2011 National HIV Prevention Conference-Plenaries-Monday.

1. Intensifying HIV Prevention in the
Communities Where HIV is
Most Heavily Concentrated
Moupali Das, MD, MPH
San Francisco Department of Public Health

2. Chicago MD
NYC MD
Baltimore MD
Atlanta MSA
Ft. Lauderdale MSA
Miami MSA
Houston MD

3. “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

4. In Memoriam:
MT, 1969-2011

5. Continuum of HIV Prevention, Care and
Treatment:
The Implementation Cascade
Testing Primary Care Treatment Virologic HIV
Diagnosis
Suppression
Linkage Engagement / Engagement /
Retention Retention

6. San Francisco’s Approach to Maximizing the
Continuum of Prevention, Care and Treatment
Primary
Prevention
Efforts
HIV
Virologic
Testing Diagnosis Primary Care Treatment Suppression
• PrEP, PEP,
condoms,
syringes Linkage Engagement Engagement
• Drivers / Retention / Retention
1. Substance
use
2. Alcohol
3. Meth
4. Crack Routine Mental Health Treatment
5. Poppers Services Adherence
Medical
6. STDs, # of Testing
partners Substance Use Medical Case
Treatment Management
 Linkage
Community & Partner Housing ART Guidelines
Testing Services Support Uptake
STD &
PCSI
SFDPH Positive Health Access to Engagement &
Services and Treatment (PHAST) Partner Services
Community Viral Load: Unified Marker of Prevention and Treatment

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

8. Major Gaps in the Implementation Cascade
1,200,000
100%
1,000,000
79%
800,000
59%
600,000
1,106,400
40%
400,000 874,056
32%
655,542 24%
19%
200,000 437,028
349,622
262,217 209,773
0
Gardner, et al. CID, 2011.

9. 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

10. San Francisco’s Approach to Maximizing the
Continuum of Prevention, Care and Treatment
Primary
Prevention
Efforts
HIV
Virologic
Testing Diagnosis Primary Care Treatment Suppression
• PrEP, PEP,
condoms,
syringes Linkage Engagement Engagement
• Drivers / Retention / Retention
1. Substance
use
2. Alcohol
3. Meth
4. Crack Routine Mental Health Treatment
5. Poppers Services Adherence
Medical
6. STDs, # of Testing
partners Substance Use Medical Case
Treatment Management
 Linkage
Community & Partner Housing ART Guidelines
Testing Services Support Uptake
STD &
PCSI
SFDPH Positive Health Access to Engagement &
Services and Treatment (PHAST) Partner Services

11. 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

12. Simply Testing and Treating will not
eliminate the epidemic...
Coates. Lancet, 2008.

13. Treatment is Prevention

14. Substance Use Treatment is Prevention

15. Mental Health Treatment is Prevention

16. Housing is Prevention

17. Food Security is Prevention

18. “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."

19. 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

20. San Francisco’s Approach to Using the Data in Hand
to Evaluate the Implementation Cascade
Median CD4 % Linked to Median CD4
at HIV Care within 3 % Engaged % Virologic
at ART
diagnosis Months of Dx in Care Suppression
initiation
Time to ART Initiation
Time to Virologic Suppression
HIV
Diagnosis Primary Care Treatment Virologic
Testing Suppression
Engagement Engagement
Linkage
/ Retention / Retention
Community Viral Load: Unified
Marker of Prevention and Treatment

21. Months from Diagnosis to Start of ART and from
diagnosis to Suppression
0 5 10 15 20 25 30 35
2004
N=352
N=454
2005
N=283
N=384
2006
N=213
N=329
2007
N=138
N=296
2008
N=135
N=212
Months from diagnosis to start of ART Months from HIV diagnosis to suppression
Das et al CROI 2011

22. 6 month, 12 month Virologic Suppression 6 month, 12 month Virologic Suppression Rates
Rates (viral load <75) by year of diagnosis (viral load <75) by year of diagnosis among all
among those who achieved suppression^ newly diagnosed and reported cases*
p<0.001 p<0.001
80% 80%
60% 60%
N=212
N=212
N=296
40% 40%
N=296
N=329
N=135
N=135
N=138
N=454
N=213
N=384
N=329
N=352
20% 20%
N=138
N=283
N=454
N=384
N=213
N=352
N=283
0% 0%
2004 2005 2006 2007 2008 2004 2005 2006 2007 2008
% suppressed within 6 months % suppressed within 6 months
% suppressed within 12 months % suppressed within 12 months
^These data are among cases with a viral *Cases with no viral load data were
load and who were suppressed designated unsuppressed
Das, et al. CROI, 2011.

23. Greatest Population-Level Impact:
Community-Level Harm Reduction
Frieden. AJPH. April, 2010.

24. Minimum, Most Recent, Maximum CVL and
Newly Diagnosed and Reported HIV cases
45,000 1000
864
737 800 Minimum CVL
(p=0.003)
30,000 590 588 540 600
506 Most recent CVL
(p<0.001)
400
15,000
Maximum CVL
200 (p=0.01)
0 0
2004 2005 2006 2007 2008 2009
Das, et al. CROI, 2011.

25. 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

26. CVL Disparities, SF 2004-2008
Overall N (%) Mean CVL*
San Francisco 12,512 (100) 23,348
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
*(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.

27. Recommended Action
Measure 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.

28. CVL: New York & Washington D.C.
Laraque, et al. CROI, 2011. Abstract #1024. Castel, et al. CROI, 2011. Abstract #1023.

29. U.S. HIV Incidence, 2006-2009
120
100
80
60
40 2006
2007
20
2008
0 2009
Prejean, et al. PLoS One, 2011.

30. The Legacy and the Future

31. Acknowledgments
People living with HIV/AIDS in San Francisco
SFDPH UCSF
Priscilla Chu, Glenn-Milo Santos, Susan Diane Havlir, Brad Hare, Steve Deeks, Edwin
Scheer, Willi McFarland, Grant Colfax, Charlebois, Steve Morin, Eric Vittinghoff
Annie Vu, H. Fisher Raymond, Israel CDC
Candice Kwan, Kate Buchaz, Greg Millet, CVL
Nieves-Rivera, Isela Gonzalez, Tracey Working Group Members, Thomas Frieden
Packer, Dara Geckeler, Bill Blum, Susan Univ of Miami
Philip, Stephanie Cohen, Tomas Aragon, Lisa Metsch
Barbara Garcia, Mitch Katz