1. 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.

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

3. 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

4. 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

5. Getting to Zero, Overview
Oliver Bacon

6. 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

7. 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

8. 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

9. SF G2Z Steering Committee

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

11. “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

12. 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

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

14. 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

15. 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.

16. RAPID Regimens
Truvada/DRV/r
Descovy/DTG
Genvoya

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

18. 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.

19. 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

20. 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

21. 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

22. 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

23. PrEP demographics compared with new diagnoses in 201523

24. 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

25. 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

26. Getting to Zero PrEP Ambassadors26

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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:
3/new-generation-of-aids-activists/
And also read this: remembering-social-drivers-hivaids/

34. 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

35. On the Web: Join the effort:
treatment.html
Join the effort:

36. 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 ed.
----- Meeting Notes (11/16/15 23:24) -----
introduce self and ask for participants to introduce themselves. 36