1. HIV

2. HIV END as an epidemic ing Supporting people who are living with HIV
Preventing others from getting HIV

3. Achieving Together A Community Plan to End the HIV Epidemic in Texas
GOALS
Prevent HIV Transmission and Acquisition
Increase Viral Suppression
Eliminate Health Disparities
Cultivate a Stigma-Free Climate

4. 90 90 90 50 Achieving Together by 2030… Combination Prevention
A Community Plan to End the HIV Epidemic in Texas
by 2030…
Combination
Prevention 90 90 90 50
90% of people who are diagnosed are on ART*
90% of people on ART* achieve viral suppression
50% decrease in incidence
For everyone with increased vulnerability
90% of PLWH are diagnosed

5. Combination Prevention
PrEP
nPEP
Client Autonomy
HIV/STI Testing
Behavioral Interventions
TasP
Condoms
Lubricant
Talking to medical provider; sex partners

6. STATUS
NEUTRAL

7. Current System Referrals Lab work Eligibility Worker
Medical & Psychosocial Assessment
Navigator
ART Prescription
Ongoing Support
Referred to “care”
Case Manager
Medical Provider
Current System
Referred to “prevention”
Risk Reduction conversation
ART Prescription
PrEP referral
Medical Provider

8. HIV Prevention Continuum
NEUTRAL
HIV Care Continuum
STATUS
Combination
Prevention
Screening for Prevention Services
Medical
and
Psychosocial
Assessment
Diagnosed
Insurance & Entitlements
HIV Prevention Services
ART Prescription
Mental Health
ART Prescription (PrEP or PEP)
Housing
Viral Suppression
Adherence to Prevention Services
Substance Use
Income Stabilization
Repeat Testing
Maintenance & Ongoing Support
Maintenance & Ongoing Support

9. Undetectable = Untransmittable
U=U
Science > Stigma
Facts > Fear
Undetectable = Untransmittable

10. Science > Stigma

11. U=U Timeline
1998
2000
2005
2008
2011
2017
SF Cohort:
ART during pregnancy to reduce vertical transmission.
Transmission was reduced to approaching zero.
Ugandan Cohort: 400 mixed-status couples.
Zero transmissions when VL was less than 1500 copies/ml
Spanish Cohort:
393 mixed-status couples observed from where the negative partner acquired HIV.
Zero transmissions in couples where the PLWH had achieved an undetectable VL
Swiss statement:
Expert opinion/evidence review of >25 small studies looking at impact of ART on HIV transmission.
Transmission would not occur with an undetectable viral load.
HPTN 052:
1,763 mixed-status heterosexual couples, randomized to immediate or deferred ART.
All transmissions occurred only when people had a detectable VL.
PARTNER:
~900 mixed-status couples who were NOT using condoms.
Zero transmissions after more than 58,000 condomless sex acts, when the PLWH had an undetectable viral load (<200 copies/ml)
Opposites Attract:
358 mixed-status gay male couples.
Zero transmissions when VL was undetectable (<200 copies/ml)
DHHS guidelines: Theoretical plausibility of reducing transmission risk used to promote early ART
PARTNER:
~900 mixed-status couples who were NOT using condoms.
Zero transmissions after more than 58,000 condomless sex acts, when the PLWH had an undetectable viral load (<200 copies/ml)
Opposites Attract:
358 mixed-status gay male couples.
Zero transmissions when VL was undetectable (<200 copies/ml)
HPTN 052:
1,763 mixed-status heterosexual couples, randomized to immediate or deferred ART.
All transmissions occurred only when people had a detectable VL.
Swiss statement:
Expert opinion/evidence review of >25 small studies looking at impact of ART on HIV transmission.
Transmission would not occur with an undetectable viral load.
Spanish Cohort:
393 mixed-status couples observed from where the negative partner acquired HIV.
Zero transmissions in couples where the PLWH had achieved an undetectable VL
DHHS guidelines:
Theoretical plausibility of reducing transmission risk used to promote early ART
Ugandan Cohort:
400 mixed-status couples. Zero transmissions when VL was less than 1500 copies/ml
SF Cohort:
ART during pregnancy to reduce vertical transmission.
Transmission was reduced to approaching zero.

12. Facts > Fear

13. to ACHIEVE undetectable viral load
EFFECTIVELY
NO RISK
1-6 months
6 months
to ACHIEVE undetectable viral load
to MAINTAIN undetectable viral load after first undetectable test result
of transmitting HIV
as long as you continue treatment and maintain an undetectable viral load
UNDETECTABLE
Take ART as prescribed

14. Additional Support for U+U
Antiretroviral therapy (ART) is recommended for all individuals with HIV, regardless of CD4 T lymphocyte cell count, to reduce the morbidity and mortality associated with HIV infection (AI).
ART is also recommended for individuals with HIV to prevent HIV transmission (AI)
- NIH, Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV, 10/14/17
“Across three different studies, including thousands of couples and many thousand acts of sex without a condom or pre-exposure prophylaxis (PrEP), no HIV transmissions to an HIV-negative partner were observed when the HIV-positive person was virally suppressed. This means that people who take ART daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner.” – CDC Dear Colleague letter, 9/27/17
“Getting and keeping your HIV under control is the best thing people living with HIV can do to stay healthy. Another benefit of reducing the amount of virus in the body is that it helps prevent transmission to others through sex or needle sharing, and from mother to child during pregnancy, birth, and breastfeeding. This is sometimes referred to as “treatment as prevention.” -  CDC, Treatment as Prevention, 10/17/17

15. 7-21 days* Every 3 months >90% effective
EFFECTIVE DRUG LEVELS
to reach appropriate levels of PrEP
*7 days for receptive anal sex; 21 days for vaginal sex, injection drug use
to confirm HIV- status, screen for STIs, and monitor renal function, adherence, and side effects.
in preventing HIV acquisition from sexual partners*
When adherent to treatment; other prevention methods only add to PrEP’s effectiveness
When we focus on ART as PrEP, we see a different timeline for protection from exposures.
Depending on the type of sex the individual has, it can take up to 3 weeks to reach appropriate levels of PrEP in the body… Every 3 months PrEP patients are monitored by their medical provider and checked for STDs… from there, we can say that PrEP is over 90% effective…
A couple of crucial components of PrEP prescription is that patients receive their HIV test result every 3 months and take their medication daily
*among PWID, PrEP reduces the risk of acquisition by more than 70% when used consistently
Take ART as prescribed