Nearly 700,000 Americans have died of AIDS since the beginning of the epidemic in the 1980s, and more than 1.1 million are living with HIV today.
Advances in medical science have provided people with access to highly effective treatments for HIV. But is it possible to eliminate the disease altogether?
Some cities are trying. On the latest episode of The Dose, Grant Colfax and Susan Buchbinder of San Francisco's public health department talk about how the city is trying to eliminate HIV.
Through a range of projects, from increasing the uptake of preventive medicine to running mobile clinics to serve hard-to-reach patients, the city is making progress toward its goal of getting to zero HIV infections, deaths, and stigma.
Susan Buchbinder: We’ve had patients who have then done things like called their mother up and said, “Mom, I need to tell you that I became infected with HIV, but the good news is I’ve started treatment right away, so you don’t need to worry about me.”
Shanoor Seervai: Hi everyone. Welcome to The Dose. On this episode we’re going to be talking about how one city, San Francisco, is trying to eliminate AIDS. My guests today are Grant Colfax, San Francisco’s public health director, and Susan Buchbinder, who directs an HIV prevention program called Bridge HIV at the city’s public health department.
Grant, Susan, welcome to the show.
Grant Colfax: Thank you.
Susan Buchbinder: Thank you so much.
Shanoor Seervai: So to get us started, paint me a picture of what prevention looks like in San Francisco now. What are you doing? What are your strategies to get people using these preventive treatments?
Susan Buchbinder: Well, the single most highly effective prevention strategy that we have right now is something called preexposure prophylaxis, which is taking a pill a day to try to prevent HIV. And we’ve done a lot in San Francisco to try to increase both the supply of PrEP, so training providers, making providers aware of PrEP, helping them to figure out how to integrate PrEP into their clinical practices, and giving them the support that they need to be able to provide PrEP to patients, as well as increasing the demand for PrEP among people who might most benefit from it.
So getting the word out about PrEP, helping people to navigate the insurance system, because generally PrEP can be provided at low or no cost. But because we’ve got such a fragmented health care system, we often need to help people to navigate their insurance and other kinds of programs that help to offer PrEP at low or no cost.
So we’re doing both of those things: trying to increase supply and increase demand, as well as trying to measure what kind of impact we’re having and where is PrEP being taken up. And then I think right now the big challenge is not just having people start PrEP, but stay on PrEP during the periods of time when they might benefit from it most.
Shanoor Seervai: Right. Because you say that this is a pill that somebody has to take every single day. And I imagine that with some of the populations you work with, I know that the homeless population, for example, in San Francisco is still badly hit by the AIDS crisis. And so, how do you ensure that people who have such transient lives are able to take a pill every single day?
Susan Buchbinder: So we’re trying to make breakthroughs. And there’s a lot of research going on in both helping to support people in their use of PrEP, as well as trying to find other ways to administer PrEP. So PrEP is generally a pill a day, but it also can be used in what we call a two-on-one kind of a regimen, where you take two pills, two to 24 hours before sex, one pill 24 hours after that, and another pill 24 hours after that. That is also a highly effective way of preventing HIV in men who have sex with men.
It’s not been tested or shown to be effective for women, or for people who inject drugs. So for those individuals right now, daily PrEP is the one option that they have available. But we’re actively doing research, trying to find long-acting injectable agents that may be able to be administered every other month, so that you could just come to your doctor for an injection every other month and be highly protected.
So that’s being tested right now. We have vaccines that we’re testing to try to prevent HIV infection. Monoclonal antibodies to try to prevent HIV infection. Topical agents, like vaginal rings or microbicides, which are gels or lubricant that might also be able to prevent HIV. And we think we’re going to need a variety of options because, as you point out, taking a pill a day isn’t an easy thing for everybody to do and it’s not something that everybody wants to do. So trying to find other strategies, so that people have some choice, is very important.
Grant Colfax: Some of the other parts of our prevention continuum in San Francisco consist of syringe access programs, right? So if we think about the risk of people who use drugs, in terms of HIV transmission if they do share needles. And that’s something, again, that San Francisco started very early on in the epidemic, and it’s helped us address the epidemic, particularly among people who use drugs.
And I think the other component to emphasize is that treatment is prevention. So there’s robust data that show that if somebody is adequately treated, and their viral load is suppressed, that they do not transmit the virus. So ensuring that on the treatment side we appropriately reach, engage, retain, and virally suppress the virus in people who are living with HIV is not only of critical benefit to the person who’s living with HIV, but also prevents transmission.
And going back to your point about people experiencing homelessness and HIV, one of the key interventions of people who are living with HIV who are experiencing homelessness is to provide them with housing. Right? And we have robust data that show that there’s a direct correlation between housing stability and viral load suppression. Again, not only a key intervention for that person living with HIV, but from a prevention standpoint and major prevention intervention as well.
Shanoor Seervai: And working with communities and giving people the tools to do this is sort of what underlies the work that both of you have been involved with. San Francisco’s Getting to Zero initiative. Can you talk a little bit about that?
Susan Buchbinder: Sure, so Getting to Zero we launched in early 2014. And it really grew out of a recognition that we were working together on a variety of different projects, but we didn’t really have a full comprehensive engagement of all sectors of the community, working together towards this common goal of zero new HIV infections, zero HIV-associated deaths, and zero HIV stigma.
And so a group of us came together and we now are over 300 volunteers from all sectors — from advocates, community-based organizations, different kinds of providers, researchers, people from the health department, people from the university, people from other sectors of government, people from industry — have all come together and said, “What can we do to towards this common goal?”
So for instance, I talked earlier about trying to figure out how we were going to scale up PrEP. That really took multiple people coming together from different areas of provision, of prevention and treatment services to say, “What do we need to do to scale up supply? What do we need to do to scale up demand? And how can we measure this?” And so, bringing together all these different kinds of expertise has been really important in helping us. Now we’ve cut the number of new diagnoses by more than 50 percent, just in that period of time since we started Getting to Zero.
Shanoor Seervai: As you’ve cut the number of new diagnoses, there are also new challenges, right? There are new populations that are being affected, specifically African Americans and the Latinx community. And of course there are ongoing challenges. Can you talk a little bit more about what these are?
Susan Buchbinder: Sure. So, we do see these health inequities. We now, for the first time, have a larger number of new diagnoses and the Latinx community than we have in the white community. And when you look at a per population basis, per 100,000 population, the greatest rate of new diagnoses are in African Americans. And so we really need to address this issue that there are people who we’re not reaching with our prevention strategy.
So for instance, we have specifically created programs for getting PrEP to the African American community, to the Latinx community, to youth, and to the transgender community, because those are our four populations that are disproportionately affected by HIV and where PrEP levels are not as high as they are in other communities.
You mentioned earlier that we have a challenge with homeless population. This last year 20 percent of our new diagnoses were in people who are homeless. And so, again, we need to try to provide services for people who are unstably housed. And we have a variety of different strategies for doing that. Doing street-based medicine, doing medicine at our navigation centers, and creating what we call a pop-up clinic at Zuckerberg San Francisco General Hospital, at Ward 86, where they provide some of the world’s best HIV care. They have now a place for people to drop in who are unstably housed and not virally suppressed, to try to get all of their needs met, not just their medical needs, but their psychosocial needs as well. They get food, they get clothing, they get assistance with housing support. And they also get their medication and they get ways of getting support for being able to take their medication to get them virally suppressed.
Grant Colfax: While the focus in these situations needs to be on HIV, we also recognize, I think, as a department and with our other stakeholders, that HIV is often an outcome of multiple issues that fall along the fault lines of poverty, racism, stigma, and discrimination, that include institutional racism, include implicit and explicit biases, including biases within the health care systems and in the societies in which we live.
So doing the work through that lens, so even the delivery of biomedical interventions, how those are delivered, who’s delivering them? How are they supported, and how are they being supported, engaged by key stakeholders? What’s the community perspective on these interventions? Those all need to be built in appropriately in terms of approaching the issue through a health equity lens, and really acknowledging the broader context in which people continue to become infected with HIV, live with HIV, and perhaps are not able to realize the same benefits as other people living with HIV do in other communities.
Susan Buchbinder: And the community is also really fully behind this idea that we can’t just address HIV in isolation. That we need to address substance use, homelessness, mental health issues, but also we need to address the syndemics of sexually transmitted infections and hepatitis C.
And so we need strategies that are going to integrate our prevention and treatment strategies for all of those diseases, as well as to address issues of homelessness, substance use, and mental health issues.
Shanoor Seervai: And one of the ways, Susan, that you mentioned a little earlier that you reach the homeless population is through street medicine, and through having a pop-up clinic. Can you talk more about how both of these initiatives work?
Susan Buchbinder: Well the pop-up clinic really grew out of a recognition that we were seeing patients who were unstably housed. They were coming in for drop-in care because they had other needs. And sometimes they were psychosocial needs, social service needs, rather than necessarily medical needs. Sometimes they were medical needs, but what they weren’t able to do was to come in for primary care visits on the schedule that we were imposing on them. And so this idea was, well, why don’t we welcome them into the clinic, give them the kinds of support that they need, food, housing, clothing, other kinds of supportive services, and at the same time then be sure that we’re delivering primary care to them, not just taking care of their urgent medical needs, but really trying to look at the long term, what kinds of care is it that they need and what kind of treatment do they need?
So really developing wraparound services for people who are unstably housed. And we have a really talented team based at Zuckerberg San Francisco General, who lead that effort and are caring for a very vulnerable population.
Grant Colfax: Just to add, I work at the clinic where the pop-up clinic happens, and it’s just been remarkable in the last few years to see the change in the medical culture. Because working in urgent care myself, we used to say, “Oh okay, we’ll deal with the rash you have or the headache you have, but come back in two weeks to have a conversation with your primary care provider to start treatment,” right?
Now the docs at the pop-up clinic are just right there with the patients starting treatment immediately. It’s actually quite inspiring to see that change in our culture and how we’ve more effectively responded to meeting clients where they are.
Shanoor Seervai: That’s great to hear. As we’re wrapping up, I thought I should ask what other cities could learn from San Francisco. What are some of the things that you’re doing that you think are scalable and could be replicated elsewhere? And what are some of the things that you think are really specific to the context in which you’re operating?
Susan Buchbinder: Well, I think that one of the things that really drives what we do is collecting excellent data. So we have one of the world’s leading surveillance units that really tracks the epidemic. And that drives a lot of what we do, because we really need to see who are the populations that we’re missing through our current efforts? And then how do we develop programs to specifically meet their needs? So I think that’s a thing that all cities can use, is making sure that they’re collecting good data and letting the data drive what the programmatic issues are.
The other thing is really bringing together multiple sectors of society. Grant said earlier, it really started in the very earliest years of the epidemic that what turned the epidemic around wasn’t the medical profession. It really was the community themselves who rose up, took care of each other, and also advocated within the medical system for the kind of care that we can now provide, and for the research that was needed to actually address the epidemic.
So bringing together multiple sectors of society with the community as being a really core group — that’s included community-based organizations, policymakers, providers of all kinds, clinicians, government officials, researchers — all coming together to look at what the local epidemic is telling them. And then making some plans for how to address those specific needs, I think, is really generalizable to multiple cities.
The other thing I would just say is that we’re learning from other cities as well. We have a website, GettingtozeroSF.org, where people can download our protocols, for instance, for PrEP, or for same-day treatment. But we’re also constantly seeking out the advice and examples of what other cities are doing to try to address their epidemic, because we need to learn from them as much as we want to try to provide lessons that we’ve learned for others.
Grant Colfax: I would just add one broader policy point, which is, in San Francisco we rapidly scaled up implementation of the Affordable Care Act with Medicaid expansion. And I think as much as HIV continues to fall along the fault lines of poverty, it would be very difficult to do this in communities where Medicaid was not expanding, because access to things like for instance PrEP, which we just talked about, can be very dependent for many people who need it most, on having coverage, including Medicaid coverage.
So I think from a policy perspective, if you’re talking about cities or even states, it’s very important to expand Medicaid as an intervention for not only HIV but for the broader health of people living with HIV, and the broader health of communities at large. But I think we need to emphasize the Medicaid component to the work that we’re doing here in San Francisco, and what it’s allowed us to do in terms of the resources that it has provided.
Shanoor Seervai: Great. Well thank you both so much for joining me today.
Susan Buchbinder: Thank you.
Grant Colfax: Thank you very much.
Guest bio: Grant Colfax
Guest bio: Susan Buchbinder
Illustration by Rose Wong