including traditional prevention efforts like condoms as well as prep which is an incredibly important newer method of dramatically reducing the rate of hiv infection. all of this allows to have a future where we have no hiv infections and if we do it right here in san francisco it will spread to other the parts of the country and the world, and we know in order to make this successful we have to put the resources behind the effort. this doesn't happen for free and we know in saving this community and the community saving itself through the height of the hiv epidemic this city did that because city government even when there wasn't the state and federal support, and we continue to get more federal cuts today even, this city put the resources behind these efforts, and we need to do that again today making sure that

people have access, not just to testing, but also to treatment, and also to prep, and i know we have to continue to do a lot of work to make sure that we're expanding access to preexposure prove axis and i asked to be assigned to the budget committee because i know we're all working hard to come forward with a proposal for the next budget to make sure we're funding some of these getting to zero efforts so it's exciting and i look forward to working with everyone and move forward, and i want to offer supervisor campos the opportunity to speak before we get to our wonderful list of speakers today. >> thank you supervisor wiener and i want to thank the chair and the committee, budget committee for hearing this item. i think it's important to have this hearing as we're beginning the process of completing a city budget. i think that the issue of hiv/aids needs to be a critical part of the equation as

we put together a budget which ultimately reflects our priorities as a city. i also want to thank the provider community that is here, and look forward to the discussion and presentation. one thing that i would say is that i think our goal should be that we eradicate hiv infection here in san francisco that that to the extent san francisco has been a sanctuary for so many different people and issues that we are a sanctuary city city for immigrants that we should aim to be a sanctuary where there is no hiv/aids infections here in san francisco. i think that's the objective. i also think that you have to put the context -- provide some context for what is happening here. we have come a long way, but we still have some

ways to go, and there are still many disparities in certain communities, the african-american community, the latino community, the transgender community, and i think that the reason why san francisco has been so successful in leading the way is because we're not afraid to try new things and that's where i think this new focus on prep has come in, and i think that we have taken an important first step but it's only a first step. i think a lot more needs to happen for us to really pat ourselves on the back and we're doing everything that we need to do. the last thing that i would say, and i would encourage the folks in this room and people who are paying attention to hiv/aids funding is that for hiv/aids funding to be successful it cannot exist in a vacuum. you cannot talk about serving those living with hiv without talking about the other issues that

impact their lives. housing is an important issue and we have a housing crisis in san francisco and let's be honest. city hall has done very little to build affordable housing. we still have a large number of erks visions. the ellis act evictions are down but overall they're up in san francisco and in the mission, the castro a lot of people, including members of the lgbt community are being pushed out. access to health care on so many levels is unequal in san francisco and then we have a large number of the lgbt community who are homeless, and more people are living on the street. many of them are living with hiv and the fact they're on the street does not help the situation, so i hope that as you're coming to this building to make sure that hiv funding is protected that

you also take the time to advocate for other funds that is critical to the communities you're trying to protect so i look forward to the presentation. thank you. >> thank you supervisor campos and before we get to the speakers i want to thank adam taylor and my office for the work and representing the office for the getting to zero consortium so we have several different speakers today. first we're going to hear from several participants in the getting to zero consortium and then the department of public health and then from happen, the hiv/aids providers and when dph presents i am interested in knowing what the likely federal budget cuts are going to be in the next fiscal year, and it's sad that we have to assume they're going to be more cuts but given the insanity and melt down in washington, d.c. which impacts

many different things we know every year there are millions more -- although i think it's less this year and ryan white and cdc funds and the mayor and board has been great in back filling the federal cuts and we're doing beyond that in terms of moving forward with great prevention efforts. i want to start with the getting to zero consortium and followed by the aids foundation, dph and ucsf. >> good morning supervisors. i am jeff sheea and living with hiv and i was the hiv advocate to gavin newsom and serve on the governing board on the california institute of regenerative medicine. thank you supervisor wieners and supervisor campos for

sponsoring this meeting and thank you supervisor farrell for the opportunity to present today and thank you barbara garcia and the department of public health and i am part of the consortium and we're here to talk about the historic opportunity for san francisco, ground zero in 1981 at the beginning of the aids epideppic to be the first mutiny of injury new infections, zero deaths from hiv and zero stig ma. this is a realistic goal for several reasons. first there is the amazing and compassionate response from the san francisco community to hiv/aids starting with initiatives by mayor dianne feinstein and speaker willie brown and every mayor and the board of supervisors. san francisco has the finest system of care and prevention in the world. thank you. second, two major studies have presented results recently. one showed

that healthy people without hiv but at risk for becoming infected can achieve greater than 95% protection from getting infeblghted if they take a single anti-hiv pill everyday, prep. the others show that patients with hiv who are successful treated to the point that virus levels in the blood are undetectable would have near normal life spans and reduce the ability to transmit to the uninfected partners by 96%. we are presenting initiatives that target three key populations. prep for those at risk for infection, rapid, therapy for those newly infected with hiv and a retention initiative which we hope over the years to include more and more on housing because all of us agree with supervisor campos that the elephant in the room for anything that is happening in san francisco right now is the

desperate need for housing, especially for middle, low income people and people affected by disabilities like hiv. our retention effort will focus these patients at risk of becoming loss to care or loss in care. it's important this is feasible and a financially sound initiative because the expansion of access to health insurance due to the affordable care act so we have a great debt of thanks to president obama. let me introduce my consortium members presenting today. dr. diane hadley chief of the division of san francisco aids in san francisco general hospital. dr. susan buck binder at bridge and at san francisco department of public health and kneel jewel ano and the first presenter and the chief executive officer of the san francisco aids foundation.

>> good morning. thank you mr. chairman, supervisors. i will present some information today just to give you an up date on the data and you will hear specifically about the proposal in a bit as well. this pin wheel is important. it's as important as it is colorful because it represents all of the various partners within the community who are involved, members of the consortium, partnering organizations in the public and private sector as well as the steering committee members. to point out that no one entity no one organization, foe one group is. >> >> get to zero by itself. this chart shows the success in reducing new infections and reducing the number of deaths in san francisco to hiv/aids. and

increase of persons living with hiv in san francisco and i'm not going to go through these specifically. you have the presentation, but it's a good trend but as indicated earlier with 359 new diagnosis in 2013 we have a way to go in reduces infections in san francisco so what are some of the trends? the overall number decreased just in about every cohort, men and women, african-americans and caucasians, men who have sex with men, decrease in people who infect drugs but we see an increase in the 25-29 years old and while we know disparities remain and there is the highest new infections in african-americans and latinos. really great message and a true success story with regard to hiv in san francisco is the

tremendous advancement in pediatric cases and you look at the great success there are no hiv infections in newborn babies since 2006. the hiv care cascade has been talked about and looked about in the united states and closely in san francisco as well. what you see in the red bars are the percentage of peoples in the united states on the far left that are aware of the hiv status. the middle, blue and red indicating those linked to care and on the far right the significant impression of the fact that 63% of our folks in san francisco are virally suppressed while nationally the number is only 25%. this poses a great opportunity for us because we need to increase that number from 63% to 100%. when people are viralally suppressed as you heard they are not infectious and the virus can't

be spread so that's an important part why we can be successful being the first city to end hiv in san francisco so good news that overall death rates and positives have decrease since 2006 but the disparities still remain. more than three quarters of the death occur in people over 50 years of age. and we're seeing now that survival among the homeless population can be as good as people in that are housed with hiv positive and probably is because of the housing related initiatives which points out to the comment that supervisor campos made just a little bit earlier. it's very important for us to remember that there is a relationship between what we're doing in housing and hiv. there is a relationship to what we're doing with mental health and hiv. these things that

you're going to hear in a bit in regard to getting to stwrr are not in a vacuum all by themselves and we note the great positive trends and commitments of you and others in the community have made. supervisors and the mayor have been very committed to the health and well being of san francisco by back filling position can -- cuts that came through state levels and we would make note that the goal here and talking about this initiative of getting to zero this initiative is on top of and over and above all of the things that we're currently doing. this is not a replacement program to replace funding for the existing supports and programs that is taken place so we appreciate the back filling that has taken place, and the support for the existing programs in the community today and we're here to talk about a

new commitment, a commitment to get us to zero that is a multi-year effort and we believe and the experts involved in the work that takes place in san francisco enables san francisco to be the first city to end hiv transmission and with they will turn it over to diane or susan. >> thanks so much neil and thank you to the supervisor frs giving us the opportunity to speak here so i'm going to be talking about -- there are thee three initiatives, prep, rapid and retention and those are in addition to what we're currently doing. we are planning to hold ourselves accountable at supports and town hall meetings on world aids day and we just had one on december 1 of this past year of 2014 so i'm going to talk first about preexposure

prove lax us and reminding people that the formulation of two medicines can prevent hiv infections. there have been multiple trials now showning it's preventing hiv negative people from being positive through drug or transmission. the effectiveness is over 90% if taken daily and it's a well tolerated medicine with low side effect profile. the cdc and the world health organization have both endorsed this program for hiv uninfected people that are at risk for people to exposure and men who have sex with men and women and drug users and that's during what we call "seasons of risk" so it's not

receive long therapy which unfortunately hiv treatment is. it's really during periods of time when people might be exposed and i want to state that this program is a game changer when you look at where we have been. we have been in the same place for hiv prevention for the lasted 30 years promoting condoms and risk reduction. we haven't had new tools to prevent infections until the proof that this program works and that's why time magazine named it in the top 10 medical breakthroughs in 2010 so i think you may have all seen the really wonderful advertising campaign that san francisco aids foundation and others have undertaken to advertise and get the word out to individuals who may benefit from prep, and i just want to remind you that san francisco

really has been at the hub of the preexposure prove lax us world from the on set and the department of public health participated in the first prep studies in the united states, both a safety trial conducted by cdc and the groundbreaking study and bob grant at ucsf -- i'm sorry gladstone and the san francisco aids foundation initiated and coordinated and was a principle investigator and that studied show that prep was effective and with men who have sex with men and san francisco was one of the two u.s. sites. there is a campaign that the foundation has launched the first project outside of a clinical trial took place at san francisco city clinic here in san francisco and cdc has granted a contract to san francisco general hospital to provide guidance to provider who is want to administer prep. if you look at the next slide you

will also see that kaiser is one of the largest providers of prep nationwide and probably worldwide. they're now -- they have been offering prep and you can see if you know about this the theory of innovation diffusion you can see there is a tipping point and the number of people who have been initiating prep has really taken off so it's now 30 to 40 people a month at least who are initiating prep, and in all of those -- that large number of people who have started this program there have been no new hiv infekdzs, again demonstrating the power of this help in preventing new inventions. >> if i can jump in. it's important -- the kaiser study. unfortunately the headlines out of that study in that cohort there was a reduction in condom use so some of the people

trying to deligitimize prep latch on to that and the press unfortunately focused on that. the bigger news even if there was a reduction in condom use that not a person zero converted and that is extraordinary and that should have been the head line and i appreciate you including that in the presentation. >> absolutely. i think people don't recognize that condoms don't work all of the time. they break, slip and sometimes not used properly and people don't always use them properly, so their effectiveness is probably 80% in preventing hiv transmission. and so the next slide is really about paying for prep because it could be expensive. the great news is the cdc made the recommendation that it's provided. medi-cal covers this in california and

medicaid nationally. most employee sponsored programs pay for it and we have patient assistance programs outlined here but it's a complex situation and people seeking prep need a lot of assistance because each plan within a given program pays for a different amount and may cover one component but not visits or lab tests, and so we really need what we found is most successful in getting people prep is having the navigators that help them arrange the appropriate insurance and find providers willing to provide it, so we have a three pronged approach for what is needed for prep. we need assistance from providers. there are providers not comfortable providing prep so support for the new prep clinics and training on line tools and assistance for the users and we still have the disparities and we need the information about availability into the

communities most impacted by hiv. we would like to set up a user hot line so people can call and get information. there's a lot of questions that individuals have about prep and we need to address affordability and then we want to measure the impact of prep, both theup take of prep, the benefits of prep but also any negative consequences and in particular we know of one case life insurance denied to a person initiated prep and we want to make sure those discriminatory practices for people caring for their health don't continue and i will turn this over to diane who will talk second two initiatives rapid and retention. >> so our second two initiatives are based on a strong scientific foundation which is there are benefits to treating individuals with hiv for the individual and the community. if i can get the

next slide up. sorry. so i will keep talking while we're getting the slide going, so we know that early -- it's the same treatment for all hiv positive individuals, reduces infections, tuberculosis, and cancer. it also prevents liver and heart and brain damage and reduces death. we are committed to the health of the person living with hiv in san francisco but there is a two for one benefit for offering treatment for hiv infeblghted individuals. hiv treatment is a very strong preventive agent for forward transmission. scientific studies have shown us that hiv treatment of an infected individual reduces hiv transmission by 96% by lowering

hiv /rna or virus levels in the blood so effective treatment for those living with hiv is central to getting to zero san francisco, so one might ask with all of the benefits of treatment why aren't we treating everyone with hiv and hasn't been happening for a long time? there are two main reasons that the strategy of treating everyone hasn't taken traction until recently. the first is that we did not really understand that during the early phases of hiv when patients appear to be a sim attic that the levels of virus in the blood are causing inflammation and affecting their organs. by treating people early we can prevent the damage to these organs. the second reason we weren't treating all individuals is because early on the drugs had side effects so what we thought would be the best

strategy to wait until people progressed in their disease to a point where the benefits of treatment out weighed the risk. everything has changed now and now we know at all stages of hiv disease the virus is more toxic than medications. therefore we should start treatment immediately and for this reason in 2010 our clinic at san francisco general hospital served by the department of public health put forward a policy of treatment of all individuals for therapy of living with hiv. we had a community forum. it was highly controversial. it was fevered in the -- featured in the "new york times" and other cities followed suit. the current u.s. guidelines now recommend treatment for all individuals living with hiv and global guidelines are going in the same direction. so what do we need to do right now? well

there is a gap in successfully starting and maintaining treatment that you saw from the earlier slides. as well there continues to be new hiv infections in our city and we know that starting therapy right after a new hiv diagnosis is very advantageous. let me tell you two reasons why it's advantageous. first when someone starts therapy after the disease gins they can reduce the reservoir of hiv in the individual and hoping to have a cure in the future and that reservoir will be smaller. second after infection with hiv virus levels are extraordinarily high posing this as a high risk time for transmission so by offering treatment immediately it's once again advantageous for the individual and for the community. so our first -- the program which is our second initiative in getting to zero is called rapid ar t and this

program has been in effect in a small scale for the past year. what is new about the program? what happens as soon as a person is ditioned we offer treatment on the spot. instead of waiting for weeks for medication and there are delays and people don't start therapy we're compressing it into one step and supporting continued counseling for adherence. so this removes logistical barriers to provide a client the opportunity to start therapy immediately so what we're asking in this initiative, our initiative number two in getting to zero is expand what is working. we have a system working. the rapid program is offered at clinics and san francisco general hospital. we want to offer this by city wide and by a small investment in navigators and some coordination

of good standard practices we can offer this across the city and i can tell you there's already great interest around the united states about expanding this program and model to other cities. so initiative number 3 for the first year getting to zero is strengthening retention. it means we're happy we have more insurance options for people but i can't imagine there is anybody in the room who hasn't experienced a change in job, a disruption in the insurance and it becomes complicated where you go, where you get your medicines. for many diseases having a short interruption isn't devastating. it's not the case for hiv. when they stop the therapy the virus levels immediately surge and it's very unhealthy for the patient and also puts the community at risk for transmission, so we need to work together, to close the gaps,

connect the dots, and put in simple programs that are affordable such as a hot line that individuals can call when they lose the insurance so they can make sure that the medicine supply is not disrupted and stay in care and we need staffing at this time during the time for the patients and we need continued support of the current services, attention to housing and mental health in addition to these three new initiatives for us in order to get to zero. the united states as featured in time magazine is looking to san francisco. the world is looking at san francisco to lead the way and end the aids epidemic. i am proud to be part of the consortium and express the gratitude for the support they have shown us and hope the strong support they're about to

give us so thank you very much. >> supervisor campos. questions? >> thank you. i am wondering if we can ask about the consortium and the work of the consortium? i don't know who the person to speak about that. >> sure. so the consortium started -- it really came out of the world aids forum we had a year ago so that included supervisor wiener, the san francisco aids foundation, department of public health, ucsf and project inform. we started talking about the possibility at that forum of getting to zero. >> >> and they said "why are you guys working together and talking to each other?" so we started a series of meetings and have been addin