HIV

HIV END as an epidemic ing Supporting people who are living with HIV Preventing others from getting HIV

Achieving Together A Community Plan to End the HIV Epidemic in Texas GOALS Prevent HIV Transmission and Acquisition Increase Viral Suppression Eliminate Health Disparities Cultivate a Stigma-Free Climate

90 90 90 50 Achieving Together by 2030… Combination Prevention A Community Plan to End the HIV Epidemic in Texas by 2030… Combination Prevention 90 90 90 50 90% of people who are diagnosed are on ART* 90% of people on ART* achieve viral suppression 50% decrease in incidence For everyone with increased vulnerability 90% of PLWH are diagnosed

Combination Prevention PrEP nPEP Client Autonomy HIV/STI Testing Behavioral Interventions TasP Condoms Lubricant Talking to medical provider; sex partners

STATUS NEUTRAL

Current System Referrals Lab work Eligibility Worker Medical & Psychosocial Assessment Navigator ART Prescription Ongoing Support Referred to “care” Case Manager Medical Provider Current System Referred to “prevention” Risk Reduction conversation ART Prescription PrEP referral Medical Provider

HIV Prevention Continuum NEUTRAL HIV Care Continuum STATUS Combination Prevention Screening for Prevention Services Medical and Psychosocial Assessment Diagnosed Insurance & Entitlements HIV Prevention Services ART Prescription Mental Health ART Prescription (PrEP or PEP) Housing Viral Suppression Adherence to Prevention Services Substance Use Income Stabilization Repeat Testing Maintenance & Ongoing Support Maintenance & Ongoing Support

Undetectable = Untransmittable U=U Science > Stigma Facts > Fear Undetectable = Untransmittable

Science > Stigma

U=U Timeline 1998 2000 2005 2008 2011 2014 ------ 2016 2017 SF Cohort: ART during pregnancy to reduce vertical transmission. Transmission was reduced to approaching zero. Ugandan Cohort: 400 mixed-status couples. Zero transmissions when VL was less than 1500 copies/ml Spanish Cohort: 393 mixed-status couples observed from 1991-2003 where the negative partner acquired HIV. Zero transmissions in couples where the PLWH had achieved an undetectable VL Swiss statement: Expert opinion/evidence review of >25 small studies looking at impact of ART on HIV transmission. Transmission would not occur with an undetectable viral load. HPTN 052: 1,763 mixed-status heterosexual couples, randomized to immediate or deferred ART. All transmissions occurred only when people had a detectable VL. PARTNER: ~900 mixed-status couples who were NOT using condoms. Zero transmissions after more than 58,000 condomless sex acts, when the PLWH had an undetectable viral load (<200 copies/ml) Opposites Attract: 358 mixed-status gay male couples. Zero transmissions when VL was undetectable (<200 copies/ml) DHHS guidelines: Theoretical plausibility of reducing transmission risk used to promote early ART PARTNER: ~900 mixed-status couples who were NOT using condoms. Zero transmissions after more than 58,000 condomless sex acts, when the PLWH had an undetectable viral load (<200 copies/ml) Opposites Attract: 358 mixed-status gay male couples. Zero transmissions when VL was undetectable (<200 copies/ml) HPTN 052: 1,763 mixed-status heterosexual couples, randomized to immediate or deferred ART. All transmissions occurred only when people had a detectable VL. Swiss statement: Expert opinion/evidence review of >25 small studies looking at impact of ART on HIV transmission. Transmission would not occur with an undetectable viral load. Spanish Cohort: 393 mixed-status couples observed from 1991-2003 where the negative partner acquired HIV. Zero transmissions in couples where the PLWH had achieved an undetectable VL DHHS guidelines: Theoretical plausibility of reducing transmission risk used to promote early ART Ugandan Cohort: 400 mixed-status couples. Zero transmissions when VL was less than 1500 copies/ml SF Cohort: ART during pregnancy to reduce vertical transmission. Transmission was reduced to approaching zero.

Facts > Fear

to ACHIEVE undetectable viral load EFFECTIVELY NO RISK 1-6 months 6 months to ACHIEVE undetectable viral load to MAINTAIN undetectable viral load after first undetectable test result of transmitting HIV as long as you continue treatment and maintain an undetectable viral load UNDETECTABLE Take ART as prescribed

Additional Support for U+U Antiretroviral therapy (ART) is recommended for all individuals with HIV, regardless of CD4 T lymphocyte cell count, to reduce the morbidity and mortality associated with HIV infection (AI). ART is also recommended for individuals with HIV to prevent HIV transmission (AI) - NIH, Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV, 10/14/17 “Across three different studies, including thousands of couples and many thousand acts of sex without a condom or pre-exposure prophylaxis (PrEP), no HIV transmissions to an HIV-negative partner were observed when the HIV-positive person was virally suppressed. This means that people who take ART daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner.” – CDC Dear Colleague letter, 9/27/17 “Getting and keeping your HIV under control is the best thing people living with HIV can do to stay healthy. Another benefit of reducing the amount of virus in the body is that it helps prevent transmission to others through sex or needle sharing, and from mother to child during pregnancy, birth, and breastfeeding. This is sometimes referred to as “treatment as prevention.” -  CDC, Treatment as Prevention, 10/17/17

7-21 days* Every 3 months >90% effective EFFECTIVE DRUG LEVELS to reach appropriate levels of PrEP *7 days for receptive anal sex; 21 days for vaginal sex, injection drug use to confirm HIV- status, screen for STIs, and monitor renal function, adherence, and side effects. in preventing HIV acquisition from sexual partners* When adherent to treatment; other prevention methods only add to PrEP’s effectiveness When we focus on ART as PrEP, we see a different timeline for protection from exposures. Depending on the type of sex the individual has, it can take up to 3 weeks to reach appropriate levels of PrEP in the body… Every 3 months PrEP patients are monitored by their medical provider and checked for STDs… from there, we can say that PrEP is over 90% effective… A couple of crucial components of PrEP prescription is that patients receive their HIV test result every 3 months and take their medication daily *among PWID, PrEP reduces the risk of acquisition by more than 70% when used consistently Take ART as prescribed