HIV Network Dinner August 30, 2016 Getting To zero (Part 1) Sponsored by: 2424 Mission Street, San Francisco 94110 Mercedes Azcarate ----- Meeting Notes (11/16/15 23:24) ----- introduce self and ask for participants to introduce themselves.

Co-founder of the HIV/AIDS unit at SFGH (5B -> 5A) Dedication Steve Keith, RN 7/4/1952 - 8/23/2016 Co-founder of the HIV/AIDS unit at SFGH (5B -> 5A)

Panelists: (in order of appearance) Oliver Bacon, MD – Assistant Professor of Medicine, UCSF Division of HIV & Infectious Disease Clarissa Ospina-Norvell, RN, MS, ANP – UCSF Division of HIV/AIDS & Infectious Disease at SFGH Ward 86 Miranda Nordell – PrEP Coordinator, San Francisco Department of Public Health Hyman Scott, MD, MPH – Medical Director, Clinical Research, Bridge HIV, SFDPH, Assistant Clinical Professor, UCSF Austin Padilla – Youth, LGBT, HIV/AIDS Advocate, Office of District 6 Supervisor Jane Kim, Huckleberry Youth Program, Getting to Zero ----- Meeting Notes (11/16/15 23:24) ----- acknowledgements Objectives

Objectives After this program participants will be able to explain: what the Getting to Zero Initiative is the role of the RAPID program the role of the PrEP program the role of fighting stigma what we (network members) can do to make sure San Francisco succeeds in Getting to Zero ----- Meeting Notes (11/16/15 23:24) ----- Question

Getting to Zero, Overview Oliver Bacon

Zero stigma and discrimination Getting to Zero is a multi-sector independent consortium, operating under principles of collective impact: “Long-term commitment of groups from different sectors to a common agenda to solve a specific social problem.” Improve HIV for persons living with disease and at risk in San Francisco Maintain funding for existing efforts Achieve success in signature initiatives Secure funding and broad city/private sector support Create innovative programs Exchange best practices with other cities Highlight: Long term commitment of multisector partners to work together to improve HIV for persons living with it and at risk for it in SF. Commitment NOT to cannibalize existing resources, but to secure broad public and private support Share our challenges and successes w others Structure of consortium Inclusion: both push (interested persons encouraged to join) and pull (recruitment -steering committee -consortium meets quarterly, open to public, solicits ideas, reports on goals and progress -individual project committees meet regularly to move initiatives forward Name several of the groups that are representative of the breadth of collective By 2020 90% fewer HIV infections 90% fewer HIV deaths Zero stigma and discrimination 6

We have been heading toward zero New HIV diagnoses and deaths in SF 2010: ART at diagnosis; HIV test scale-up 2006: HIV test w/o written consent 2011: LINCS 2012: PrEP To highlight: 1. The number of new HIV cases and HIV related deaths have both decreased substantially in the last years. 2. G2Z built on a series of initiatives, successes. Started with initiatives that responded to the global, national and local evidence. These are all programs that were started in response to the the rapid expansion of knowledge regarding HIV treatment and prevention in the last decade: dearth of testing in SF, therefore need to increase; improved outcomes from abandoning CD4-guided therapy therefore universal ART; he dramatic step-offs in the care cascade and the crucial importance of linkage and retention, and lessons from PHAST, therefore LINCS; the need for new, effective HIV prevention interventions, therefore PrEP. Delay in implementing universal ART, therefore RAPID pilot at W86. 2014 306 HIV diagnoses 177 HIV-related deaths 7

The Goal: Test, Treat, Retain, and PrEP I. Universal, accessible HIV/STI testing -Frequency determined by risk -Testing for acute infection in high-Priority populations/settings MAKE TESTING FRIENDLY IF (-) IF(+) II. COMBINATION PREVENTION Condoms and Risk Reduction coaching Referrals for Substance use treatment, Mental health care PEP for occasional exposures PrEP for Pts with elevated risk: Inconsistent condom use Multiple partners/non-monogamous steady partnerships Serodiscordant partners including periconception h/o Rectal STIs, PEP Reduce stigma, promote resilience III. Immediate ART Eliminate OIs/AIDS ↓ nonAIDS complications ↓ transmission to partners Retention in care to maintain suppression Partner services to find recent sex partners -> test Reduce Stigma, promote resilience Patients receiving combination prevention (III) continue to receive frequent HIV testing (I). 8

SF G2Z Steering Committee

Clarissa Ospina-Norvell, NP August 30, 2016 RAPID Getting to Zero Clarissa Ospina-Norvell, NP August 30, 2016

“RAPID” Rapid ART Program Initiative for New HIV Diagnosis A pilot project at Ward 86 saw it’s first patient in 2013 Vision is to provide immediate ART to all patients newly diagnosed with HIV In 2013 Providers at SFGH piloted an early treatment program for acute HIV infection. Dr. Hatano saw her first patient in July of 2 013before the formal start of the RAPID program. 11

Three Phases Pilot: newly diagnosed patients in acute infection Expanded Populations: Include other newly diagnosed patients (low CD4 count, OI, Sero- discordant couples) Clinic Standard for all untreated HIV positive patients

New Positives: What do we do? Disclosure Post-test counseling/support /education Partner and family notification Linkage to primary care Referral to research

RAPID: What does it take? Quick/Easy Access Interdisciplinary Team approach Drop-in/next day appointments Eligibilty and Insurance support Tracking/outreach Psycho-social stabilization

Why Immediate Treatment? Lack of immediate access to medical care following a new dx may be a barrier to testing, linkage and ART initiation. Decrease transmission.

RAPID Regimens Truvada/DRV/r Descovy/DTG Genvoya

Challenges Coordination of team members Navigating insurance coverage Resource intense Understanding factors influencing retention Expanding services beyond SFGH

Antoine (Acute) 30yr old African-American MSM Tested at SFGH ED 12/10/14 – requested HIV testing due to exposure (unprotected sex with HIV+man who stated he was on ART/undetectable Last HIV negative one month ago; frequent tester ( per records from Magnet) Rapid negative; VL sent; came back on 12/15/14 >2 million Called into Ward 86 for disclosure/RAPID linkage to care on 12/15/14; Suicide risk assessment RAPID ART DTG+TVD Barriers to linkage: Mental Health: depression, past suicide attempt Insurance: had started application for ACA/Covered California, unable to fill refill Rx of ART Follow Up: 2 follow up visits; then 4 missed/cancelled visit; numerous outreach efforts; off meds for 3 months then finally linked to Kaiser and restarted on meds. Ongoing depression.

Acknowledgements Oliver Bacon, MD Diane Havlir, MD Hiroyu, Hatano, MD Chris Pilcher, MD ZSFGH Clinical Laboratory PHAST/RAPID TEAM Fabioloa Calderon, SWA Susa Coffey, MD Diane Jones, RN Clarissa Ospina-Norvell, NP Joe Pelletier, RN Sandra Torres, SWA

SF Department of Public Health PrEP Implementation Efforts and SF Getting to Zero Initiative Hyman Scott, MD, MPH Medical Director, Clinical Research, Bridge HIV, SFDPH Assistant Clinical Professor, UCSF Miranda Nordell PrEP Coordinator San Francisco Health Network

STD Clinic as a Sentinel Site for PrEP surveillance Since 2011, HIV-negative MSM seeking routine sexual health services have been asked: Have you heard of PrEP? Are you currently on PrEP? Hiatus in questions during peak of demo project enrollment 21

PrEP knowledge and use among HIV-negative MSM at SFCC In 2015, 20% of HIV-neg MSM at the clinic reported being on PrEP (up from 0.9% in 2011) and 85 % reported having heard of PrEP (up from 19% in 2011) 22

PrEP demographics compared with new diagnoses in 2015 23

2016 GTZ PrEP Goals and Priorities Create a sustainable city-wide model of delivery Build capacity Enhance funding City-wide PrEP Navigators Reach those populations that are currently underserved Youth, transwomen and men, MSM of color, people who use drugs, incarcerated Expand and diversify Ambassador program Reach into neighborhoods and community organizations Monitor our progress and use data to inform strategies and decisions Integrate data from diverse sources

Collective PrEP expansion efforts PrEP delivery sites >30 clinics >100 clinical providers and >50 HIV test counselors trained on PrEP delivery and referrals/navigation >10 PrEP navigators funded across clinics and CBOs

Getting to Zero PrEP Ambassadors 26

Citywide PrEP Navigator’s group Created in April 2016 ~25 attended first meeting representing PrEP navigators in SF, East Bay, and South Bay Provide networking, support, share best practices, troubleshooting Key issues What is a PrEP navigator? Different organizations have different capacity for delivering PrEP vs. identifying those at risk and referring / assisting with access to PrEP Training needed: Addressing access barriers Transgender competency PrEP and youth – helping folks on parents’ insurance PrEP and HIV – using common language and consistent messages Effectiveness of PrEP Toronto patient

PrEP Access Majority (90%?) in SF wanting PrEP can access it for little or no costs through insurance, Medi-Cal, assistance programs for out-of-pocket costs and for uninsured. Access at SF AIDS Foundation/Strut, Kaiser, SF City Clinic, API Wellness, SF Health Network clinics, private providers Gaps: Youth w/parents’ insurance who don’t want their parents to know they are on PrEP Access for uninsured adolescents Some Medicare plans have high out-of-pocket costs for PrEP and don’t accept assistance programs Pts with “bronze” insurance plans have high out-of-pocket costs and assistance programs don’t cover all costs (i.e., pt might be able to pay for 6-9 months with help of assistance programs but after that responsible for high copays on own) 28

PrEP in the SF Health Network SF Health Network is an integrated primary care delivery model across SF 14 Community Based Clinics and 4 hospital based clinics PrEP Program started in early 2015: Develop local clinical PrEP guidelines Establish PrEP referral clinic at Ward 86 Provider trainings on PrEP implementation: Over 100 clinicians (MDs, NPs) trained since 1/2015 Clinical guidelines Developed disseminated in late 2015 Working on QI project to identify gaps in initiation follow-up within team-based model PrEP Clinic at Ward 86 Launched in November 2015 with PrEP Coordinator. Continue to pursue outreach and referrals Provider Trainings Over 100 clinicians (MDs, NPs) trained since 1/2015 29

PrEP Demonstration Project SFDPH is one of 12 jurisdictions nationally participating in this CDC-funded 3 year demonstration project Increase uptake of PrEP among MSM of color and transgender persons Enhance Data to Care activities D2C uses HIV surveillance and other data to identify HIV-diagnosed persons not in care, and to link, engage, or re-engage them in HIV medical care

Strategies to increase PrEP uptake among MSM and transgender persons Formative work with actual/potential users as well as providers Increase user knowledge and interest in PrEP Social marketing campaign, Popular Opinion Leader Increase linkage of focus populations to PrEP City-wide PrEP navigator using innovative social media strategies “Data-to-PrEP”– use of STI surveillance to link patients diagnosed with rectal STIs and syphilis to PrEP Learning community for PrEP navigators across SF: share best practices Increase primary care provider engagement in PrEP Public Health Detailing

Acknowledgements Patients Study participants Early adopters Susan Buchbinder Albert Liu Stephanie Cohen Monica Gandhi Diane Havlir Robert Blue Oliver Bacon Anne Hirozawa Tracey Packer Susan Scheer Patients Study participants Early adopters 32

Getting to Zero Stigma Austin Padilla Austin did not use slides - and we lacked capacity to record what he said, but you can hear him here: https://ww2.kqed.org/perspectives/2015/04/1 3/new-generation-of-aids-activists/ And also read this: http://www.gettingtozerosf.org/importance- remembering-social-drivers-hivaids/

QUESTIONS & ANSWERS and DISCUSSION Need to add photo credit and ad campaign Please specify to which one of the panelists you are addressing your question or comment

On the Web: Join the effort: http://www.nytimes.com/2015/10/06/health/san-francisco-hiv-aids- treatment.html Join the effort: http://betablog.org/getting-to-zero-how-san-francisco-is-making-progress/

HIV NETWORK DINNER GETTING TO ZERO (PART 2) Save the date: HIV NETWORK DINNER GETTING TO ZERO (PART 2) September 27, 2016 (Venue TBD) Invitations will be e-mailed. ----- Meeting Notes (11/16/15 23:24) ----- introduce self and ask for participants to introduce themselves. 36