“Getting to Zero” in San Francisco Consortium Zero new HIV infections Zero HIV deaths Zero stigma and discrimination Photo by Jim Herd

Agenda Welcome & Overview Update on Funding SF HIV Epidemiology Data Committee updates PrEP RAPID Ending Stigma Retention & Re-engagement Panel Discussion: HIV Navigation Thank you Will Hagerty

Getting to Zero SF: What are we? Multi-sector independent consortium– operates under principles of collective impact: “Commitment of groups from different sectors to a common agenda to solve a specific problem.” Vision Become the first municipal jurisdiction in the United States to achieve the UNAIDS vision of “Getting to Zero”

GTZ reach since last meeting Government SF part of FTCI launch and website Updates with DPH Director Barbara Garcia and Senator Feinstein Health Commission presentation 9/22 Update to National Institutes of Health and DC City efforts Conferences- Community and Scientific Adherence 2016, May 9-11 AIDS 2016, July 18-22 USCA, Sept 15-18 Media PBS NewsHour HIV plus Takepart Bay Area Reporter Star Observer (AU) San Francisco Chronicle KGO-TV San Francisco/abc7news Collaborations Meeting with representatives from South African representative, England Modeling Paris/London/Amsterdam Collaboration

Getting to Zero SF: Global Movement: Fast Track Cities Initiative www.fast-trackcities.org

Update on Funding

Increasing PrEP uptake among MSM of color, young MSM, and Trans women Community-based Increase PrEP services for African American MSM, Latino MSM, young MSM, and Transwomen. Emergency Truvada for youth unable to use patient assistance programs. Pharmacy Demo Project. SFDPH PrEP Coordinator and PrEP Navigator to support a Tele-PrEP program in SFDPH Primary Care. >300 PrEP starts among these priority populations **Award GTZ PrEP RFPs in 2017**

Project Pride (funded by CDC) Increase user knowledge and interest in PrEP Social marketing campaign, Popular Opinion Leader Increase linkage of focus populations to PrEP City-wide PrEP coordinator and navigator using innovative social media strategies “Data-to-PrEP”– use of STI surveillance to link patients diagnosed with rectal STIs and syphilis to PrEP PrEP navigators Group: share best practices Increase primary care provider engagement in PrEP Public Health Detailing

Expand City-wide RAPID Program Focus on providers serving MSM of color and youth. Evaluation of process and outcome measures, stratified by age, race/ethnicity, and gender. Academic Detailing Provider training and technical assistance for RAPID hubs across SF. LINCS RAPID Specialist Support RAPID implementation for all newly diagnosed patients in SF. Decrease time from diagnosis to viral suppression.

Increasing Retention and Re-engagement in Care Increasing support services for Persons living with HIV Community-based Intensive Case Management (via RFP) Addressing Food Insecurity (via RFP) Increasing Employment Training (via RFP) In-home Support for those over 50 (via RFP) ZSFGH PHAST Team at Ward 86 Expanded Navigation services LINCS Team (MAC AIDS Yr. 2) Data to Care Increase viral suppression among those most likely to be out of care.

Increase capacity to address HIV-related stigma in SF. Addressing Stigma Develop an anti-stigma initiative (via RFP) Stigma is an important barrier for HIV prevention, care, and treatment. Create an initiative with sustainable impact on the community and providers. Representation from disproportionally impacted communities: young MSM and MSM >50; MSM of color; and women at risk. Increase capacity to address HIV-related stigma in SF.

Requests for Proposals (RFPs) 22-2016: Support Services and Program Coordination for HIV-positive Adults Age 50 and Older (here) 23-2016: Communications Support and Capacity‐Building for HIV Frontline Workers Group (here)

Requests for Proposals (RFPs) 24-2016: Getting to Zero: Community‐Based Intensive Case Management Services for HIV‐positive Clients with Complex Needs (here) 25-2016: G2Z: Community‐Based Intensive Pre‐Exposure Prophylaxis (PrEP) Services (here)

HIV Epidemiology Annual Report 2015

HIV Epidemiology Section Annual Report 2015 Susan Scheer, PhD, MPH Director HIV Epidemiology Section susan.scheer@sfdph.org

Outline Key highlights from the recently released HIV Epidemiology Section 2015 Annual Report including trends in key indicators Encouraging trends on the population level Overall declines in new HIV diagnoses Declines in deaths and late diagnoses Care and treatment items along the HIV care continuum Not all San Franciscans have experienced the same improvements; significant health disparities identified By race/ethnicity, particularly African-Americans, in treatment and care outcomes, survival and new diagnoses Gender disparities in survival and viral suppression People experiencing homelessness have very low engagement care and viral suppression

New HIV diagnoses, deaths, and prevalence, 2006-2015, San Francisco Last year saw a 19% decrease in new diagnoses from 382 to 309 This year new diagnoses decreased 17% from 309 to 255 Number of deaths is becoming leveling or stable Now nearly 16,000 people living with HIV

Among women, # stable, %↑ In all races, # ↓ except AA, # stable, %↑ Most new dx in ages 30-39 60% PLWH >50; ⅟₄ >60 years MSM dis-proportionately affected

Number of persons newly diagnosed with HIV infection by race/ethnicity 2016-2015, San Francisco

Annual Rates of men newly diagnosed with HIV Infection per 100,000 population by Race/ethnicity, 2006-2015, SF Rates 2015 140 AA 83 Latino 52 White 24 Other

Annual Rates of women newly diagnosed with HIV Infection per 100,000 population by Race/ethnicity, 2006-2015, SF Rates 2015 31 AA 8 Latina 5 White 2 Other

Disparities and Health Inequities: Late HIV Diagnosis by Race/Ethnicity

Number and percent of homeless persons newly diagnosed with HIV infection by year of diagnosis 2006-2015, San Francisco

Continuum of HIV care among persons newly diagnosed with HIV infection 2012-2104, San Francisco

Continuum of HIV Care among persons living with HIV San Francisco, 2014

Time Between the Steps in the HIV Care Continuum Improving 2012-2014, San Francisco

Estimate of ART use among living HIV cases with chart review by nadir CD4 level December 2015, San Francisco

Disparities and Health Inequities: Viral Suppression

Disparities and Health Inequities: Survival after AIDS

Number of STD diagnoses among persons living with HIV by year of STD diagnosis 2010-2014, San Francisco

Summary Positive trends: new diagnoses, late diagnoses and care & treatment outcomes Significant health disparities. Not all San Franciscans experiencing the same improvements African-Americans, in particular, experiencing health inequities: disproportionately diagnosed; poorer treatment and care outcomes, poorer survival Other population groups also experiencing disparities: Latinos most likely to uninsured at diagnosis and less likely to be engaged in care and virally suppressed Women and transwomen are less likely to achieve viral suppression Persons experiencing homelessness are less engaged in care and virally suppressed Asians are most likely to be diagnosed late Women and PWID have poorer survival Younger people less engaged in care and virally suppressed Disparities in our most vulnerable populations will need to be addressed to achieve the goal of Zero New Infections for all San Franciscans

Questions

GTZ Committee Updates

GTZ PrEP Committee Co-Chairs: Al Liu & Robert Grant PrEP User Subcommittee Co-chairs: Pierre Crouch & Stephanie Goss PrEP Provider Subcommittee Co-chairs: Tracey Packer & Stephanie Cohen PrEP Metrics Subcommittee Chair: Susan Scheer Members: Oliver Bacon, Halvard Bagoien, Jackson Bowman, Susan Buchbinder, Jim Dilley, Edvard Engesaeth, Jonathan Fuchs, Jesus Gaeta, Jayne Gagliano, Ruben Gamundi, Hans Gangeskar, Ron Goldschmidt, Robert Grant, Brad Hare, Geoff Hart-Cooper, Jen Hecht, Mike Hickey, Anne Hirozawa, Alison Hughes, Cait Koss, Skot Land, Montica Levy, Paul Marcelin, Julia Marcus, Erick Martinez, John Melichar, Gavin Morrow-Hall, Austin Nation, Trang Nguyen, Miranda Nordell, Sergio Paz, Susan Philip, Greg Rebchook, Michael Reyes, Hyman Scott, Matt Sharp, Miriam Sheinbein, Lisa Stern, Eric Tang, Adam Taylor, EB Troast, Paul Urban, Dana van Gorder, Jonathan Volk, Shannon Weber, Sophy Wong

Updates & Recent Activities (since March 2016) 2 transgender PrEP demonstration projects funded by CHRP [UCSF, SFDPH] (April) Presented on GTZ PrEP activities at Adherence 2016 meeting (May) Updated SFHN PrEP guidelines published (May) Hired PrEP navigators through Campos RFP Scale up of PrEP services at Mission Neighborhood Health Center and CHPY (Cole/Larkin) Coordinated monthly city-wide PrEP navigator meetings (ongoing) Provided PrEP trainings to >50 clinical providers and >150 front-line staff since March 2016 Launch of E-referral system for PrEP consultation (Sept) Awarded 2 NIH supplements to evaluate PrEP cascade and PrEP retention in SF (Sept)

Our new citywide PrEP team Montica Levy Citywide PrEP Coordinator Miranda Nordell SFHN Lead PrEP Navigator Michael Barajas Citywide PrEP Navigator Alyson Decker, NP PrEP Academic Detailing

PrEP social marketing and digital stories launched in June 2016 www.apiwellness.org/prep

PrEP Committee Plans – next 6 months User Expand PrEP ambassador program, specific outreach to African-American MSM, youth Looking for volunteers for Folsom/Castro Fairs Investigate strategies to increase PrEP access for homeless Launch PrEP Demo project in transgender women and men Provider Launch academic detailing program, with focus on clinics serving prioritized populations Work to establish Truvada medication access program for youth and pharmacy delivered PrEP program in Mission Establish quarterly mtgs of community of practice of PrEP providers: Next mtg November 9 Measurement Update metrics, from community-based surveys and medical providers, every 3 months (posted to GTZ website) Establish PrEP cascade measures and begin measurement in transgender cohort in SF Launch study to evaluate reasons for poor retention in PrEP programs GTZ PrEP RFP for 2016-2017

G2Z RAPID Committee

Progress since Last Meeting New RAPID protocol with updated linkage algorithm Additional RAPID clinics enrolled Larkin Private Offices FHC 2 Detailing/outreach specialists hired $$ for RAPID navigation specialist Inclusion of RAPID indicators in Surveillance Data

Lesson Learned: 2016 Provider acceptance high Greatest challenge: linkage/insurance navigation Uninsured but non-MediCal/HSF eligible are most challenging Disparities a challenge Race/ethnicity Homelessness

RAPID Goals for 2016-17 Systematic RAPID detailing of all HIV providers G2Z funding for 1 year of detailing assistance RAPID linkage Navigation “bootcamp” for navigators/test sites Bridging RAPID ART site to care for difficult-to-link patients ??using Ryan White (A) funds while they are being navigated?? G2Z funding a RAPID navigator to work with LINCS Shorten time from diagnosis to care, care to ART, diagnosis to viral suppression: goal is 56 days +5 from diagnosis to suppression A plan to address disparities in ART

Austin Padilla, Wayne Steward Co-Chairs Austin Padilla, Wayne Steward Members Tez Anderson, Samuel Berston, Jonathan Gomez, Stephanie Goss, Robert Grant, Alison Hughes, Brandon Ivory, Shaddai Martinez-Cuestas, Mark Molnar, Thomas Muyunga, Jenna Rapues, Armando Rodriguez, Ashley Rojas, Will Vincent, Lance Toma

Upcoming Committee Meeting Tuesday, October 4, 6p San Francisco City Hall, Room 270 *Security requires people with backpacks to enter through the loading dock entrance on Grove Street

Retention & Re-engagement Amanda Newstetter/bay area aetc Andy Scheer/sfdph sf city clinic (co-chair) Austin Padilla (Stigma Committee rep.) Beth Mazie/prc Bill Hirsh/alrp + hapn Chip Supanich/hiv planning council Chuan Teng/prc Dana Van Gorder/project inform Darpun Sachdev/sfdph lincs navigation Dave Jordan/shanti + hhspn Dean Goodwin/sfdph hhs Edwin Charlebois/ucsf caps (co-chair) Erin Antunez/sfdph lincs navigation Eva Mureithi/ucsf w86 Gale Sandoval/ifr Hyman Scott/dph Joanna Eveland/tom waddell Joe Ramirez-Forcier/prc Julie Lifshay/sfaf Kat Christopoulos/ucsf w86 Kate Darling/ucsf Kate Franza/api wellness Kristi Dizon/ahf Linda Walubengo/catholic charities Lori Thoemmes/ucsf ahp Marc Vincent/ucsf Monica Gandhi/ucsf w86 Susan Scheer/sfdph Tracey Packer/sdfph

Updates & Recent Activities MAC AIDS Fund, LINCS Lessons Learned Clinic-based and Surveillance-derived data effective in locating and re-engaging Pts in care; in 9-month period, 120 clinic-based referrals enrolled in LINCS Navigation increases viral suppression, supporting TasP biomedical intervention Approx 1/3 of Pts are homeless and 1/2 substance-using; more support needed to address these issues MAC AIDS Fund, Current Practices Survey DPH/Public/Private providers surveyed: majority use pre-appointment reminders (phone/voicemail/SMS) & do missed visit follow-up Few clinics pass on out-of-care patient info to the DPH for re-engagement in care Clinics willing to develop links to programs for PrEP and RAPID ART start Clinics interested in support with linkage to MH & SU tx resources Metrics Development: Work group formed, met, goal-setting commenced Retention & Re-Engagement Toolkit: Content developed; funding secured; moving on to design & distribution phase RFP Development: Intensive Case Mgmt, Communications, Frontline Workers, Aging Services RFP’s released

Committee Plans – next 6 months MAC AIDS Fund Renewal, LINCS Y2: Develop novel approaches for clients who use substances Continue data-to-care efforts in collaboration w/ DPH Surveillance & clinics MAC AIDS Fund Renewal, Best Practices Y2: Optimize and evaluate R&R package Finalize & disseminate findings Metrics: Establish and obtain preliminary measures, review ID measures currently not being evaluated R&R Toolkit: Finalize design; academic detailing to practices; group trainings RFP Initiatives: Support implementation Pharmacy Workgroup: Convene workgroup for leveraging pharmacies for retention & re-engagement collaboration GTZ Cross-Committee Collaboration: on MH, SU, housing, benefits navigation, and other issues that impact retention in treatment and prevention interventions

HIV Navigation Panel

GTZ Navigation Panel LINCS Navigator, Nora Anderson LINCS Navigation patient, Robert SF AIDS Foundation Navigator, Naomi Prochovnick LINCS Program Coordinator, Erin Antunez

HIV Navigation Community Discussion