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HIV ResearchSan Francisco Department of Public Health

Health CommissionAugust 2, 2011

HIV Epidemiology

Susan Scheer, PhD, MPH

AIDS cases, deaths, and prevalenceSan Francisco, 1980-2010

0

2,000

4,000

6,000

8,000

10,000

80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10

Num

ber o

f Cas

es/D

eath

s

Year of Diagnosis/Death

Persons Living with AIDS AIDS Cases AIDS Deaths

Race/Ethnicity of Men Living with HIV/AIDS Compared to the General Population of

San Francisco, December 2010

Male HIV/AIDS CasesN= 14,597

San FranciscoMale Population

Presenter

Presentation Notes

Done

Kaplan-Meier survival curves for persons diagnosed with AIDS in 1980-1989, 1990-1995, and 1996-2010, San Francisco

0%

20%

40%

60%

80%

100%

0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 180 192 204 216 228 240 252 264 276 288 300 312 324

Months of Survival

Perc

ent S

urvi

ving

Diagnosed in 1980-1989 (N=8,607)Diagnosed in 1990-1995 (N=12,082)Diagnosed in 1996-2010 (N=8,104)

Proportion surviving five years for persons diagnosed with AIDS between 1996 and 2010 by race/ethnicity,

exposure category, and gender

82%

74%

84% 86% 85%

66%76%

81% 82%73% 73%

0%

81%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Perc

ent S

urvi

ving

5 Y

ears

Race Exposure Category Gender Overall

* Transfemale data include all transgender cases. Transmale data are not released separately due to potential small population size.

2000 2010

* Transfemale data include all transgender cases. Transmale data are not released separately due to potential small population size.

Estimated antiretroviral therapy use among persons living with AIDS by gender, race/ethnicity, and exposure category

Newly diagnosed HIV infections and two methods of estimating incident HIV infections, 2006-2011

HIV Research

Jonathan Fuchs, MD, MPH

A Tradition of Innovative Research to Prevent HIV/AIDS

SF City Clinic Cohort Study- HIV antibody test- Natural history- Long term non-progression (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

Presenter

Presentation Notes

Plan and Implement multi-level prevention studies Foster a new generation of HIV researchers Develop and implement innovative community engagement programs

HVTN:

San Francisco, CA

Seattle, WA

Cleveland, OH

Rochester, NY

New York, NY (4)

Bethesda, MD

Santo Domingo, Dominican Republic

Iquitos, Peru

Annandale, VA

Port-au-Prince, Haiti

Soweto, Klerksdorp, Medunsa and Durban (2), South Africa

Boston, MA (2)Philadelphia, PA

Orlando, FL

Chicago, IL

Denver, CO

Houston, TX

Nashville, TN

Birmingham, AL

San Juan, Puerto Rico

Lausanne, Switzerland

Los Angeles, CA

Dallas, TX

Cape Town, South Africa

Atlanta, GA

Lima Peru Sao Paulo, Brazil

A global public/private partnership to test the safety and efficacy of preventive HIV vaccine candidates

Presenter

Presentation Notes

Tax paying dollars Participants may not assume that our particular site is part of a larger network. It may be reassuring for them to know that we are indeed part of the HVTN (explain) and associated with the NIH, institutions or at least ideas people usually trust. You could say: Like I said, we are part of the DPH in San Francisco, but we’re also part of a world-wide network that tests HIV vaccines. No one site can conduct an entire clinical trial on their own, so we collaborate with other sites in different cities. In 505, all 1350 participants will be from U.S. cities like New York, Philadelphia, LA, etc. So if you move, you may still be able to be in the study. If they ask why: circumcision rates are lower outside the U.S. and prevalence of Ad5 is higher. It was anticipated that it would be too difficult to recruit.

• 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)

Presenter

Presentation Notes

Time Magazine’s # 1 medical breakthrough Enrolled at 11 sites Discuss SMS to improve adherence

• 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

Presenter

Presentation Notes

Intentionally engage with diverse communities about HIV prevention research: Recruitment for clinical trials: Organizational goal: By 6/30/12, have at least 30% people of color (POC) participate in our clinical trials East Bay Initiative: identify need in the EB and increase the number of POC in the efficacy trial Community Education “Hot and Healthy with Garza” “Let’s Talk About Sex with Garza and Dulce” video series Blog: www.trialsandvials.org RAMP Scholar – focus group: “How can we better reach Latino gay men and other MSM into HIV prevention research” Community Advisory Board (CAG) Implement a strategic plan to maximize participation from CAG members

Fostering the nextgeneration of HIV

researchers

HIV Prevention

Moupali Das, MD, MPH

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

• PrEP, PEP, condoms, syringes

• Drivers1. Substance

use2. Alcohol3. Meth4. Crack5. Poppers6. STDs and #

of partners

Primary Prevention

Efforts

Testing Diagnosis Primary Care Treatment Virologic Suppression

Community

Testing

Linkage & Partner Services

Mental Health Services

Substance Use Treatment

Housing Support

Treatment Adherence

Medical Case

Mgmnt.

Routine Medical Testing

Median CD4 at HIV

diagnosis

% VirologicSuppression

Time to Virologic Suppression

Time to ART Initiation

Linkage

HIV

Engagement / Retention

Engagement / Retention

SFDPH Positive Health Access to Services and Treatment (PHAST)

Median CD4 at ART

initiation

Implementation Cascade: Improving Testing, Linkage, and Care Outcomes at the Population Level

% Linked to Care within 3 Months of Dx

% Engaged in Care

Community Viral Load: Unified Marker of Prevention and Care

STD/PCSI

ART Guidelines

Uptake

Engagement & Partner Services

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

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

Presenter

Presentation Notes

This is an offer Not a mandate These observations – combined with the availability of antiretroviral regimens that are more effective, more convenient, and better tolerated than previously used antiretroviral combinations – argue in favor of early ART initiation for all motivated patients, regardless of CD4 count or HIV viral load. The strength of this recommendation is greater in patients with CD4 counts <500 cells/mm3. However, in general all patients should be offered ART unless there is a reason to defer therapy.

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

CVL Disparities, San Francisco 2004-2008

Overall 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 1,822 (15) 26,744African-American 1,825 (15) 26,404

Women 786 (6) 27,614Transgender 291 (2) 64,160

IDU 1,011 (8) 33,245MSM-IDU 1,791 (14) 36,261

Not on treatment 2,924 (23) 40,056Not engaged in care 4,637 (37) 36,992

Presenter

Presentation Notes

The overall San Francisco mean CVL was 23,348 copies /mL for the 12,512 unduplicated HIV-positive individuals reported in the surveillance database and who had at least one VL from 2005 through 2008. Table 1 shows mean CVL for different populations according to reported VL and with imputation for missing VL (total missing 4,312). Relative mean CVL and significant findings did not change when using the imputed values. Remaining findings are therefore presented using the observed data. Significant disparities in mean CVL track with known HIV related disparities by race/ethnicity, transmission risk, and clinical care variables.

798

642

523 518434

935(CI: 658, 1212)

792 (CI: 552, 1033)

621(CI: 462, 781)

0

200

400

600

800

1000

1200

0

5,000

10,000

15,000

20,000

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30,000

2004 2005 2006 2007 2008

Num

ber o

f HIV

cas

es

Mea

n CV

L co

pies

/ml

Year

Newly diagnosed and reported HIV cases HIV Incidence(p= 0.028) (Mean CVL & HIV-incidence p=0.3)(Mean CVL & newly diagnosed HIV p=0.005)

Mean CVL and New HIV Infections, 2004-2008

Das, et al. 2010.

San Francisco Modeling Results

Charlebois, Das, Porco, Havlir. CID, 2011.

HIV Health Services

Bill Blum and Dean Goodwin

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.

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.

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.

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

Project Organizational StructureSan Francisco HIV Health Services

Project Grantee / Coordinating Agency

Bill Blum, Principal Investigator / Project DirectorRobert Whirry, Project Coordinator

Sajid Shaikh, Fiscal Monitor

Demonstration Site # 1

360: The Positive Care Center at UCSF

UCSF Parnassus Campus

Malcolm John, MD360 Medical Director

Demonstration Site # 2

Positive Health Program Ward 86 Clinic at

SF General Hospital

C. Bradley Hare, MDWard 86 Medical Director

Thank You

hiv research - sfdph 2/aug 2 hiv... · hiv research. san francisco department of public health....

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