Molecular Surveillance: What does it all mean? Clinical - - PowerPoint PPT Presentation

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Molecular Surveillance: What does it all mean? Clinical - - PowerPoint PPT Presentation

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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

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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

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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

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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
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The Status Neutral Continuum

Thanks to Hyman Scott, CROI 2018 Adapted from https://www.nastad.org/domestic/hiv-prevention-health-equity

Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed At Risk Aware

  • f PrEP

Linked to PrEP Prescribed PrEP Retained

  • n PrEP
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Going back to the cluster data…

HIV Testing PrEP Treatment as Prevention

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Prevention - HIV Testing

https://www.cdc.gov/hiv/guidelines/testing.html

  • 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
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Prevention - HIV Testing

CDC Jan 2018 Update https://www.cdc.gov/hiv/testing/laboratorytests.html

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Prevention - HIV Testing

CDC Jan 2018 Update https://www.cdc.gov/hiv/testing/laboratorytests.html

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Prevention - PrEP

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Prevention - PrEP

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HIV Testing PrEP Treatment as Prevention

Going back to the cluster data… ✓ ✓

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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
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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

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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

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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

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Treatment – Standard of Care

  • 132 days until virologic suppression

Pilcher et al. JAIDS 2017.

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Treatment – RAPID San Francisco

Pilcher et al. JAIDS 2017.

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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.

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Treatment –Tiered care strategies

  • Seattle MAX Clinic
  • Walk in care
  • High-intensity support and coordinated care
  • Incentives

Dombrowski, CROI 2018.

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Treatment – U=U

The Lancet HIV 2017 4, DOI: (10.1016/S2352-3018(17)30183-2)

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San Antonio Response

May 2017

  • Cluster 51 presentation to SA HIV/Syphilis Testing Task Force

June 2017

  • Advocates, Ryan White Administrative Agent, community based organizations, health care providers meet
  • End Stigma End HIV Alliance formed

Oct 2017

  • First Fast Track Cities Initiative Convening Meeting

Dec 2017

  • San Antonio becomes a Fast Track City

Feb 2018

  • Results based accountability for goals and metrics for 90-90-90

April 2018

  • Youth Listening Tour: 20 sites, 172 13-24yos
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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
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Thank you!

TaylorB4@uthscsa.edu