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AIDS 2016: San Francisco Sees Progress in Getting to Zero Initiative

San Francisco continues to make good progress with its "Getting to Zero" initiative, which aims to achieve the triple goal of zero new HIV infections, zero AIDS deaths, and zero stigma for people living with HIV. But not all groups are doing equally well, according to a presentation at the recent 21st International AIDS Conference (AIDS 2016) in Durban.

The Getting to Zero Consortium, formed in 2013, includes experts and stakeholders from the San Francisco Department of Public Health, the University of California at San Francisco, local AIDS service organizations, private care providers including Kaiser Permanente, city government, and community advocates.

Getting to Zero is working to reach its goals using a 3-prong strategy of expanded access to pre-exposure prophylaxis (PrEP) for HIV prevention, rapid linkage to care and access to antiretroviral therapy (ART), and retention and re-engagement of HIV-positive people in care, as well as an initiative to end stigma around HIV.

In 2010 San Francisco was the first city to recommend ART for all people living with HIV regardless of CD4 T-cell count, and the city's RAPID program aims to get newly diagnosed people on treatment as soon as possible, ideally the same day. San Francisco has also been a pioneer in developing and expanding access to PrEP.

Shannon Weber from the University of California at San Francisco, representing the Getting to Zero Consortium, presented an overview and update in a poster at AIDS 2016. Consortium leaders gave a more extensive annual update last December.

The consortium's PrEP committee worked to get the word out through the media, social networking, and PrEP "ambassadors," and improved access through provider training and health navigators who help people figure out how to pay for PrEP. During the last year PrEP delivery sites increased to more than 30 clinics, over 120 providers were trained to deliver PrEP, and community surveys of gay and bisexual men found that PrEP use increased from 15% to 22%.

The RAPID committee expanded the same-day care and antiretroviral treatment protocol to 3 additional sites. To date, more than 100 newly diagnosed people have been enrolled citywide and the average time from HIV diagnosis to viral suppression has fallen to 87 days.

The retention and re-engagement committee placed care navigators at 3 city clinics with vulnerable patient populations and formed a frontline worker group for training and capacity building; 3 public health clinics are implementing an evidence-based re-engagement and retention package. In addition to retaining patients in care, the initiative seeks to identify people who have recently fallen out of care and are not virally suppressed and prioritize them for re-linkage efforts. After a year, 73% of such patients enrolled in navigation were re-linked to care.

Finally, the Ending Stigma committee is developing a citywide needs assessment to address HIV stigma, expanding a digital storytelling social media program, and attempting to include consistent measures of stigma in community surveys

Numbers Improving But Uneven

The consortium's poster included data through 2014, showing that the number of newly diagnosed HIV infections fell from 519 in 2006 to 302 in 2014, with a steeper drop starting in 2012. The number of deaths among people with HIV dropped from 327 to 177 during the same period.

But progress was uneven across groups. Looking just at men -- who account for about 90% of people living with HIV and new infections -- rates of new diagnoses ranged from 69 per 100,000 among white men, to 107 and 127 per 100,000 Latino and black men, respectively. Death rates were 84, 55, and 178 per 100,000 white, Latino, and black men with HIV, respectively.

On September 1, the Department of Public Health released its HIV Epidemiology Annual Report 2015, showing that the number of new diagnoses has continued to fall, reaching a low of 255 -- a 17% decline from 2014. But disparities remain, and in fact may be widening. African-Americans, in particular, have not benefited from the same progress as the population as a whole, and are the only racial/ethnic group for whom new diagnoses are stable rather than declining.

"Getting to Zero has achieved strong participation and coordination of >200 community advocates, providers, researchers, city employees, and members of the private sector," the consortium concluded in their poster. "Together, we are implementing a strategic set of activities to reduce the number of HIV-related deaths and new infections by 90% within this decade. We are working in particular to reach people of color and under-served communities."

PleasePrEPMe

Weber also presented another poster describing PleasePrEPMe.org, a crowd-sourced, location-based statewide directory that helps interested individuals find "PrEP-friendly" providers in California.

Last yearresearchers with the Centers for Disease Control and Prevention reported that a nationwide survey found that one-third of U.S. healthcare providers had not heard about PrEP. Some providers who are aware of PrEP do not feel comfortable prescribing it, and some people seeking PrEP have reported that they have encountered judgmental providers who are unwilling to do so.

Launched in June 2015, PleasePrEPMe is thought to be the largest public PrEP provider directory in existence. At the time of this report, the directory included more than 200 clinics and more than 1400 public and private PrEP providers, as well as curated PrEP resources for both patients and providers. A Spanish language version was added in January 2016. Over 9000 users have visited the website to date.

End-users were consulted and involved at all stages of development of the directory and its web interface. Challenges have included low response rates from areas with lower HIV incidence -- including 4 counties with "extremely limited health services" -- and the need to collect a variety of information such as whether providers are LGBT-friendly or women-friendly and what kinds of insurance they accept.

In the future, PleasePrEPMe hopes to take advantage of open-enrollment season to help users enroll into PrEP-friendly health plans, expand the website to include consumer reviews, do online marketing via Facebook and hookup apps, and offer PrEP navigation services. Ultimately, the goal is to expand into a multi-state or nationwide effort.

"A statewide PrEP directory requires collaboration among multiple stakeholders," the study team concluded, adding that, "PrEP provider trainings in low HIV incidence locations may be warranted."

9/1/16

References

S Weber and S Buchbinder/San Francisco Getting to Zero Consortium. The Getting to Zero San Francisco consortium: early results. 21st International AIDS Conference. Durban, July 18-22, 2016. Abstract WEPEE609.

S Weber, J Gaeta, C Watson, et al. Lessons learned from launching PleasePrEPMe.org, a crowd-sourced, location-based, searchable statewide California PrEP Provider Directory to connect consumers interested in PrEP to PrEP-friendly providers. 21st International AIDS Conference. Durban, July 18-22, 2016. Abstract THPEE604.