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HIV NETWORK DINNER AUGUST 30, 2016 GETTING TO ZERO (PART 1) Sponsored by: 2424 HIV NETWORK DINNER AUGUST 30, 2016 GETTING TO ZERO (PART 1) Sponsored by: 2424 Mission Street, San Francisco 94110 Mercedes Azcarate

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

Panelists: (in order of appearance) • Oliver Bacon, MD – Assistant Professor of Medicine, 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 – Pr. EP 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

Objectives After this program participants will be able to explain: • what the Getting 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 Pr. EP program • the role of fighting stigma • what we (network members) can do to make sure San Francisco succeeds in Getting to Zero

Getting to Zero, Overview • Oliver Bacon Getting to Zero, Overview • Oliver Bacon

Getting to Zero is a multi-sector independent consortium, operating under principles of collective impact: 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 • • • By 2020 90% fewer HIV infections 90% fewer HIV deaths Zero stigma and discrimination Secure funding and broad city/private sector support Create innovative programs Exchange best practices with other cities

We have been heading toward zero New HIV diagnoses and deaths in SF 2006: We have been heading toward zero New HIV diagnoses and deaths in SF 2006: HIV test w/o written consent 2014 306 HIV diagnoses 177 HIV-related deaths 2010: ART at diagnos is; HIV test scaleup 20 11: LIN CS 201 2: Pr. E P

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

SF G 2 Z Steering Commit tee SF G 2 Z Steering Commit tee

RAPID Getting to Zero 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 “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

Three Phases Pilot: newly diagnosed patients in acute infection Expanded Populations: Include other newly Three Phases Pilot: newly diagnosed patients in acute infection Expanded Populations: Include other newly diagnosed patients (low CD 4 count, OI, Serodiscordant 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 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 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 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 RAPID Regimens Truvada/DRV/r Descovy/DTG Genvoya

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

Antoine (Acute) 30 yr old African-American MSM Tested at SFGH ED 12/10/14 – requested Antoine (Acute) 30 yr 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 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 Pr. EP Implementation Efforts and SF Getting to Zero SF Department of Public Health Pr. EP 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 Pr. EP Coordinator San Francisco Health Network

STD Clinic as a Sentinel Site for Pr. EP surveillance Since 2011, HIV-negative MSM STD Clinic as a Sentinel Site for Pr. EP surveillance Since 2011, HIV-negative MSM seeking routine sexual health services have been asked: Have you heard of Pr. EP? Are you currently on Pr. EP?

Pr. EP knowledge and use among HIV-negative MSM at SFCC 100 90 80 PERCENT Pr. EP knowledge and use among HIV-negative MSM at SFCC 100 90 80 PERCENT 70 60 50 Heard of Pr. EP 40 On Pr. EP 30 20 10 0 2011 2012 2014 YEAR 2015 2016

Pr. EP demographics compared with new diagnoses in 2015 Pr. EP demographics compared with new diagnoses in 2015

2016 GTZ Pr. EP Goals and Priorities Create a sustainable city-wide model of delivery 2016 GTZ Pr. EP Goals and Priorities Create a sustainable city-wide model of delivery Build capacity Enhance funding City-wide Pr. EP Navigators Reach those populations that are currently underserved Youth, transwomen and men, MSM of color, people who use drugs, incarcerated Expand 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 Pr. EP expansion efforts Pr. EP delivery sites >30 clinics >100 clinical providers Collective Pr. EP expansion efforts Pr. EP delivery sites >30 clinics >100 clinical providers and >50 HIV test counselors trained on Pr. EP delivery and referrals/navigation >10 Pr. EP navigators funded across clinics and CBOs

Getting to Zero Pr. EP Ambassadors Getting to Zero Pr. EP Ambassadors

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

Pr. EP Access Majority (90%? ) in SF wanting Pr. EP can access it Pr. EP Access Majority (90%? ) in SF wanting Pr. EP can access it for little or no costs through insurance, Medi-Cal, assistance programs for outof-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 Pr. EP Access for uninsured adolescents Some Medicare plans have high out-of-pocket costs for Pr. EP 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

Pr. EP in the SF Health Network is an integrated primary care delivery model Pr. EP in the SF Health Network is an integrated primary care delivery model across SF 14 Community Based Clinics and 4 hospital based clinics Pr. EP Program started in early 2015: Develop local clinical Pr. EP guidelines Establish Pr. EP referral clinic at Ward 86 Provider trainings on Pr. EP implementation: Over 100 clinicians (MDs, NPs) trained since 1/2015

Pr. EP Demonstration Project SFDPH is one of 12 jurisdictions nationally participating in this Pr. EP Demonstration Project SFDPH is one of 12 jurisdictions nationally participating in this CDC-funded 3 year demonstration project Increase uptake of Pr. EP among MSM of color and transgender persons Enhance Data to Care activities D 2 C 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 Pr. EP uptake among MSM and transgender persons Formative work with Strategies to increase Pr. EP uptake among MSM and transgender persons Formative work with actual/potential users as well as providers Increase user knowledge and interest in Pr. EP Social marketing campaign, Popular Opinion Leader Increase linkage of focus populations to Pr. EP City-wide Pr. EP navigator using innovative social media strategies “Data-to-Pr. EP”– use of STI surveillance to link patients diagnosed with rectal STIs and syphilis to Pr. EP Learning community for Pr. EP navigators across SF: share best practices Increase primary care provider engagement in Pr. EP Public Health Detailing

Acknowledgements Susan Buchbinder Albert Liu Stephanie Cohen Monica Gandhi Diane Havlir Robert Blue Oliver Acknowledgements 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

Getting to Zero Stigma • Austin Padilla Austin did not use slides - and 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: //ww 2. kqed. org/perspectives/2015/04/1 3/new-generation-of-aids-activists/ And also read this: http: //www. gettingtozerosf. org/importanceremembering-social-drivers-hivaids/

QUESTIONS & ANSWERS and DISCUSSION Please specify to which one of the panelists you QUESTIONS & ANSWERS and DISCUSSION Please specify to which one of the panelists you are addressing your question or comment

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

Save the date: HIV NETWORK DINNER GETTING TO ZERO (PART 2) September 27, 2016 Save the date: HIV NETWORK DINNER GETTING TO ZERO (PART 2) September 27, 2016 (Venue TBD) Invitations will be e-mailed.