Denver Committed to Ending the AIDS Epidemic by 2030

Aug. 15 marked a proud day in Denver’s history — it was the day the city signed the Paris Declaration and, in doing so, joined the Fast-Track Cities Initiative. What is the significance of this? Well, it means Denver has committed itself to ending the AIDS epidemic by 2030. It may sound ambitious, but of the more than 200 cities signed on to the initiative, Denver is one of the most well-positioned to succeed.

“If any city in the world can do and will do it, it’s Denver,” says Benjamin Young MD, the senior vice president and chief medical officer of the International Association of Providers of AIDS Care (IAPAC). IAPAC is one of four key partner organizations in this initiative, the other three being the city of Paris, the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the United Nations Human Settlements Programme (UN-Habitat).

To reach the 2030 goal, the initiative has gone ahead with a 90-90-90 targets plan, which aims for 90 percent of people living with HIV knowing their HIV status; 90 percent of people who know their HIV-positive status being on HIV treatment; and keeping 90 percent of people on treatment with suppressed viral loads. All of this by 2020. The initiative also calls for an end to discrimination, including stigma. [quote]“Without working towards decreasing stigma, it makes it a lot more difficult to think about truly ending the epidemic.”
— Sarah Rowan, MD[/quote]

“Denver is very close to achieving these 2020 targets,” says Young.

Sarah Rowan MD is the interim director of HIV and Viral Hepatitis Prevention with Denver Public Health (DPH), and she backs Young’s claims. She is steering the citywide effort to measure the data for the 90-90-90 targets, as well as playing an important role in testing, treatment, and prevention.

According to Rowan, the Denver Metro area (Denver, Adams, Arapahoe, Douglas, and Jefferson County) has already reached the 90 percent point when it comes to diagnosis. Even conservative estimates point to no fewer than 86 percent. “Denver has come a long way in reaching previously undiagnosed persons,” she says, while advancing that DPH is still trying to identify ways of targeting the remaining 10 percent.

The second target presents the biggest obstacle. Of those in the Denver Metro area that know they are HIV-positive, about 74 to 80 percent are in care (though not necessarily on medication). Rowan says DPH is trying to develop tools to close what, on the surface, appears to be a small gap. “It will be a challenge.”

Fortunately, due to a change in guidelines, Denver is well on track to reach the third target. About 82 percent of people in care have suppressed viral loads in the Denver Metro area. The reported numbers should increase in the near future, as DPH expects everyone who is HIV-positive to be in treatment. “We can certainly get to that last 90 as well. I think that’s definitely attainable in the next five years.”

[quote]“Some of the best economic models suggest that when you put people on treatment, you actually save healthcare systems’ money.”
— Benjamin Young, MD[/quote]

Young, who has been a frontline HIV clinician in Denver since 1995 and currently takes care of people with HIV at Denver’s APEX Family Medicine, agrees. “It’s really not an issue of whether this is feasible — it’s an issue of whether there is sufficient imagination and courage to demand that these things happen.”

In light of signing the Paris Declaration, Denver’s answer appears to be “yes” on both counts. “That signature was symbolic of the community organizations and the individuals that support those organizations strongly committing to ending the epidemic in our community, and doing so on a real timeline.”

The hows are incredibly important here, and they’re already coming together.

Earlier this year DPH launched Denver Bring It Up, a public information campaign that addresses stigma. It focuses on testing, considering pre-exposure prophylaxis (PrEP), getting on treatment, and more. Reducing discrimination is a big component of the Fast-Track Cities Initiative because of the unlikelihood that those who have experienced stigma will enter the healthcare system to get tested or to seek treatment.

“Without working towards decreasing stigma it makes it a lot more difficult to think about truly ending the epidemic,” says Rowan. To that end, DPH set up a pledge page where people can support the 90-90-90 initiative.

DPH also plans to expand testing sites and to get into harder to reach communities. What’s more, they’re also aiming their marketing efforts at encouraging those who are HIV-positive to take their medications because, “when people are on HIV meds they are much less likely to transmit.”

As for getting people into care, she says frontline workers have been successful in that regard. But keeping them there is another story. “Staying in care is our biggest challenge,” she admits. Using surveillance tools to promote retention is a possibility DPH is looking into.

With regards to work around viral suppression, Rowan says the contributions of pharmacists and HIV clinics have been invaluable, and that the positive results are evident. “We know that the medications are highly effective.”

Of course there are those that will undoubtedly claim that the goals outlined in this initiative are too costly. Not so, says Young.

“Some of the best economic models suggest that when you put people on treatment, you actually save healthcare systems’ money,” he says. “It’s actually cost-effective to treat people in the long run.”

As far as resources go, he believes the government can find them. “The US spent two trillion dollars in Afghanistan and Iraq. And those are different kinds of dollars and such, but that’s the kind of money that eradicates or treats everybody with HIV for centuries.”

The human cost is far greater, with an average of 4000 people dying everyday around the world from HIV-related causes. Young demands our outrage. “At the height of the Nazi Holocaust, 4000 people died in ovens in Auschwitz. So metaphorically, we are witness to an Auschwitz everyday.”

On a local level, according to a city surveillance report there were 132 new cases of HIV in Denver County in 2013, this compared to 148 in 2012 and 157 in 2011. So with numbers already on the decline and those 90-90-90 targets almost entirely reached, why sign the Paris Declaration?

“To get all the stakeholders together with the same set of goals is really helpful to us,” explains Rowan. Denver signing on means support for DPH’s new programs and approaches, and a wider reach in terms of HIV programming, as DPH doesn’t provide all the care or testing in the city. As for IAPAC’s role, she believes they’ll be helpful in “getting information out to the general public.”

In 2030, HIV and AIDS will still exist. Total eradication is seemingly impossible. But if IAPAC, DPH, and their partners have it their way, the AIDS epidemic will certainly be a tragedy of the past.

“The initiative is about ending epidemics,” says Young. “I believe that that’s entirely achievable.”