4,000
6,000
8,000
10,000
80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10
Num
ber o
f Cas
es/D
eath
s
Year of Diagnosis/Death
Persons Living with AIDS AIDS Cases AIDS Deaths
Race/Ethnicity of Men Living with HIV/AIDS Compared to the General Population of
San Francisco, December 2010
Male HIV/AIDS CasesN= 14,597
San FranciscoMale Population
Kaplan-Meier survival curves for persons diagnosed with AIDS in 1980-1989, 1990-1995, and 1996-2010, San Francisco
0%
20%
40%
60%
80%
100%
0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 180 192 204 216 228 240 252 264 276 288 300 312 324
Months of Survival
Perc
ent S
urvi
ving
Diagnosed in 1980-1989 (N=8,607)Diagnosed in 1990-1995 (N=12,082)Diagnosed in 1996-2010 (N=8,104)
Proportion surviving five years for persons diagnosed with AIDS between 1996 and 2010 by race/ethnicity,
exposure category, and gender
82%
74%
84% 86% 85%
66%76%
81% 82%73% 73%
0%
81%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
ent S
urvi
ving
5 Y
ears
Race Exposure Category Gender Overall
* Transfemale data include all transgender cases. Transmale data are not released separately due to potential small population size.
2000 2010
* Transfemale data include all transgender cases. Transmale data are not released separately due to potential small population size.
Estimated antiretroviral therapy use among persons living with AIDS by gender, race/ethnicity, and exposure category
Newly diagnosed HIV infections and two methods of estimating incident HIV infections, 2006-2011
HIV Research
Jonathan Fuchs, MD, MPH
A Tradition of Innovative Research to Prevent HIV/AIDS
SF City Clinic Cohort Study- HIV antibody test- Natural history- Long term non-progression (LTNP)
Vaccine Preparedness Studies- Recruitment and retention of at-risk cohorts- Risk factors for infection- Per-contact risk
Behavioral and Biomedical Interventions- Individualized, client centered counseling- Preventive Vaccines- STD interventions (HSV-2 suppression)- Pre-exposure Prophylaxis- Peer navigation among black MSM
Evaluating Platforms for Intervention Delivery and Building Research Capacity- Combination Prevention- Implementation Research- Fostering a new generation of HIV researchers
HVTN:
San Francisco, CA
Seattle, WA
Cleveland, OH
Rochester, NY
New York, NY (4)
Bethesda, MD
Santo Domingo, Dominican Republic
Iquitos, Peru
Annandale, VA
Port-au-Prince, Haiti
Soweto, Klerksdorp, Medunsa and Durban (2), South Africa
Boston, MA (2)Philadelphia, PA
Orlando, FL
Chicago, IL
Denver, CO
Houston, TX
Nashville, TN
Birmingham, AL
San Juan, Puerto Rico
Lausanne, Switzerland
Los Angeles, CA
Dallas, TX
Cape Town, South Africa
Atlanta, GA
Lima Peru Sao Paulo, Brazil
A global public/private partnership to test the safety and efficacy of preventive HIV vaccine candidates
• Daily FTC/TDF reduced HIV infection by 42% compared to placebo when delivered as part of a prevention package among 2,499 MSM• Higher levels of detection in those with detectable drug
• We are addressing several additional research questions • Acceptability and uptake in at-risk populations
• Pill taking/risk practices in real world settings• New strategies to promote pill use
• Biomarkers of use (hair levels)• Alternate regimens (drugs, intermittent dosing)
• Disproportionate impact of the HIV epidemic among black MSM
• HPTN 061 (UNITY) completing follow-up this fall• Analyses underway
• STI rates• Sexual networks and behavioral risk• Access to care• Feasibility of peer health navigation
• Hiring a new Director of HIV Disparities and Community Engagement
Fostering the nextgeneration of HIV
researchers
HIV Prevention
Moupali Das, MD, MPH
Substance Use and Health Equity
• Substance use drives disparities in health outcomes in San Francisco, including disproportionate:• HIV acquisition• HIV transmission
• HPS Research Portfolio includes randomized clinical trials to evaluate diverse approaches to address substance use and dependence to prevent HIV and improve health in San Francisco• Behavioral • Pharmacologic
• PrEP, PEP, condoms, syringes
• Drivers1. Substance
use2. Alcohol3. Meth4. Crack5. Poppers6. STDs and #
of partners
Primary Prevention
Efforts
Testing Diagnosis Primary Care Treatment Virologic Suppression
Community
Testing
Linkage & Partner Services
Mental Health Services
Substance Use Treatment
Housing Support
Treatment Adherence
Medical Case
Mgmnt.
Routine Medical Testing
Median CD4 at HIV
diagnosis
% VirologicSuppression
Time to Virologic Suppression
Time to ART Initiation
Linkage
HIV
Engagement / Retention
Engagement / Retention
SFDPH Positive Health Access to Services and Treatment (PHAST)
Median CD4 at ART
initiation
Implementation Cascade: Improving Testing, Linkage, and Care Outcomes at the Population Level
% Linked to Care within 3 Months of Dx
% Engaged in Care
Community Viral Load: Unified Marker of Prevention and Care
STD/PCSI
ART Guidelines
Uptake
Engagement & Partner Services
Improving HIV Testing, Linkage, and Engagement Outcomes and Equity
• Maximize outcomes along Implementation Cascade
• Randomized Clinical Trials to Improve Testing, Linkage, and Engagement in Care Outcomes• STOP Study• CTN 0032• Project AWARE• Project HOPE
Universal Offer of ART on Ward 86 and All SFDPH Community Health Clinics
“All patients, regardless of CD4 count, will be evaluated for initiation of antiretroviral therapy (ART)”
Decision to start ART made by the individual in conjunction with the provider
Modified from slide courtesy of Brad Hare, SFGH Community Forum
Community Viral Load Disparities
• Even in relatively richly-resourced San Francisco, disparities in CVL track with poor five-year survival and neighborhood concentration of poverty
• CVL may be a useful marker for public health departments to target resources and address geographic disparities in HIV transmission and survival
CVL Disparities, San Francisco 2004-2008
Overall N (%) Mean CVL*
San Francisco 12,512 (100) 23,348
*(p<0.001 by Kruskal-Wallis test) in mean CVL by treatment history, race/ethnicity, age, gender, HIV transmission risk category, insurance status, and clinical status.
Sub-groups N (%) Mean CVL*
Latino 1,822 (15) 26,744African-American 1,825 (15) 26,404
Women 786 (6) 27,614Transgender 291 (2) 64,160
IDU 1,011 (8) 33,245MSM-IDU 1,791 (14) 36,261
Not on treatment 2,924 (23) 40,056Not engaged in care 4,637 (37) 36,992
798
642
523 518434
935(CI: 658, 1212)
792 (CI: 552, 1033)
621(CI: 462, 781)
0
200
400
600
800
1000
1200
0
5,000
10,000
15,000
20,000
25,000
30,000
2004 2005 2006 2007 2008
Num
ber o
f HIV
cas
es
Mea
n CV
L co
pies
/ml
Year
Newly diagnosed and reported HIV cases HIV Incidence(p= 0.028) (Mean CVL & HIV-incidence p=0.3)(Mean CVL & newly diagnosed HIV p=0.005)
Mean CVL and New HIV Infections, 2004-2008
Das, et al. 2010.
San Francisco Modeling Results
Charlebois, Das, Porco, Havlir. CID, 2011.
HIV Health Services
Bill Blum and Dean Goodwin
From March 2009 through February 2010, HIV Health Services conducted a qualitative study on the needs and life circumstances of persons 65 and older living with HIV in San Francisco through funding by the Flowers Heritage Foundation. LFA Associates conducted a total of eleven 3-hour interviews for both male and female subjects ranging from 66 to 80 years of age.
Key 65 & Older Study Findings:• Interviewees indicated a high level of satisfaction with existing HIV
services and felt that their health needs were generally well met. • Key unmet service needs included in-home care, transportation,
affordable housing, and social support programs.• Availability of social support plays a critical role in health and quality
of life.• Real or perceived HIV stigma affects interviewees’ health and social
support.
In early 2009, members of the San Francisco HIV Health Services Planning Council and the Mayor’s Long Term Care Coordinating Council began meeting to identify local needs related to HIV and aging. The two groups produced a Policy White Paper authored by Randy Allgaier in June 2010 which highlighted key and emerging needs related to aging populations.
Key White Paper Recommendations:• By the end of 2012, over 50% of persons living with HIV/AIDS in SF will
be age 50 and older. The city must begin shifting significant resources and focus to meet the needs of this population.
• The population of older persons living with HIV is diverse and will require services that reflect their ethnicity, gender, cultures, age, and sexual orientation.
• Aging support service providers must serve as equal partners with HIV medical providers.
• The HIV care system must plan for a higher burden of care for persons 50 and older based on decreased income and insurance sources within this population.
In October 2010, SF HIV Health Services received a total of $1.2 million in funding over 3 years through the HIV Patient-Centered Medical Home Project of the California HIV/AIDS Research Program (CHRP) to develop and test one or more new models of integrated HIV and aging care services to address the complex needs of HIV-infected persons 50 and older in the context of the HIV-specific patient-centered medical home.
Project models will incorporate expanded geriatric specialty elements that may build upon successful aging care models in other fields. The project also will rely on interaction with and support from geriatric specialty consultants. The project will collect data to track impacts on factors such as patient health and wellness, medication adherence, retention in care, and satisfaction with services.
Beginning in 2013, the project will begin to utilize findings to produce and disseminate new best practices guidelines for HIV and aging care both in San Francisco and throughout California and the nation and will seek to develop an effective patient-centered medical home model specifically for older adults living with HIV.Each site will utilize a multidisciplinary team to develop and implement integrated 50 and older care models. The teams will meet regularly to plan and implement services and discuss project findings and will also meet together in cross-site planning meetings.Composition of Site-Based Multidisciplinary Teams:- Medical Director - Pharmacist- RN or Nurse Practitioner - Administrative Assistant- Social Worker - Gerontological Consultant
Project Organizational StructureSan Francisco HIV Health Services
Project Grantee / Coordinating Agency
Bill Blum, Principal Investigator / Project DirectorRobert Whirry, Project Coordinator
Sajid Shaikh, Fiscal Monitor
Demonstration Site # 1
360: The Positive Care Center at UCSF
UCSF Parnassus Campus
Malcolm John, MD360 Medical Director
Demonstration Site # 2
Positive Health Program Ward 86 Clinic at
SF General Hospital
C. Bradley Hare, MDWard 86 Medical Director
Thank You