Status - The San Francisco AIDS Foundation Newsletter

Targeting Limited Resources on Most Effective HIV Prevention Programs

(Graphic: Distribution of new HIV/AIDS cases diagnosed in 2008. Credit: San Francisco Department of Public Health)

Local AIDS prevention experts say that the best approach to driving down HIV infection rates in an era of diminished resources is focusing on strategies proven most effective in combating the disease. Over the past 27 years, San Francisco has determined what works to prevent HIV infection from research and community experience.

“Scientific evidence tells us that providing widespread HIV testing and partner notification services to high-risk populations, encouraging harm reduction practices like access to clean syringes and safer sex, reducing methamphetamine and other substance use, and diagnosing acute HIV infections are among the most successful tools we have,” says Dr. Grant Colfax, director of HIV Prevention and Research at the San Francisco Department of Public Health.

Despite the uncertainty caused by the economic downturn and budget cuts to HIV/AIDS prevention programs, the San Francisco AIDS Foundation remains committed to fulfilling three goals by 2015: Reducing new HIV infections in San Francisco by 50 percent, assuring that all city residents ages 13 to 64 know their current HIV status, and making certain that all HIV-positive San Franciscans receive primary medical care that includes HIV treatment.

Key to achieving these ambitious goals will be actively collaborating with research, clinical and public health experts as well as local government and donors.

“We are prioritizing our resources so that the money we spend on prevention has the greatest effect on reducing new infections,” said CEO Mark Cloutier. “We are expanding HIV testing to the highest risk groups in the city to enable them to know their status, get more HIV-positive people into treatment and reduce the risk of further transmission.”

For the past three years, the Foundation has provided HIV testing—as well as screening and treatment for other sexually transmitted diseases—at Magnet, a community health center in the Castro. The Foundation will soon offer testing at its headquarters at Market and Sixth streets, serving counseling and syringe exchange clients as well as others in the surrounding Tenderloin neighborhood. Studies show that the highest HIV transmission rates in San Francisco are concentrated in the Castro, Mission and Tenderloin (see map above of newly reported HIV/AIDS cases).

The Foundation is aggressively pursuing support for this expansion of services including grants to enhance mental health counseling to substance users, increase HIV risk counseling to African-American and Latino men who have sex with men, develop services for intravenous drug users such as HIV testing and hepatitis vaccinations, and further Magnet’s detection of HIV infection during its earliest, most acute phase using specialized RNA blood tests.

“The personal knowledge that comes with testing has a huge impact on how people manage their health and alter their behavior to reduce the risk of spreading the virus,” says Magnet Director Steve Gibson. He notes that one in five HIV-positive people are unaware of their serostatus and, on top of that, studies show that 25 percent of those who know they have HIV are not yet in treatment.

The Foundation is also working to eliminate the barriers to health care for people living with HIV so that they can gain access to antiretroviral medication, thereby lowering their viral load and their risk for transmission.

“We are empowering our clients to seek appropriate medical care, and advocating for public policies that ensure universal access to health care through legislative reform and the establishment of a National HIV/AIDS Strategy,” says Cloutier.

First Person—Walid Dalal

Testing is Key to Wellness

  

Life in San Francisco can be lovely, hectic, eclectic, political, and always individual. It is a city at the forefront of health, whether that means striving to have health care coverage for its workers, or offering activities that help improve our well-being. As an HIV-negative male, I have always found it important to regularly check my HIV status so I can know how my body is doing, both inside and out. I’m living in the real world, so I know that sex is one of the ways people get HIV and other infections.  That’s why it’s important to be tested regularly and learn how to take care of your body.

    Testing can be stressful. I have found that it forces me to ponder my own recent sexual practices. Depending on where you go, however, testing can be an opportunity to talk about your experiences and what you can do to minimize your risk. In the last few years, I have chosen to get tested at Magnet, a testing center in the heart of the Castro. It is a casual place, where men are made to feel comfortable discussing anything and everything. I can hang out, eat, check e-mail and, of course, set up appointments for HIV and other STD testing. Magnet also has monthly exhibits for local artists and many types of dance gatherings, comedy, poetry and more.

    Whether gay or straight, negative or positive, people in San Francisco have options that allow us to stay aware of our health.  Knowing your HIV status is more important today than ever before.  It gives you the power to change what you can, and the knowledge to work with what you cannot.  It also helps you be up front about a complicated conversation, allowing HIV to be dealt with directly, actively and in good faith.  If we cannot talk about our status, then we cannot talk about HIV; and if we cannot talk about HIV, then we cannot find better ways to enhance our health and wellness in the future.

Commentary

Successful HIV prevention is a moving target. Recently we learned that an AIDS vaccine trial in Thailand showed early promise in preventing HIV. But because a fully effective vaccine is many years off, we must continue to rely on condoms, clean syringes and access to frank information about sex and sexuality as our leading allies against HIV. Furthermore, it is imperative that prevention strategies exist for people who will not or cannot rely on methods such as condoms to reduce their risk. To make good on our ambitious plan to reduce new HIV infections in San Francisco by 50 percent by 2015, the AIDS Foundation is keeping a close eye on promising interventions moving through the research pipeline.

In a few months, I hope to be able to share news about the most talked-about development in prevention: pre-exposure prophylaxis, which goes by the acronym PrEP. Though still being studied, some already believe PrEP will radically change HIV prevention in the United States and in countries that struggle with skyrocketing infection rates.

The scientific principle behind PrEP is simple: HIV-negative people take antiretroviral medication before potential exposure to the virus to help them avoid HIV infection. Because PrEP could alter the global prevention landscape, prevention advocates are already asking important questions about PrEP implementation.

Chief among these is whether PrEP will exacerbate existing disparities of health care access. In resource-limited settings, there aren’t enough condoms—to say nothing of antiretroviral drugs—for all of the HIV-positive people who need them. What if PrEP is added to the prevention tool box only in regions that can afford it? To deploy even a fraction of the limited medicine available for prevention when millions of infections go untreated will demand painstaking planning, unless we are prepared to accept further stratification between the haves and have-nots of global health.

Many of those regularly exposed to infection, including commercial sex workers and men who have sex with men, are highly stigmatized here and abroad. PrEP may be a particularly potent prevention strategy for these groups. But how will we stop conservative forces from imposing deliberate hurdles, denying PrEP’s benefits in the name of discouraging “immoral” behavior?

The questions don’t end there. Who will pay for PrEP? How will PrEP recipients be counseled about safe and consistent use? As with the vaccine results, if PrEP proves less than 100 percent effective, will people know to supplement PrEP with continued use of prevention tools such as condoms and clean syringes?

A series of clinical trials is underway across the globe, and some results are expected as early as late 2009. The studies involve nearly 20,000 people—from injection drug users in Thailand to heterosexual men and women in Africa. In San Francisco, where the study cohort is composed entirely of gay men, the release of efficacy data should make headlines—even if questions remain about how to roll out a complicated prevention method when persistent inequity already plagues public health.

Of course, should PrEP be deemed effective, the San Francisco AIDS Foundation will play an integral role in its deployment. Because we embody the community demand for fairness, scientific evidence and ethical treatment, we commit to keeping PrEP front-and-center for all of our audiences.

Mark Cloutier, CEO
San Francisco AIDS Foundation

Foundation In Motion

Why I Ride

When I tried to figure out what—apart from a bone-crunching weekend of cycling—connected me to my fellow participants in the Seismic Challenge, I realized that this ad- hoc community shared a love for biking, the beauty of Northern California, the physical challenge, and a chance to put body and mind on the line to raise funds and visibility for the San Francisco AIDS Foundation.

My connection to the Foundation is deeply personal. In 1988 I was involved in a campaign to defeat two California ballot propositions seeking to quarantine HIV-positive persons, among other things. The first statewide meeting to formulate a response to these bills was hosted by the San Francisco AIDS Foundation.

The Foundation was already a powerful and credible source of information, direct service, and political influence. More than 20 years later, the political landscape may have changed, but the Foundation remains at the forefront of education, direct service and smart, well-targeted legislative influence. For that, I would gladly ride any distance.

That same year, I met my first partner Tom, with whom I became involved in HIV/AIDS political activity. Even though knowing his status would have helped him to make smart choices, Tom didn’t find out that he was positive until 1994, when his health was seriously compromised. I firmly believe that if he had known his status earlier, Tom might be here today. The Foundation wants everyone in San Francisco between 13 and 64 to know their current HIV status. If this were its only mission, I would still ride hundreds of miles.

My Seismic pals and I ride to remind the world and our own communities that HIV is here and that the need for education, compassion and advocacy is continuous. I ride for a sense of community and common purpose…and I ride to remember and honor Tom and our many friends who should be here today. (photo: Karl Christiansen tackles Seismic Challenge 2.0 in October.)

AIDS/LifeCycle 9 information sessions and training rides are underway for our 545-mile bicycle journey from San Francisco to Los Angeles from June 6-12, 2010. Visit www.aidslifecycle.org for a detailed schedule. Whether you are a veteran or a newcomer, we hope you will join us for the next AIDS/LifeCycle. Please attend our annual ALC kick-off party on Sunday, January 24, 2010, from noon to 3 p.m. at the Mezzanine, 444 Jessie, in San Francisco.

Looking for a new adventure and a way to further the Foundation’s work? Attend an information session about our spring endurance event. We’re registering participants now for our Wildflower
Triathlon Training Program, set to begin in mid-January 2010. Curious? Visit www.begreaterthanone.org or call (415) 487-3032.

The first time Heather Clifton learned that someone she knew had been diagnosed with AIDS, it was 1998. She was working at an advertising agency and recalls feeling utterly powerless when her colleague gave her the news.

“I was devastated beyond belief,” Heather says. “At that time, it still seemed like a death sentence.”

That very night, she received a call from the San Francisco AIDS Foundation asking for her support. A big believer in coincidences, she chose that moment to stand alongside the Foundation.

“All in one day, I went from feeling angry, sad, frustrated and hopeless to realizing that I can’t change the world but there’s some contribution I can make in a positive direction,” recalls Heather.

More than 10 years later, that friend survives with successful treatment and Heather continues to support the Foundation, both because of its programs to prevent future HIV infections and because it provides support services for people who are HIV-positive and in need of help.

Heather attributes her sense of social justice to growing up in Canada, where she says safety nets are in place to support people who are less fortunate. By contrast, she says: “In the United States, everyone’s responsible for themselves. If you’re not successful, it’s considered a personal failing."

She also credits her mother as a role model in personal giving, particularly when resources are scarce like today. “She was famous for taking in waifs and strays, friends of mine and my brother’s, in troubled times.”

Since 1998, Heather has made monthly contributions to the Foundation through Partners in Caring. Both the discipline and the flexibility meet her philanthropic needs to adjust the amount of her contribution depending on her circumstances. When the recession hit, for example, Heather increased her gifts because she was grateful that she still had a job.

Visa Inc., where Heather works as head of marketing and consulting, now matches the personal donations of its employees up to $5,000 a year and provides time off for charitable commitments.

“For a very big company, they take their social responsibilities very seriously,” she says.

HIV Health News

Once- vs. Twice-Daily Kaletra
Simplified HIV medication regimens, including pills that can be taken once rather than twice a day, have been linked with better adherence—and therefore better health.

A recently released study found that the popular antiretroviral combination lopinavir/ritonavir (Kaletra) works just as well when taken once as twice daily by treatment-experienced individuals.

Study participants took either twice-daily doses of Kaletra (400 mg lopinavir plus a 100-mg ritonavir “boost”) or a once-daily double dose of the drug (800 mg lopinavir plus 200 mg ritonavir), along with other antiretrovirals. Forty-eight weeks later, 55 percent of those in the once-daily group had an undetectable viral load—a primary goal of HIV therapy—compared with 52 percent of those who took pills twice a day. Increases in CD4 cell count (a sign of improving immune health) were comparable in both groups, as were drug side effects.

Past studies demonstrated that Kaletra works equally well when taken once or twice daily as part of a first-line treatment regimen. This new study suggests that treatment-experienced individuals, including those with drug-resistant HIV, benefit just as much from a single daily dose—welcome news for those seeking to simplify their antiretroviral therapy.

New HIV Strain
In August, researchers reported the discovery of a new strain of HIV—designated “HIV-1 group P”—in a 62-year-old woman from Cameroon. Previously discovered types of HIV-1 are believed to have originated in western central African chimpanzees, whereas the new strain appears more closely related to an HIV-like virus that infects gorillas. The woman, however, reported no contact with gorillas or with the “bush meat” of monkeys and apes hunted for food in rural regions.

Researchers do not know how broadly distributed or aggressive the strain is because HIV-1 group P is not detectable by standard HIV tests and has been found in only one individual, The Cameroonian woman, who now lives in Paris, was diagnosed with HIV in 2004 and remains untreated. Although her CD4 count of 300 cells/mm3 indicates the need for antiretroviral therapy according to most European and U.S. treatment guidelines, further research is required before definitive statements can be made about how rapidly HIV-1 group P disease progresses and how the strain responds to antiretroviral therapy.

Vaccine to Prevent Anal Cancer?
Merck’s vaccine Gardasil, currently approved for girls and women ages 9 to 26 for the prevention of cervical cancer, may soon be available to boys and men at risk for anal cancer.

A Merck-sponsored study recently showed that the vaccine prevented 90 percent of cases of genital warts in a study sample of 4,000 HIV-negative boys and men—proof enough for a U.S. Food and Drug Administration advisory panel to recommend expanding the vaccine’s approval to include young males.

While Merck’s study focused on genital warts, two of the HPV strains blocked by Gardasil—HPV-16 and HPV-18—are responsible for most anal and genital cancers, suggesting that the vaccine may also help reduce alarmingly high rates of anal cancer in people living with HIV.

HIV-positive men and women are nearly 100 times more likely to develop anal cancer than is the general population. Recent research shows that the annual number of new anal cancers rises from 28 per 100,000 in HIV-positive people 10 years post-infection to a whopping 348 cases per 100,000 in people living with HIV longer than 15 years.

It is not yet clear how well Gardasil works in people who have already been exposed to HPV, or how HIV may undermine the vaccine’s effects. However, another study estimated that more than 88 percent of men in the sample would likely benefit from vaccination, assuming that it is found that HIV infection does not impair immune response to the vaccine.

Merck is now enrolling participants in a pilot study to test the safety and efficacy of Gardasil for HPV prevention in HIV-positive men.

BETA, the Foundation’s HIV treatment and prevention magazine, is available for free. To subscribe or find a pick-up location, visit www.sfaf.org/beta or call 415-487-8060.

Federal Policy Update

By focusing on the long-awaited issue of health care reform, the fall session of the 111th Congress has proven to be one of the most significant in decades with legislative proposals to transform health care access, funding and delivery. The AIDS Foundation has been actively engaged in the debate, advocating for expanded services for people living with HIV. The Foundation is playing a key role in the HIV Health Care Access Working Group, a coalition of 84 national and community-based AIDS service organizations.

The Ryan White HIV/AIDS Treatment Modernization Act, the largest federal program focused exclusively on HIV/AIDS care, was set to expire on Sept. 30 but national AIDS advocacy groups persuaded government leaders to extend the legislation through Oct. 31 to ensure a continuation of funding. The extra month gave the House and Senate time to finalize a four-year extension of the program, which provides critical medical and treatment resources to more than 500,000 Americans who lack sufficient health-care coverage or financial resources to cope with HIV disease, including thousands of San Franciscans. With strong bipartisan support, the bill was expected to pass both chambers of Congress. 

The White House is moving forward on creating a National HIV/AIDS Strategy by holding town hall meetings across the country to seek recommendations on how to achieve three major goals: reducing HIV incidence, increasing access to care and optimizing health outcomes, and reducing HIV-related health disparities. A meeting took place in San Francisco on Oct. 16, one of 14 planned forums this year in regions of the country with diverse communities affected by HIV/AIDS.

The Foundation and other HIV prevention organizations renewed their pressure on Congress this year to lift the 21-year ban on federal funding of syringe exchange programs. Partial victory was achieved when the House of Representatives voted to remove the ban. However, an amendment to the House bill would prevent any federally financed syringe exchange within 1,000 feet of sites where children gather-—a restriction that would make it impossible for San Francisco and other dense urban areas to locate exchanges in key neighborhoods. As members of the House and Senate confer on an appropriations bill, the Foundation and others are continuing to advocate for federal support of syringe exchange-—scientifically proven as one of the most cost-effective methods for preventing HIV.

World View

Scientific Advancement Achieved in AIDS Vaccine Research
A clinical study in Thailand has provided the first evidence that a vaccine can protect against HIV infection in humans, but scientists cautioned that much more work is necessary before a vaccine is available to the public.

The vaccine cut the risk of HIV infection by 31 percent in the study of more than 16,000 heterosexual participants, the largest-ever AIDS vaccine trial. It did not, however, lower the viral loads of those men and women who were vaccinated but contracted the virus anyway.

Known as RV 144, the vaccine is a combination of two genetically engineered vaccines that proved ineffective when tested separately. Since the vaccine was designed to combat the most common strain of the AIDS virus in Southeast Asia, scientists said they could not determine whether the new vaccine would prove effective against strains of the virus in Africa and the United States.

World AIDS Day 2009
Since 1988, World AIDS Day has provided an opportunity to gather in memory of people we have lost to the virus and steel ourselves for the commitments still to come. Because December 1 brings increased attention to AIDS, communities around the world try to optimize the occasion, delivering messages about their work to a range of audiences. UNAIDS selects World AIDS Day to release its bi-annual report on the global epidemic. Local organizations use World AIDS Day to teach people about HIV prevention, encourage HIV testing, and draw media attention to their programs. In countries whose leaders still fail to acknowledge HIV as a threat, World AIDS Day often means demonstrations, protests and civil disobedience designed to override political apathy.

San Francisco’s historic connection to the epidemic has special meaning on World AIDS Day. This year, the San Francisco AIDS Foundation will highlight the city’s role at the vanguard of prevention, care and treatment, and we are asking for your help.

Volunteers, clients, staff and board members from the Foundation will engage Bay Area residents with a campaign that tracks the progress we have made bringing down the number of new HIV infections, but reminding us of the critical work that remains.

If you would like to join the San Francisco AIDS Foundation on World AIDS Day, please contact Emily Mariko-Sanders at 415-487-8081 or emariko@sfaf.org.

Pangaea Project Expands to Reach HIV-Positive Young Women in Zimbabwe
Pangaea Global AIDS Foundation researchers Nancy Padian and Megan Dunbar recently secured a grant from the National Institutes of Health that will allow them to expand their HIV prevention work in Zimbabwe by broadening their focus to include female adolescents who are HIV-positive.

Padian and Dunbar have led the development of SHAZ! (Shaping the Health of Adolescents in Zimbabwe)-—an HIV prevention intervention and research study in Zimbabwe that empowers adolescent female orphans to avoid sexual risk behaviors by improving economic opportunities and linking them to life skills-based HIV education and clinical care. The new grant will allow the SHAZ! team to add 650 HIV-positive adolescent girls to the program.

“We’re tremendously excited to have the opportunity to expand our focus to include HIV-positive young women with the hope that we can help them control their disease, reduce the chance that they’ll infect others, and put them on the road to economic independence,” said Dunbar, principal investigator of the expanded program, known as “SHAZ!-Plus. “Our goal is to find a formula that works for these young women that can inform program and policy decisions throughout Africa.”

Zimbabwe is confronting the synergistic plagues of a generalized HIV epidemic and rapid economic decline. Both have contributed to the large number of orphans and vulnerable children estimated at 1.5 million in 2007. Young women in this population have limited access to educational and economic opportunities, are twice as likely to be HIV-infected than their male counterparts, and are more likely to engage in high-risk sexual behavior. The risk of secondary HIV transmission is increased by the psychological consequences of being poor and HIV-positive.

SHAZ!-Plus will link the young women to clinical care and randomly assign them to vocational training and guidance counseling. Researchers will evaluate the effect of SHAZ!-Plus on issues that include adherence to care and treatment, health outcomes and behaviors associated with the secondary transmission of HIV.

The program is a collaboration between Pangaea, the Women’s Global Health Imperative at RTI International, the University of Zimbabwe-UCSF Research Programme and the HIV/AIDS clinic at the Chitungwiza Hospital. Pangaea’s primary role is to help ensure quality care and treatment for all participants in the program.

Pangaea’s Megan Dunbar (left) with SHAZ! participants in Zimbabwe

PANGAEA’S GOOSBY CHOSEN BY PRESIDENT OBAMA TO BE GLOBAL AIDS COORDINATOR

In 1979, Dr. Eric Goosby was an intern at University of California San Francisco when he encountered his first case of what he later realized was HIV at San Francisco General Hospital. The patient was a 22-year-old Haitian man who was in the intensive care unit for treatment of a rare form of lymphoma. Goosby was able to stabilize his patient that first night, but the young man would die two weeks later.

In the months and years to come, as this previously unknown and unnamed disease was killing young men in the gay community in San Francisco and other cities around the country, Goosby would be one of the doctors at the center of the early response to HIV/AIDS.

Three decades after that first encounter with the disease, President Barack Obama nominated Goosby-—currently CEO and Chief Medical Officer of Pangaea Global AIDS Foundation—to the position of Global AIDS Coordinator. On June 19, Goosby was confirmed by the U.S. Senate. He  will leave his post at the San Francisco AIDS Foundation’s global affiliate to take up the reins of PEPFAR—the President’s Emergency Plan for AIDS Relief—that has supported treatment for more than 2 million people around the world since 2004.

Goosby’s medical practice and public health policy role have steadily expanded over the last 30 years, taking him from San Francisco to Washington and then to countries in Africa, Asia and Europe in the battle against emerging HIV epidemics around the world.

“Some of the lessons we learned at the beginning of the epidemic have great relevance today, including the importance of focused prevention efforts and comprehensive care and treatment for people with AIDS,” he says.

For the first 10 years of his career, Goosby was an integral part of the AIDS team at San Francisco General Hospital, working as medical director of the clinic serving one of San Francisco’s poorest African-American neighborhoods before moving to San Francisco General’s AIDS Clinic as associate medical director from 1987 to 1991.

In the early ‘90s, Goosby was tapped by the Clinton administration to play a new role in Washington, D.C. He was deputy director of the White House National AIDS Policy Office, director of the Office of HIV/AIDS Policy of the Department of Health and Human Services, and was the first director of the Ryan White CARE Act, which funds community AIDS programs around the United States.

Goosby returned to San Francisco in 2001 to lead the newly formed Pangaea because he knew the time was right to turn his attention to international work. Pangaea’s early efforts focused on broadening access to HIV antiretroviral therapy in resource-limited settings with projects in Rwanda, South Africa and Uganda: “When I first visited the countries in Africa so devastated by AIDS in the late ‘90s, I felt like I had been transported back in time to San Francisco before the advent of antiretroviral drugs,” says Goosby. “I recall my incredible frustration standing in hospital wards in Rwanda, Tanzania, and South Africa and watching people die. I knew then that we had to find a way to bring treatment to the people in these countries.”

In Goosby’s testimony before the U.S. Senate Foreign Relations Committee on June 9, he stressed themes that would guide his work if confirmed: intensifying HIV prevention, pursuing strong country partnerships, strengthening health systems, and boosting effective programs to achieve better health outcomes.

“The history of PEPFAR has demonstrated what can happen when we dare to think big,” Goosby testified. “Working closely with our global partners, we can help reclaim the lives of millions of people who will otherwise be lost to the infection.

COMMENTARY

The San Francisco AIDS Foundation has been battling cuts to state HIV/AIDS funding for two months. Though the governor’s proposal declared nothing short of Armageddon for HIV services, the Foundation quickly rallied clients, donors, political allies and media attention to advocate for a legislative compromise that, as of this writing, promises modest cuts that will not dramatically impede our ability to prevent new HIV infections and improve care for people living with HIV.

Are there lessons to be learned from another round of grassroots activism?

As long as this country suffers from an HIV epidemic, there will never be a right time to cut services nor a population that can sustain a dramatic reduction in support. Even in a discouraging economy, any budget plan that targets HIV and AIDS puts an undue burden on those least able to accommodate it: poor and uninsured beneficiaries of the AIDS Drugs Assistance Program (ADAP), communities of color with the highest rates of new infections, and those who have been living with HIV for years.

What’s more, cutting public funding jeopardizes our capacity to achieve the end of HIV and AIDS. Never before has there been a moment like this. Following years of hopeful panaceas, we finally know what it takes to beat HIV once and for all. Scientific evidence imbued with community experience mean that resources—time, expertise and funding—really do equate with success. At the San Francisco AIDS Foundation, adequate dollars to buy clean syringes leads to a quantifiable number of high-risk acts averted. Keeping Magnet’s doors open longer means more people can be tested for HIV infection, more people can be screened for STDs, and more people can receive the culturally competent care for which Magnet is known in the Castro and beyond.

But the bigger story here is protecting a system of care that benefits everyone. Around the country, the pendulum is moving away from accepting health disparities towards improving access. We may be a far cry from universal coverage, but our reform-minded president has already signed legislation to provide health insurance for disadvantaged children and the unemployed, and has made affordable coverage for all a priority. By agreeing to implement a National AIDS Strategy, President Obama put HIV and AIDS at the top of a crowded health reform list.

Because California’s proposed budget cuts would have devastated programs operated by the San Francisco AIDS Foundation, we will be vigilant in support of the compromise when it reaches the governor for his signature. Hereafter, the only thing we will accept from any leader is an unswerving commitment to prevention, care and treatment that we know works.

In the Bay Area, community-based organizations have been national leaders, stabilizing infection rates and markedly improving health for people living with HIV. As we forge ahead with innovative prevention activities based on sound science and make inroads in an entrenched epidemic, public understanding—and the public funding that comes with it—must follow.

Mark Cloutier, CEO
San Francisco AIDS Foundation

HIV HEALTH NEWS

Safer Sex—What’s Viral Load Got to Do with It?
Recent studies suggest that antiretroviral treatment can reduce viral load sufficiently to limit the risk of HIV transmission—in short, less virus in the body should mean a lower risk of passing on HIV. Two recent trials found significantly fewer new infections among HIV-negative people when their HIV-positive partners were on successful antiretroviral therapy. A large, longer-term study is underway to determine whether this strategy has a lasting effect.

However, two other studies also presented at February’s Conference on Retroviruses and Opportunistic Infections indicate that low viral load is not a ticket to risk-free condomless sex. A French study of 145 men with undetectable blood viral loads (less than 40 or 50 copies of the virus per milliliter of blood) found that 5 percent had detectable levels of HIV in their semen. A Toronto-based study likewise found that at least half of the participants had “viral shedding” in semen even when blood viral load was undetectable. Research is ongoing to explore the link between blood and semen viral loads.

Expanded Treatment as HIV Prevention
Mathematical models built on the premise that reduced viral load means reduced transmission risk suggest that expanded treatment may help quell the HIV pandemic. For example, one model predicts that South Africa could see HIV prevalence drop to less than 1 percent over 50 years if the country implemented voluntary HIV testing for everyone and immediate antiretroviral treatment for those found to be HIV positive, regardless of their CD4 cell count (a marker of immune health that helps guide when to start treatment).

While highlighting the potential benefit of treatment as prevention, the model raises serious questions: for example, is it ethical to ask people to begin lifelong antiretroviral treatment before it is necessary for their own health? For some individuals—particularly those already struggling to meet their health, housing and nutritional needs—starting a complicated treatment regimen before it is medically necessary may simply introduce an additional burden and ultimately prove unmanageable. But while the issue of very early treatment remains controversial, expanded voluntary testing and treatment are strategies that everyone can get behind.

New Drug “Boosters” in the Pipeline
The anti-HIV drug ritonavir (Norvir) is frequently taken to boost the levels of other antiretroviral drugs in the blood, allowing for fewer pills per day. Yet ritonavir’s benefits come with unwanted side effects and a hefty price tag. Two new “pharmacoenhancing” agents may give ritonavir a run for its money.

In one early study, Gilead’s GS 9350 helped maintain blood levels of other drugs better than did ritonavir. A second study showed that a one-pill, once-daily regimen combining GS 9350 with tenofovir (Viread), emtricitabine (Emtriva), and elvitegravir, the company’s experimental integrase inhibitor, was safe and well-tolerated. A more advanced trial is in the works to pit this new combination pill against the popular Atripla, which combines tenofovir, emtricitabine, and efavirenz (Sustiva). 

Sequoia Pharmaceuticals’ SPI-452 also looks promising, having boosted blood levels of all HIV protease inhibitors (PIs) in laboratory and animal studies. In human trials, SPI-452 increased blood levels of the PIs atazanavir (Reyataz), darunavir (Prezista), saquinavir (Invirase), and lopinavir (normally taken in combination with ritonavir in the Kaletra pill) and was well-tolerated.

While neither “booster” works directly against HIV, both appear to make antiretroviral drugs work harder in the body, which could ultimately translate into less frequent dosing, lower pill burden, fewer side effects and reduced cost.