Ending the HIV epidemic in New York: Lessons from New Amsterdam

Demetre Daskalakis.jpgDr. Demetre Daskalakis is the deputy commissioner of the Division of Disease Control at the New York City Department of Health and Mental Hygiene, where he directs the public health laboratory and all infectious disease programmes. Dr Daskalakis is one of the plenary speakers at NCHIV 2017, where he will be giving a talk entitled "Ending the HIV epidemic in New York: Lessons from New Amsterdam". During the summer, we caught up with Dr Dasklalakis and spoke to him about the HIV epidemic in New York and the strategies that the city is employing to tackle the epidemic.

Could you tell us how you came to be working in the HIV field?

Well, I wanted to be a physician all my life. When I was at college, in the early 1990s, I helped organize an event where we displayed the AIDS memorial quilt. Seeing so many people affected by HIV or AIDS made me realise I wanted to focus on gay health. I went to medical school at NYU and did further training in Boston. At some point, while I was working in Boston, there was a controversial case of acute infection with a multidrug resistant strain of HIV that occurred in the context of crystal methamphetamine use at a commercial sex venue in New York City (NYC).  This case prompted me to return to NYC where i ultimately became a public health official. 

Your talk at NCHIV is entitled “Ending the HIV epidemic in New York: Lessons from New Amsterdam”. Could you describe the HIV epidemic in New York?
The epidemic in NYC is different from other parts of the USA. We have around 100,000 people living with HIV in our jurisdiction. Based on a recent serosurvey and CDC model, we estimate that 96% of these people living with HIV are aware of their status. Through efforts to increase testing, we have reduced the percentage of people unaware of their diagnosis from 14% in 2010 to 4% in 2015. But, of course, 4% of 100,000 is still not great.

In terms of the 90-90-90 targets, we have around 92-93% of people living with HIV in care, 88% are on antiretroviral therapy (ART) and 90% have viral suppression. So our increased testing means we now need to work harder to get more people on ART to achieve the 90-90-90 target.

What does the population of people living with HIV look like in NYC?
Our epidemic is primarily male. We had 2493 new diagnoses in 2015, about 80% of which were in men. Women represent around 400-500 new diagnoses a year, 91% of these are black or Latina. This is one of the challenges. We also have about 40-50 transgender individuals newly diagnosed each year.

About 60% -70% of the new diagnoses are in black and Latino MSM. This illustrates what happens when you have a better-tested population versus one that’s less well tested and it also demonstrates how stigma drives our epidemic among black and Latino populations in NYC. Interestingly, though, numbers are improving among the younger black/Latino population. In 2015 we also saw the biggest decrease ever in MSM. I think this reflects treatment becoming more pervasive in the community, combined with very good messaging about treatment. PrEP uptake increased just at the close of 2015, so we are optimistic that this trend will continue and accelerate as treatment continues to scale up and PrEP reaches the right communities.

What have you done in terms of messaging?
We were the first US city to sign up to U=U [undetectable=untransmittable]. While we think that viral suppression is powerful, we’ve blended the message with PrEP, trying to get across that these interventions are statusless. At their core, treatment or PrEP are identical interventions. Our message is that HIV status is only a part of the calculus of how to customise prevention and that you should go on whatever intervention you need to stay healthy. This message was quite controversial when it came out in our “PlaySure” campaign, but I really believe we need to lean into issues of risk and pleasure, not fight them or dictate a solitary strategy for all people living with or at risk of HIV.

The campaigns are designed to reflect our approach and we felt strongly that no-one should look sad or defeated. Any HIV status, negative or positive, is workable for living a full and rewarding life.  The only status that doesn’t empower people is “unknown.”  Our new campaign is called “Bare it All” and has received very good feedback. We have posters on the subways, bus shelters, and billboards in English and Spanish, as well as digital media including Instagram, Facebook, and hook-up applications. My favourite image is of a happy and handsome transgender man who has his shirt off, showing his surgery scars and looking glowing and overjoyed to share his truth. The aim is to make everything status-neutral. It’s not about HIV, it’s just about talking to your doctor or other healthcare provider about your life, baring it all to them. And if you can’t, switch. We’ve vetted over 100 doctors and can connect people to these doctors if their current provider does not serve their needs.

What about women?
The numbers are going down among women, but there is still a disparity. So we have decided not to be subtle. We are about to send out letters to providers in New York City to encourage them to follow the strategy we have implemented in our sexual health clinics. This strategy is that any woman in the jurisdiction who’s diagnosed with gonorrhoea should be offered PrEP, just as we do for MSM. It’s a very aggressive stance, but our gonorrhoea rate matches the HIV rate.

There are also certain areas in our city that have a higher incidence of HIV for women. So we’re asking providers to women, especially women of colour, from these areas to minimise risk assessment if they ask to start PrEP. These women don’t want to talk about HIV risk. The social drivers that lead to HIV infection are particularly stigmatising in this community and are often enveloped in silence because of cultural norms. Therefore, if these women are asking for PrEP, providers should assume that that is confirmation that they are at risk of HIV exposure and infection. No need to interrogate.

Is there a barrier among providers to offering HIV testing to women?
I think we have the same challenge as in Amsterdam. Risk-based testing is still happening, even though according to state law anybody over 12 should be offered HIV testing if they encounter healthcare. PrEP is like the panacea. We are therefore developing a completely different PrEP campaign focused just on women. Based on the approach of pharmaceutical sales representatives (provider detailing), we hired people to go into practices and teach about PrEP. After visiting 3000-4000 providers, we saw increases in the numbers of providers prescribing. However, the detailing kit we used was very MSM and trans-focused. So we’re redeveloping it for women and we’re going to do another round or two of this detailing targeting only providers that serve women. The core message is based on testing, which is the bigger barrier for women.

How are you trying to reach the 4% who are undiagnosed?
it’s hard to reach that final percentage. These are people who may never come into contact with healthcare. We have a jurisdictional testing strategy called “New York Knows” that has been very successful in areas with high HIV incidence and prevalence. In addition, we’re mobilizing the community to do far more testing by leveraging PrEP: people are motivated by PrEP, but the only way to get to it is by testing. We’re also doing a lot of molecular epidemiology now to reach deeper into communities that may not access services.

How do you obtain the sequences for the molecular epidemiology work?
Due to the structure of our surveillance system, we usually only get them after 3-6 months. So our public health laboratory in the city has started offering free resistance testing, first to our sexual health clinics and soon to our large diagnosers of new HIV cases as well. It’s a big selling point. As everyone is trying to do rapid initiation of therapy, a free resistance test before people have insurance and with a turnaround time of one week is perfect. We use the data to build clusters, on the basis of which we reprioritize our approach to accessing out of care people living with HIV. The ultimate goal is to get resistance testing for all new diagnoses done in our lab.

What about people who inject drugs?
Although we are currently in the middle of an opioid epidemic in NY, our numbers for HIV among people who inject drugs have improved dramatically; last year we had under 80 new cases of HIV. It’s substantially better because we have pretty good harm reduction strategies. They are probably not as good as in Amsterdam, but we do have syringe exchange everywhere and medical replacement therapy. Unlike Amsterdam, we don’t have safe consumption rooms yet, but I think and hope that they’re on the horizon.

Any specific strategies to detect acute HIV?
We’ve created a number of different strategies. First, we think there’s value in doing full nucleic acid testing (NAT) in high-risk populations. So our sexual health clinics do full NATs for most MSM who get tested. It’s a pretty effective strategy, since we diagnose 20% of the acute infections in the city at our clinics.

In addition, as part of our PrEP strategy, anyone who has symptoms gets a solo test instead of a pooled NAT, which is faster. Finally, in terms of the messaging to our providers, all our information about PrEP discusses acute infection and our providers know we offer NAT testing at our clinics.

We also have a pretty good level of attendance at our clinics: about 80,000 visits a year, but by making them more appealing, we hope to do even better. We’re trying to lower the threshold from hyper-medical to barely medical and are already seeing the clinics becoming more popular and less stigmatized places. We also have initial plans for a Dean Street-style clinic in NYC.

It sounds like New York City is working hard to halt its HIV epidemic. Amsterdam was recently hailed as one of the first cities to reach the UNAIDS 90-90-90 targets and is now aiming to become an AIDS-free city. How realistic do you think this is and what do you think is needed to achieve this?
It’s good to have a goal, particularly when you’re a shining star like Amsterdam. I think 100% is hard; 95% is do-able. It’s hard to have a fully-suppressed, fully-in care, fully-diagnosed population. Even if we have good numbers, social drivers like poverty, drug use, and mental health illness will always exist no matter what. So 95% or even 98% is achievable, but I’m scared of saying 100% as people might think it’s over.

So is 98% your goal for New York?
We’ll take 98! But we shouldn’t forget that, with 90% suppressed, 10% of 100,000 unsuppressed is still a big number and that population is the hardest to reach.