State Office of AIDS Update April 25, 2018 Karen E. Mark, MD, PhD Chief, Office of AIDS California Department of Public Health 1

Office of AIDS (OA) California Dept of Public Health (CDPH) Lead responsibility for coordinating state programs, services, and activities relating to HIV/AIDS HIV prevention HIV care HIV treatment: ADAP and OA-HIPP HIV/AIDS surveillance, research, and program evaluation 2

Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018 The Big Picture Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018

Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018 Demographic Characteristics of Persons Living with HIV: California, 2016 Gender Risk Category Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018

Race/Ethnicity of Persons Living with HIV: California, 2016 Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018

Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018 Demographic Characteristics of Persons Newly Diagnosed with HIV, California, 2016 Gender Risk Category Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018

Race/Ethnicity of Persons Newly Diagnosed with HIV: California, 2016 Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018

Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018 Age Distribution of Persons Newly Diagnosed with HIV and Persons Living with HIV: California, 2016 Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018

California’s Continuum of HIV Care – 2016 Data were obtained from the HIV surveillance system for persons diagnosed and meeting CDC case definition for HIV, and living in California as of 12/31/2016. In HIV care includes persons with at least one care visit during 2016. Retained in HIV care includes persons with at least 2 or more care visits 3 months apart during 2016. Achieved viral suppression includes persons with most recent viral load test results ≤ 200 copies /mL during 2016. *The HIV infected estimate is based on the current CD4 count based estimation model, used starting with 2016 surveillance data. Hall HI, Song R, Tang T, An Q, Prejean J, Dietz P, Hernandez AL, Green T, Harris N, McCray E, Mermin J HIV Trends in the United States: Diagnoses and Estimated Incidence JMIR Public Health Surveillance 2017;3(1):e8 Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018

California’s Continuum of HIV Care - 2016 Data were obtained from the HIV surveillance system for persons diagnosed and meeting CDC case definition for HIV, and living in California as of 12/31/2016. In HIV care includes persons with at least one care visit during 2016. Retained in HIV care includes persons with at least 2 or more care visits 3 months apart during 2016. Achieved viral suppression includes persons with most recent viral load test results ≤ 200 copies /mL during 2016. Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018

Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018 Viral Suppression of Persons Living with diagnosed HIV by Race/Ethnicity — California, 2016 Goal: 80% by 2021 This slide has been modified to show percent viral suppression for diagnosed persons to match objectives outlined in the Integrated Plan. (Jan 2018) Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018

Viral Suppression Rates by County, California, 2016 Statewide Average: 62% 2021 Goal: 80% * Indicates Prevention Funded Counties Source: HIV/AIDS Surveillance, eHARS data as of January 26, 2018

Office of AIDS Guiding Documents National HIV/AIDS Strategy (NHAS) President’s HIV Care Continuum Initiative Laying the Foundation for Getting to Zero: California’s Integrated HIV Surveillance, Prevention, and Care Plan

Getting to Zero June 2014: New York State’s Plan to End AIDS December 2014: San Francisco’s “Getting to Zero” Initiative July 2015: National HIV/AIDS Strategy updated August 2015 – July 2016: California Assembly Select Subcommittee on Infectious Diseases in High Risk Disadvantaged Communities’ hearings on “A California Plan to End AIDS” October 2016: Laying a Foundation for Getting to Zero: California’s Integrated HIV Surveillance, Prevention, and Care Plan

Getting to Zero: Why now? Affordable Care Act Availability of preventive services Access to comprehensive health coverage for PLWH through Medi-Cal Expansion and Covered California Undetectable = Untransmittable Persons with sustained undetectable viral load do not transmit HIV to sex partners HIV test technologies can detect acute HIV infection Broaden window for intervention during time when HIV most likely to be transmitted to others HIV Pre-Exposure Prophylaxis (PrEP) Reduce risk of HIV acquisition by over 90%

Getting to Zero: Why Now? Scientific tools now exist Modeling shows can end transmission by rapid diagnosis, treatment, and viral suppression Modeling shows that increasing the proportion of at-risk negative persons on PrEP further improves the rate of prevention of new infections Actual data from California and elsewhere suggest that already seeing declines in new infections due to increased viral suppression

Getting to Zero in California Zero new HIV infections Zero AIDS-related deaths Zero stigma and discrimination against people living with HIV (PLWH)

Laying a Foundation for Getting to Zero: Overall Approach Vision and possibility Challenging but potentially achievable objectives Broad support throughout Governor Brown’s administration—all state partners, including Medi-Cal, Covered California, California Department of Corrections and Rehabilitation, California Department of Education Broad support from local public health partners Broad support from community Add prior slide – What do we mean by “get to zero”?

Laying a Foundation for Getting to Zero: Goals Goal 1: Prevent new HIV infections Goal 2: Increase access to care and improve health outcomes for PLWHA Goal 3: Reduce HIV/AIDS-related health disparities Goal 4: Achieve a coordinated response to the HIV epidemic in California

Laying a Foundation for Getting to Zero: Objectives to be achieved by 2021 Add slide after this of the objectives focused on health disparities.

Laying a Foundation for Getting to Zero: Objectives to be achieved by 2021 Add slide after this of the objectives focused on health disparities.

Laying a Foundation for Getting to Zero: Objectives to be achieved by 2021 Add slide after this of the objectives focused on health disparities.

Laying a Foundation for Getting to Zero: Fifteen Strategies Improve PrEP Utilization Increase and Improve HIV Testing Expand Partner Services Improve Linkage to Care Retention in Care Overall Quality of HIV-Related Care Availability of HIV Care Integration of HIV Services with STD, TB, Dental, and Other Health Services Case Management for PLWH with High Need

Laying a Foundation for Getting to Zero: Fifteen Strategies Increase Rates of Insurance/Benefits Coverage for PLWH or on PrEP HIV Prevention and Support Services for People Who Use Drugs General HIV Education & Awareness and Reduce Stigma around HIV, Sexual Orientation, and Gender Identity Improve Usability of Collected Data Enhance Collaborations and Community Involvement Further Leverage Existing Resources to Better Meet the Needs of People at Risk for and Living with HIV in California

Laying a Foundation for Getting to Zero: Baseline Report Baseline Report to be release spring 2018 Revised baseline measures including 2015 data Annual targets for each objective Summary of 2016 OA activities Local-level objectives and annual targets

Laying a Foundation for Getting to Zero: Recent activities Prevention/Surveillance Received new CDC Prevention/Surveillance funding for 2018-2022 New emphasis on using HIV surveillance data to guide program decisions and serve clients Prevention Guidance emphasizes 5 Plan Strategies: Improve PrEP Utilization Increase and Improve HIV Testing Expand Partner Services Improve Linkage to Care Increase and Improve HIV Prevention and Support Services for People Who Use Drugs

Laying a Foundation for Getting to Zero: Recent activities PrEP Assistance Program (PrEP AP) provides assistance to low-income PrEP users Started April 2018 for uninsured persons Program for insured PrEP users expected late spring 2018

Laying a Foundation for Getting to Zero: Recent activities Quality of HIV care Continuing to collaborate with Medi-Cal to monitor and improve viral suppression by managed care plan Fact sheet on viral suppression among Medi-Cal enrollees under development Initiating Ryan White Part B quality improvement project to improve viral suppression among PLWH aged 18-24 years Developing Standards of Care for all Ryan White Part B services

Laying a Foundation for Getting to Zero: Recent activities Integration of HIV services with STD, TB, dental, and other health services Added more STD medications to ADAP formulary Case management ADAP Access and Adherence program started fall 2017 Health insurance coverage Expanding ADAP health insurance premium payment program to cover employer-based health insurance

Laying a Foundation for Getting to Zero: Recent activities Improve HIV education Supporting development of the California Department of Education HIV/STD curriculum Improved usability of data California HIV Surveillance Report (2016) released with expanded data tables, including local continuums of HIV care

What Can Clinicians Do to Help California Get to Zero? Screen all persons aged 15-65 years for HIV Ensure persons newly diagnosed with HIV can get an appointment in your practice setting within days Start newly diagnosed persons on ARVs at their initial visit Follow up with patients who miss visits Work with available services to meet the needs of high-need patients

Laying a Foundation for Getting to Zero: California’s Integrated Surveillance, Prevention, and Care Plan https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/IP_2016_Final.pdf 32

Acknowledgments Office of AIDS Surveillance, Prevention, Care, ADAP, and Support staff Local AIDS Directors and local surveillance, prevention, care, and ADAP staff HIV providers, advocates, and stakeholders State and local HIV planning groups Persons living with and at risk for HIV 33