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San Francisco Getting to Zero Update Hears U=U Message

San Francisco continues to make progress in reducing new HIV infections and expanding access to early treatment, according to a World AIDS Day update on the city's Getting to Zero initiative, held on November 29, 2017.

Effective antiretroviral therapy (ART) that suppresses viral load prevents both disease progression and transmission, as studies have now clearly shown that people with undetectable viral load do not transmit HIV.

Getting out the message that that "Undetectable Equals Untransmittable" -- or "U=U" -- would encourage HIV-positive people to start and stay on treatment as well as reducing stigma, according to a panel of people living with HIV and service providers.

"It is absolutely clear that treatment as prevention, or U=U, is working and is an incredibly sound public health intervention," said Mike Shriver, a member of the Getting to Zero steering committee and the board of directors of the National AIDS Memorial Grove. "Gay men are quite capable of staying adherent to our treatment regimens and we deserve to have healthy sex lives."

The 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. It relies on a 3-prong strategy of expanded access to PrEP, rapid initiation of antiretroviral therapy, and retaining HIV-positive people in care.

The San Francisco Department of Public Health's latest HIV epidemiology report, released in September, shows that new HIV infections declined to 223 in 2016, a new all-time low. The city outdoes the country as a whole when it comes to helping people get tested, start treatment as soon as possible after diagnosis, and stay on therapy to achieve viral suppression.

But the latest data show that stubborn disparities persist, with some groups -- including young gay and bisexual men, transgender people, people of color, and homeless people -- having higher rates of infection and poorer treatment outcomes.

"We lost 165 people living with HIV in San Francisco last year," said Susan Buchbinder, director of DPH's Bridge HIV research program. "We still have a long way to go."

The way forward may become more challenging in the years ahead due to policy changes at the federal level.

Courtney Mulhern-Pearson of the San Francisco AIDS Foundation gave an overview of tax reform legislation that could lead to millions of people opting out of health insurance once the individual mandate and tax penalties are removed. Some advocates fear that steep cuts to Medicaid and Medicare could soon be on table.

San Francisco will see substantial cuts to its HIV budget next year, as funds from the Centers for Disease Control and Prevent are reallocated to jurisdictions with more new infections. But = Mayor Ed Lee and the Board of Supervisors have agreed to "backfill" these cuts, keeping funding near its current level. [Acting mayor London Breed, who took over after Lee's sudden death in December, is not expected to change this decision.]

At the state level, a new PrEP assistance program is expected to start in 2018, which will cover out-of-pocket costs for Truvada (tenofovir/emtricitabine) for HIV prevention and associated lab work, according to Mulhern-Pearson. She also said the state Senate will again consider AB 186, the supervised injection bill that narrowly lost this year.

Albert Liu of the DPH gave an update on behalf of the Getting to Zero PrEP committee, noting that an estimated 40% of eligible men who have sex with men -- or around 12,300 gay and bi men -- have started PrEP. But here too, disparities remain.

"The good news is we're starting to see some improvement in the gaps," Liu said, noting that PrEP use had risen among Latinos. He said the Getting to Zero initiative has 4 PrEP programs underway, for young gay and bi men, African Americans, Latinos, and trans women. The city maintains a PrEP emergency fund for youth and has developed a phone app for PrEP advice.

Susan Coffey of the University of California at San Francisco (UCSF), on behalf of the RAPID committee, reported that the median time from HIV diagnosis to entering care has dropped to 5 days, and the time from starting care to initiating ART has fallen to zero days, meaning most people are prescribed treatment during or soon after their first care visit.

The latest epidemiology report shows that homeless people are less likely to start treatment and achieve viral suppression. Edwin Charlebois from the retention and reengagement committee outlined efforts to help homeless people obtain cell phones -- and to provide charging stations at HIV clinics -- to enable them to stay in contact with health services.

Getting to Zero recently started an adolescent and young adult committee, with a goal that all young people in the city will have had an HIV test by the time they turn 25. "The goal is not so much to find a lot of new infections," but to raise awareness and connect them with health services, according to committee member Adam Leonard.

U=U

Matt Spinelli of UCSF outlined research supporting the concept that people with viral suppression do not transmit HIV, and the history of the movement around it. In September, the Centers for Disease Control for the first time formally endorsed "U=U."

"Scientists are conservative," Spinelli said. "This was driven by the community."

Two large studies -- the PARTNER study, which included mostly heterosexual participants, and the Opposites Attract Study, which focused on gay men -- saw zero cases of HIV transmission in around 75,000 sex acts between serodiscordant partners when the HIV-positive partner was on treatment with an undetectable viral load.

Panel members living with HIV spoke of the stigma, fear of infecting a partner, and fear of rejection that resulted from the persistent belief that HIV-positive people could not safely have sex without condoms no matter how well they adhered to treatment or how low their viral load fell.

"[U=U] gives people a reason to be on meds and it's a tool for reengagement in care," said Rob Newells of the AIDS Project of the East Bay. "It's not just sexual health but emphasize sexual pleasure. PrEP let HIV-negative people relax during sex and not worry about transmission, U=U plays the same role for HIV-positive people."

In addition to having more enjoyable sex, Clarissa Ospina-Norvell, a nurse practitioner at Zuckerberg San Francisco General Hospital's Ward 86, added that U=U "tells people that a reproductive future is available if they desire that."

U=U can be a great organizing tool, but the real goal is overcoming disparities and getting people into care, according to Shriver.

"The fact remains that the benefit from HIV treatment is not equal across all the impacted communities and this has to be rectified if we are to see an end to new HIV infections in San Francisco," he said. "Now more than ever we need to listen to and address the needs of those individuals and those communities that are still experiencing disparities in terms of access to care and culturally appropriate, community-specific services."

Wrapping up the forum, founding consortium member and openly HIV-positive city supervisor Jeff Sheehy sounded a similar theme.

"We're probably at the most challenging time I've seen in Getting to Zero," Sheehy said. "We have claimed the low-hanging fruit. The challenge is to do something really innovative to reach the people who are missing. In the epidemic all along there have been disparities, but we can again be a model in San Francisco."

12/7/17