“We are in a new era in the HIV epidemic. We are moving towards the end of the HIV epidemic,” states Diane Havlir, MD, from the podium at a recent town hall forum in San Francisco. The forum’s topic? Getting to “zero.” Explaines Dr. Havlir, “We’re talking about zero new HIV infections, zero deaths among people living with HIV, and zero stigma.”
Today, Dr. Havlir is chief of the HIV/AIDS division and Positive Health Program at San Francisco General Hospital, as well as professor of medicine and principal investigator of the AIDS Clinical Trials Group at the University of California, San Francisco. In 2012, she co-chaired the 19th International AIDS Conference in Washington, DC, and was instrumental in launching the “DC Declaration,” a nine-point action plan to end AIDS.
Ending HIV transmission, AIDS deaths, and stigma was virtually unfathomable when Dr. Havlir first became involved in the epidemic. “I was a medical student in 1981, when the Morbidity and Mortality Weekly Report first noted a cluster of unusual cases of Pneumocystis pneumonia among gay men from Los Angeles”—the report that would come to mark the AIDS epidemic’s beginning. Fascinated by this report, and by others that followed from San Francisco and New York, she pursued an internal medicine residency program at UCSF, right in the heart of the city’s epidemic.
“For those of us who were young physicians in training at the time, the terrible irony was not lost on us,” Dr. Havlir recalls. “We were at the point of realizing our dreams to practice medicine, and at the same time we were taking care of young men whose dreams had been shattered in the prime of their life.” Caring for people dying from AIDS-related illnesses affected her profoundly and was, she says, “my calling to my lifelong goal to change the course of this epidemic.”
In pursuit of that goal, Dr. Havlir pioneered studies of early treatments, including highly active antiretroviral therapy (HAART) to overcome HIV’s ability to mutate and become resistant to individual drugs. “I vividly remember the fax—yes, that is how we communicated back then—with our new data from those lucky patients receiving the first combination HIV treatments,” she shares. “After treatment, HIV levels were staying suppressed, not rebounding after a few months as we had seen previously with every failed attempt to keep the virus at bay.”
“I knew, at that moment, everything would change. And it did. I still receive Christmas cards from these heroic patients who volunteered in the first studies of HAART.”
Thanks to combination drug therapy and ever-evolving HAART strategies, today an HIV diagnosis is no longer the death sentence it was when Dr. Havlir began her residency in 1984: HIV is now considered a manageable, chronic illness. (In fact, she notes, among clinicians and long-term survivors, “we have anxiety about HIV and aging,” as more people with HIV live longer and experience age-related health challenges that many never expected to face.)
Over the past few years, Dr. Havlir has seen the epidemic reach another turning point, with exciting new science pointing the way toward ending HIV transmission and progression to AIDS. “Arguably, the most important breakthrough was the HPTN 052 study that definitively showed that effective HIV treatment not only saves lives but reduces the risk of HIV transmission in couples—by an astounding 96%,” she observes. “That was the moment for me, when I became exhilarated by the concept that we can end AIDS.”
Around the same time, pre-exposure prophylaxis, or PrEP—in which HIV-negative people take a daily antiretroviral pill before HIV exposure—was shown to reduce infection risk, providing another powerful tool to curb the epidemic. San Francisco has led the way with PrEP research and demonstration projects, and with community education about this new strategy.
“We can, I firmly believe, be the first community that gets to zero—and we can do that by continuing investment, innovation, and implementation,” adds Dr. Havlir. “And when we do that, we want to build community health in the process.” Fostering a healthy—and informed—community is part of the work ahead. “In San Francisco, treatment is up. The number of new infections is down. But we still have a long way to go to get to the goal of zero.”
An anecdote demonstrates the need to educate community members and build on current momentum: “The other day, I was working on my laptop, looking at a scientific presentation about ending AIDS, and the person next to me looked over and said, ‘Oh, what are you doing?’ And I blurted out, ‘We can end AIDS!’ To be honest, it was a conversation killer,” Dr. Havlir laughs. “But you know why? Because people are not ready to hear this message yet.”
Getting to zero will take bold initiatives. “‘Boldness’ means we speak up in the face of doubt and adversity,” she says. “We did that in the 1980s, when the HIV epidemic first appeared. We did that in 2010, when we were the first to recommend treatment for all persons living with HIV”—a move that paved the way for earlier HIV treatment and both better HIV health and reduced risk for transmitting the virus. “We’re doing it now, with the current research and studies we have toward finding a cure, with vaccine research, and being at the forefront of PrEP.”
After nearly three decades in the HIV/AIDS field, what drives Dr. Havlir today? “I’m inspired by all the new initiatives that people in the San Francisco community are spearheading—starting with the gay men’s health center in the Castro,” she says. The new center for gay men’s health and wellness, slated to open in 2014, will bring San Francisco AIDS Foundation’s programs for sexual health, substance use treatment, and community-building under one roof on Castro Street and will expand programs and services to meet the community’s whole-health needs. “That’s very, very exciting: talking about HIV and health, and thinking about the health of the community.”
It’s an approach that resonates with her experience of the earliest days of AIDS, when community members worked side by side with the city’s clinicians, medical researchers, and others to understand and cope with the devastating new disease. “The community partnered with the scientists and with political leaders,” she recalls. “I think one of the joys and privileges of living in San Francisco is that the response to the AIDS epidemic has always been one that has brought everybody to the table."
Have you seen how people in our community—clinical trial volunteers, HIV and public health advocates, and researchers and clinicians like Dr. Havlir—are helping get us closer to "zero"? Leave them a word of encouragement in the comments below. What do you think it will take to end the HIV epidemic? Leave a comment and let us know!
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