Molecular Surveillance: What does it all mean? Clinical Implications and Community Response Barbara Taylor, MD, MS Associate Professor of Infectious Diseases, UT Health San Antonio Lunch Plenary Lecture 2018 National Latino HIV and Hepatitis C Conference San Antonio, Texas May 18, 2018
Learning Objectives • Participants will understand approaches to identifying HIV transmission clusters • Participants will be able to describe the prevention benefits of identifying HIV transmission clusters • Participants will understand potential effective community responses to challenges highlighted by HIV transmission clusters
What does this mean for people living with HIV and providers? • Implications for prevention • Guidelines and models of clinical care • Community response in San Antonio
The Status Neutral Continuum Aware Retained Linked Linked to Retained in Virally At Risk Diagnosed Prescribed PrEP Prescribed ART on PrEP to PrEP of PrEP Care Suppressed Care Thanks to Hyman Scott, CROI 2018 Adapted from https://www.nastad.org/domestic/hiv-prevention-health-equity
Going back to the cluster data… HIV Testing Treatment as Prevention PrEP
Prevention - HIV Testing • Routine, opt out testing for all 13-64 yos in all health care settings • Repeat annual screening • MSM • If on PrEP: q3 month screening • Individual RF, local epidemiology or policy: > annually? • Injection drug use and sex partners • Transactional sex work • Those with partners living with HIV • Anyone with >1 sex partner or with a partner with >1 partner since last HIV test https://www.cdc.gov/hiv/guidelines/testing.html
Prevention - HIV Testing https://www.cdc.gov/hiv/testing/laboratorytests.html CDC Jan 2018 Update
Prevention - HIV Testing https://www.cdc.gov/hiv/testing/laboratorytests.html CDC Jan 2018 Update
Prevention - PrEP
Prevention - PrEP
Going back to the cluster data… ✓ HIV Testing Treatment as Prevention ✓ PrEP
What does this mean for people living with HIV and providers? • Implications for prevention • Guidelines and models of clinical care • Community response in San Antonio
Treatment – Genotype Testing at Care Entry • Recommended for persons with HIV at entry into care to guide selection of the initial regimen (AII) • Genotypic testing is recommended as the preferred resistance testing in ART-naive patients (AIII) • In special circumstances, ART initiation should not be delayed while awaiting resistance testing results https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/6/drug-resistance-testing
Treatment – Pretreatment Drug Resistance • In the US and Europe, transmitted drug resistance ranges from 10-17% • Resistance is rising in low and middle income countries WHO, HIV Drug Resistance Report 2017
Treatment – Innovative linkage strategies • Transition from diagnosis to care engagement is the most perilous of the cascade • Innovative strategies • Compressing the cascade (eg. rapid start) • Tiered Strategies • Financial incentives? “Re -linking individuals to the same system of care that failed to engage them in the first place is not an effective strategy.” Dombrowski, CROI 2018
Treatment – Standard of Care • 132 days until virologic suppression Pilcher et al. JAIDS 2017.
Treatment – RAPID San Francisco Pilcher et al. JAIDS 2017.
Treatment – RAPID San Francisco RAPID: 56 days to virologic suppression Universal ART: 132 days to virologic suppression Strategy also being implemented in Atlanta, Baltimore, Uganda Pilcher et al. JAIDS 2017.
Treatment – Tiered care strategies • Seattle MAX Clinic • Walk in care • High-intensity support and coordinated care • Incentives Dombrowski, CROI 2018.
Treatment – U=U The Lancet HIV 2017 4, DOI: (10.1016/S2352-3018(17)30183-2)
San Antonio Response • Cluster 51 presentation to SA HIV/Syphilis Testing Task Force May 2017 • Advocates, Ryan White Administrative Agent, community based organizations, health care providers meet • End Stigma End HIV Alliance formed June 2017 • First Fast Track Cities Initiative Convening Meeting Oct 2017 • San Antonio becomes a Fast Track City Dec 2017 • Results based accountability for goals and metrics for 90-90-90 Feb 2018 • Youth Listening Tour: 20 sites, 172 13-24yos April 2018
San Antonio Response • PrEP access expanded • Hospital systems signing on to routine testing • Coordination of efforts between agencies • 90% diagnosed: HIV/Syphilis Testing Task Force • 90% linked: EIS/Linkage to Care Committee • 90% suppressed: Clinical Management Team • Rapid start • Youth outreach • NACCHO Facilitation Support
Thank you! TaylorB4@uthscsa.edu
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