1. Getting to Zero: Will San Francisco be the first city to succeed? Diane Havlir, MD, Professor of Medicine, UCSF, Chief HIV San Francisco General Hospital Susan Buchbinder, SF Department of Public Health, Director of Bridge Professor UCSF

2. Outline San Francisco epidemic Key aspects of the response Getting to Zero

3. New HIV diagnoses & deaths, San Francisco

4. Characteristics of new HIV diagnoses, San Francisco 93% male 86% MSM or MSM/IDU Total of 14 new dx’es in women 2014 71% 25-49 yo 12% <25 yo 17% >50 yo

5. Total # new HIV diagnoses by race/ethnicity, San Francisco * Significant decline *

6. Characteristics of persons living with HIV, San Francisco 92% Male 39% Persons of Color 4% <25 years of age 58% >50 years of age

7. HIV and Non-HIV Deaths in PWA, SF

8. Non-HIV Causes of Death, SF

9. Summary 1.The number of new HIV diagnoses has decreased in San Francisco, but we still have hundreds of new HIV infections every year 2.New diagnosis are being recognized in all adult age groups, and are disproportionately affecting persons of color 3.We have an aging population of persons living with HIV and continue to have preventable deaths

10. HIV testing in San Francisco HIV testing is the gateway to treatment and prevention 93% of persons with HIV in San Francisco are aware of their HIV status Key lesson learned: Multi-pronged approach to HIV testing scale up successful in San Francisco –2010 18,000 tests –2014 25,000 tests

11. Median CD4 at time of HIV Diagnosis, San Francisco YearCD4 cells/mm 3 at diagnosis 2008394 2009409 2010411 2011438 2012422 2013443

12. HIV Care Cascade, San Francisco compared with CA and USA

13. Summary 1.HIV diagnosis is occurring earlier after infection, but 18% are “late presenters” (develop AIDS within 3 months of first HIV diagnosis) 2.ART is being initiated earlier after diagnosis 3.Linkage, retention and viral suppression still have major gaps

14. SF Response: Key components Political will and financial support –Ryan White essential, SF City backfills federal cuts in funding Innovation at program level –HIV testing access –Treat on diagnosis– first in world 2010 –San Francisco Model of Care Innovation comes from NIH and state funded research –PrEP, care delivery (US and global), cure, vaccine

15. “Getting to Zero” in San Francisco Consortium Zero new HIV infections Zero HIV deaths Zero stigma and discrimination Photo by Jim Herd Photo by Rich Niewoski www.gettingtozerosf.org

16. How it began…. “This is all interesting, but are you working together?” --Community member

17. 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” 90% reduction in new HIV infections by 2020

18. Strategic Plan: Signature Initiatives 1.City wide coordinated PrEP program 2.Rapid ART start with treatment hubs 3.Patient centered linkage, engagement, retention in care Committee for each initiative + stigma committee has action plan, metrics and milestones. City of San Francisco provided additional funding 2015-6 for new initiatives

19. PREP use in Kaiser San Francisco July 2012-Feb 2015 1035 referrals 677 initiations 20 re-starters Volk, Hare, CID, 2015

20. Second Initiative: RAPID: Treatment on Diagnosis 1.Concept of “Collapsing the cascade” or “Treatment Upon Diagnosis” --being evaluated here in San Francisco and in Africa 2.Treatment on Diagnosis Reduce risk of HIV complications For acute/early HIV decrease the size of the HIV reservoir Reduce HIV transmission May help empower patient May increase retention

21. Third Initiative: Retention -- Achilles Heal of the Cascade We know many of the barriers: socioeconomic, unstable housing, addiction, stigma, denial, fragmented health system, mental health We don’t understand enough about motivations of our clients and where and how we might make a difference – need research We need to act while waiting for the research by expanding and evaluating innovative city programs

22. Getting to Zero: Will San Francisco Be the first city to succeed? Test, PreP and Treat, “San Francisco style” Universal ART PrEP Getting to Zero