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

SF HIV infections and
deaths fall, report says


New HIV diagnoses, deaths, and prevalence in San Francisco, 2006-2014. Photo: Courtesy SF DPH
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Newly diagnosed HIV infections and deaths among people living with HIV in San Francisco reached new lows in 2014, and the city continues to do a better job getting people tested and treated than the state or nation as a whole, according to a new report.

But some notable disparities persist with regard to race, age, gender identity, and homelessness, according to the SF Department of Public Health's latest HIV Epidemiology Annual Report.

The report, which covers data through the end of 2014, and was released last month, shows that the number of new HIV diagnoses in San Francisco fell by 18.5 percent, from 371 in 2013 to 302 in 2014 – the lowest number since the start of the epidemic. The total number of new HIV infections (known as incidence) – estimated at 358 in 2014 – is higher than the number of newly diagnosed cases because not everyone is tested immediately.

"The 2014 report shows a decrease in newly diagnosed infections, among other successes in HIV prevention and care," said Tracey Packer, the health department's director of community health equity and promotion. "This decrease is due to the success of new HIV prevention strategies developed in partnership with community members, HIV prevention and care organizations, and the health department."

The decline in new infections is thought to be due to a combination of factors, including widespread testing, early antiretroviral treatment, and possibly early signs of the impact of pre-exposure prophylaxis, or PrEP.

In 2010, San Francisco was the first city to recommend antiretroviral therapy for everyone diagnosed with HIV regardless of CD4 T-cell count; U.S. treatment guidelines adopted the same recommendation in 2013. Prompt treatment lowers the risk of illness and death, and people on treatment with an undetectable viral load have a near-zero risk of transmitting the virus.

The U.S. Food and Drug Administration approved Gilead Science's Truvada (tenofovir/emtricitabine) for PrEP in July 2012, but adoption was initially slow. Interest began to rise more steeply after the Centers for Disease Control and Prevention recommended in May 2014 that people at substantial risk for HIV infection should consider using it. But the level of PrEP uptake was likely not yet high enough to have had a substantial effect on last year's HIV incidence numbers.


Fewer deaths, more people in care

The number of deaths due to all causes among HIV-positive people in the city decreased by 15.3 percent, from 209 in 2013 to 177 in 2014. As deaths have declined thanks to effective treatment, the total number of people living with HIV (known as prevalence) has risen, reaching 15,979 in 2014. Of these, 9,567 people had stage 3 HIV disease, or AIDS.

San Francisco continues to do a good job of encouraging people at risk for HIV to get tested and those living with HIV to access care and start treatment, the report noted.

According to the report, 93 percent of people with HIV in San Francisco know their status, compared with 87 percent nationwide. Among San Franciscans newly diagnosed with HIV in 2013, 83 percent were linked to care within three months, 70 percent were retained in care three to nine months later, most were prescribed antiretroviral therapy, and 67 percent achieved viral suppression. Among all people living with HIV – whether diagnosed or not – the city estimates that 60 percent have undetectable viral load, compared with just 30 percent nationwide.

"These data show that San Francisco leads the nation in progress against HIV," Project Inform Executive Director Dana Van Gorder told the Bay Area Reporter. "They result from an intense emphasis on assuring high levels of HIV testing and linkage to care, encouraging early uptake of HIV treatment, and PrEP implementation – in addition to an extensive network of social services."

But not everyone in the city has benefitted equally from efforts to stem the epidemic.

The majority of living HIV cases in San Francisco are gay men age 50 and over. African Americans – who make up under 6 percent of the city's population – account for 13 percent of HIV-positive people, while Latinos account for 18 percent. Homeless people are also disproportionately affected by HIV.

According to the report, the majority of new HIV infections in 2014 occurred in the 30-49 age bracket. That age demographic accounted for 54 percent of people newly diagnosed with HIV last year. The number of new infections among people age 18-29 fell to 29 percent, from 34 percent in 2013, whereas the number of new infections in people age 50 and older increased 5 percent to a total of 17 percent in 2014.

Only 6 percent of San Francisco residents with HIV were non-transgender women, while trans women accounted for 2 percent of cases – far higher than their percentage in the population. No children have been diagnosed with HIV in the city since 2006.

African Americans, young adults, people over age 50, people who inject drugs, and women – both cisgender and transgender – were less likely to access HIV care and achieve viral suppression.

"Even with this good news, there are HIV health disparities that we need to continue to address," said Packer.

The findings in the annual report show that the city is making progress toward Getting to Zero – a collaborative effort to make San Francisco the first U.S. jurisdiction to achieve the UNAIDS goals of eliminating new HIV infections, HIV-related deaths, and HIV stigma, using a three-prong strategy of expanded access to PrEP, rapid access to antiretroviral therapy, and retention of HIV-positive people in care.

Some people, however, have suggested that the news is not all good. Brian Basinger, director of the AIDS Housing Alliance/San Francisco, told the B.A.R. that people with HIV are being displaced from the city due to the high cost of housing, while others say the people most vulnerable to HIV infection can no longer afford to live here.


More funds on the way

On September 8 the CDC announced that SF DPH is among 17 organizations across the country that will receive more than $185 million in total funds to prevent HIV among gay and bisexual men and transgender people, particularly African Americans and Latinos.

San Francisco is receiving funding, to be provided over three years, to accelerate PrEP uptake and engage more people in HIV care, according to CDC media liaison Nikki Mayes.

The new CDC money – along with funds provided by Mayor Ed Lee and forthcoming PrEP funding allocated by the Board of Supervisors – are expected to help address the disparities highlighted in the annual report.

"As well as we have done, San Francisco must address key challenges in order to get to zero," Van Gorder concluded. "Young gay men of color, transgender women, and women of color need greater focus and strengthened services. And, once linked to care, we have to do a much better job of making sure that all people with HIV are supported to remain in care and treatment – these encouraging data suggest that we can succeed in doing so."


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