Treatment with antiretroviral drugs can suppress the HIV virus, but only if people who are infected can access and stay on treatment, a multi-state study has found.

The study, published in the Annals of Internal Medicine and funded by the National Institutes of Health, found that rates of viral suppression improved from 32 percent in 1997 to 86 percent in 2015, among nearly 32,000 adults receiving treatment for HIV at eight U.S. medical centers, including two in California at UC San Francisco and UC San Diego.

Reducing HIV to undetectable levels means a person can no longer transmit the virus to others, according to the National Institute of Allergy and Infectious Diseases.

About a third of the study participants were patients at either UCSF or UCSD. The patients from San Francisco received care at UCSF’s Ward 86 and the patients from San Diego came from UCSD’s Owen Clinic. Both clinics are safety-net HIV clinics, caring for many patients who are low-income and from racially or ethnically diverse populations, along with other vulnerable groups, such as those who use substances, are homeless and have psychiatric illness, according to researchers.

“This is a fantastic study … it demonstrates that we are doing a much better job overall in addressing the HIV epidemic,” said David J. Grelotti, director of mental health services at the Owen Clinic at UC San Diego Health “However, it also shows us that we need to do a lot better. And it gives us important insight into where we need to do better.”

The study found that not all demographic groups achieve the same level of viral suppression. Among key findings from the national study were that people with HIV who were younger than 30 were more likely to have detectable levels of the virus and that viral suppression was 8 percent lower in African Americans than in whites.

The most recent California data, found that African Americans were more likely to be diagnosed with HIV. Among 4,948 people newly diagnosed with HIV in 2015, the overall rate was 12.7 cases per 100,000 people, but among African Americans the rate was 39.5 HIV diagnoses per 100,000 people.

“I think socio-economic vulnerabilities remain the biggest challenge to HIV care in San Francisco (the county with the highest rate of HIV cases in the state), particularly housing instability/homelessness and substance use,” says Katerina Christopoulos, an associate professor at the UCSF School of Medicine who specializes in HIV-treatment retention and was an author of the study.

Diagnosis And Treatment Together

California had the highest rate of new HIV diagnoses in 2016 in the U.S. according to data from the U.S. Centers for Disease Control and Prevention, and San Francisco has the highest rate in the state, at 30 cases per 100,000 people.

But California is also a leader in innovative approaches to providing HIV-treatment care for all population groups. In an editorial that accompanied the recent study, Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, specifically cited an initiative launched at UCSF that provides antiretroviral therapy to reduce HIV-viral load with a goal of starting treatment on the same day a person gets positive test results.

“The steps from HIV testing to confirmation of HIV diagnosis to ART (antiretroviral therapy) initiation are often time-consuming and difficult to navigate logistically and emotionally,” said Katerina Christopoulos, who is heading demonstrations of the treatment, known as Rapid ART, at three HIV-testing sites in San Francisco.

Roberto Martinez, who is 26 and lives in San Francisco, was diagnosed with HIV a year ago. At the time he was using drugs and alcohol and largely living on the streets, or “moving from hotel to hotel.” The City Clinic in San Francisco notified him that he might have contracted an STD from someone he had sex with and needed to be tested. He went to City Clinic, which does testing for free, and learned he had antibodies to the HIV virus. From there they sent him to Ward 86 at San Francisco General, the first dedicated HIV clinic in the country.

“It wasn’t just the medication for HIV,” Martinez said. “They also got me into a great rehab and helped me find my apartment and job.”

He now lives in a sober-housing building and pays the rent himself, from the salary he makes as a manger for a coffee company, a job Ward 86 social service staff helped him find. Martinez said having a safe place to live makes it easy to take his daily medication, “something hard to imagine if I’d had to do that a year ago.”

‘As San Francisco Goes’

According to the California Department of Public Health, as of 2015, the last year for which there is data, 61 percent of Californians with HIV have had their viral loads suppressed, compared with 59 percent of all Americans with HIV. Through funding to the 18 counties with the highest rates of HIV infection, the state is specifically aiming outreach efforts at African Americans, American Indian/Alaska Natives, Latinos, young adults ages 13 to 24 years old, people who are transgender and men who have sex with men and were infected through injection drug use. Recent studies suggest that the opioid crisis may be a factor in increasing HIV, due to infected needles.

In September 2016, the state public health department launched a five-year plan called “Getting to Zero.” One of the plan’s four goals is to reduce HIV-related disparities and health inequities in California.

Experts say initiatives in San Francisco are important to. “As San Francisco goes, so goes California, and then as we model, the rest of the country,” said Edward Cachay, who specializes in HIV and other infectious diseases at the Owen Clinic at UC San Diego.

At the San Francisco Aids Foundation, for example, a care coordinator not only reminds patients of upcoming appointments, but also can help with transportation to the doctor’s office. And staff members even occasionally accompany patients to visits to be sure they understand the treatment and how to access and take the medication.

“Other cities in California don’t have funding for that level of help,” said Cachay.

Nick, who is 45 and declined to give his last name because of the health details he shared, was diagnosed with HIV more than 30 years ago and has been a patient at the Owen clinic ever since. He lives in San Francisco, where he works at a deli, and says he barely has money to pay for his phone and electricity after paying his share of $500 for the $1000 a month apartment he shares with his boyfriend, who is also HIV positive.

Because of his limited income, Nick said he’s grateful for the coordinated care at the clinic. At his income level, Nick’s medical needs are fully covered by a program administered by the state, but he still have to complete “tons of paperwork” to get care and his medication. Nick said the insurance manager is known as “God” among the patients. “He’s always reminding me to bring this or fill in that. Without that help, I don’t know where I’d be.”

Building Community Trust

Limited access to social services, such as housing, remains a critical obstacle to ending HIV disparities, said Morty Diamond, manager of Black Health Centers of Excellence at the San Francisco Aids Foundation. One example Diamond shared is that in San Francisco, there’s a shortage of 800 to 900 shelter beds, which means people are living on the streets where their medicine can be lost, stolen or moved, making it difficult to stay on daily therapy.

Diamond said clinicians also need to provide culturally sensitive materials that show African Americans in the photos, for example, so that patients can connect with the information.

“A very successful initiative to gain trust in the community has been group meetings several times a month for people with HIV that include meals, such as breakfast or lunch,” Diamond said.

Data from the National Institutes of Health-funded study is three years old and the most recent state data is two years old, which makes Edward Cachay wonder whether immigrants who are fearful of deportation for themselves or family members if they access treatment are undercounted among the numbers of people whose virus levels are not suppressed.

And the study only includes people who were tested, know they are HIV-positive and accessed care, said Grelotti. “People who are unaware of their HIV status or have not accessed HIV care are even more vulnerable. We know less about this group, but they also suffer from significant health disparities because of substance use, depression, poverty, or the way the health system is organized (or disorganized) in their communities.”