zero new hiv infections zero hiv deaths zero stigma and ......•sb 159 –prep/pep furnished by...

Getting to Zero San Francisco

Consortium

Zero new HIV infections

Zero HIV deaths

Zero stigma and discrimination

Agenda

1. Welcome

2. Policy Updates, Q&A

3. GTZ @ Pride & AIDS Walk

4. Panel & Community Discussion: Exploring women’s experiences and challenges for HIV prevention & treatment

SAN FRANCISCO AIDS FOUNDATION //

Policy Update

Ande Stone

April 25, 2019

SAN FRANCISCO AIDS FOUNDATION //

Agenda

1 Local Updates

2 State Updates

3 End the Epidemics Campaign

4 Questions

2

SAN FRANCISCO AIDS FOUNDATION //

Local Updates

SAN FRANCISCO AIDS FOUNDATION //

Local Updates

• City Budget Advocacy

– requesting funding to backfill for any and all federal level HIV funding reductions;

– 3% Cost of Doing Business increase for all grant-funded contracts to address and ensure

sustainability for all safety net programs;

– Support new housing subsidies for seniors and adults with disabilities, including people

living with HIV, to address the greatest disparity in health outcomes – housing status;

– Continued funding for enhanced mental health services to benefit long term survivors of

HIV;

– overdose death prevention services;

– Sustain Residential Care Facilities for the Chronically Ill (RCFCI); critical resource for

seriously ill, multiply diagnosed people living with AIDS at risk of program closure.

• Meeting with the Mayor - RCFCI

4

SAN FRANCISCO AIDS FOUNDATION //

State Updates

SAN FRANCISCO AIDS FOUNDATION //

Legislative & Budget Updates

• AB 362 – Supervised Injection Facilities (Overdose Prevention Services)

– Passed out of Public Health Committee & Public Safety Committee

– Next Step is Assembly Floor

• SB 159 – PrEP/PEP furnished by Pharmacies

– Amendments added, only allows pharmacists to furnish 30 days worth of PrEP and then

patient must be referred to provider for follow-up

• $60 million – HIV, HCV & STD Prevention Budget

– Budget Hearings are ongoing, more updates soon!

– Statewide lobby day coming up on April 30 (more info soon)

6

SAN FRANCISCO AIDS FOUNDATION //

#EndTheEpidemics

SAN FRANCISCO AIDS FOUNDATION //

End the Epidemics

• Overview

• Consensus Statement• 150 organizations!

• Is your organization signed on?

• End the Epidemics Day of Action• Tuesday - April 30th

• 28 folks from across the Bay Area & Northern California

• 54 advocates from across the state

• Direct Outreach• We’ve gathered 285 signatures

• Hunky Jesus + Ojos Que No Ven (IFR) + AIDS Survivors Storytelling (Shanti) +

• Please share with your orgs and invite us to do outreach at your events!

• Sign up www.sfaf.org/HANEvents

8

SAN FRANCISCO AIDS FOUNDATION //

Sign the PetitionText RESIST to the number 52886

9

SAN FRANCISCO AIDS FOUNDATION //

Ande Stone

Community Mobilization Manager, San Francisco AIDS Foundation

astone@sfaf.org

10

Questions?

SAN FRANCISCO AIDS FOUNDATION //

Volunteer at the GTZ-SF booth! Play spin-the-wheel, give away fun prizes

+ talk with the community about our work!

Opportunities to share Getting to Zero SF in the Community: Sign up at the table

This year we’re printing signs to carry at the Pride parade!Let us know if your organization would like 1-2 for the event.

~ Co-Moderators ~

Tracey Packer, San Francisco Department of Public Health

Cecilia Chung, SF Health Commission & Transgender Law Center

~ Guest Presenters & Panelists ~

Erin Wilson, San Francisco Department of Public Health

Elise Riley, University of California San Francisco

Clarissa Ospina-Norvell, UCSF/SFGH Ward 86

DK Haas, Community Member & Alliance Health Project

Breonna Mccree, Community Member & UCSF

Women & HIV: Addressing challenges experienced by cis &

transgender women in prevention & treatment

HIV and getting to zero new

infections among trans women in

San FranciscoERIN WILSON

ERIN.WILSON@SFDPH.ORG

SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH

HIV Annual report -

2017

N = 384 trans women in the HIV core surveillance data living with HIV

Trans women made up 3% of all persons diagnosed with HIV from 2016-2017, while they comprise <1% of the San Francisco population6 trans women diagnosed with HIV in 2016

Only 50% were virally suppressed within a year

Disparities in Viral Suppression

68% 69% 69%67%

32%

68% 70% 70%67%66%

68%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Pe

rce

nta

ge

Vira

lly S

up

pre

sse

d

74%

All Population Viral Suppression

Rate

Courtesy of Susan Scheer

HIV prevalence among trans women in SF –data from behavioral surveillance

35.00%

38.80%

33.70%

31.60%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

TRANS

COMMUNITY

HEALTH STUDY,

1997

TEACH 2010 TEACH 2013 TEACH 2016

HIV PREVALENCE

77%

90%85%

65%

81% 81%

44%

69% 64%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

HIV care continuum among trans women in SF2010, 2013, 2016

Raymond et al, 2019

Race/ethnicity of trans population

in San Francisco

32%

3%

18%1%

1%

17%

28%

Hispanic/Latinx

Asian

Black/African American

Native American

Native Hawaiian or

Pacific Islander

Other/Multiple

White

Intersectionality & HIV risk

Race/

Ethnicity

Youth

Transwomen & youth

Gender Identity

Youth & young adults

accounted for 21% of

all new HIV infections in

2017

African Americans

accounted for

43% of all HIV

infections as of

2017 and 13% of

US population

Transwomen in the

US have a 21.7%

pooled HIV

prevalence in the

US and <1% of the

population

Racial/ethnic

disparities in

HIV among

trans women

in San

Francisco

15%

8%

19%

12%

41%

29%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Hispanic/Latino African American

SF in 2010 (census) Living HIV cases in 2016 Transwomen living with HIV 2016

Disparities in the PrEP Continuum and social determinants for trans women (Trans*National) compared to MSM (NHBS) in SF (2016-2018)

79%

36%

15%10%

97%

55%

40%35%

0%

20%

40%

60%

80%

100%

PrEP awareness Talked with a

provider

PrEP use On PrEP and

adherent

Transwomen MSM

PR 0.77 (0.73-0.81)

PR 0.87 (0.83-0.91)

PR 0.80 (0.76-0.84)

PR 0.78 (0.74-0.82)

• Significant differences in social determinants were also found.

• Compared to MSM, trans women had significantly: lower education lower income Less employment More homelessness More engagement with

providers More health insurance

Liu, Wilson et al, HIVR4P 2018

Stay Trans PrEP

demonstration

project

enrollment by site 38 37

29

2022

Tom Waddell

Urban Health

Center

Tri City Health

Center

Castro Mission

Health Center

San Francisco

Community

Health Center

**25 Van Ness

146 trans

people on PrEP

What will it take to get to Zero new HIV

infections among trans women?

Anti-

trans

stigma

Research links anti-trans stigma to

Family rejection

Limitations in educational opportunities

Unemployment

Lack of health care access

Targeted violence from law enforcement and

others

Affects access to medical care (mistrust) Violence

Housing instability

(Santis et al., 2009; Khan et al., 2008; Wilson et al., 2011)

TEACH 2016 – trans women

living with HIV

• Unstable Housing

significantly associated with

detectable viral load

Stay 2018 - PrEP participants

• 38.7% were unstably housed

• 8.5% were homeless

Current housing situation

Couch surfs with…

Homeless/shelter

SRO

Residential treatment facility

Transitional/supportive…

Owns house

Rents house or apartment

Other

17 (2.7%)

278 (44.2%)

47 (7.5%)

106 (16.9%)

122 (19.4%)

17 (2.7%)

20 (3.2%)

22 (3.5%)

Unstably

housed:

313

(49.8%)

Interventions - What’s working

and what to consider Biomedical HIV prevention-

Continue expansion of access to PrEP in trans-specific and PrEP only clinics

Increase access to new biomedical HIV prevention modalities

2-1-1 for trans women

Injectable PrEP and other intervention trials

Radical new approaches that address upstream factors to increase HIV prevention use and HIV care outcomes

Interventions to reduce mental health stress, substance use and sexual risk behavior by reducing

Stigma against trans and racial minority identity people

Violence against trans women

Housing

Trauma

Fund and Partner

with Trans-led City

& Non-profit

Initiatives Compton’s Transgender Cultural District

Kween Culture Initiative

TranshomeSF

El/La Para TransLatinas

Transgender Law center

Thank You!

Trans*National Study team - Karen Aguilar * Jade Deva * Corey

Drew * Marla Fisher * Rafael Gonzalez * Catherine Kazbour * Victory

Le * Jacqueline Lewis * William McFarland * Andres Pomart * Henry

Fisher Raymond * Sofia Sicro* Orianna Saportas* Theo Beltran

Stay Study team – Sean Arayasirikul, Christina Sanz Rodriguez, Albert

Liu, Corey Drew, Jayne Gagliano, Viktor Belmont, Jasmine Infiniti

Community Health Equity and Promotion, San Francisco

Department of Public Health

National Institute on Minority Health and Health Disparities (R01-

MD010678)

California HIV/AIDS Research Program- UC Office of the President

Elise D. Riley, PhD, MPH

Professor

UCSF Department of Medicine

Division of HIV, Infectious Disease and Global Health

Zuckerberg San Francisco General Hospital

Women Living with HIV in San Francisco

Women Living with HIVin the United States

• Fewer women receive antiretroviral (ART) therapy than men

• Among individuals who do receive ART, women are twice as likely to discontinue therapy compared to men

HIV Epidemiology, Annual Report, SFDPH, 2017

HIV Epidemiology, Annual Report, SFDPH, 2017

HIV Epidemiology, Annual Report, SFDPH, 2017

Survival of Persons Diagnosed with Stage 3 HIV (AIDS) in San Francisco

Shelter, Health and Drug Outcomes among Women (SHADOW) Study

● 47=mean age

● 49% African-American

● 17% incarcerated (past 6 months)

● 46% used cocaine

● 18% used heroin

● 50% used cannabis

● 60% had an outpatient health care visit in the past 6 months

● 71% had an HIV case manager

Baseline Characteristics (n=129)

Socioeconomic factors ● age, race, education, income, insurance, housing

Health care ● primary care, case management, ART use

Social support ● close friends, instrumental support

Drug use ● cocaine, heroin, meth, opioid analgesics, alcohol

Predictors of Mental Health Status

Main Effect of Adjusted Adjusted 95% Adjusted tVIMPopulation Confidence p-value RankEffect Interval

Unmet subsistence needs -5.37 (-7.34, -2.35) <.0001 1

>90% ART adherence 5.07 (2.12, 7.76) .0006 2

Has a close friend/confidant 3.20 (1.05, 4.98) .0014 3

Crack cocaine use -4.55 (-7.20, -1.69) .0018 4

Slept on the street -2.92 (-4.47, -0.49) .0036 6

Cocaine withdrawal -3.02 (-4.95, -0.34) .011 7

At-risk alcohol use (>1d/day) -2.78 (-5.44, -0.38) .032 8No reported sources of instrumental Support -2.26 (-4.49, -0.15) .040 9

Ranked Influence of Study Factors on Mental Health (n=129)

(Riley et al., PLoS One. 2012; 7 (4): e35207, 1-7)

Factors Associated with Unsuppressed Viral Load

Study Characteristics

Demographics(age, race income)

Housing(# nights homeless or in an SRO)

Social supportFood insecurityIncarcerationViolenceDrug use (cocaine, meth, heroin, alcohol, pain killers)

Clinical characteristics (recent primary care, case management, insurance)

● 60% >1 unsuppressed viral load over 3 years

● 19% unsuppressed at every visit

Unsuppressed Viral Load (n=129)

Factors Associated with Unsuppressed Viral Load (N=129)

Study Characteristics (past 6 months)

Adjusted Odds Ratio (95% CI)

# nights slept on the street 1.10 (1.01-1.19)*

# nights slept in a shelter 1.15 (1.05-1.26) *

# nights slept in an SRO 1.04 (1.02-1.07)*

Any incarceration 3.17 (1.61-6.23)*Heroin use 1.91 (0.98-3.74)Cannabis use 1.55 (1.01-2.36)*

“I discovered that my environment had a lot to do with my mental state. So, when I had my own place, I was in control of the environment. You know, there was no drama, everything was nice and mellow, and so I was able to function... It was when other people and situations were introduced into my environment that I couldn’t get away from, that would send me over the edge.”

(Knight et al., Int J Drug Policy 2014)

The Social Context of Housing

“WLWH continue to experience poor outcomes across the HIV care cascade and overall health, an appreciable proportion of which may not be disease-related but due to socio-structural barriers that impact health.”

(Shokoohi et al., PLoS One, 2019)

Acknowledgements

The women who participate in our studies

The SHADOW and PULSE study teams

The National Institute on Drug Abuse (R01 DA037012 and K24 DA039780)

The research presented here was made possible by

Thank you!