The Future of HIV Care in Nevada TRUDY LARSON, MD PROFESSOR AND DEAN, SCHOOL OF COMMUNITY HEALTH SCIENCES UNIVERSITY OF NEVADA, RENO

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1 The Ftre of HIV Care in Nevada TRUDY LARSON, MD PROFESSOR AND DEAN, SCHOOL OF COMMUNITY HEALTH SCIENCES UNIVERSITY OF NEVADA, RENO

2 Learning Objectives Identify the similarities and differences between the early events of the HIV/AIDS epidemic and crrent challenges to Get to Zero List the barriers that impede progress to redce HIV/AIDS infections in Nevada Otline ftre policies and practice changes that mst be implemented in order to Get to Zero

3 What is the FUTURE we desire for HIV/AIDS? Cre those infected Find all those who are HIV+ Stop transmission No HIV

4 How do we get to a ftre goal of Getting to Zero? It will reqire teamwork It will reqire persistence It will reqire compassion It will reqire a common voice It will reqire medical advances It will reqire adherence It will reqire discovery It will reqire acceptance It will reqire action It will reqire access It will reqire commitment It will reqire resorces and a MAJOR CULTURE CHANGE

5 Initial Reports Jne 5, 1981: 5 cases of PCP in gay men from UCLA (MMWR) Jly 3, 1981: 26 additional cases Dec 10, 1981: 3 NEJM papers describe cases Gottlieb MS NEJM 2001;344:

6 Other Early Developments 1982: Term AIDS coined, First cases in women reported First transfsion and vertically transmitted cases reported Transmission patterns defined!! 1983: Isolation of a retrovirs from a patient with AIDS by Montagnier s grop in France 1984: Detection of HTLV-III in pts with and at risk for AIDS (Gallo) in US Sepkowitz K NEJM 2001;344:

7 Other Early Developments 1985: antibody test 1986: NIH establishes the AIDS Clinical Trials Grop 1987: Proportion srviving FDA approves first commercial HIV AZT = first antiretroviral approved by FDA Months after OI diagnosis Sorce : National AIDS case srveillance data, CDC

8 Social Isses Diagnosed cases of AIDS in marginalized poplations Gay men IV drg absers People of color Groped in areas with low socioeconomic spport in big cities and in poor areas in the soth Stigma and discrimination by all facets of society redced access to care Medical personnel afraid of transmission Lost jobs, kicked ot of homes, rejected by families

9 What happened? HIV/AIDS spread Perinatal transmission Sexal and drg sharing transmission Prevention messages censored (don t say condoms or mention sexal intercorse) Federal response extremely slow and blame based Medical providers frstrated becase every patient died Cold only treat opportnistic infections Learned abot hospice care (AIDS hospice hospitals and wards developed)

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11 Early Antiretroviral Therapy : ddi, ddc approved Seqential monotherapy Ryan White Care Act passed 1993: Covered care, medications and edcation Concorde: no difference in death rates over 3 yrs with early vs. deferred AZT

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13 Early Antiretroviral Therapy Sccess 1994: ACTG 076: AZT redces mother-to-child transmission of HIV Pregnant HIV infected women given AZT dring pregnancy redced the transmission of HIV from them to their infants by 66% (from 22% to 8.5%) Intervention with AZT (pls other ARTs now) in pregnancy redced perinatal transmission to 0 in Washoe Conty ( )

14 The New Treatment Era : HIV viral load testing became available Clinicians cold directly assess the effect of antiretrovirals (ARTs) on viral replication (HIV RNA) First protease inhibitors approved by FDA

15 Advocacy Gay men organized and stormed the NIH offices Pressred NIH director to look at fast tracking of HIV medications ACT UP became politically active Hard to find advocates from poplations impacted with high rates of poverty

16 AIDS Mortality Rates: Deaths per 100 person-years Mortality vs. ART tilization USE OF ART DEATHS Percentage of patient-days on ART Palella F et al. 8th CROI 2001; abstract 268b.

17 HIV Medication Timeline stavdine zalcitabine didanosine zidovdine Between 87 and 95 (9 years), 4 antiretrovials were lanched. Since 95 (11 years), 25 new prodcts introdced!! lamivdine lamivdine/zidovdineemtricitabine nevirapine efavirenz delavirdine tenofovir abacavir emtricitabine/ tenofovir abacavir/ lamivdine/ zidovdine NRTI NNRTI saqinavir ritonavir nelfinavir atazanavir tipranavir darnavir PI FI indinavir saqinavir amprenavir didanosine enfvirtide Kaletra fosamprenavir Corrections Crriclm Development, NY/NJ AETC

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19 How does that history inform or Ftre? Major medical advances do HAPPEN Resorces for social spport, medication spport, and access HAPPEN Caregivers with compassion and no fear HAPPEN Teamwork and clinical teams HAPPEN Wide spread testing and diagnosis of all HIV+ people has NOT HAPPENED Universal linkage and retention in care has NOT HAPPENED Adherence is better bt perfect adherence has NOT HAPPENED Getting rid of stigma and discrimination has NOT HAPPENED

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21 Persons Living with Diagnosed or Undiagnosed HIV Infection HIV Care Continm Otcomes, 2014 United States Note. Receipt of medical care was defined as 1 test (CD4 or VL) in Retained in continos medical care was defined as 2 tests (CD4 or VL) 3 months apart in Viral sppression was defined as <200 copies/ml on the most recent VL test in 2014.

22 The ftre of care in Nevada mst look to or care continm We mst measre statewide and local care continms to inform resorce distribtion Measrement can be done Use this information to allocate resorces to where they are needed keep high fnctioning programs fnded We need to geomap viral load, HIV diagnoses, and available resorces to improve linkages We need to garantee access to ART and coordinated care Social spport Mental health spport

23 For Prevention Opportnities Stats Prevention Measre Timing Uninfected, nexposed Uninfected, exposed (precoital/coital) Uninfected, exposed (postcoital) Infected Behavioral, strctral interventions (eg, condoms, circmcision) PrEP PEP Treatment of HIV to redce infectivity Years Hors 72 hors Years Cohen MS, et al. J Clin Invest. 2008;118: Cohen MS, et al. J Int AIDS Soc. 2008;11:4. Slide credit: clinicaloptions.com

24 The ftre of care in Nevada mst inclde prevention Mst link prevention and care together In planning In fnding In programs Mst increase access to PREP and PEP Edcation of providers and patients needed This linkage mst be transparent and withot sqabbling abot territory

25 ART for Prevention of HIV Transmission in Serodiscordant Coples HPTN 052: HIV-infected partner in healthy serodiscordant coples randomized to early or deferred ART (N = 1763 coples) [1] Overall 93% redction in risk of transmission with early therapy No linked HIV transmissions where index partner sppressed on ART PARTNER: observational stdy in serodiscordant coples where HIV-infected partner on sppressive ART and condoms not sed (N = 888 coples) [2] No linked transmissions recorded in any cople Median follow-p: 1.3 yrs; ~ 58,000 sex acts 1. Cohen MS, et al. N Engl J Med. 2016;375: Rodger A, et al. JAMA. 2016;316: Slide credit: clinicaloptions.com

26 The logical conclsion U=U

27 Crrent Recommendations Move from diagnosis to Immediate prescription of ART In an effort to redce HIV transmission (Skarbinski et al. JAMA IM 2015 and START)

28 Percentage of People with HIV and Percentage of HIV Transmissions at Each Stage of the Care Continm, U.S. and Perto Rico, % 90% 80% Percentage 70% 60% 50% 40% 30% 20% People with viral sppression People prescribed ART withot viral sppression People receiving care bt not prescribed ART People with diagnosis and not receiving care People with ndiagnosed HIV infection 10% 0% 13 People living with HIV Infection 23 Transmissions 92% of new HIV infections are transmitted from HIV-positive persons who are ndiagnosed or diagnosed bt not in care Frieden T, et al. N Engl J Med 2015;373:

29 The ftre of HIV care in Nevada mst inclde test and treat Need to enhance TESTING Mst have rotine testing in all clinical sites Mst have readily available testing in targeted sites Mst make testing COOL Mst make testing SAFE

30 The ftre of HIV care in Nevada mst inclde test and treat Mst develop protocols that allow treatment at the time of diagnosis Sccessfl models in San Francisco, at USC emergency room Possible becase of safer medications with mch better coverage even for most resistant virs (no need to wait for phenotype) Easy to draw labs at time of giving them the medication or same day when getting an appointment Need rapid follow p to complete the linkage to care (next day or even same day) Need warm hand offs in any transitions and link to social spport Reslts show rapid VL sppression, better linkage to care, better adherence

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32 Ftre of HIV care in Nevada mst embrace Getting to Zero Reqires that all members and stakeholders in this vision mst commnicate and plan cohesively Mst inclde impacted poplations, mst inclde providers of care, mst inclde media and marketing, mst inclde payers for care, mst inclde policy makers, mst inclde. WELL EVERYONE ACTUALLY

33 Past, crrent and ftre challenges to Getting to Zero Past, present and ftre Testing and treatment stigma, fear and discrimination Access to testing, care, prevention and spport Coordinated care Edcating providers and patients Adherence Crrent Ftre PREP stigma and discrimination STI explosion and crrent state of safe sex (condoms) Creation of a Vaccine Development of a Cre

34 If the Goal is No HIV then. Crrent challenges mst be addressed together In a spirit of trst, collaboration and sharing Practicing transparency Involving everyone Stressing innovation From a mlticltral, mltidisciplinary, mltifaceted Sandbox soltion Stigma and discrimination can be tackled throgh policies, marketing and innovative programs Exciting edcation for patients, for the pblic and for providers can be crafted Programs can grow to address mental and behavioral health for those with and at risk for HIV

35 Can we get there? Remember, Brilliant scientists already fond the virs that cased HIV Big pharmacetical companies and independent researchers fond safe and effective medications Global research involving thosands of people has shown that U=U ADA, HIV as a disability, ACA federal programs have impacted discrimination and access Team based care is the new norm HIV tests are now 4 th generation and fast and easy These achievements have made HIV a chronic disease with a normal life span and redced new infections for adlts and children

36 What are we missing in HIV/AIDS? A cre A vaccine However ntil brilliant scientists get this task done, we mst focs on the cltral, social and behavioral challenges to Get to Zero