The City of Love Could Lead the Way Toward Ending HIV Transmission

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As we enter our fourth decade without a cure for HIV, public interest in ending new infections has seemed to wane. Now’s not the time to stop talking about AIDS. With important new treatment and prevention tools in our arsenal, San Francisco — known as the City of Love — could be the first U.S. city to end HIV transmission.

The world looks to San Francisco for leadership in HIV control with good reason. Driven by love and the desire to connect, grassroots movements among gay men made great strides in promoting a sex-positive culture that embraced condoms in the 1980s and adapted sexual practices to HIV status in the 1990s. The first HIV specialty clinic was established here in 1982, just after the first cases of AIDS cases were reported. Since that time, we have stayed at the cutting edge of HIV diagnoses, treatment, and prevention. We established routine HIV testing with the use of ultra-sensitive tests as standard practice, and we have one of the best HIV diagnoses rates in the world. It’s estimated that as many as 94 percent of people living with HIV here are aware of their status, with a great percentage of those on suppressive treatment. With linkage to effective treatment, there has not been a case of perinatal transmission in more than 10 years.

We need to do more. After many years of decline, the estimated rate of new infections did not change between 2010 and 2012 in San Francisco. More than one new HIV infection happens every day here.

We now have medications that can prevent HIV infection. Post-exposure prophylaxis (or PEP) can be taken after a single-event potential exposure to the virus; pre-exposure prophylaxis (or PrEP) can be taken regularly with more frequent exposure to HIV. PEP and PrEP have been proven to be safe, effective, and feasible during large-scale, multinational, randomized, controlled clinical trials conducted by researchers at San Francisco’s Gladstone Institutes, the University of California San Francisco (UCSF) and the San Francisco Department of Public Health. PrEP using a drug called Truvada was approved by the FDA in 2012 and is now recommended by the Centers for Disease Control and Prevention and the World Health Organization.

PrEP provides an astoundingly high level of protection: It’s estimated to reduce risk by more than 96 percent if used daily. In addition to protecting against HIV infection among those with frequent HIV exposure, it allows mixed-status heterosexual couples to conceive safely and motivates HIV testing and increases frequency of screening for sexually transmitted infections among the sexually active. Indirectly, PrEP allows us to stand up to stigma as a broader coalition, with and without HIV infection. We are all sexual beings; HIV exploits and then attacks the core of our humanity.

Consumer demand for PrEP has exceeded the supply in San Francisco. Although PrEP is currently offered at the San Francisco Kaiser Permanente, the Veterans Administration infectious disease clinic, the UCSF 360 Sexual Health Initiative, and several private practices, wait times for appointments can be longer than a month. Almost all insurance covers PrEP, although deductibles and copayments can be prohibitive. The manufacturer of PrEP offers medications through a patient-assistance program to low-income people, and copayment assistance regardless of income. Healthy San Francisco covers PrEP as a safety net of last resort, although a list of providers willing to provide PrEP in this system has not been made available. These programs leave significant gaps in coverage. As we approach open enrollment for insurance, people should consider which plans make PrEP feasible for them.

Many San Franciscans and healthcare providers continue to be uninformed about PrEP and PEP. To end HIV transmission in San Francisco, we will need to increase awareness and uptake of these valuable HIV-prevention tools in addition to continuing our focus on diagnosis and treatment. More complete coverage for PrEP is important to avoid disparities in access. Making this happen will require us to put aside political differences, our fear of HIV, our fear of anti-HIV drugs, and our fear of our own potential for human connection. This all can be possible in the City of Love.

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