In San Diego's Hepatitis Outbreak, Lessons Learned From HIV/AIDS
OUR TOP STORY AND MIDDAY ADDITION: EVENTS ARE BEING HELD IN SAN DIEGO TO MARK WORLD AIDS DAY. 29th ANNUAL DOCTOR BRAD TRACK AWARD CEREMONY WILL BE HELD AT THE AG -- LGBT COMMUNITY CENTER AND MAMA'S KITCHEN WILL HOLD THEIR PLAN WILL EVENT. SAN DIEGO COUNTY LAUNCHED AN EFFORT WITH AIMS OF ERADICATING CASES OF HIV AIDS IN 10 YEARS. WE WILL CHECK ON THE PROGRESS OF THAT INITIATIVE AND ASK IF ANY LESSONS LEARNED FROM THE SPREAD OF HIV AIDS IS BEING USED TO STEM THE HEPATITIS A OUTBREAK. JOINING ME IS TERRY CUNNINGHAM, THE RETIRED DIRECTOR OF THE HIV STD AND HEPATITIS BRANCH OF THE SAN DIEGO COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES. TERRY, WELCOME.THANK YOU VERY MUCH.YOU CHAIR THE COMMITTEE THAT CAME UP RECOMMENDATIONS FOR THE INITIATIVE ON HIV-AIDS. REMIND US WHAT THAT PLAN CALLS FOR.THE TITLE OF THE PLANE IS GETTING TO ZERO. BASICALLY WHAT THAT MEANS IS GETTING TO NO NEW INFECTIONS, NO DEATHS, NO STIGMA AGAINST AIDS OR PEOPLE WITH AIDS OR HIV DISEASE.SO, HOW IS THAT PLAN PROGRESSING?WELL, IT IS PROGRESSING SLOWLY BECAUSE IT WAS AN UNFUNDED POLICY. WE HAVE TO USE EXISTING FUNDS THAT WE GET BASICALLY FROM THE STATE AND SOME FUNDS CAN BE USED THAT WE GET THROUGH RYAN WHITE CARE ACT TO HELP US GET TO THE POINT OF ZERO. BUT IT IS A SLOW PROCESS, AND WE ARE TAKING MEASURED STEPS TO GET THERE.NOW, I KNOW THAT A CENTRAL FACTOR OF THIS PLAN IS TO RAISE AWARENESS IN THE PUBLIC, BUT IT IS IT ALMOST -- IS IT ALSO TO RAISE AWARENESS IN THE MEDICAL PROFESSION?IT IS TO RAISE AWARENESS EVERYWHERE. UNFORTUNATELY, WE ARE IN THE TIME OF COMPLACENCY BECAUSE OF THE NEW DRUG THAT ARE OUT THAT PROLONG LIFE MAKE PEOPLE FEEL BETTER, HAPPIER, HEALTHIER, AND SOME PEOPLE THEY HAVE NOT SEEN THE NUMBER OF DEATHS THAT WE SAW BEFORE IN THE EARLY DAYS OF THE EPIDEMIC, AND THERE ARE NO REAL REMINDERS OF THE FACT THAT PEOPLE NEED TO GET TESTED. EVERYONE NEEDS TO GET TESTED IF THEY ARE SEXUALLY.NOW, WHEN THIS INITIATIVE FIRST PAST IT WAS SAID THAT ONE SIGN OF SUCCESS WOULD ACTUALLY BE AN INCREASE IN DIAGNOSED HIV CASES BECAUSE MORE PEOPLE WOULD BE SCREENED FOR THE DISEASE. IS THAT WHAT WE ARE SEEING?WELL, THAT IS HARD TO DETERMINE AT THIS POINT. THAT IS HARD TO DETERMINE AT THIS POINT BECAUSE WE DON'T HAVE A LOT OF TIME LAPSED BETWEEN THE OPTION OF THE POLICY NOW. WE STILL HAVE APPROXIMATELY 2000 PEOPLE WERE INFECTED IN SAN DIEGO AND DON'T KNOW THAT THEY'RE INFECTED. WE ALSO HAVE PEOPLE WHO ARE CURRENTLY LIVING WITH HIV, CLOSE TO 14,000. IT IS VERY DIFFICULT FOR PEOPLE TO TAKE FOR MEDICATIONS ON A REGULAR BASIS SO THEY GO IN AND OUT OF BEING ABLE TO TRANSMIT THE DISEASE. WE NEED TO GET PEOPLE REGULARLY ON MEDICATIONS, TAKING THEM CONSISTENTLY BECAUSE RECENTLY IT JUST CAME OUT THAT UNDETECTABLE IS UNTRANSLATABLE. THAT IS WHAT WE NEED TO GET TO.THE NUMBER OF NEW HIV TYPE OCS LAST YEAR IS AT 499. THAT IS VIRTUALLY THE SAME AS IT WAS IN THE PAST 2 YEARS. IS THAT WHAT YOU ABOUT THE FACT THAT IT IS REALLY TOO EARLY TO TELL WHETHER THIS NEW INITIATIVE IS REALLY MAKING ANY PROGRESS?RIGHT. THAT IS ABSOLUTELY RIGHT. WE ARE STILL SEEING ABOUT ONE YOUR PORTABLE CASE EVERY 18 HOURS IN SAN DIEGO COUNTY. WHAT WE WANT TO SEE IS NO REPORTABLE CASES. WITH ALMOST 500 IT IS A VERY DIFFICULT COAL TO ACHIEVE.WHAT IS THE HIGHEST RISK COMMUNITY FOR HIV INFECTIONS IN SAN DIEGO?IT IS STILL AMONG MEN WHO HAVE SEX WITH MEN BUT IT IS GOING INTO MORE OF THE MINORITY COMMUNITIES. THERE ARE HIGHER STATISTICS THERE. THE RATES ARE HIGHER IN AFRICAN-AMERICAN AND LATINO MEN, MEN WHO HAVE SEX WITH MEN BUT THIS IS NOT JUST A GAY DISEASE. IT IS A DISEASE OF HUMAN BEINGS AND ANYONE CAN CONTRACTED IF THEY ARE NOT SAFE.DO YOU SEE ANY SIMILARITIES BETWEEN THE SPREAD OF HIV AIDS AND HOW THE HEPATITIS OUTBREAK TOOK HOLD IN SAN DIEGO?THEY ARE BOTH AMONG DISENFRANCHISED POPULATIONS. WITH HEPATITIS A, IT WAS ORIGINALLY INJECTION DRUG USERS IN THE HOMELESS. WITH HIV WAS AMONG GAY MEN AND INJECTION DRUG USERS. AGAIN, DISEASES THAT ARE TEDIOUS WILL JUMP POPULATIONS. THAT IS WHAT WE ARE REALLY AFRAID OF, THAT SOME POINT IN TIME THIS IS REALLY GOING TO TAKE HOLD IN OTHER POPULATIONS AND IT COULD SPREAD IF WE ARE NOT DILIGENT ABOUT GETTING PEOPLE TESTED.DID WE USE ANY LESSONS LEARNED FROM THE HIV AIDS EPIDEMIC IN THE COUNTIES APPROACH TO THE HEPATITIS A OUTBREAK?I THINK ABSOLUTELY. THE COUNTY HAS BEEN VERY PROACTIVE IN GETTING PEOPLE VACCINATED FOR HEPATITIS A. THE COUNTY IS THE LARGEST PROVIDER OF HIV TESTING. I THINK THE COUNTY IS DOING A VERY GOOD JOB ON BOTH FRONTS.NOW, OF COURSE, THERE IS A VACCINE TO PROTECT PEOPLE AGAINST HEPATITIS A. OTHER TRIALS UNDERWAY FOR VACCINES AGAINST HIV?YES. CONSTANTLY, THERE IS WORK BEING DONE TO TRY TO CREATE A VACCINE. THE BEST THING WE HAVE RIGHT NOW IS PROPER PREEXPOSURE PROPHYLAXIS. THAT IS SOMETHING THAT IS AVAILABLE IF PEOPLE ARE LOW INCOME THEY CAN GET THE DRUGS FOR FREE. IT IS ONE PILL A DAY. WE ARE TRYING TO GET AS MANY PEOPLE ON PREP AS POSSIBLE.IS THE USE OF THE PREP PILL, IS IT MAKING A DIFFERENCE HERE IN SAN DIEGO?I THINK IT IS DEFINITELY MAKE A DIFFERENCE KEEPING THE SPREAD OF THE DISEASE DOWN.YOU SAID WE HAVE THE LATEST NUMBERS THAT ARE ABOUT 500 DIAGNOSIS OF HIV AIDS LAST YEAR. WE ARE TRYING TO GET TO THAT ZERO NUMBER. HE SAID, THAT IS PRETTY MUCH AN UPHILL CLIMB. HOW OPTIMISTIC ARE YOU ABOUT US BEING ABLE TO GET THERE BY 2026?I AM VERY OPTIMISTIC ABOUT IT. I THINK IT IS SOMETHING WE CAN DO. WE JUST NEED TO BE VERY DILIGENT ABOUT IT. WE NEED TO PUT THE RESOURCES INTO IT AND WE NEED TO KEEP GETTING THE MESSAGE OUT THERE THAT PEOPLE NEED TO GET TESTED BECAUSE THAT IS ABSOLUTELY THE FIRST STEP IN GETTING ON LIFE-SAVING TREATMENT.I HAVE BEEN SPEAKING WITH TERRY CUNNINGHAM, THAT THE RETIRED DIRECTOR OF HIV, STD, AND HEPATITIS BRANCH OF THE SAN DIEGO COUNTY DEPARTMENT HEALTH AND HUMAN SERVICES. TERRY, THANK YOU VERY MUCH.THANK YOU.
San Diego's hepatitis A outbreak has sickened at least 561 people since it began one year ago, according to figures released this week. Public health officials are continuing a targeted vaccination campaign, which they credit with slowing the spread of the disease.
Critics have accused officials of being slow to respond to the outbreak because it disproportionately affected illicit drug users and homeless people. The accusations recall another epidemic that continues to this day: HIV and AIDS.
Historians largely agree that the federal government was slow to respond to the HIV outbreak because it affected two marginalized groups: gay men and intravenous drug users.
"Unfortunately, there are significant parallels," said Terry Cunningham, retired chief of the HIV, STD and Hepatitis Branch of the county's Health and Human Services Department. Both diseases are easily spread by behaviors people are uncomfortable talking about, he said.
In the case of HIV, it is unprotected sex. In the case of hepatitis A, it is the spread of fecal matter.
Cunningham said that public health workers and nonprofits have had difficulty reaching the most at-risk populations for hepatitis A — people living on the streets — and have had trouble convincing them to get vaccinated.
"You have all of this fear, this misconception, these ideas that are unfounded, really exacerbating the issues at hand," he said. "It's amazing to me that we still have so many people who are uneducated about their health, about basic health care precautions. And it holds true still with HIV and with the hepatitis A outbreak."
Deputy Public Health Officer Sayone Thihalolipavan said public health officials have also learned a lot of lessons about disease prevention from the past mistakes of the HIV response, including building trust with at-risk populations and meeting them where they are, rather than expecting them to seek out help.
"Because of these stigmatized populations that we're dealing with, it's even more important to not pass judgment," he said. "They're so used to being judged that when you approach them and you don't judge them, often they're very appreciative … and they're more likely to work with you, partner with you and seek your services."
The number of hepatitis A diagnoses in the past year is fairly close to the number of yearly new HIV diagnoses in San Diego County. Officials say there were 499 new HIV diagnoses here in 2016. The number has been hovering around 500 for the past six years, meaning a new HIV infection occurs on average about every 18 hours.
The medical tools for preventing Hepatitis A are more advanced than those for HIV. The hepatitis A vaccine, introduced in the mid 1990s, is highly effective at preventing infection. There is still no vaccine for HIV, though HIV-positive individuals can become non-infectious if they are treated with antiretroviral drugs.
There is also a drug, Truvada, that is highly effective at preventing infection in HIV-negative individuals — but it has to be taken daily. The county's plan to eliminate new HIV infections within the next decade, called "Getting to Zero," relies heavily on expanding the prophylactic use of that drug in high-risk populations.
Cunningham said a major challenge in meeting the goal of zero new HIV infections is a lack of resources.
"Prevention funding was cut horribly back during the economic downturn," he said. "The County Board of Supervisors wisely passed the "Getting to Zero" policy … but it's an unfunded policy. So we don't have any more funding to do any more than we did before that policy was initiated."