Ward 86, the first dedicated HIV inpatient clinic in the United States, marked its 40th anniversary with a celebration at Zuckerberg San Francisco General Hospital (ZSFGH) on January 25. A key element of the so-called San Francisco model of comprehensive community-based care, the clinic has pioneered innovations in HIV treatment and prevention that have been adopted nationwide and around the world.
“Treatment has dramatically changed the lives of our patients,” said Diane Havlir, MD, chief of ZSFGH’s HIV, Infectious Diseases and Global Medicine Division, at the event. “But two things about Ward 86 have not changed. Number one, it is patient-centered. And second, we are constantly figuring out better ways to deliver all the scientific advances in HIV to our patients. I tell people that Ward 86 is the Silicon Valley of innovation for AIDS care.”
The Ward 86 outpatient clinic opened its doors in January 1983, followed by the opening that July of Ward 5A, ZSFGH’s designated inpatient ward for people with AIDS.
“Between the outpatient and the inpatient units, we launched a number of research initiatives and clinical care programs to improve the care of those living with HIV, not just in San Francisco but to provide models for HIV care around the country and internationally,” Ward 86 medical director Monica Gandhi, MD, MPH, told POZ.
Former National Institute of Allergy and Infectious Diseases director Anthony Fauci, MD, who stepped down from his position this past December, offered his congratulations in a video address.
“Ward 86 has a special place in HIV’s history dating back to the early dark days when San Francisco was the epicenter of the HIV epidemic in this country and previously healthy young individuals were dying despite our best efforts to provide the supportive treatments available to us at that time,” he said. “What has become known as the San Francisco model became renowned as the best approach to HIV patient care in the world.”
Four Decades of Innovation
Ward 86 has been at the forefront of the innovations in care and treatment that turned an inevitably fatal disease into a chronic, manageable condition.
“The research over the years at Ward 86 has been stellar, from some of the earliest and most important clinical trials to implementation research, notably for people experiencing homelessness and other hard-to-reach individuals,” Fauci recalled.
Ward 86 investigators helped lead some of the major clinical trials of experimental HIV treatments, including the first trial of AZT (Retrovir) and studies of protease inhibitors and combination antiretroviral therapy, which began to turn the epidemic around in the mid-1990s.
In 2010, even before the START trial definitively showed that early treatment initiation leads to better outcomes, Ward 86 and other San Francisco Department of Public Health (SF DPH) providers were the first to recommend antiretroviral treatment for all people diagnosed with HIV, regardless of CD4 T-cell count—two years before national guidelines did the same.
In 2013, Ward 86 created its RAPID ART program, which helps people start treatment as soon as possible after diagnosis to avoid falling through the cracks while waiting for test results or follow-up appointments.
Ward 86 also continues to play a role in HIV cure research. Steven Deeks, MD, and colleagues have been studying a cohort of elite controllers, people who are able to naturally control the virus without antiretrovirals, in an effort to learn how to achieve long-term remission.
In a video address that he started at Ward 86 in 1993, Deeks recalled “one of the low points” when it had become clear that available treatments were not working. In 1995, he and colleagues at the University of California San Francisco (UCSF) and the University of Pittsburgh tried an idea “that sounded completely crazy and still does”: giving activist Jeff Getty a baboon bone marrow transplant, which led to insights about the role of inflammation in HIV disease.
“Everywhere I went, people wanted to figure out what was the ‘magic sauce’ that made everything so unique at Ward 86,” Deeks said. “I always thought it was this amazing collaboration between patients and providers and the academic community and all the virologists and immunologists at UCSF and all the resources that were available. It all came together on Ward 86 at that time and since then.”
Reaching Those in Need
As Fauci noted, the population affected by HIV in San Francisco has changed over the years.
In 2008, Ward 86 opened a women’s clinic. It launched the SALUD clinic for Spanish-speaking clients in 2016. The following year saw the debut of the Golden Compass program, which provides comprehensive care for HIV-positive people over age 50. According to SF DPH’s latest HIV epidemiology annual report, 73% of city residents living with HIV are 50 or older. And Ward 86 does not limit itself to HIV treatment; it also runs a pre-exposure prophylaxis (PrEP) clinic for HIV prevention.
Today, Ward 86 serves some of the city’s most disadvantaged people living with or at risk for HIV. Many are living in poverty, 96% rely on Medicaid or Medicare, a third lack stable housing and rates of mental illness and substance use are high.
“The model of HV care at Ward 86 evolved as the epidemic unfolded and has continued to adapt to the many changes seen in more recent years,” Paul Volberding, MD, who founded Ward 86 with Donald Abrams, MD, and the late Constance Wofsy, MD, told POZ. “From the start, it brought needed services of many forms to a single site in a coordinated, compassionate and effective manner that is truly responsive to patient needs.”
In 2019, Ward 86 launched the POP-UP program to provide specialized HIV care for homeless and marginally housed people. According to the city’s latest epidemiology report, 24% of individuals newly diagnosed with HIV in San Francisco in 2021 were homeless. What’s more, HIV-positive people experiencing homelessness are least likely to have an undetectable viral load, at just 27%.
The latest Ward 86 initiative is SPLASH (Special Program on Long-Acting Antiretrovirals to Stop HIV), which aims to broaden the use of long-acting injectable treatment to a safety-net population. (See sidebar, “A Long-Acting Lifeline.”)
“I know from my time in DC that people always ask what’s happening in San Francisco, and what they were really asking is what’s happening at Ward 86,” said San Francisco Director of Health Grant Colfax, MD, who formerly served as director of the Office of National AIDS Policy during the Obama administration. “We are here today because of our doctors, our nurses, our community partners and activists who push the bureaucracy to do more and, of course, most importantly, the patients. We’ve all championed the importance of getting to zero as we continually advance our mission with compassion and equity.”
A Long-Acting Lifeline
In 2021, the Food and Drug Administration (FDA) approved the first long-acting injectable regimen, Cabenuva (cabotegravir plus rilpivirine), which is administered by a health care provider once monthly or every other month. So far, it is approved only for people who already have an undetectable viral load and wish to switch to a more convenient regimen.
But Cabenuva may also be a feasible option for people starting treatment for the first time and those who have been unable to achieve and maintain viral suppression due to challenges with treatment adherence. Ward 86 is now implementing this approach with SPLASH, the Special Program on Long-Acting Antiretrovirals to Stop HIV. The program offers a range of support, including case managers, phone or text reminders of upcoming injection visits, follow-up for those who miss appointments and even street-based nursing services.
“By trying to use these novel agents in patients with concomitant life challenges, we hope to get individuals suppressed on therapy who have never been suppressed before and change the trajectory of the HIV epidemic,” Ward 86 medical director Monica Gandhi, MD, MPH, told POZ.
Gandhi and her team evaluated outcomes among 133 people who switched to Cabenuva from an oral antiretroviral regimen. Two thirds were homeless or lacked stable housing, and many were dealing with substance use and mental health problems. A majority (76 people) already had an undetectable viral load on their current medications; all of them maintained viral suppression after switching to the injections. The more exciting finding, Gandhi reported at this year’s Conference on Retro-viruses and Opportunistic Infections, was that outcomes were nearly as good for the 57 people who started with a detectable viral load and in some cases advanced immune deficiency: All but two achieved viral suppression.
Use of Cabenuva for people without current viral suppression goes beyond the FDA-approved indication, and it might not be an option for those who don’t have the same level of intensive support provided by Ward 86. But for some, it could offer a lifeline.
“We’re seeing phenomenal results,” says Ward 86 nurse manager Jon Oskarsson, RN, MN. “People who had not in a long time or ever been able to suppress their HIV now are suppressed. It can be a tool for people who are living with a ton of complexity in their lives.”