San Francisco leads US cities in its progress against HIV. Higher percentages of HIV-positive people know their status, are linked to care and treatment and are virally suppressed than in the rest of the nation. Additionally, newly diagnosed cases of HIV infection have declined significantly in recent years. These achievements beg the question: can San Francisco become the first city to get to zero deaths from HIV, zero new infections and zero HIV-related stigma?
A consortium of agencies was formed in 2014 — led by a steering committee on which Project Inform serves — to develop and oversee implementation of a strategy for Getting to Zero. The group began with the premise that the city’s model response to the epidemic must be maintained at its current levels, and that a small and focused set of new initiatives could significantly impact controlling HIV in San Francisco.
The consortium used as inspiration the effects of a policy — adopted by the Department of Public health and its HIV clinics in 2010 — to offer HIV treatment to all individuals diagnosed with HIV. Project Inform heavily supported this effort though controversial at the time because, while evidence was mounting that early treatment not only improved health outcomes for people with HIV and also prevented transmission, the data were not yet conclusive. Multiple definitive studies now support immediate treatment initiation, and San Francisco’s policy is heavily responsible for significant increases in the health of HIV-positive people and the decline in new infections experienced in recent years.
What other focused initiatives, then, could have similar effects?
The consortium has identified three, and developed plans for how to implement them. The first, called RAPID, is to assure that people newly diagnosed with HIV are linked to medical care and treatment even more quickly than they are today. In the case of people in the earliest stages of infection when it is especially possible to transmit HIV, systems will facilitate same-day linkage to care and treatment initiation. For all other newly diagnosed individuals, linkage will be accomplished within 48 hours wherever possible.
Once linkage has occurred, it is critical that people with HIV are retained in care and treatment. However, many are lost to healthcare for a complex set of reasons. An expanded retention and re-engagement program will establish a system in which HIV patients are reminded of medical appointments, and if they miss appointments, outreach is conducted to determine what support might be needed to remain or re-engage in care. Because unstable housing, mental health and substance use issues are significant barriers to linkage and retention in HIV care and treatment for many people, the consortium will also support an expansion of funding for these support services.
Pre-exposure prophylaxis, or PrEP, has the potential to significantly reduce new HIV infections. While San Francisco has been the site of clinical trials and demonstration projects to assess its effectiveness and best practices for its delivery, uptake is currently insufficient to have an appreciable impact on the epidemic. The third element of the Getting to Zero plan therefore involves a set of measures to increase PrEP uptake through increased community and provider education, expanded PrEP clinics, and support to navigate health care and insurance systems.
The cost for implementing the Getting to Zero plan in its first year is approximately $2.3 million. Mayor Ed Lee and Health Director Barbara Garcia have expressed eagerness to support much of that cost. Corporations and foundations have requested proposals to fund the strategy, as well.
We will report regularly on the progress of Getting to Zero, its impact in San Francisco, and its ability to serve as one example to other cities throughout the US and world of how to successfully get to zero in the effort to end the HIV epidemic.