HIV Research. San Francisco Department of Public Health Health Commission August 2, 2011

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1 HIV Research San Francisco Department of Public Health Health Commission August 2, 2011

2 HIV Epidemiology Susan Scheer, PhD, MPH

3 AIDS cases, deaths, and prevalence San Francisco, ,000 Number of Cases/Deaths 8,000 6,000 4,000 2, Year of Diagnosis/Death Persons Living with AIDS AIDS Cases AIDS Deaths

4 Race/Ethnicity of Men Living with HIV/AIDS Compared to the General Population of San Francisco, December 2010 Male HIV/AIDS Cases N= 14,597 San Francisco Male Population

5 Kaplan-Meier survival curves for persons diagnosed with AIDS in , , and , San Francisco 100% Percent Surviving 80% 60% 40% 20% 0% Months of Survival Diagnosed in (N=8,607) Diagnosed in (N=12,082) Diagnosed in (N=8,104)

6 Proportion surviving five years for persons diagnosed with AIDS between 1996 and 2010 by race/ethnicity, exposure category, and gender 100% Percent Surviving 5 Years 90% 80% 70% 60% 50% 40% 30% 20% 82% 74% 84% 86% 85% 66% 76% 81% 82% 73% 73% 81% 10% 0% 0% Race Exposure Category Gender Overall * Transfemale data include all transgender cases. Transmale data are not released separately due to potential small population size.

7 Estimated antiretroviral therapy use among persons living with AIDS by gender, race/ethnicity, and exposure category * Transfemale data include all transgender cases. Transmale data are not released separately due to potential small population size.

8 Newly diagnosed HIV infections and two methods of estimating incident HIV infections,

9 HIV Research Jonathan Fuchs, MD, MPH

10 A Tradition of Innovative Research to Prevent HIV/AIDS SF City Clinic Cohort Study - HIV antibody test - Natural history - Long term nonprogression (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

11 HVTN: A global public/private partnership to test the safety and efficacy of preventive HIV vaccine candidates Chicago, IL Cleveland, OH New York, NY (4) Rochester, NY Philadelphia, PA Boston, MA (2) Bethesda, MD Annandale, VA Lausanne, Switzerland Denver, CO Seattle, WA San Francisco, CA Los Angeles, CA Nashville, TN Dallas, TX Atlanta, GA Birmingham, AL Orlando, FL Houston, TX Port-au-Prince, Haiti Santo Domingo, Dominican Republic San Juan, Puerto Rico Lima Peru Iquitos, Peru Sao Paulo, Brazil Cape Town, South Africa Soweto, Klerksdorp, Medunsa and Durban (2), South Africa

12 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)

13 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

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15 Fostering the next generation of HIV researchers

16 HIV Prevention Moupali Das, MD, MPH

17 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

18 Implementation Cascade: Improving Testing, Linkage, and Care Outcomes at the Population Level Primary Prevention Efforts PrEP, PEP, condoms, syringes Drivers 1. Substance use 2. Alcohol 3. Meth 4. Crack 5. Poppers 6. STDs and # of partners Community Testing Testing Diagnosis Primary Care Treatment Virologic Suppression Routine Medical Testing Linkage & Partner Services Median CD4 at HIV diagnosis Time to ART Initiation % Linked to Care within 3 Months of Dx Time to Virologic Suppression Linkage Mental Health Services Substance Use Treatment Housing Support Median CD4 at ART initiation Engagement / Retention % Engaged in Care Engagement / Retention % Virologic Suppression Treatment Adherence Medical Case Mgmnt. STD/PCSI ART Guidelines Uptake HIV SFDPH Positive Health Access to Services and Treatment (PHAST) Engagement & Partner Services Community Viral Load: Unified Marker of Prevention and Care

19 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

20 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

21 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

22 CVL Disparities, San Francisco Overall N (%) Mean CVL * San Francisco 12,512 (100) 23,348 Sub-groups N (%) Mean CVL * Latino 1,822 (15) 26,744 African-American 1,825 (15) 26,404 Women 786 (6) 27,614 Transgender 291 (2) 64,160 IDU 1,011 (8) 33,245 MSM-IDU 1,791 (14) 36,261 Not on treatment 2,924 (23) 40,056 Not engaged in care 4,637 (37) 36,992 *(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.

23 Mean CVL and New HIV Infections, Mean CVL copies/ml 30,000 25,000 20,000 15,000 10, (CI: 658, 1212) 792 (CI: 552, 1033) (CI: 462, 781) Number of HIV cases 5, (p= 0.028) 0 Year Newly diagnosed and reported HIV cases HIV Incidence (Mean CVL & newly diagnosed HIV p=0.005) 0 (Mean CVL & HIV-incidence p=0.3) Das, et al

24 San Francisco Modeling Results Charlebois, Das, Porco, Havlir. CID, 2011.

25 HIV Health Services Bill Blum and Dean Goodwin

26 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.

27 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.

28 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.

29 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

30 Project Organizational Structure San Francisco HIV Health Services Project Grantee / Coordinating Agency Bill Blum, Principal Investigator / Project Director Robert Whirry, Project Coordinator Sajid Shaikh, Fiscal Monitor Demonstration Site # 1 360: The Positive Care Center at UCSF UCSF Parnassus Campus Malcolm John, MD 360 Medical Director Demonstration Site # 2 Positive Health Program Ward 86 Clinic at SF General Hospital C. Bradley Hare, MD Ward 86 Medical Director

31 Thank You