The fact that the Trump administration is getting behind a new effort to end the HIV epidemic is welcome news. However, it is worth noting that some communities are way out in front of this effort in remarkable ways. In particular, an initiative that began five years ago in San Francisco has resulted in a dramatic reduction of new HIV diagnoses in the region. For instance, in the first half of 2018, there were just 81 new HIV diagnoses, according to the latest data, putting the city on track to lower the number of diagnoses to a level not seen since the epidemic began in the 1980s. Further, investigators report that the number of deaths attributable to HIV has declined by more than 50%.1

The city’s success in addressing the HIV epidemic is largely attributable to the collective efforts of Getting to Zero San Francisco (GTZ), a multisector consortium that aims to reduce HIV infections, deaths, and stigma to meet aggressive 90-90-90 goals, explains Susa Coffee, MD, chair of the GTZ’s Rapid ART Program Initiative for HIV Diagnoses (RAPID) committee, which focuses on quickly connecting patients diagnosed with HIV to antiretroviral therapy (ART).

As described by UNAIDS in 2017, the 90-90-90 goals establish that by 2020, 90% of those infected with HIV will be aware of their status, 90% of those diagnosed with HIV will be receiving sustained ART, and 90% of those receiving ART will be under virologic control. (Learn more at: http://bit.ly/2Kf3FZB.)

To reach these targets, HIV testing and linkage to care from EDs and other frontline providers are a big part of the GTZ plan. “Emergency departments also serve as important sites where re-engagement in care can be facilitated for people with known HIV who have dropped out of care,” observes Coffee, a professor of medicine in the Division of HIV, Infectious Diseases, and Global Medicine at the University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFGH).

Such functions are particularly important for the safety-net population served at ZSFGH, which includes many patients who are unlikely to present to HIV testing sites, Coffee notes. “Since the Getting to Zero initiative began in 2014, HIV testing performed in the ZSFGH ED has comprised roughly 10% of new HIV diagnoses in San Francisco,” she observes.

Establish Links to Treatment

Efforts to expand HIV testing in the ED at ZSFGH have been supported largely by its strong working relationship with the UCSF/ZSFGH Ward 86 Clinic, where the the RAPID team works proactively to connect with all patients who test positive for HIV in the ED. The ZSFGH clinical laboratory will call a designated RAPID pager for every HIV-positive result that it obtains. “Then, the RAPID team will contact the patients, whether they are still in the ED, admitted to the hospital, or discharged to home, to link them into care,” Coffee explains. “For outpatients, the RAPID team tries to schedule each person for a same-day or next-day RAPID appointment in the clinic.”

While staff members in the ED also are encouraged to contact a dedicated RAPID pager if they are aware of a patient with a new HIV-positive test result, the burden of notification and follow-up is removed from them, Coffee shares. “This has resulted in significantly more HIV testing by ED providers and a higher linkage-to-care rate for newly diagnosed people with HIV,” she says. “Emergency staff are also encouraged to refer high-risk, HIV-negative individuals to the RAPID team for PrEP [pre-exposure prophylaxis] and other HIV prevention services.”

Interestingly, although several hospitals in large urban locations automatically perform HIV tests on all patients who present to the ED and have a blood draw for any reason, the ED at ZSFGH takes a different approach. Here, nearly half of patients who present for care do not require a blood draw for their stated complaint. Consequently, it is up to each clinician to determine whether a patient should undergo testing based on their presentation, symptomology, and history, explains Malini Singh, MD, MPH, associate clinical professor of emergency medicine at UCSF and vice chief of emergency medicine at ZSFGH.

“When we take a general history … there are multiple questions about sexual practices and drug use, and those are all triggers to think about when ordering an HIV test,” Singh notes.

Further, emergency providers are encouraged to test all patients who are admitted to the hospital, patients who do not have an HIV test result indicated in their clinical record, and patients who have had any possible exposures or risk factors since their last negative HIV test result. “These recommendations are posted in ED work areas and are available online with information on risk factors for HIV infection and signs/symptoms of acute HIV,” Coffee notes.

The hospital lab conducts routine HIV testing every two hours, seven days per week. For samples with reactive results, differentiation tests are conducted every day (except Sunday). The lab will notify the RAPID team of any positive HIV tests.

“This is external to us in the ED. [The RAPID team] will call us, even before we know about the test results sometimes … and ask if we want them to come down [to the ED] and talk to the patient or counsel the patient about his or her new HIV diagnosis,” Singh notes.

The RAPID team, also referred to as the PHAST (Positive Health Access to Services and Treatment) team, is available to discuss any post-exposure or protective medicines that a newly diagnosed partner might consider, Singh adds.

“We have a very active PHAST team through Ward 86 that is involved with patients when tests return positive, and this is 24/7. Any lab notification for anyone who has been tested, whether the tests were positive or negative, the PHAST team knows about them,” Singh notes. “The reason why the PHAST team is very instrumental for us is because they [work with] the patients with a very team-based approach where it is not just about medications. It is about lifestyle counseling and partner counseling as well.”

Further, there is regular communication between the PHAST team and emergency providers regarding testing and detection rates, and how the ED compares to other HIV testing sites. “We have a real partnership with them,” Singh shares.

Partner With Care Resources

Another focus of the GTZ initiative is to increase the number of people who are taking PrEP. Investigators report that this number has grown from 4,400 when the GTZ initiative began to more than 16,000 in 2017. The ED plays a role in this effort, too, although emergency providers typically do not write prescriptions for PrEP. Instead, they will refer patients directly to Ward 86, which is located on the ZSFGH campus and provides drop-in hours for patients.

“There is no formal referral process to get patients over there. [The clinic is] always open to having patients drop in at any time, which is remarkable,” Singh says. “That has been really great for us.”

Singh credits Ward 86, which was the nation’s first HIV clinic, and the PHAST team with contacting the ED and helping change provider behaviors when it comes to testing procedures.

“I am standing on the shoulders of giants who actually started [ED-based HIV testing] when it was not popular and not considered to be emergency medicine,” she explains. “Recognizing that … the intervention is extremely important to the times has been something that we have had to learn, but I do think that the generation of emergency physicians here get it, which is why this is snowballing into other things like giving Narcan to patients who are addicted to opiates.”

How can other hospitals and communities replicate the work happening in San Francisco? “I think the biggest difference for us in the ED, and why [HIV care] is so seamless, is we partner with a lot of HIV advocates and people in the community who want to help bridge these patients … into long-term management,” Singh advises. “Making those relationships real and sustainable is super important for this work to continue.”

Singh adds that the culture of emergency medicine has begun to change. “Emergency physicians of today understand … that it is important to recognize these high-risk patients early, and that early treatment makes a difference,” she says. “Of course, offering options to their partners makes a difference as well.”

REFERENCE

  1. Kirby K. Aiming to end San Francisco’s HIV epidemic. Lancet HIV 2019;6:e77-e78.