Issue:  Vol. 48 / No. 3 / 18 January 2018

Dramatic changes in store for SF HIV prevention


Dr. Grant Colfax (Photo: Rick Gerharter)
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Come September 1 San Francisco's HIV prevention efforts are set to undergo a sea change.

New contracts totaling nearly $7 million for AIDS agencies are expected to take affect that day. Funding for HIV prevention tactics of old, however, is giving way for new priorities health officials hope will lead to dramatic reductions in HIV rates.

"We want to make San Francisco the first city to eliminate new HIV infections," Dr. Grant Colfax, the city's HIV prevention director, said at a forum last month detailing the new focus.

The changes have been under way since Colfax took over the health department's HIV Prevention Section in 2007. But it wasn't until now that he has been able to reshape the budgetary process, which is re-examined every five years.

Through the funding allocations Colfax is ushering in a new direction for how the city, and the community-based agencies it funds, approach reducing the spread of HIV. Some agencies are facing a drop in funding, while those granted contracts are being warned they will face greater oversight to ensure they are meeting agreed upon goals.

With contract negotiations still being finalized, Colfax has yet to release specifics about the agencies being funded and what services they will be providing. He has discussed the changes in broader terms.

A higher focus is being given to testing people regularly and offering treatment sooner to people who are HIV-positive in an attempt to further reduce new infections in San Francisco.

"How do you link people to care? It is hard. It is not going to be easy, but we have to do it," said Colfax.

More attention is also being paid to the overall HIV viral load in the community, as new research has shown reducing viral load counts helps bring down new HIV infections.

With many gay and bisexual men practicing sero-sorting, where they either seek out sexual partners of the same HIV sero-status or tailor their sexual behavior and condom usage based on their sexual partner's HIV status, seeing that viral loads in HIV-positive people are at undetectable levels can help to halt HIV transmission.

"If people are not going to use a condom your HIV risk is still low because of community viral load suppression," said Colfax.

With San Francisco's HIV rates stalled at endemic levels, meaning new infections have remained steady for the last 11 years, Colfax has argued the city's world-renowned system of HIV care it has relied on since the beginning days of the AIDS crisis 30 years ago is no longer viable.

"Unless we change what we do, we are not going to eliminate new infections because we are in an endemic," said Colfax.


But the HIV Prevention Section's shifting priorities have caused concern among HIV/AIDS providers who have doubts about de-emphasizing health education and risk reduction for an increased emphasis on testing.

"There has been a lot of tension around this because things are changing," said Colfax.

One of the most vocal agencies critiquing the changes has been the Asian and Pacific Islander Wellness Center. It contends that the needs of the city's API community are "being completely overlooked" as greater attention is being given to gay and bisexual men of other ethnicities, injection drug users, and transgender women.

"This is just bad public health policy," stated Mike Rabanal, the center's board chair. "The choices San Francisco makes have the power to shift national HIV policy. If we fail to address the public health needs of the significant API population locally, we're sending a message that the impact of the epidemic in our communities doesn't matter."

Openly gay Supervisor Scott Wiener, whose District 8 has some of the city's highest concentrations of HIV-positive residents, said he is aware of the criticisms some groups have raised about the new funding decisions.

At the same time, Wiener also expressed confidence in the direction Colfax is advocating the city needs to head.

"I know that changes have been made and I have spoken to Grant about those changes. I think very highly of Grant, he does amazing work and has a really strong vision," said Wiener. "But I also am open to voices in the community from people working in HIV prevention services."

San Francisco health researchers estimate that there are 736 new HIV infections each year in the city, though the number could be as low as 621. A decade ago, there were more than 1,000 new infections a year.

The city's goal is to reduce new HIV infections by 50 percent by 2017. Objectives include cutting new HIV infections among gay and bisexual men and eliminating new infections among injection drug users.

At a discussion about the impending changes during the HIV Prevention Planning Council meeting Thursday, July 14, Tracey Packer, deputy director of the HIV Prevention Section, acknowledged the section "hadn't been as open and clear" as it needed to be in explaining its new approach.

Agency officials, however, are limited in what they can say until the request for proposal process is completed, said Packer. In most cases, she said the programs would start September 1.

The process has gone on for two or three years, she noted, adding that, "for the first time, it seems like we might really see a big reduction in new infections."

In her presentation, Packer said that expected outcomes include 75 percent of gay and bi men, injection drug users, and transgender women who have sex with men in San Francisco would know their HIV status. Among other outcomes, 85 percent of HIV-positive people would have suppressed viral loads.

Officials have worked to establish targets, said Packer, "that are easy to measure," such as the number of tests that have been given.

Objectives for community-based testing include having prevention section office-supported programs conduct a total of 30,000 HIV tests annually by 2013.

Agencies in negotiations with the city in this area are the San Francisco AIDS Foundation, which oversees Magnet, working with subcontractors St. James Infirmary and Glide Memorial United Methodist Church; UCSF AIDS Health Project, collaborating with subcontractor Stop AIDS Project; and the health department's STD Prevention and Control unit.

In the health education and risk reduction to address drivers area, objectives include 90 percent of clients who are HIV-negative or don't know their status will be offered an HIV test. That figure applies to people who participate in prevention office-supported programs. Drivers include methamphetamine and alcohol use, and multiple sex partners.

Agencies included in this category include Instituto Familiar de la Raza, with subcontractors Mission Neighborhood Health Center and SFAF; Tenderloin Health; and SFAF's Stonewall Project.

HPPC member Jackson Bowman said Packer's presentation reflected "a big departure" from what's previously been done.

"The deliverables are unbelievable," Bowman said.

While he appreciated a challenge, Bowman nonetheless said he was concerned about the emphasis on what he and others call the "test and treat" model.

The new focus is "really medicalized," he said, and puts people in a position where "all we're trying to do is meet our numbers."

Bowman expressed concern about women and young people being left out.

He said the plan is "as full of as many problems as it's been before."

Council member Desmond Miller, who works at Larkin Street Youth Services, also appeared worried about young people.

"The youth we serve, they're not going to go to Magnet," the gay men's health center in the Castro neighborhood, he said.

Packer acknowledged there's more emphasis on testing, but said agencies can be creative in how they include people.

She also indicated the department would work with its contractors to be successful.

"Nobody's going to fail," she said.

Packer also defended increased emphasis on testing. She noted there are people who don't know their status, and "we can't let that happen."

Council member Denmark Diaz, a community member, said he didn't see how the prevention office "is going to be able to serve populations who are not prioritized," such as women, youth, and Native Americans.

Packer said that officials would work to address gaps but noted the department's funds are limited, and they have less money to work with than they used to.

She also said the council "made a decision we are going to prioritize our funding" for groups such as men who have sex with men and intravenous drug users. That is what the plan does, she said.

"I feel the tension in the room about who these programs are reaching" and who's not going to be reached, said Packer. But she added that reducing infections in the highest priority groups also helps to improve data for everyone else.

Packer said the agency would continue meeting with providers to discuss service gaps and other issues.

A community meeting is set for Monday, August 1, from 6 to 9 p.m. at the city's LGBT Community Center, 1800 Market Street.

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