Emily Land MD

Although AIDS conferences have previously tackled the issue of racial disparities in HIV, conversations often stop with data and urgent calls to reach “key populations” or “those most at risk for HIV,” coded language oftentimes referring to Black, brown, Latinx and Indigenous people of color in the U.S.  

Now, conversations about racism and racial justice in the wake of the murders of George Floyd, Breonna Taylor, Tony McDade, and others are permeating the largest international conference on HIV and AIDS–AIDS 2020–held virtually the week of July 6, 2020. Researchers, practitioners, and activists are discussing systemic bias in public health and our medical systems, and are providing ideas on how to incorporate anti-racist frameworks into the HIV response. Here’s some of what’s been shared.

In a presentation titled “Breathing is a human right” (Bridging Session 1), Darius Rucker, from Williams and Associates, shared his experience as a Black queer man living with HIV in order to name the racist policies and procedures that continue to place Black queer people at a disadvantage in HIV care and prevention. 

“It took eight months between my [HIV] diagnosis and linkage to medication,” said Rucker. “In April 2011, my diagnosis was given to me. Months later, I was still not on medications, and was sick. December 2011, still no meds, sick, dying, AIDS. I didn’t have a doctor, a case manager, or support. I needed someone to walk with me. What could have been different? Access to equitable healthcare, and better conversations about healthcare. Racism, homophobia, stigma and HIV still continue.” 

Wearing a Black Lives Matter shirt, Gregorio Millet, from amfAR, gave a comprehensive overview of some of the nuanced ways that historical legacies, policies, and other societal structures aggravate disparities experienced by Black Americans (Prime Session 1) in HIV and now COVID-19. He pointed to systemic biases which dictate who gets access to new technology, such as COVID-19 testing. 

“COVID-19 testing centers are less likely to take place or to be located in African American or Latino communities. And we saw the exact same thing, unfortunately, with HIV, when antiretroviral therapy became available. We saw the disparity in mortality rates actually increased between African Americans and whites during the time when ART became available. And that’s because African Americans had less access to antiretroviral therapy and thus were more likely to die,” said Millet. 

Access to pre-exposure prophylaxis (PrEP) is also an issue for many Black Americans. 

People in the South, particularly people who are Black, experience the highest rates of HIV infection in the U.S., yet have the lowest rates of pre-exposure prophylaxis (PrEP) uptake, shared Jodie Guest, from Emory University (Oral Abstract Session C08). The “PrEP to need” ratio–the number of PrEP users divided by the number of people diagnosed with HIV–is highest in the West (over 25) and lowest in the South (less than 10), pointing to the stark need for increased PrEP access in the South among people of color. In addition to access issues experienced by people in the South, Guest pointed to startling low rates of PrEP awareness (11% in one study), and concluded by emphasizing that PrEP scale up must be equitable.

In San Francisco, Jonathan Volk shared continuum of care data from the Kaiser Permanente PrEP program, which found that African American clients were less likely to receive a PrEP prescription, less likely to begin PrEP, and more likely to discontinue PrEP (Oral Abstract Session C08).

“Given the pervasive effects of systemic racism and anti-blackness in our country, it is imperative that we implement an anti-racist approach to PrEP,” said Albert Liu, MD, MPH from San Francisco Department of Public Health, in a session about creating “person-centered” PrEP programs and reducing barriers to PrEP access and retention (Bridging Session 06). 

Liu explained that, according to Ibram Kendi’s “How to be an Antiracist,” ideas and policies are either racist or anti-racist, and racist policies are the cause of racial inequities. This includes health inequities, such as those in HIV incidence and PrEP uptake, which means it’s critical for providers and those in power to upend and revise existing systems. Pointing to a “PrEP equity index” developed by Myers and colleagues, Liu said that PrEP use must increase by up to 300% in Black men who have sex with men (MSM) and 230% in Latino MSM to achieve equity with white MSM in New York City.”  

“It’s critical that we examine all steps of the PrEP continuum to ensure PrEP delivery is anti-racist,” said Liu.  

“Your HIV organization or health department probably has a racist history–all of ours do,” said Felipe Flores, from San Francisco AIDS Foundation (Satellite Session On-Demand). “Building bridges with BIPOC [Black, Indigenous, and people of color] organizations, offering resources and services to these community partners, begins to heal some of the failings that we have inherited or created.” 

Flores said it is critical to dedicate time, appointments, and resources to communities that “we have collectively failed,” and to be “loud and unrelenting about it.” 

“What holidays does your organization get time off for? What events does your outreach team go to? What languages are your materials in? Who is pictured on flyers? Integrate a racial justice framework into everything you do,” said Flores. 

Carmarion Anderson, from Human Rights Campaign, shared her perspective as a Black trans woman working in HIV advocacy to drive home the importance of understanding of intersectionality in order to connect with (not “target”) people of color living with or at risk for HIV (Symposium SS21). 

“You have to understand what barriers we face. Before you offer me an HIV test, before you offer me a biomedical intervention like PrEP, you have to understand the trauma I have gone through,” she said. “Some of these things [rejection, poverty, depression] influence how we show up as you are trying to aid us and implement the work of your organization.” 

As Anderson spoke about advocacy, she gave an important recommendation for organizations who work with Black and trans communities. 

“As a Black trans woman, I can speak up for who I am. And if I can speak up for myself, I can also sit at your table of decision. You understand what I’m saying. That means you can employ me, in order to have my voice, my narrative and my community working with you,” she said.  

Carmen Logie, from University of Toronto, also used an intersectionality framework to present the experiences of Black, Caribbean, African and Indigenous women living with HIV in Canada (Bridging Session 12). Women of color are overrepresented in the number of HIV infections that happen among women in Canada, said Logie, and oftentimes experience the intersectional stigmas related to race, gender, HIV status and sex work. 

“Ths intersecting stigma matters,” said Logie. “Racism, HIV stigma and gender discrimination are associated with ART [antiretroviral therapy] adherence issues, depression, and injection drug use. It shapes mental health. We need intersectional stigma interventions, and we need them now. We need them to be trauma-informed, and have a harm reduction approach.” 

Monica McLemore, from University of California, San Francisco, shared her personal experience being born prematurely to a Black mother as she spoke about health inequities faced by Black Americans and the importance of movements like Black Lives Matter to HIV prevention and care (Symposium SS21). 

“In New Jersey, where I was born, infant mortality was double the rate for mothers of color compared to white mothers. I am lucky and grateful to be alive.” said McLemore. “Now, we have to deal with two two pandemics at once: the novel coronavirus, and racism. We can do better, and we have to.” 

McLemore urged the HIV community to consider, and incorporate, the principles of Black Lives Matter and the movement for Black lives into the HIV response. “If we place our asks in terms of a human rights frame, the health of everyone can, and will, and should improve.”

In a presentation about including community in the plan to end HIV (Symposium SS21), Venton Jones-Hill, from Southern Black Policy Advocacy Network advocated for meaningful participation of Black communities in HIV policy. “We need to strengthen the capacity of Balck communities and leaders in the U.S. South to engage in health policy deliberations to improve policy, programs and research,” said Jones-Hill. “Community has to be in the middle of the conversation.” 

“Now, after the death of George Floyd and many others, you see this complete shift in sensibility where a majority of white Americans, Black Americans, Latino Americans, and Asians support the Black Lives Matter movement,” said Millet. “And one of the things that was really one of the happiest things that I see lately was in my own neighborhood, two blocks from where I grew up in Brooklyn, there was a rally for thousands of people in support of trans Black women’s lives–saying their lives mattered as well. We need to make sure that communities are at the center of the response and at the center of providing solutions for some of these health crises.” 

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Visit AIDS2020.org for information about the conference. Presentations and materials from the conference will be made available to the general public at the end of July, 2020 through the conference website.

In a recently published report in JAIDS, Willi McFarland, MD, PhD and colleagues describe HIV seroconversion trends among trans women in San Francisco from 2017 – 2019 collected in the TransNational Study. Young trans women (aged 18 – 24) had a significantly higher HIV incidence, as did Latinx trans women and trans women of color. 

“Perhaps the most disheartening finding is the elevated HIV incidence among young trans women,” the authors said. “The nearly four-fold higher incidence among transgender youth predicts a continuing high burden of infection for years to come.” 

“San Francisco is a small city with a lot of services for trans folks,” said Erin Wilson, DrPh, MPH, who reported some results from the study at IAS 2019. “This substantial transmission continues despite unparalleled access to gender-affirming medical procedures and social services.” 

The TransNational Study enrolled a total of 415 HIV-negative trans women, with 377 completing the 18-month study. Over the course of the study, participants received HIV testing, referrals to PrEP, and referrals to HIV care (for those who tested positive during the study). There were eight seroconversions that occurred over the course of the study, for an overall incidence rate of 1.3 per 100 person years (py). 

The trans women who seroconverted were significantly more likely to be young, identify as Latinx or a trans woman of color, have a history of incarceration, and be without health insurance. 

Young trans women ages 18 – 24 had an HIV incidence rate significantly higher than trans women who were older (3.7 per 100 py versus 1.2 per 100 py). Latinx trans women (2.6 per 100 py) and trans women of color (2.2 per 100 py) had significantly higher incidence rates than white trans women. Trans women who had been incarcerated (2.3 per 100 py) and those without health insurance (5.8 per 100 py) also experienced higher HIV incidence rates. 

“Structural factors disproportionately affecting trans women of color are also tied to poor HIV care outcomes and suboptimal access to HIV prevention use,” the authors said. “Such risks are exacerbated in our city, which has wide disparities in wealth, housing and employment opportunities.” 

Reference:

McFarland, W. and colleagues. High HIV Incidence Among Young and Racial/Ethnic Minority Transgender Women in San Francisco. JAIDS, May, 2020. 

Hear more from Erin Wilson, DrPH, MPH

Erin Wilson, DrPH, MPH shares research conducted with trans women in San Francisco, and explains why simply providing accessible gender-affirming services and HIV prevention and care isn’t enough to offset the inequities, discrimination and disadvantages that trans women may experience.

Resources for trans women in San Francisco: 

STRIDE: Transgender Hormone Therapy Program at St. James Infirmary

St. James Infirmary provides gender-affirming hormone therapy to participants. Check the schedule for services during COVID-19.

Trans Health at San Francisco AIDS Foundation 

You can access a variety of gender-affirming care options including hormone prescriptions, hormone level checks, and hormone injection assistance, in addition to peer support through our TransLife social support program.  

Transgender Clinic of Tom Waddell Health Center

In addition to gender-affirming care, you can access multidisciplinary primary care for all medical issues (not just issues related to gender), and mental health and social services. Call the voicemail line at 415-355-7588 for info about services during COVID-19. 

Transgender Health at San Francisco Community Health Center 

Access gender-affirming interventions, including hormone therapy, surgery, facial hair removal, interventions for the modification of speech and communication, and behavioral adaptations such as genital tucking or packing, or chest binding. Trans Thrive is currently suspended during COVID-19, but essential health services are being provided essential services to trans and gender non-conforming community members. 

Lyon Martin Health Services

Access medical care, sexual and reproductive health care, and gender-affirming care. Lyon Martin is currently open during COVID-19. Call 415-565-7667 to make an appointment. 

Cannabis use may be associated with less HIV-related cognitive impairment, suggests new research from Caitlin Wei-Ming Watson and colleagues at the University of California, San Diego. The study, which included about 1,000 adults with varying histories of cannabis use, found lower rates of difficulties with learning and verbal fluency in people living with HIV who used cannabis.

There were no differences in cognitive impairment between HIV-negative cannabis users and non-users, which suggests that cannabis may prevent neurocognitive impairment from HIV.

“Recent research shows that cannabinoids have anti-inflammatory properties,” said Watson. “We hypothesized that some degree of cannabis exposure may be protective for brain health in certain contexts. While in the general population, heavy cannabis use is associated with null or negative cognitive outcomes, we were interested in whether cannabis would show different effects on cognition in a disease like HIV, which is characterized by a weakened immune system and persistent inflammation.”

A total of 952 adults participated in the study (679 who were living with HIV, 273 who were HIV-negative). People with a history of non-HIV-related neurological, medical or psychiatric disorders affecting brain function were not included in the study. People with a substance use disorder (other than cannabis) in the past year, and people who tested positive for substances other than cannabis on a urine toxicology screen were also not included in the study.

The researchers assessed lifetime cannabis use and cannabis use in the previous year, categorizing study participants based on HIV status and cannabis exposure. People in the cannabis group had both a history of substantial cannabis use and cannabis use in the previous year. People in the cannabis-negative group did not use cannabis in the previous year and did not have a history of substantial use. Participants completed neurocognitive tests to assess cognitive functions including verbal fluency, learning, memory, attention, motor skills and more.

Participants ranged in age from 18 to 79 years. Most were men (76%) and identified as gay or bisexual (71%).

After controlling for race/ethnicity, current major depressive disorder and history of substantial methamphetamine use, the researchers found a significant relationship between cannabis use and neurocognitive impairment that varied by HIV status.

Rates of neurocognitive impairment among HIV-negative people were similar regardless of cannabis exposure (between 25% and 30%). However, among people living with HIV, rates of neurocognitive impairment were much higher among non-cannabis users (nearly 50%), while rates were much lower among cannabis users (about 30%).  

“Our results are consistent with the idea that under some circumstances, cannabis might be neuroprotective,” the authors said. “Given our findings did not differ in virally suppressed people living with HIV, the anti-inflammatory effects of cannabis may be important for people living with HIV who are both detectable and undetectable.”

Watson explained that the majority (70%) of neurocognitive deficits observed in people living with HIV are considered mild enough that people may not notice impairment, although even these milder forms of neurocognitive impairment may influence everyday life.

“Some research from our lab has shown that these mild impairments are linked to difficulties with medication management, employment, and other important functional and medical outcomes,” she said.

Further research is needed to clarify what aspects of cannabis are therapeutic or not therapeutic—including the effect of dose, frequency of use and type of cannabis product. Watson stated that their findings have several limitations.

“Our study was retrospective and did not capture detailed information about cannabis use such as potency, nor did we capture important factors such as psychosocial context, including motivations for cannabis use. There also may be other negative health consequences of heavy long-term cannabis smoking such as chronic bronchitis which are important to keep in mind.”

“In the future, we would like to be able to define what levels of cannabis exposure are linked to optimal brain and cognitive health, and what levels may be detrimental,” said Watson. “It is likely that beneficial effects are limited to certain dose and frequencies of use, and also vary by cannabis compound (e.g., THC vs. CBD vs. CBC).” At this point, we don’t want the take-away to be, ‘If you have HIV, you can use cannabis and that’s going to be really good for your brain health and cognition.’ We need to do much more research before we can make more specific recommendations regarding the impact of cannabis use on the brain in HIV disease.”  

Reference:

Watson, Caitlin Wei-Ming, and colleagues. Cannabis exposure is associated with a lower likelihood of neurocognitive impairment in people living with HIV. JAIDS, January 2020.

MEDICAL SUPPORT FOR PEOPLE LIVING WITH HIV OVER AGE 50

Golden Compass in San Francisco provides specialized medical care for adults living with HIV over age 50, including heart health, memory/cognitive problems, cancer and osteoporosis. For more info or to receive services, find the program online, email goldencompass@ucsf.edu or call 628-206-2473.

SERVICES FOR PEOPLE LIVING WITH HIV

Whether you’re a long-term survivor, newly diagnosed or somewhere in between, SFAF offers services, resources and social support to keep you informed about the latest advances in treatment and care, to help you start, re-start, or stay in treatment, and to help you become undetectable and untransmittable.

In a recent article published in AJPH, researchers from the Center for Latino Adolescent and Family Health at New York University promote and share startling data about the impact of HIV on Latinx communities in the U.S., pointing to a neglected and accelerating public health crisis.

“The sustained, widening, and largely unrecognized HIV disparity among US Hispanics/Latinos is a pressing public health emergency,” the authors wrote.  

“When we think about the Latino/Hispanic community, I think there’s a tendency for things to go unrecognized,” said Vincent Guilamo-Ramos, PhD, MPH, LCSW, ANP-BC, AAHIVS, the lead author. “Latino/Hispanic HIV incidence has been going up both in terms of new diagnoses and also estimated incidence of new infections, and those increases haven’t really been fully recognized. This article was a way of drawing attention and saying, ‘Hey, we need some focus here as well’ because with focus comes the possibility of actually having some of the progress that’s been made elsewhere also benefit the Latinx community.”

Guilamo-Ramos and colleagues highlight three key Latinx sub-populations most affected by HIV: young Latinx men who have sex with men; trans Latina women; and, recent Latinx immigrants. Annual HIV infections among Latinx gay men have increased by 30% since 2010, an estimated one in four trans Latinas is living with HIV, and at least one in three new HIV diagnoses among Latinx individuals in 2017 were among individuals born outside the U.S. (with the majority of infections happening in the U.S.).

What is surprising, said Guilamo-Ramos, is the existence of “HIV transmission clusters” that have been identified by the CDC. In these networks of individuals who are connected socially, sexually or through drug use, HIV transmission is occurring at rates up to 33 times the national average.

“What emerges is that they are heavily composed of young people, persons of color, who are Latino and also men who have sex with men,” said Guilamo-Ramos. 

Identifying the unique challenges faced by these individuals—for example, HIV-related stigma, language barriers, mistrust of health systems and lack of culturally appropriate care—is essential so that local and national programs can address needs.

Access to PrEP—highly effective medication that can reduce risk of HIV by more than 99%—is essential to reducing HIV transmissions in Latinx populations.

“PrEP has the potential to have a dramatic impact on the communities that are disproportionately impacted,” said Guilamo-Ramos. But at this point, one unintended consequence of PrEP is that in some ways it’s exacerbating disparities because white communities are achieving fairly high levels of PrEP coverage while communities of color including Latino communities are not. The idea of PrEP as the way forward is very important.” 

On a structural level, lack of insurance-related access to health care remains the most significant barrier to HIV prevention and care. Latinx individuals, including those born outside the U.S., are the most uninsured and underinsured racial/ethnic group in the U.S.

With approximately 59 million Latinx residents in the U.S.—and a population expected to double by 2060—effective HIV public health responses tailored to Latinx communities are much needed. 

“Failure to address gaps in the national response to the Hispanic/Latino HIV crisis has significant population-level implications for the fight against HIV/AIDS,” the authors said.

The authors outline a few priority areas for the CDC plus federal, state and local partners, including reducing HIV stigma by normalizing HIV prevention and treatment, ensuring cost-free access to HIV treatment for undocumented immigrants, collaborating with Latinx community leaders, and more.

“I want folks to know that on the policy level, we’ve got to create bridges for Latino communities to be able to access culturally competent care, and think about how to better engage a Latino community along that whole continuum,” said Guilamo-Ramos.

En un artículo reciente publicado en AJPH, investigadores del Centro de Salud para Familias y Adolescentes Latinos en la Universidad de Nueva York promueven y comparten datos alarmantes acerca del impacto del VIH en las comunidades latinas en los EUA, indicando una crisis de salud pública desatendida y en aceleración.

“La sostenida y creciente disparidad en el VIH y en gran parte no reconocida entre los hispanos y latinos en los EUA es una emergencia de la salud pública”, escribieron los autores.

“Cuando pensamos en la comunidad latina/hispana, pienso que hay una tendencia a que las cosas pasan sin reconocerse”, dijo el autor principal, Vincent Guilamo-Ramos, PhD, MPH, LCSW, ANP-BC, AAHIVS. “La incidencia del VIH latino/hispano ha estado aumentando tanto en cuanto a nuevos diagnósticos como en la incidencia estimada de nuevas infecciones, y esos aumentos no se han reconocido completamente. Este artículo fue una manera de llamar la atención y decir, ‘Miren, necesitamos enfocarnos un poco aquí también’ porque con enfoque viene realmente la posibilidad de que algo del progreso que se ha tenido en otras partes también beneficie la comunidad latina.

Guilamo-Ramos y sus colegas destacan tres sub-poblaciones latinas clave más afectadas por el VIH: hombres jóvenes y latinos que tienen relaciones sexuales con hombres; mujeres trans y latinas; e inmigrantes latinos recientes. Infecciones anuales por VIH entre hombres gay y latinos han aumentado un 30% desde 2010, se estima que una de cuatro trans latinas vive con el VIH, y por lo menos uno de tres nuevos diagnósticos de VIH entre personas latinas en 2017 estaba entre las personas nacidas fuera de los EUA (con la mayoría de las infecciones ocurriendo en los EUA).

Lo que extraña, dijo Guilamo-Ramos, es la existencia de “grupos de transmisión del VIH” que el CDC ha identificado. En estas redes de personas que están conectadas social o sexualmente o por el consumo de drogas, la transmisión del VIH ocurre a tasas de hasta 33 veces el promedio nacional.

“Lo que surge es que están compuestos considerablemente de personas jóvenes, personas de color, que son latinas y también hombres que tienen relaciones sexuales con hombres”, dijo Guilamo-Ramos.

Es imprescindible identificar los desafíos únicos que afrontan estas personas – por ejemplo, el estigma relacionado con el VIH, las barreras lingüísticas, la falta de confianza en los sistemas de salud y falta de cuidados culturalmente apropiados – para que programas locales y nacionales puedan tratar las necesidades.

El acceso a PrEP—un medicamento altamente efectivo que puede reducir el riesgo de contraer el VIH por más del 99%—es esencial para reducir las transmisiones del VIH en las poblaciones latinas.

“PrEP tiene la posibilidad de tener un impacto dramático en las comunidades que están desproporcionadamente afectadas”, dijo Guilamo-Ramos. Pero hasta ahora, una consecuencia no intencionada de PrEP es que en algunas maneras está agravando las disparidades porque las comunidades blancas están recibiendo niveles de cobertura de PrEP bastante altos mientras que las comunidades de color incluyendo las comunidades latinas no. La idea de PrEP como el camino hacia delante es muy importante”.

A nivel estructural, la falta de acceso a la atención médica asociada al seguro sigue siendo la barrera más importante a la prevención y al cuidado de VIH. Las personas latinas, incluyendo las nacidas fuera de los EUA, son el grupo étnico/racial menos asegurado y más subasegurado de los EUA.

Al haber aproximadamente 59 millones de residentes latinos en los EUA – y una población que se espera que se duplique para el 2060 – son muy necesarias las respuestas eficaces a la salud pública de VIH  personalizadas a las comunidades latinas.

“El no tratar las brechas en la respuesta nacional a la crisis del VIH hispana/latina tiene importantes implicaciones a nivel de población en la lucha contra el VIH/SIDA”, dijeron los autores.

Los autores destacaron unas cuantas áreas de prioridad para el CDC más los socios federales, estatales, y locales, incluyendo reducir el estigma del VIH normalizando la prevención y tratamiento de VIH, asegurar el acceso libre de costos al tratamiento del VIH para inmigrantes no documentados, colaborar con líderes de la comunidad latina, y más.

“Quiero que la gente sepa que a nivel de políticas, tenemos que crear puentes para que las comunidades latinas puedan acceder a cuidados culturalmente competentes, y pensar en cómo mejor incluir a la comunidad latina en todo ese continuo”, dijo Guilamo-Ramos.

Historically, HIV treatments have included three or more medications (oftentimes combined in one pill) to keep HIV suppressed and help people living with HIV reach and maintain undetectable viral loads. In the spring of 2019, the U.S. Food and Drug Administration (FDA) approved the complete regimen combo pill Dovato (dolutegravir + lamivudine), manufactured by ViiV Healthcare, giving clinicians for the first time a two-drug option to treat individuals just beginning HIV treatment.

Now, recently updated U.S. Department of Health & Human Services (DHHS) HIV treatment recommendations list a two-drug regimen (dolutegravir + lamivudine) as a first-line recommended therapy. But, Monica Gandhi, MD, MPH, from Zuckerberg San Francisco General Hospital’s Ward 86 gives a strong word of caution due to concerns over drug resistance.

“I’m concerned that this will lead to massive amounts of Dovato use, two-drug therapy, that will bite us down the road,” said Gandhi, who is medical director of Ward 86. “We have lots of experience with three drugs, and there is a concern about resistance with a two-drug regimen.”

Gandhi explained that lamivudine (3TC), the NRTI in Dovato, has a low barrier to resistance—meaning that it’s easy for a person to develop resistance to the effects of 3TC so that the drug no longer works. When this happens if a person is taking Dovato, the person is effectively on dolutegravir monotherapy. And, people taking only dolutegravir can develop resistance mutations that would rule out future treatment with dolutegravir and, likely, other integrase inhibitors. Dolutegravir monotherapy, Gandhi said, is “a terrible idea.”

“If you lose [develop resistance to] dolutegravir after some time, you’ve just lost the entire first-line class of drugs that we have to treat HIV [INSTIs],” she said. 

Drug resistance can be transmitted (i.e., it’s possible for a person who has never taken HIV medications to already have a resistance mutation), so HIV clinicians test for resistance mutations prior to starting therapy. If a person has a resistance mutation, HIV providers can tailor the drug treatment to work around resistance. Resistance can also develop if someone taking HIV medication isn’t adherent to treatment—for instance if they forget to take or aren’t able to take medications every day as prescribed. 

For these reasons, Gandhi urges clinicians to consider adherence when prescribing two-drug regimens—knowing that “we’re just not that good” at estimating how adherent a person can be.

“I would be more comfortable at this point giving people a chance to adhere and do well with a three-drug regimen, and then maybe downgrading them to a two-drug regimen if they are adherent,” said Gandhi. “Patients should be aware of the importance of adherence, which is true of any regimen, but particularly true with a two-drug therapy. I wouldn’t want them to miss any doses. And I would want them to talk to their provider about how to take medication, so that they both could be reassured.”

Gandhi said she worries that health care providers who do not specialize in HIV treatment may miss some of these nuances with the new DHHS guidelines—opting to prescribe a two-drug regimen out of concerns over toxicities in regimens with three drugs.

“Young healthy people probably aren’t going to get toxicities with TAF or abacavir (the third drug in the combo pills Biktarvy and Triumeq, respectively). I think it’s interesting that we are talking about two-drug therapy now due to concern about toxicities. For example, NSAIDS (e.g., ibuprofen) can cause renal issues, but we don’t even think twice before putting people on long-term NSAIDS if they’re young and not at risk of renal toxicity. You want to tailor your toxicity concerns to risk factors of that individual. If they have risk factors for cardiovascular disease, you should be concerned about abacavir.  If they have risk factors for renal toxicity, you should be concerned about TAF,” said Gandhi 

FDA approved Dovato for the initial treatment of HIV based on the results of the GEMINI 1 and 2 studies, which enrolled over 1,400 people starting HIV treatment for the first time. The studies found that 86% of individuals had undetectable viral loads <50 copies after 96 weeks (compared to 89.5% of people taking a three-drug regimen of dolutegravir + TDF/FTC). 85% of participants were men and two-thirds were white.

Although these study results show that dolutegravir + lamivudine can be a successful treatment option for some, Gandhi said that she questions the extrapolation of one phase 3 study to the entire population of people living with HIV.

“People who get into clinical trials are often very rarified populations. They are adherent, they come in for clinical trial visits. They are often white and they are often men. We need some real-world studies, some demonstration projects, that include women and people who may have adherence difficulties,” said Gandhi.

Also new in the DHHS guidelines is a recommendation that HIV treatment be started immediately or as soon as possible after diagnosis, to decrease the time required to achieve viral suppression and reduce risk of HIV transmission, a recommendation Gandhi supports and said she was pleased to see.

The challenges—and opportunities—of two-drug regimens

What are some of the issues with injectables and other two-drug therapies? Find out what you need to know about HIV two-drug regimens. Plus, get an overview of other combinations currently being tested. Read more here. 

Dive into the world of drug resistance

Here’s a low-down on HIV drug resistance, including what it is and how you get tested for it. Also, get advice from HIV clinicians on prevention and what to do if you do develop HIV drug resistance.

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San Francisco AIDS Foundation receives funding from corporate partners including those in the pharmaceutical industry. Editorial decisions on our blog and website are made independently. For more information about SFAF funding, please refer to our financial and tax documents.

• EMILY LAND, MAEmily Land is the editor-in-chief of BETA blog and content marketing manager at San Francisco AIDS Foundation.

“Linkage to care” is a well-spoken mantra in the field of HIV: Make sure that people who are living with HIV are seeing an HIV care provider and have access to HIV medications. As simple as it may seem, the changing nature of San Francisco’s HIV epidemic means that more and more people are not accessing—or are not able to access—HIV prevention or care from traditional medical clinics.

HIV providers and frontline staff must confront the challenge of bringing HIV care to people—beyond simply linking people to care.  

“Access to HIV care is so much more than making sure a person has a place to receive medical treatment and can afford it,” said Julie Lifshay, MPH, PhD, from San Francisco AIDS Foundation. 

“Even if a person knows where to go and has insurance or a way to pay for care, they may not be able to afford the bus ride to get there. Or they can’t navigate the health system to make an appointment, they can’t afford their medication copays, or they can’t pick up prescriptions because that would mean missing their place in the food line. It’s complicated, and there are so many things that can put HIV care just out of reach,” said Lifshay. 

“People who are unhoused face a lot of barriers accessing care,” said Beth Rittenhouse-Dhesi, MS, from San Francisco Community Clinic Consortium. “It’s not as easy as walking into a clinic and getting needs met. Because of stigma, many people have had bad experiences and so they choose to stay away. The other issue is that people living on the street are dealing with a lot of survival issues. They’re worried about food, water, shelter and clothing. So even very serious health concerns can be put on the back burner.”

In San Francisco, 20% of new diagnoses were among people experiencing homelessness, a proportion which has been increasing in recent years. Getting to Zero SF, San Francisco’s plan to reach zero new HIV infections, zero AIDS-related deaths and zero HIV stigma hinges on the success of reaching and providing services to people experiencing homelessness. 

Ensuring that people living with HIV have access to HIV care and medications not only improves an individual’s health, it also prevents transmission since people with undetectable viral loads do not transmit HIV.   

The recently-established POP-UP clinic at Zuckerberg San Francisco General Hospital is one example of how HIV services can be delivered in ways that fit into the lives of people experiencing homelessness.

POP-UP is open to people who are homeless or unstably housed, are off antiretrovirals or have a detectable viral load. The program sees people on a drop-in basis without appointments, starts people on antiretrovirals and provides comprehensive medical care, medication storage, food, clothing, housing assessments, mental health care and gift card incentives for staying in care.

“We call it POP-UP because when people come into the clinic, our team grows around them and we work to meet their needs and concerns,” said Elizabeth Imbert, MD, MPH from Zuckerberg San Francisco General Hospital. “We don’t start with the medical stuff—we try to get to know them, figure out what they want, and what’s important to them. We find out what their health goals are, what has gotten in the way [of meeting goals], and how we can help meet them.”

Since January of 2019, over 95% of people in POP-UP have started on ARVs, and more than half (32 out of 59) are virally suppressed, reported Imbert at a Getting to Zero meeting in December 2019.

Street Outreach Services, of the San Francisco Community Clinic Consortium, reaches people who are unhoused by delivering services in a mobile medical clinic. Most often, medical providers treat skin and soft tissue infections, abscesses, podiatry problems and provide support for substance use.

Street Outreach Services does not provide ongoing treatment for chronic conditions including HIV, but the team does connect people with regular care, help people figure out transportation to medical appointments, and follows up with clients to make sure they receive HIV care.

Rittenhouse-Dhesi said the van frequents neighborhoods that not only have homeless residents but also a low concentration of service providers.

“We provide care to anyone who is unhoused—our goal is to connect with people in their own environment of places where they’re gathering. That may be a camp, or another place outdoors, or at a meal program. The whole objective is to come to people, and not always expect people to come to a four-walls clinic. After you make that initial relationship, you can help people navigate into other services,” said Rittenhouse-Dhesi.

At San Francisco AIDS Foundation (SFAF), a new program reaches Latinx community member immigrants experiencing homelessness through a group of community health educators.  

The “Todos Somos Familia” project, though Latino Programs at SFAF, recruited and trained a group of currently and formerly homeless Latinx immigrants on topics such as overdose prevention, accessing social services, HIV prevention and getting into HIV care. In turn, members of the program reached out into the community and into their networks to share HIV and health information and services, facilitating access to case management, drug treatment, testing, PrEP and HIV care. 

“There is a lack of investment in reaching immigrants without housing,” said Jorge Zepeda, from SFAF. “These individuals may not be aware of the services they can access, and may not trust them. This project helped SFAF become a safer and friendly space for Spanish-speaking communities, and showed that we can reach people with these services if we do so in culturally competent ways.” 

“We’re seeing these great disparities in HIV in San Francisco,” said Lifshay. “It’s because we are dealing with social determinants of health including income disparities, the housing crisis, displacement issues and racism. We have to address those things to get to zero. It’s such a big task, but a smaller piece is making sure our resources go to the people most impacted by these issues. We have to reach homeless folks with HIV care—we must do a better job of that.” 

END THE EPIDEMICS

Sign the petition to End the Epidemics, a campaign calling for a statewide plan to end the HIV, STD and hepatitis C epidemics in California. Urge California leaders to make serious investments in public health and help us lead the nation in ending the HIV, STD and hepatitis C epidemics. 
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HIV SUPPORT & HEALTH NAVIGATION AT SFAF 

We offer a range of services that help connect you to HIV treatment, benefits, housing subsidies, and insurance. 
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STREET OUTREACH SERVICES 

SOS provides high-quality, nonjudgmental health services directly to people experiencing homelessness in places where they live and congregate. 
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• EMILY LAND, MAEmily Land is the editor-in-chief of BETA blog and content marketing manager at San Francisco AIDS Foundation.

A new cure strategy designed to harness the power of the immune system to achieve HIV remission in people living with HIV will begin at the University of California, San Francisco in 2020. The study was described and announced at the amfAR 2019 HIV Cure Summit held on November 21, 2019.

“This is kind of an unprecedented human clinical trial, putting together a lot of things that we think will optimally stimulate the immune system,” said Rachel Rutishauser, MD, PhD, from UCSF and Zuckerberg San Francisco General Hospital. “The main clinical outcome will be to understand the proportion of people who are getting the vaccine in the combination trial who achieve post-treatment control [of HIV].”

This small pilot study will enroll 20 people living with HIV who have been on stable, continuous antiretroviral therapy for 12 or more months.

To measure the safety of the cure strategy, the study will assess adverse events that may include lab toxicities or clinical symptoms. To measure efficacy, the study will measure the proportion of study participants who do not experience viral rebound (i.e., who have suppressed viral loads without HIV medication) 24 weeks after the treatment is administered.

The treatment involves a combination of therapies meant to boost the immune system’s CD8 T-cell response to identify and kill off latently HIV-infected cells and reduce the size of the HIV reservoir.

“The advantage of CD8 T-cells is they can recognize infected cells specifically, and they can actually kill them,” said Rutishauser.

During stages 1 – 3 of the study (lasting 24 weeks), participants will receive a “prime-boost” DNA plasmid vaccine to elicit an initial CD8 T-cell response along with a boosting agent. (This is the same vaccine being tested in a prevention vaccine study by the HIV Vaccine Trials Network.)

In stage 4 of the study, participants will receive two immunomodulatory agents: a toll-like receptor-9 (TLR9) agonist and broadly neutralizing antibodies (bNAbs). The TLR9 agonists are expected to broadly activate the immune system—by getting the virus to come out of latently-infected cells and “present” itself to the immune system, boost the response of CD8 T-cells, and also increase the effectiveness of natural killer (NK) T-cells which kill off HIV-infected cells. Broadly neutralizing antibodies will also be given during this stage to reduce the size of the HIV reservoir.

The last stage of the study includes a treatment interruption, with a final dose of broadly neutralizing antibodies being given right as treatment is stopped.

“The broadly neutralizing antibodies should control the virus on their own. But as they wear off, you give the virus a chance to sort of come out but be partially controlled by the broadly neutralizing antibodies. And our hope is that we’ve created an immune response that will then outpace the virus or sort of beat the virus as it’s coming out of latency,” said Rutishauser.

Established in 2015 with a five-year, $20 million grant, the amfAR Institute for HIV Cure Research brings together collaborative research teams with the goal of establishing a scientific basis for a cure by the end of 2020. Find out more about the road to an HIV cure in this video by amfAR.