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San Francisco reports record low number of new HIV diagnoses
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Researchers in San Francisco identified 223 new HIV diagnoses in 2016 — the lowest ever recorded in the city.
Meanwhile, treatment coverage and viral suppression rates were at an all-time high, according to Susan Scheer, PhD, MPH, director of the HIV Epidemiology Section at the San Francisco Department of Public Health, and colleagues. The researchers attributed this progress to a series of citywide HIV prevention and treatment programs that are now formalized under San Francisco’s “Getting to Zero SF” effort. The initiative is led by a multisector consortium of public health, academic and community-based organizations. Their goals are to have zero new HIV infections, zero HIV-associated deaths and zero HIV stigma and discrimination in the city.
For their study, recently published in Clinical Infectious Diseases, Scheer and colleagues examined trends in HIV before and after the Getting to Zero SF interventions were rolled out in 2010. The interventions include:
- administration of ART regardless of CD4 cell count (2010);
- increasing coverage of and targeted HIV testing (2011);
- relinking HIV patients who have fallen out of care (2011);
- initiating same-day ART at HIV diagnosis (2012); and
- expanding access to pre-exposure prophylaxis (PrEP) for high-risk groups (2013).
Study data showed that the total number of new HIV diagnoses declined from 473 in 2009 to 329 in 2014 (P = .005). More recent data released by the city’s health department revealed even fewer diagnoses in 2016 — just 223. According to the researchers, the decline in new HIV diagnoses in San Francisco mirrors an overall trend in the United States. However, the proportion of new diagnoses increased among men (P = .005), Asian/Pacific Islanders and Latinos (P = .02), and men who have sex with men, or MSM (P = .003).
In other results, linkage to care within 3 months increased from 85.8% in 2009 to 91.8% in 2014 (P = .04); ART initiation within 1 year of diagnosis increased from 63.2% to 90.7% (P < .001); viral suppression within 1 year of HIV diagnosis increased from 49.2% to 82.3% (P < .001); and the proportion of patients who developed AIDS within 3 months decreased from 26.9% to 16.4% (P < .001).
There were substantial reductions in the average time from HIV diagnosis to ART initiation (9 months vs. 1 month; P < .001) and viral suppression (11 months vs. 3 months; P < .001). However, there were no significant changes in the proportion of patients retained in care 6 to 12 months after linkage to care, which was approximately 70%, or in the proportion of patients who died within 1 year of diagnosis, which remained below 4%.
To ensure that progress continues, the Getting to Zero SF consortium will expand its citywide HIV programs, according to the researchers. By 2020, the consortium aims to reduce 90% of new HIV diagnoses and HIV-associated deaths that were reported in 2013.
“This would require that new diagnoses decrease from 399 in 2013 to 40 in 2020, and HIV-associated deaths from 261 in 2013 to 26 in 2020,” the researchers wrote.
Scheer and colleagues said there is a particular need to improve programs that focus on retention in care. They also noted that it will be important to ensure that patients continue to have access to care.
“New approaches to ensure that everyone living with HIV has access to HIV care will be necessary, especially given that the Affordable Care Act — which has enabled many low-income and previously uninsured persons to access HIV treatment, care and PrEP — is currently undergoing challenges and may be repealed and replaced,” they wrote. “Although currently proposed changes and their impact on persons living with or at risk for HIV are unknown, it appears likely that many such persons will find it harder to access and maintain appropriate HIV care and prevention.” – by Stephanie Viguers
References:
San Francisco Department of Public Health. HIV Epidemiology Report 2016. https://www.sfdph.org/dph/files/reports/RptsHIVAIDS/Annual-Report-2016-20170831.pdf. Accessed November 11, 2017.
Scheer S, et al. Clin Infect Dis. 2017;doi:10.1093/cid/cix940.
Disclosures: Scheer reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Oliver Bacon, MD, MPH
This progress in the control of HIV in San Francisco has been made possible by the collaborative effort undertaken by Getting to Zero SF consortium members and stakeholders in HIV care and prevention, including community-based, academic and public health organizations, as well as individual care providers. The structure of the “Getting to Zero” effort with quarterly accountability in the form of consortium meetings, which are open to the public, has been very helpful in keeping progress moving.
The overall decline in new HIV diagnoses is very encouraging. The proportion of patients linked to care within 3 months of diagnosis increased somewhat, and that is a really important advance. The proportion of people who developed AIDS within 3 months of their diagnosis decreased because people are getting diagnosed earlier and at a higher CD4 count. This is due to the explosion of HIV testing in San Francisco.
What remains a concern are disparities in new diagnoses among certain sociodemographic groups. Even though the absolute number of new diagnoses decreased, the proportion of new diagnoses in MSM, Asian-Pacific Islanders and Latinos increased over time. Also of concern is the proportion of persons retained in care. The Getting to Zero SF consortium is already working on this, but more resources are needed to improve intensive case management for the most vulnerable persons living with HIV in San Francisco who need help accessing services like mental health care, housing support, food support, substance use treatment and services that ensure patients are attending their medical appointments. Although the focus is certainly on all newly diagnosed patients, it is important to spend extra effort making sure that vulnerable populations who make up a higher proportion of new cases are linked to care and receive ART.
Another topic that Scheer and colleagues mention and cannot be overemphasized is the expansion of PrEP in San Francisco. From the biomedical perspective, there are two sides of the coin. One is getting everyone aware of their diagnosis, on treatment and virally suppressed as quickly as possible, then ensuring that they maintain viral suppression and stay in care. The other is making sure that everyone who is HIV-uninfected but at high risk for infection has access to the best possible prevention tools. First and foremost among them is PrEP.
In terms of access to PrEP and timely ART, the increased availability of health insurance provided by the Affordable Care Act, and particularly Medicaid expansion, has been absolutely essential. We are all concerned that this support system for getting people into care and on treatment or preventive treatment may go away. Medi-Cal serves some of the most vulnerable populations. Keeping expanded Medi-Cal in place is very important.
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