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San Francisco Sees Declines in New HIV Infections and Deaths of People with HIV

The number of new HIV cases diagnosed in San Francisco decreased by more than 18% between 2013 and 2014, and deaths among people with HIV also fell during the same period, according to a progress report on the city's "Getting to Zero" initiative presented to the San Francisco Health Commission last week.

"The decline in new infections and deaths is very encouraging and shows we are on our way to zero," said Susan Buchbinder, director of Bridge HIV at the SF Department of Public Health. "We believe the decline comes from a strong base of community support, community organizations, and clinicians serving multiple HIV-affected communities in San Francisco."

Experts agree that the decline in new infections is due to a combination of factors including widespread testing, early antiretroviral therapy (ART), and possibly pre-exposure prophylaxis -- although PrEP is probably too recent to have had a substantial effect yet.

The Getting to Zero Consortium aims to eliminate new HIV infections, HIV-related deaths, and HIV stigma and discrimination using a 3-prong strategy of expanded access to PrEP, rapid access to ART, and retention of HIV-positive people in care.

As part of her update at the July 7 Health Commission meeting, Buchbinder, gave a preview of data from the department's annual HIV epidemiology report, which will be released in late August.

Buchbinder reported that the number of new HIV diagnoses in San Francisco fell by 18.5%, from 371 in 2013 to 302 in 2014 -- the lowest number since the start of the epidemic. The actual number of new HIV infections is greater than the number of newly diagnosed cases, since not every infection is immediately diagnosed. The SF DPH estimates that 94% of people living with HIV in the city have been diagnosed.

The number of deaths due to all causes among HIV-positive people in the city fell from 209 in 2013 to 177 in 2014, a decrease of 15.3%.

Since the advent of effective antiretroviral treatment in the mid-1990s, deaths due to AIDS have steadily declined and most HIV-positive people now die of other causes. The drop in deaths of people living with HIV in San Francisco may not be entirely good news, however.

"There has not been any radically new and improved therapy that can explain the decrease in deaths, so we must look for other contributing factors," said Brian Basingerof the AIDS Housing Alliance. "The reason is displacement. People with HIV -- especially the most vulnerable disabled long-term survivors -- are getting kicked out of their homes and dying elsewhere. We have displaced HIV deaths, not ended them."

[Editor's note: Buchbinder told the news blog 48Hills.org that the death figures include all people diagnosed with HIV in San Francisco, regardless of where they died, based on matching with local, state, and national death records.]

Role of PrEP

PrEP, or use of antiretroviral drugs to prevent HIV from taking hold in the body after exposure, can dramatically reduce the risk of infection if used regularly.

The iPrEx trial of mostly gay and bisexual men -- the group that accounts for about three-quarters of new HIV infections in San Francisco -- showed that Truvada (tenofovir/emtricitabine) taken once-daily reduced the risk of HIV infection by 44% overall, rising to 92% among participants with blood drug levels indicating consistent use. More recently, the U.K. Proud and French Ipergay studies found that daily or "on demand" PrEP reduced the risk of infection by 86%.

In July 2012 the Food and Drug Administration approved Truvada for PrEP, and in May 2014 the Centers for Disease Control and Prevention (CDC) recommended that people at substantial risk for HIV infection should consider using it.

Adoption of PrEP was initially slow, however. The number of San Francisco residents seeking PrEP did not begin to climb steeply until the fall of 2013 -- largely due to awareness and advocacy within the gay community -- according to figures from City Clinic and Kaiser Permanente. Thus, the level of PrEP use was likely not yet high enough to have had a substantial effect on the 2014 figures presented by Buchbinder.

At this year's Conference on Retroviruses and Opportunistic Infections, iPrEx investigator Robert Grant from the Gladstone Institutes at UCSF reported that an estimated 10% of San Francisco gay men had used PrEP during the prior 12 months -- or approximately 5000 total, based on an estimated citywide population of 50,000 men who have sex with men.

Grant's team estimated that this level of PrEP use would decrease annual HIV diagnoses to just over 300 -- similar to the actual observed number for 2014. But this represents only about one-third of all at-risk people who could benefit from PrEP, and wider use could reduce new infections by 70 percent.

"I find the numbers incredibly encouraging," study investigator Dave Glidden of UCSF said of the 2014 figures. "San Francisco is doing so many progressive things to reduce the number of new HIV diagnoses that it is hard to parse out the contributions of each. The scale-up of PrEP is comparatively recent and some of the work of my colleagues suggests it can play a big role in continuing to drive down the number of new HIV infections."

"The impact of any single intervention is impossible to quantify exactly, but new HIV diagnoses began to fall when more people got their viral load under control several years ago, and we are beginning to see the same thing happen at the same time as PrEP uptake has increased substantially," said David Evans of Project Inform. "Advocates have long said that the addition of PrEP to our tool box of prevention interventions could really bend the curve on new infections. This data indicate we were right, and we look forward eagerly to what will be gained as more and more people avail themselves of the first new tool available to HIV-negative people since the introduction of condoms many decades ago."

Another factor contributing to the decrease in new HIV diagnoses -- which has been underway since 2008, but with a steeper decline since 2012 -- is the widespread availability of early treatment.

In 2010 San Francisco was the first city to recommend antiretroviral therapy for everyone diagnosed with HIV regardless of CD4 T-cell count; U.S. treatment guidelines adopted the same recommendation in 2013.

As recently confirmed by the START trial, prompt treatment significantly lowers the risk of illness and death for people with HIV. In addition, HIV-positive people on treatment with an undetectable viral load have a near-zero risk of passing the virus on to others.

San Francisco leads the way in getting people living with HIV into care. Among people newly diagnosed with HIV in 2012, 89% were linked to care, most of these were prescribed antiretroviral therapy, and 68% achieved viral suppression. Under the RAPID ART program, people diagnosed with HIV at San Francisco General Hospital and DPH clinics are offered treatment on the spot, and the city aims to expand this initiative to other providers.

"Despite being a huge PrEP advocate, I caution against over-selling the contribution of this very new intervention in San Francisco's ongoing success in reducing HIV infections," said prevention advocate Jim Pickett from the AIDS Foundation of Chicago. "But the city's efforts around testing, linkage to care, offering treatment, and viral suppression -- coupled with condom provision, sterile syringe access, health care expansion, and other efforts, including PrEP -- are clearly coming together in a very robust package of combination prevention that is producing results worthy of applause, kudos, and high fives."

"San Francisco is a role model once again," added Kenneth Mayer, medical researcher director at the Fenway Institute in Boston. "Other elements worth considering are the increased access to health insurance and coverage for medication and clinical visits that is feasible in a blue city in a blue state, and the high levels of cultural competence of San Francisco providers in taking care of [gay men] and transgender women. We are seeing favorable trends in Massachusetts, but when I talk with people in Houston, Atlanta, and Jackson, Mississippi, uptake has been impeded by non-supportive health care environments. There's lots of work to do on a national scale, let alone global impact."

"In the last few years, we've entered into a new era in HIV prevention, with a pill that is more than 90% effective in preventing infections. When we combine that with early treatment for all who are HIV infected, we can both eliminate new infections and maintain health in people living with HIV," Buchbinder concluded. "We are now realizing the benefits of these synergies -- highly effective prevention and treatment to turn the curve on new infections and deaths. We are working on eliminating stigma and discrimination, which drives much of the HIV epidemic globally. It takes both treatment and prevention to get us to zero."

7/14/15