Latinos now have highest rate of new SF HIV cases

  • by Liz Highleyman, BAR Contributor
  • Tuesday December 5, 2023
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San Francisco Health Director Dr. Grant Colfax. Photo: Rick Gerharter
San Francisco Health Director Dr. Grant Colfax. Photo: Rick Gerharter

The 2022 HIV epidemiology report released by the San Francisco Department of Public Health Tuesday showed that for the first time, Latino men had a higher HIV diagnosis rate than Black men. The city is ahead of California and the country when it comes to PrEP use and other indicators of care, but disparities persist, especially for people of color, people who inject drugs and those experiencing homelessness.

Overall, new HIV diagnoses in San Francisco fell in 2022, following an uptick in the wake of the COVID pandemic, according to the latest epidemiology report from the health department.

"We are pleased to see that HIV diagnoses have declined substantially since Getting to Zero was launched in 2013 and that many people are receiving the immediate care they need," Health Director Dr. Grant Colfax, a gay man, said in a statement. "However, we will not be satisfied until we get to zero new infections, and more must be done. Breaking down barriers to provide stigma-free care that reaches the community is key, and working together across San Francisco's robust HIV care and prevention infrastructure, we will do just that."

The city's Getting to Zero program aims to reduce new HIV transmissions and HIV deaths by 90% by 2025, in addition to reducing stigma.

There were 157 new HIV diagnoses in San Francisco in 2022, down slightly from 166 in 2021. The 2021 number exceeded the 147 cases reported in 2020, which could have been due to a resumption of HIV testing following the COVID shutdown. New cases have decreased by 12% since 2019, which is greater than the 2% nationwide reduction but far below the 56% decrease seen in the pre-pandemic years from 2013 to 2019.

"We've seen a bit of a slowing in the decline in the number of new diagnoses," Dr. Susan Buchbinder, director of DPH's Bridge HIV and co-chair of the SF Getting to Zero steering committee, told the Bay Area Reporter in an interview. "We're not seeing the same rapid decline that we saw previously, which means we need to redouble our efforts to reach the people we're not reaching."

Most people newly diagnosed with HIV in 2022 were men (84%), including 61% men who have sex with men and 11% gay or bisexual men who also inject drugs. In 2021, the proportion of cases among gay and bisexual men who don't inject drugs fell below half for the first time. Buchbinder suggested the higher proportion for gay men in 2022 may in part be attributable to the drop in cases among cisgender women, which fell from 14% to 9%. In addition, 6% of new cases were among transgender women and 1% among trans men.

A majority of people newly diagnosed in 2022 was between the ages of 25 and 50. Eighteen people were ages 18 to 24 at diagnosis. No infants have been born with HIV and no children have been diagnosed with HIV since 2005.

Latinos made up the largest share of new cases, at 43%, followed by white people (29%), Black people (15%), and Asians and Pacific Islanders (10%). What's more, Latinos were the only group to see an increase in new diagnoses, while Black and white people saw a decline. Looking at HIV rates relative to share of the population, Latino and Black men had the highest rates (84 and 68 cases per 100,000 people, respectively) compared with 19 and 9 per 100,000 for white and Asian/Pacific Islander men, respectively. Most newly diagnosed cisgender women were Black.

The report shows that disadvantaged groups bear the brunt of the city's HIV epidemic. People who inject drugs accounted for 19% of new diagnoses in 2022, down from 27% in 2021, while people experiencing homelessness accounted for 17%, down from a peak of 23% in 2021.

The new data bring the total number of San Franciscans living with HIV to 11,798 at the end of 2022. A higher number (15,537) were city residents at the time of diagnosis. People ages 50 or older now make up 73% of the HIV-positive population, reflecting longer lifespans thanks to effective treatment. No children or adolescents ages 17 or under were living with HIV in 2022, according to the report.

Dr. Susan Buchbinder leads the health department's Bridge HIV program. Photo: Liz Highleyman  

The aging population helps explain the rising number of deaths among people with HIV, which reached 312 in 2022. Non-AIDS cancers accounted for 16% of deaths during 2018-2021, followed closely by heart disease at about 15%. But drug overdoses also played a major role, responsible for 18% of deaths.

"One in five deaths of people with HIV from an overdose is really unacceptably high, which is why our health access points — low barrier comprehensive services targeting specific populations — all incorporate harm reduction services and overdose prevention," Buchbinder said. The health access points focus on priority populations including Black and Latino people, people who use drugs, and people experiencing homelessness.

HIV care indicators
Compared with the nation as a whole, San Francisco does a good job providing care for people living with and at risk for HIV.

The use of PrEP, which was first approved in 2012, has steadily risen over the past decade. In 2022, just over three-quarters of people who could benefit from PrEP were receiving it in San Francisco, including 72% of Latino and 67% of Black gay and bisexual men seen at City Clinic. In contrast, only about a third of people eligible for PrEP were receiving it nationwide, falling to 20% for Latino and 11% for Black men who have sex with men, according to the national Centers for Disease Control and Prevention.

So far, few people in San Francisco are using cabotegravir injections (Apretude) every other month for HIV prevention, but DPH and partner organizations are working to roll it out in an equitable way, Buchbinder told the B.A.R. City Clinic is starting to reach people who aren't on oral PrEP, including a growing proportion of women.

"This is a huge breakthrough in prevention for people who can't or don't want to take pills," she said. "We're reaching people that we don't normally reach by using injectable PrEP."

The vast majority of people living with HIV in San Francisco — 97% — know their status. However, 14% were diagnosed with late-stage disease in 2022, a proportion that has held steady for several years. DPH aims to increase prompt diagnosis with the "Take Me Home" program, which offers home test kits for HIV and sexually transmitted infections.

The report shows improvements over time in the proportion of people who receive HIV care and antiretroviral treatment. Among people diagnosed in 2022, 90% were linked to care within one month and, on average, individuals started treatment the same day they were diagnosed. However, linkage to care was lower than the 95% figure reported in 2019, likely reflecting ongoing disruptions due to the COVID pandemic.

Of those diagnosed in 2022, 80% achieved viral suppression within six months, about the same as the pre-COVID percentage. Looking at all SF residents living with HIV (not just those newly diagnosed), the viral suppression rate fell to 73%. This is a concern, as keeping community viral load low plays a key role in preventing transmission, officials noted.

Here, too, disparities are evident. Latino people were the least likely of all racial/ethnic groups to receive HIV care, and both Latino and Black people had lower rates of viral suppression compared with white people. Only 52% of people experiencing homelessness achieved viral suppression, but this is a substantial improvement over the 27% figure reported in 2021. People who inject drugs also had a low viral suppression rate.

Despite these gaps, San Francisco continues to do better than the rest of California and the country as a whole. Nationwide, just over 82% of newly diagnosed people were linked to care within a month, and two-thirds of those diagnosed in 2021 achieved viral suppression, according to the CDC. California's statewide indicators are similar to the national figures.

"It is encouraging to see a slight decline in the number of new HIV infections and relatively high rates of engagement in care and viral suppression among people living with HIV," Tyler TerMeer, Ph.D., a gay Black man living with HIV who is CEO of the San Francisco AIDS Foundation, told the B.A.R. "As one of the city's largest providers of PrEP and a supportive network for many people living with HIV, San Francisco AIDS Foundation remains committed to addressing disparities in HIV through all of our programs and services."

The full HIV Epidemiology Annual Report 2022 is available here.

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