ending the epidemic of hiv: a focus on prep · 2018-06-06 · ending the epidemic of hiv: a focus...

Ending the Epidemic of HIV: A Focus on PrEP

Julie Myers, MD, MPHDirector of HIV Prevention, Bureau of HIV/AIDS Prevention and Control

New York City Department of Health and Mental Hygiene

[email protected]

#ENDAIDSNY2020

No es mi primera vez aquí…

Hospital Vall d’Hebron1998

#ENDAIDSNY2020

Overview

! Epidemiology and context! Introduction to PrEP! Strategy and programs! Next steps

#ENDAIDSNY2020

History of the Epidemic History of the Epidemic

AIDSNY2020

#ENDAIDSNY2020

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Male Female Transgender MSM Transgender IDU Heterosexual High Very High

Transmission RiskGender

Source: NYC DOHMH, Bureau of HIV Surveillance Data

N= 2,279 HIV Diagnoses

Poverty

New HIV Diagnoses, NYC, 2016

#ENDAIDSNY2020

Ending the Epidemic (EtE): A Recipe

Community

Science

Political Will

April 2015

What Does Ending the Epidemic Mean?

! Identify persons with HIV who remain undiagnosed.

! Link and retain persons diagnosed with HIV in health care.

! Facilitate access to PrEP for HIV negative persons at risk.

D. Holtgrave

! Identify persons with HIV who remain undiagnosed and link them to health care.

! Link and retain persons diagnosed with HIV in health care to maximize viral suppression.


! Identify persons with HIV who remain undiagnosed and link them to health care.

! Link and retain persons diagnosed with HIV in health care to maximize viral suppression.


Introduction to PrEP(Profilaxis Pre-Exposición)

#ENDAIDSNY2020

PrEP: A New Approach

! PrEP uses antiretrovirals for HIV prevention! Offers the receptive partner more control! Reduces anxiety associated with intimacy! But does PrEP work?

#ENDAIDSNY2020

PrEP Efficacy Now Proven in Multiple Clinical Trials

#ENDAIDSNY2020

Adherence is Critical

#ENDAIDSNY2020

Guidelines for Use

#ENDAIDSNY2020

Guidelines for Use: Spain

2016

#ENDAIDSNY2020

Guidelines for Use: Spain

2016

GUÕ A CLÕ NICA!"#$%&'()*+,-.#"(/"(0123

!"#$%&'

#ENDAIDSNY2020

PrEP: What We Already Know

! Drug resistance does occur when PrEP is initiated when already acutely HIV-infected! PrEP is safe! PrEP is well-tolerated

Adapted from L-G Bekker, CROI 2018.

#ENDAIDSNY2020

PrEP: Controversies?

! Impact on STI incidence (“risk compensation”)1

! Mixed results: some studies of PrEP users show increases in individual-level risk behavior

! Trend of increasing STIs at population-level precededPrEP (multi-factorial)

! Trend of decreasing HIV infections has followed PrEP! Cost2

! Potentially cost-effective when groups with highest incidence are prioritized (e.g., MSM) but largely depends on cost of medication

1Schillinger, CROI 2018.2Gomez et al., PLoS One 2017.

#ENDAIDSNY2020

Current Status

! Global! Inconsistent

implementation! ~200,000 users, <5%

coverage! US: About 150,000 users

! Spain! Checkpoint BCN! Gilead trial! Black market PrEP

NYC’s Strategy and Programs

#ENDAIDSNY2020

The New York City EtE Plan: Strategies to Address Disparities

1. Launch PrEP and Optimize PEP Delivery 2. Transform City STI clinics3. Destigmatize sex and HIV (Make NYC HIV Status

Neutral)4. Support Key Populations 5. Improve NYC Viral Suppression

#ENDAIDSNY2020

Launch PrEP: Detailing Program

#ENDAIDSNY2020

Launch PrEP: The PlaySure Network

#ENDAIDSNY2020

Repair PEP Delivery in NYC

PEP CENTERS OF EXCELLENCE

Urgent Care Model

Immediate starts regardless of

insurance status

PrEP Linkage

24 HR PEP LINE

Clinician staffed

Free starter packs e-prescribed to a 24h

pharmacy

Link to PEP Center next business day

#ENDAIDSNY2020

Repair PEP Delivery in NYC

#ENDAIDSNY2020

PrEP Prescription Trends in NYC(PrEP Prescription/100,000 Patients at 602 Ambulatory Care Practices, 2014–2016)

Edelstein, Salcuni et al., unpublished data 2017.

0

200

400

600

800

1000

1200

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2014 2015 2016

PrEP

pre

scrip

tions

per

105

pat

ient

s see

n

Quarter

Overall Males Females

#ENDAIDSNY2020




#ENDAIDSNY2020

New Marketing for “New” Clinics

#ENDAIDSNY2020

FULL COURSES OF PEP IMMEDIATE PrEP STARTS“JumpstART”

SAME DAY ART

Transform City STI Clinics

Assessment for Social Service and Mental Health Needs

Navigation to Care for both HIV Negative and Positive Clients

Immediate Starts of ARV Treatment and Prevention

#ENDAIDSNY2020

“JumpstART”(Treatment Initiation)

Launched Nov. 2016

254 ART Starts

Immediate PrEP Initiation

Launched Dec. 2016

1,061 PrEP Starts

PEP

Launched Oct. 2016

1,516 PEP Starts


#ENDAIDSNY2020




#ENDAIDSNY2020

Prevention=Treatment

#ENDAIDSNY2020

Treatment=Prevention

Next Steps

#ENDAIDSNY2020

Achieving EtE GOALS: New HIV Diagnoses and Estimated Incident HIV Infections, NYC, 2010-2020

35273386

31232871 2775

24772279

20101791

15661350

2050

2424

20981883 1869

1623 1541

1110941

766600

0

400

800

1200

1600

2000

2400

2800

3200

3600

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Total new HIV diagnoses Incident HIV infections

The number of new HIV diagnoses from 2010 to 2015 was reported to NYC DOHMH as of June 30, 2016. Incident HIV infection estimates from 2010 to 2015 were calculated using the CDC Stratified

Extrapolation Approach (SEA). All data from 2016 to 2020 are estimates based on the slope of decline previously observed.

Actual Data Projection

#ENDAIDSNY2020

Ending the Epidemic (EtE): A Recipe

Community

Science

Political Will

April 2015

#ENDAIDSNY2020

Ending the Epidemic: We Have Done it Before

PWID cases

Perinatal cases

#ENDAIDSNY2020

Ending the Epidemic: A Reality

NYC

#ENDAIDSNY2020

Ending the Epidemic: A Reality

Acknowledgements

! NYC DOHMH leadership

! Mary Bassett

! Demetre Daskalakis

! City and State Leadership

! EtE Task Force

! Other NYC DOHMH colleagues, including:

! BHIV

! Oni Blackstock

! Benjamin Tsoi

! Graham Harriman

! Sarah Braunstein

! Adriana Andaluz

! Jennifer Matsuki

! Zoe Edelstein

! Lena Saleh

! Terrance Gardet

! Davida Farhat

BHIV, cont.

! Rafael Ponce

! Paul Kobrak

! Elizabeth Ortiz

! Lucila Lopez-Bloise

! BSTD

! Susan Blank

! Christine Borges

! Tarek Mikati

! Julie Schillinger

! Preeti Patela

#ENDAIDSNY2020

¡Gracias!¿Preguntas?

[email protected]

#ENDAIDSNY2020

PrEP for Women: Living Sure

#ENDAIDSNY2020

PrEP Initiation

Started 12/22/16

STARTED IN ONE CLINICNOW AT 6th CLINIC

1,061 PrEP Starts57% Black/Latino

“JumpstART”

Launched 11/23/16

STARTED IN ONE CLINICSIX MORE NOW ON

BOARD

254 JumpstARTs71% Black/Latino

PEP 28Started 10/31/16

ALL CLINICS1,516 PEP Starts

61% Black/Latino

PrEP NavigationLaunched 10/31/16

ALL CLINICSOver 8,000 Encounters


#ENDAIDSNY2020

Expanded Services and Hours will Make Sexual Health Clinics “Destination Clinics”

! Expand hours and triage to improve access! M-F schedule for all clinics; Saturdays, select clinics! Triage Nurses at ALL clinics

! Restore screening services for asymptomatic clients! Modernize STD diagnostics

! HSV testing, Hepatitis C, Trichomonas testing! Enhance HPV-related services

! Anal/cervical screening (PAPs)! Colposcopy! High Resolution Anoscopy! HPV vaccines

! Quick Start contraceptives for women! Engage with community to improve services

#ENDAIDSNY2020

HIV Prevention Continuum in NYC

100%83%

69%53%

30%

0%

25%

50%

75%

100%

PrEP Candidate†‡ Provider visit,past 6 months

Sexual hx andprovider visit,^past 6 months

Discussed PrEP withprovider,

past 6 months

On PrEP,past 6 months

Perc

enta

ge o

f par

ticip

ants

*Sample includes sexually active MSM aged 18-40 years and who report HIV-negative/unknown status †PrEP candidates defined as reporting diagnosis of an anal STI in the past year or any of the following in the previous 6 months: unprotected anal intercourse, transactional sex, use of cocaine, crack, methamphetamines, or injection drugs, using PEP or having had an HIV-positive partner. Definition mirrors NYS PrEP guidance. ‡PrEP candidates represent 83 % of all HIV-negative respondents. ^Sexual history ever taken by a provider visited in past 6 months

Edelstein, et al., submitted, 2017.

Sexual Health Survey, Spring 2016Aggregate Online and In-person Sample

(n=677)

#ENDAIDSNY2020


!"#$% &'(#)*"+', - ./0#)"0

+&123 456!"#$%&' ()*#+,"'-./"*'-01-23"%)#'-45#%&#6+'-702

!"! #$%% 7789/::+;*;%9<=>?=@<

&*1",/109&12& !"#$%94A68/69#'-7:#6+#

&'(')*+',-./01*-2/'+

$345 BC89/::+;*;%9=@<CD89/::+;*;%9<=>?=@<

=@<A9!"#$%94E6!,;<=#6#

6*-7809'70.7:0;*9'7

<#== BA89/::+;*;% <=>?=@<

F*,GH'H9=/,':'I+1 !"#$%947645#%&#6+

>?@+ #$== 7J89/::+;*;%9=@<

1Grant et al. N Engl J Med. 2010. 2Baeten et al. N Engl J Med. 2012. 3Thigpen et al. N Engl J Med. 2012.4Choopanya K, et al. Lancet. 2013.

#ENDAIDSNY2020


!"#$% &'(#)*"+', - ./0#)"0

+&123 456!"#$%&' ()*#+,"'-./"*'-01-23"%)#'-45#%&#6+'-702

!"! #$%% 7789/::+;*;%9<=>?=@<

&*1",/109&12& !"#$%94A68/69#'-7:#6+#

&'(')*+',-./01*-2/'+

$345 BC89/::+;*;%9=@<CD89/::+;*;%9<=>?=@<

=@<A9!"#$%94E6!,;<=#6#

6*-7809'70.7:0;*9'7

<#== BA89/::+;*;% <=>?=@<

F*,GH'H9=/,':'I+1 !"#$%947645#%&#6+

>?@+ #$== 7J89/::+;*;%9=@<

<2KL&12& 4D68/69#'-01-23"%)#'-4#6$#6%#

A*9'7 <%4= <=>?=@< M9:#"+)+"%9N7?55O

PQR>294B601-23"%)#'-7:#6+#'->%?@#@=/

A*9'7 4=#% =@<9M9:#"+)+"%9NJ?55OP*GS9=<P9G/)9NT$O9M9:#"+)+"% NJ?55O<=>?=@< :*+)/$9NE?5EO

1Grant et al. N Engl J Med. 2010. 2Baeten et al. N Engl J Med. 2012. 3Thigpen et al. N Engl J Med. 2012.4Choopanya K, et al. Lancet. 2013.

5VanDamme et al. N Engl J Med. 2012. 6Marrazzo et al., CROI. 2013.

#ENDAIDSNY2020

PrEP Effectiveness Now Proven, Too!"#$% &'(#)*"+', -,"./0.,"+', 1.2#)"2&13456789!"

!"!# $%&'()*'+*%,-./*' $0121$34//*+5&6*,7(8,+*9&:*+,$0121$3

:;<6.==+>*>%

-&?1@AB 7C9#$%&'()*+%&%,%

!"!#,$%&'()*'+*% -./*' $0121$3,;7*'6<+%57*',+.(5')

:;<6.==+>*>%

1McCormack et al., Lancet 2016. 2Molina et al., NEJM 2015.

#ENDAIDSNY2020

Conclusions

! New York City: HIV/AIDS epidemic on the decline! NYC EtE : Multi-prong approach to systematically

eliminate disparities and decrease HIV incidence & prevalence via improving access to PrEP/PEP and improving viral suppression! Progress is evidence! Rigorous evaluation is needed

#ENDAIDSNY2020

Launch PrEP: HealthMap

https://a816-healthpsi.nyc.gov/NYCHealthMap/home/ByServices?services=16

#ENDAIDSNY2020

Launch PrEP: The PlaySure Network

Lifetime Risk of HIV Diagnosis, by State

Estimated Lifetime Risk of HIV

CDC

#ENDAIDSNY2020

The #PlaySure Kit

ending the epidemic of hiv: a focus on prep · 2018-06-06 · ending the epidemic of hiv: a focus...

Documents