City's HIV epidemic said to be over
by Matthew S. Bajko
Speaking at the San Francisco AIDS Foundation gala in May, the agency's executive director did not mince words. Two sentences into his speech that night, Mark Cloutier made a startling announcement.
"The HIV epidemic is over. Yes. The HIV epidemic in San Francisco is over," said Cloutier, according to a copy of his prepared remarks.
Instead, Cloutier and other health officials now consider HIV to be endemic in the city, meaning it is a disease that persists in the community without substantially increasing or decreasing over time.
"It is not an epidemic anymore, not when you are getting a slow down of incidences," said John Newmeyer, an epidemiologist at the Haight-Ashbury Free Clinic. "I don't have any concerns about dropping epidemic. It is something we have worked for for a long time."
Designating HIV as endemic could have wide-ranging consequences for how San Francisco addresses not only preventing HIV infections but also cares for those people living with HIV and AIDS. The push to adopt such a change comes as community members host a town hall forum tonight (Thursday, July 26), the first of numerous meetings scheduled over the next six months, to kick off a public debate on how the city should adapt its now 26-year-old system of AIDS care.
A parallel discussion is taking place at the HIV Prevention Planning Council, which is updating the city's 2004 HIV Prevention Plan. As part of its discussions, the council is considering whether to drop epidemic for endemic in the plan, which sets out guidelines for how the health department and AIDS agencies reduce HIV rates.
Overseeing that debate will be the city's HIV prevention director, who serves as a co-chair of the HPPC. The city is close to announcing a permanent person for that post, and sources have told the Bay Area Reporter that the top two candidates are Grant Colfax, director of HIV prevention studies in the health department's HIV research section, and Dan Wohlfeiler, with the California Department of Public Health's STD Control branch.
Neither Colfax nor Wohlfeiler responded to requests for comment.
"We were fortunate to have a number of very strong candidates for this position. As soon as we make a decision and a candidate accepts, we will be pleased to make the announcement public," Barbara Garcia, deputy director of the health department, stated in an e-mail.
Six years of stable HIV rates
HIV in San Francisco is no longer the out-of-control scourge it once was in the 1980s and 1990s. Since 2001, infection rates in the city have leveled off, with new HIV cases remaining fairly stable at between 800 and 1,000 a year.
Thus, HIV no longer fits the definition of an epidemic, which city health officials define as meaning the spread of a disease is increasing.
"My own personal opinion would be, from a technical point of view, we have an AIDS endemic, not an epidemic, based on what the words mean. Epidemic means an exponential growth in new cases," said Health Director Dr. Mitch Katz. "All the data still shows it is stabilized. Endemic is the more correct term."
Not everyone agrees it is time to drop the word epidemic, fearing doing so would send the wrong message to the community, and gay men in particular, that HIV is no longer a serious health problem. Gay men continue to account for the bulk of HIV cases in San Francisco.
"I don't like the idea of it not being called an epidemic. It will give people the impression they can let their guard down," said Mike Smith, executive director of the AIDS Emergency Fund. "It seems to me the choice of which word to use is a matter of semantics."
Stop AIDS Project deputy director Jason Riggs also expressed concerns about how a shift in words would be interpreted by gay men and others. Using endemic not only overlooks those parts of the community where HIV continues to spread, such as among African American men, said Riggs, but also implies that HIV will be a part of the gay community for years to come.
"What's in a name? It doesn't change the facts of HIV transmission. The fact is almost 1,000 people are getting infected in San Francisco and that is still too high," said Riggs. "Three hundred men a year die of AIDS in San Francisco. It is like a plane crashing each year in San Francisco. We need to remain vigilant."
Dr. Willi McFarland, chief of the health department's HIV Epidemiology Section, told the HPPC in May that HIV rates among gay and bisexual men, and in the city as a whole, "could very well" be characterized as endemic. But he stopped just short of endorsing dropping epidemic.
In an interview this week McFarland said the current data he has seen does not show an upswing in infections, but nor does it show a precipitous drop in rates. Nonetheless, he is still hopeful that instead of HIV rates being endemic that new infections will continue to decline.
"We should think about the possibility we may be entering a phase where it will oscillate between 500 and 1,000 new infections each year. If it is neither rising nor falling than it is leaning toward an endemic," he said. "I hope this isn't what is going to happen and that things will continue on downward."
Back in 2004, the HPPC did drop use of the word epidemic when it came to HIV rates among injection drug users. According to the plan, needle exchange programs and prevention efforts reduced HIV infections in that subgroup to "endemic (as opposed to epidemic) levels."
But overall the plan refers to "San Francisco and its HIV and AIDS epidemic." Some council members have asked if epidemic should be dropped altogether in the 2008 revised plan. The council voted in April to have its "Show Me the Data" committee determine if HIV is now endemic among gay and bisexual men.
Others remain skeptical. HPPC member Randy Allgaier said while HIV rates may indeed be endemic among gay men, he does not think the same can be said of infection rates in other communities.
"It seems a little gay-centric. In other communities I think it is an epidemic," said Allgaier. "I would be hard pressed to find an African American woman who wouldn't say this is an epidemic in her community."
HPPC Co-Chair Tracey Packer, the city's interim HIV prevention director, said this month she is not ready, yet, to declare the HIV epidemic over. And even if endemic is a more accurate description for the city's HIV rates, it doesn't change the health department's ultimate goal to see those rates decline further, she said.
"Endemic to me is as important as epidemic," said Packer. "We don't want the numbers to be stable. We want the numbers to be going down."
Cloutier stressed a similar stance in his speech this spring. Even flat HIV rates, he argued, remain problematic and require people to continue to take precautions to protect themselves and their sexual partners.
"If talk of disease stability makes it look as if we've averted the kind of crisis that would throw the world into total chaos, perhaps we should be thankful. But since HIV transmission is 100 percent preventable, we've earned very few bragging rights," he said.
Debate about the word change may appear to be a needless semantic argument, but those pressing to see the city drop the word epidemic argue doing so will give better guidance to San Francisco health officials as they address how to fight against HIV going forward.
Cloutier said in an interview last week that referring to an HIV endemic would result in changes to how health providers and AIDS agencies address the disease.
"If it is endemic, meaning it has become stable, you need a different set of responses from a prevention perspective and a services perspective. You need new tools to break that cycle," he said. "An endemic framework leads you to ask questions, such as what can we do further to work with the HIV positive population to reduce new infections in addition to the HIV-negative population."
Packer, however, wasn't convinced switching terms would mean a wholesale change in how her section approaches HIV prevention. Prevention with positives, for example, already is a top priority in San Francisco.
"Regardless whether it is epidemic or endemic, we need to study the data on what we know about risk behavior," said Packer. "We don't know that we would do prevention differently."
Tonight's town hall forum is designed to elicit input from community members on just what the future of HIV prevention and care in San Francisco should look like. As the city continues to see its share of federal dollars to treat and prevent HIV decline, the answer is especially important, organizers said.
"The epidemic has changed so our response has to change," said Steven Tierney, SFAF's deputy director of programs.
The meeting will take place from 6 to 8 p.m. tonight in the Milton Marks Conference Center at the California State Building, 455 Golden Gate Avenue (between Larkin and Polk Streets).