Intensifying HIV Prevention in the Communities Where HIV is Most Heavily Concentrated

Moupali Das, MD, MPH

San Francisco Department of Public Health

Chicago MD

NYC MD

Baltimore MD

Houston MD

Ft. Lauderdale MSA

Miami MSA

Atlanta MSA

“Test & Treat,” or “High-Impact Combination Prevention,” or the “Medical Model”….

“Medical Ethics and the Rights of People with HIV Under Assault” by Sean Strub

“Going too far to battle AIDS? Drug experiment on blacks looms in Washington, D.C.” by Terry Michael Washington Post March 17 2010

In Memoriam: MT, 1969-2011

Testing Diagnosis Primary Care Treatment Virologic Suppression

Linkage

HIV

Engagement / Retention

Continuum of HIV Prevention, Care and Treatment:

The Implementation Cascade

Engagement / Retention

Primary Prevention

Efforts

• PrEP, PEP, condoms, syringes

• Drivers1. Substance

use2. Alcohol3. Meth4. Crack5. Poppers6. STDs, # of

partners

Testing Diagnosis Primary Care TreatmentVirologic

Suppression

Linkage

HIV

Engagement / Retention

Engagement / Retention

San Francisco’s Approach to Maximizing the Continuum of Prevention, Care and Treatment

Community

Testing

Linkage & Partner Services

Mental Health Services

Substance Use Treatment

Housing Support

Treatment Adherence

Medical CaseManagement

Routine Medical Testing

SFDPH Positive Health Access to Services and Treatment (PHAST)

STD & PCSI

ART Guidelines Uptake

Engagement & Partner Services

Community Viral Load: Unified Marker of Prevention and Treatment

Exciting Advances in HIV Prevention, Care, Treatment, and (Cure?!)

1,106,400

874,056

655,542

437,028349,622

262,217 209,7730

200,000

400,000

600,000

800,000

1,000,000

1,200,000100%

79%

59%

40%

32%24%

19%

Gardner, et al. CID, 2011.

Major Gaps in the Implementation Cascade

We Can and Must Do Better!

• Mean/Median CD4 at diagnosis in SF: 400s

• U.S. Median still less than 200• Most people meet criteria for

treatment by the DHHS guidelines at Dx

• 20% still do not know HIV status

• % lost before linkage• % lost during care• ADAP waiting lists• % not virologically suppressed

for individual and community benefit

Primary Prevention

Efforts

• PrEP, PEP, condoms, syringes

• Drivers1. Substance

use2. Alcohol3. Meth4. Crack5. Poppers6. STDs, # of

partners

Testing Diagnosis Primary Care TreatmentVirologic

Suppression

Linkage

HIV

Engagement / Retention

Engagement / Retention

San Francisco’s Approach to Maximizing the Continuum of Prevention, Care and Treatment

Community

Testing

Linkage & Partner Services

Mental Health Services

Substance Use Treatment

Housing Support

Treatment Adherence

Medical CaseManagement

Routine Medical Testing

SFDPH Positive Health Access to Services and Treatment (PHAST)

STD & PCSI

ART Guidelines Uptake

Engagement & Partner Services

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

Slide modified from slide courtesy of Brad Hare, SFGH Community Forum

Simply Testing and Treating will not eliminate the epidemic...

Coates. Lancet, 2008.

Treatment is Prevention

Substance Use Treatment is Prevention

Mental Health Treatment is Prevention

Housing is Prevention

Food Security is Prevention

“Si-w bay medikaman san manje, se lave men, siye até”

"Giving drugs without food is like washing your hands and

drying them in the dirt."

The data are in hand…

“But once the data are in hand, it is the failure to use those data for public health purposes that must be justified.” (Fairchild and Bayer, 2007)

• Surveillance data and other programmatic data should be used to monitor and evaluate, and for real-time continuous quality improvement– Prior diagnosis

– Current and past location of care: Medical records

– Treatment history, co-infections, resistance

Testing Diagnosis Primary Care Treatment Virologic Suppression

Linkage

HIV

Engagement / Retention

Engagement / Retention

San Francisco’s Approach to Using the Data in Hand to Evaluate the Implementation Cascade

Median CD4 at HIV

diagnosis

% VirologicSuppression

Time to Virologic Suppression

Time to ART Initiation

Median CD4 at ART

initiation

% Linked to Care within 3 Months of Dx

% Engaged in Care

Community Viral Load: Unified Marker of Prevention and Treatment

N=352

N=283

N=213

N=138

N=135

N=454

N=384

N=329

N=296

N=212

0 5 10 15 20 25 30 35

2004

2005

2006

2007

2008

Months from diagnosis to start of ART Months from HIV diagnosis to suppressionDas et al CROI 2011

Months from Diagnosis to Start of ART and from diagnosis to Suppression

N=3

52

N=2

83

N=2

13

N=1

38 N=1

35

N=4

54

N=3

84 N=3

29

N=2

96 N=2

12

0%

20%

40%

60%

80%

2004 2005 2006 2007 2008

% suppressed within 6 months% suppressed within 12 months

6 month, 12 month Virologic Suppression Rates (viral load <75) by year of diagnosis among those who achieved suppression^

N=3

52

N=2

83 N=2

13

N=1

38

N=1

35

N=4

54

N=3

84 N=3

29 N=2

96

N=2

12

0%

20%

40%

60%

80%

2004 2005 2006 2007 2008

% suppressed within 6 months% suppressed within 12 months

6 month, 12 month Virologic Suppression Rates (viral load <75) by year of diagnosis among all newly diagnosed and reported cases*

*Cases with no viral load data were designated unsuppressed

^These data are among cases with a viral load and who were suppressed

p<0.001 p<0.001

Das, et al. CROI, 2011.

Greatest Population-Level Impact:Community-Level Harm Reduction

Frieden. AJPH. April, 2010.

Minimum, Most Recent, Maximum CVL and Newly Diagnosed and Reported HIV cases

864

737

590 588 540506

0

200

400

600

800

1000

0

15,000

30,000

45,000

2004 2005 2006 2007 2008 2009

Minimum CVL(p=0.003)

Most recent CVL(p<0.001)

Maximum CVL(p=0.01)

Das, et al. CROI, 2011.

Community Viral Load Disparities

• Even in relatively richly-resourced San Francisco, disparities in CVL track with poor 5-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, SF 2004-2008Overall 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 1822 (15) 26,744

African-American 1825 (15) 26,404

Women 786 (6) 27,614

Transgender 291 (2) 64,160

IDU 1011 (8) 33,245

MSM-IDU 1791 (14) 36,261

Not on treatment 2924 (23) 40,056

Not engaged in care 4637 (37) 36,992

Recommended ActionMeasure and utilize community viral load: Ensure that all high prevalence localities are able to collect data necessary to calculate community viral load, measure the viral load in specific communities, and reduce viral load in those communities where HIV incidence is high.

CVL: New York & Washington D.C.

Laraque, et al. CROI, 2011. Abstract #1024. Castel, et al. CROI, 2011. Abstract #1023.

0

20

40

60

80

100

120

2006

2007

2008

2009

U.S. HIV Incidence, 2006-2009

Prejean, et al. PLoS One, 2011.

The Legacy and the Future

Acknowledgments

SFDPH

Priscilla Chu, Glenn-Milo Santos, Susan

Scheer, Willi McFarland, Grant Colfax,

Annie Vu, H. Fisher Raymond, Israel

Nieves-Rivera, Isela Gonzalez, Tracey

Packer, Dara Geckeler, Bill Blum, Susan

Philip, Stephanie Cohen, Tomas Aragon,

Barbara Garcia, Mitch Katz

UCSFDiane Havlir, Brad Hare, Steve Deeks, Edwin

Charlebois, Steve Morin, Eric VittinghoffCDCCandice Kwan, Kate Buchaz, Greg Millet, CVL

Working Group Members, Thomas FriedenUniv of MiamiLisa Metsch

People living with HIV/AIDS in San Francisco