Featuring our Faculty: Achieving zero HIV transmissions will require SF to address stigma, disparities
Having achieved significant reductions in new infections and effective treatment, San Francisco is a model city for combating HIV — but even so, The City is not expected to meet its goal of a 90 percent reduction in HIV diagnoses and deaths by 2020.
The prevailing reasons: stigma and disparities.
The Department of Public Health is expected to release this summer HIV data for 2016. The results will show 223 new HIV diagnoses and 165 HIV deaths, health officials told the San Francisco Examiner.
In 2015, there were 255 new HIV diagnoses and 197 deaths. In 2013, there were 382 new HIV diagnoses and 261 deaths.
Today, nearly 16,000 San Francisco residents are living with HIV.
While new cases are declining, Dr. Susan Buchbinder, director of an HIV prevention research unit in DPH, told the Health Commission last month that The City is not expected to meet the 90 percent reduction goal by 2020.
Buchbinder said “we could be getting close” to the 90 percent reduction for new diagnoses “on our current schedule.” However, she noted that the downward trend may not remain constant since testing and other services are not reaching all segments of the population uniformly.
“We know that we are not reaching certain communities, so we don’t expect that this is going to be a linear decline,” Buchbinder said. “And it is clear that we need new programs and more work in that area.”
In 2014, a consortium of groups fighting the HIV epidemic joined together to launch a “Getting to Zero” initiative with the goal of making San Francisco the first city in the world to achieve zero new HIV transmissions and deaths and eliminate stigma.
STIGMA AND DEATH REDUCTION
The City may soon have more answers for how to reduce HIV-related deaths.
Health officials are studying the causes of death of those with HIV to look for areas to improve treatment directly tied to the infection, or if there are other needs such as suicide prevention.
“We are not seeing really a substantial decline in the number of deaths,” Buchbinder said during a May 2 Public Health Commission hearing on an update on the Getting to Zero effort. “I have to say that, in the initial look at those data, that stigma clearly is a huge component of it, and we absolutely need to address it or we won’t get to zero.”
Health Commissioner Cecilia Chung said that the fact that stigma continues to exist in a city as liberal as San Francisco was “sobering.”
The prevalence of stigma is illustrated in the department’s March 2017 report on a survey of 465 HIV-positive patients who had at least one medical care visit in 2013 or 2014.
Fifty-two percent of those patients surveyed had difficulty telling others about having HIV, and 46 percent said they hid their HIV status from others. Twenty-four percent felt guilty, 20 felt ashamed and nearly 18 percent sometimes felt worthless for having HIV.
Patients also experienced stigma when seeking care. Twenty-four percent reported health care system hostility or disrespect due to their HIV diagnosis, and 32 percent reported discrimination.
One of the most glaring challenges are the disparities in low-income and minority communities, which are faring far worse in rates of transmission and treatment.
“While we are seeing a significant decline in new diagnoses in all of these racial and ethnic groups, we still see these disparities with substantially higher rates of new diagnoses in African-American men and Latino men,” Buchbinder said. The 2015 rate of new HIV diagnoses per 100,000 people by race is 140 among black men, 83 among Latino men and 52 among white men.
“Of concern, in African-American women the rate is 31 new diagnoses per 100,000 population, which is almost as high as it is in white men,” Buchbinder said. “While, in general, the number of new diagnoses of women is substantially lower, we do see this very intensive epidemic in African-American women.”
Health Commissioner James Loyce Jr. said he didn’t know how best to make inroads in these hard-to-reach populations, but existing strategies are not paying off as hoped.
“Even in 2017, we are still talking about stigma as it relates to the African-American community and other communities of color, and we’ve developed all these different strategies, but the impact of stigma is still very large in our communities,” Loyce said. “Even though our population is shrinking in numbers, the devastating impact of the burden of disease in our communities has not changed. Matter of fact, it is getting worse.”
Making testing more convenient and more integrated in regular medical care visits at health clinics and emergency rooms could reduce disparities, health officials said.
The San Francisco AIDS Foundation has a mobile testing program, which parks its roaming facility near Dolores Park on Saturdays, that allows people to get tested without having to step into a clinic.
The 3rd Street Youth Center and Clinic, which sees about 1,000 clients annually ages 14 to 24 — many of whom are black females — rolled out daily HIV testing at its Bayview location for drop-in clients in 2014.
“Our hardest-to-get-tested are our young black males,” said Joi Jackson-Morgan, executive director of 3rd Street Youth Center and Clinic, which recently joined the consortium. “Without symptoms, they are the hardest to get in for regular care.”
Jackson-Morgan noted that despite the clients being engaged in risky behavior — about 25 percent report using condoms all the time, 25 percent never and 50 percent sometimes — they’ve had few cases of positive HIV tests since opening in 2005.
“They’ve been lucky in that sense,” she said.
Jackson-Morgan said that some of their patients are sex workers who receive care frequently.
“We are really trying to tackle getting them tested for syphilis or getting them on PrEP, trying to keep the risk very low in our community.”
The march toward Getting to Zero is an effort emboldened by the advent of anti-retroviral drug Truvada, a pre-exposure prophylaxis (PrEP) drug manufactured by Gilead Sciences and approved by the U.S. Food and Drug Administration in 2012.
If taken daily, studies show Truvada can reduce the risk of contracting HIV by up to 92 percent.
In 2014, then-Supervisor Scott Wiener, who’s now a state senator, announced publicly he takes PrEP to end the stigma and increase its usage.
Many have hailed the drug as a game-changer in the fight against HIV.
While PrEP usage has increased in San Francisco among homosexual men, the highest increase is for white residents. In 2014, nearly 25 percent of those who were white and eligible for PrEP were on the drug, and that increased to more than 45 percent in 2016, according to data provided by DPH. The second highest percentage is for black people, of which 30 percent of those eligible were on the drug — an increase from less than 10 percent in 2014.
Another effort is tailoring PrEP access for youth without using health insurance.
“Some young people do have insurance and some people don’t,” said Tracey Packer, DPH’s director of Community Health Equity and Promotion. “But even if they do, it might be their parents’ insurance, and they are not wanting to have their prescriptions or their visits show up.”
The City has enrolled 10 youth patients, ages ranging from 16 to 20, in a new program that provides them with PrEP. A collaboration with Mission Wellness Pharmacy, which currently doesn’t offer PrEP, may soon allow people to obtain PrEP there with a prescription.
“We are in the process of working out the details for this collaboration and are hopeful that it will be in place later this summer,” DPH spokesperson Rachel Kagan told the Examiner.
To improve keeping patients in treatment, new methods are being explored.
City health officials are exploring the idea of providing lockers for medicines of HIV patients, in the way the San Francisco AIDS Foundation currently provides medicine lockers for those who are homeless or marginally housed, to ensure they don’t lose their Hepatitis C medications or have them stolen.
“We have this idea of developing lockers where people can put their medication and come and take it on a daily basis,” Packer, said.
To encourage people to show up at appointments, patients may start receiving cellphones to receive reminders or call to reschedule.
“We are working on getting cellphones and places for people to charge them,” Packer said.
The cellphones are meant to ensure people receive the care the care they need and reduce the risk of transmission.
“Where we are not seeing the substantial improvement is being retained in care within six to 12 months of linkage,” Buchbinder said. “A lot of our efforts really need to focus on this issue of retention and care.”
In 2010, UNAIDS called for a global “getting to zero” strategy, in which San Francisco responded to with “the getting to zero” consortium.
An assessment of the global effort last year found it wasn’t on track to reduce to under 500,000 new HIV infections throughout the world by 2020.
“Declines in new HIV infections among adults have slowed, threatening further progress toward the end of the AIDS epidemic,” reads the UNAIDS 2016 Prevention Gap Report. “Since 2010, the annual number of new infections among adults (15+) has remained static at an estimated 1.9 million [2015 range of 1.7 million–2.2 million].”
An estimated 35 million people have died from AIDS-related illnesses since the epidemic began and an estimated 78 million people have become infected with HIV.