San Francisco's 2023 HIV epidemiology annual report continued a trend of declining new diagnoses, with 133 reported for the year. The report comes as sexually transmitted bacterial infections gonorrhea, chlamydia, and syphilis continue to decline year-to-date in 2024 from 2023 — though this year more San Francisco City Clinic patients have tested positive for HIV than in 2023, despite fewer tests being done.
In related news, City Clinic, the longtime municipal public health center, granted the Bay Area Reporter a tour of its deteriorating space at 356 Seventh Street. The public health care facility is slated to relocate if the Proposition B infrastructure bond measure passes on the November 5 ballot.
The HIV surveillance report released by the San Francisco Department of Public Health September 23 showed that in 2023 the city saw 133 new diagnoses of HIV — one more than preliminary 2023 numbers had shown in a semi-annual report released in August. That represents an ongoing decline, as 2022 saw 157 new cases and 2021 saw 166 new cases, according to the reports.
"San Francisco has long been a national leader in HIV research, epidemiology, prevention, testing, and care. We are thrilled to see that HIV diagnoses in our city continue to go down," Mayor London Breed stated in a news release. "Today's report underscores just how important it is to have trusted, world-class public health facilities such as SFDPH's San Francisco City Clinic and Zuckerberg San Francisco General Hospital, as well as incredible community partners, whose ongoing work in providing critical HIV services to our community have helped make these declines possible."
As the B.A.R. previously reported, 2023 HIV diagnoses in the Latino community had also declined to 40 — down 46% from the 2022 figure of 74 new diagnoses, a number that set off alarm bells in Latino and public health communities.
The release stated that 95% of those newly diagnosed in San Francisco in 2023 were linked to care within one month. City health officials also reported that 84% of people diagnosed in the first nine months of the year were virally suppressed within six months.
"This report gives us many reasons to be encouraged and shows that our efforts are making a difference," stated Dr. Grant Colfax, a gay man who is director of health. "Incredible advancements have been made in HIV prevention and care, and we must continue to make sure that communities across San Francisco have access to high-quality, culturally competent services so that this report is part of a sustained trend that marches us towards an HIV/AIDS free generation."
Dr. Susan Philip, the city's health officer, stated that people need to be aware of the resources available to them.
PrEP, or pre-exposure prophylaxis, refers to the use of antiviral drugs to prevent people exposed to HIV from becoming infected. The pill Truvada was first approved for PrEP use in 2012 by the U.S. Food and Drug Administration; since then the FDA has also approved the pill Descovy for some groups, and the drug Apretude as an injectable treatment.
PrEP is a key component of Getting to Zero San Francisco, which aims to reduce new HIV transmissions and HIV deaths by 90% by 2025, in addition to reducing stigma. Similarly, Ending the HIV Epidemic in the U.S. is the federal government's goal of reducing HIV infections by 90% by 2030.
"To ultimately succeed in our fight against HIV, it is critical for people to know and understand the many services that are available to them, which cannot be done without continued planning and coordination with community, academic, and health system partners," Philip stated. "The tools both inside and outside of traditional medical settings are there, and the more we connect with and inform our communities, the better chance we will have in tackling the challenges in front of us."
Rafael Mandelman, a gay man who represents District 8, including the Castro neighborhood, on the San Francisco Board of Supervisors, heralded the report as "great news, especially in the steep decline in new diagnoses among Latinx people."
"Of course there is more work to do," he added. "We will not be done until we truly get to zero, but this is real progress, and DPH, UCSF, and our nonprofit partners deserve real congratulations."
District 6 Supervisor Matt Dorsey, a gay man living with HIV, represents the South of Market neighborhood where City Clinic is located. He stated that the report is "doubly good news — not solely for its overall decline in new HIV diagnoses, but for even steeper declines in BIPOC [Black, Indigenous and people of color] communities that have historically been overrepresented among new HIV cases."
"These numbers show that our focus on equity is working, and for that I'm grateful to SFDPH and its director, Dr. Grant Colfax, and all of our community-based partners," he stated. "At the same time, I hope our progress reminds all of us that 'Getting to Zero' really is within reach, and it remains a worthy goal not just for HIV prevention and care, but for healthcare access for all."
Gay state Senator Scott Wiener (D-San Francisco) stated that the report is a sign San Francisco continues to lead on the fight against HIV/AIDS.
"San Francisco has shown once again that the horror of the HIV epidemic is not inevitable when we let our communities lead," Wiener stated. "Thanks to the extraordinary work of City Clinic and San Francisco General Hospital, we've made gains fighting this disease in the communities of color too many others had given up on. I applaud the amazing work of our medical and public health officials, and look forward to continued progress in our fight to get to zero."
Dr. Stephanie Cohen, a straight ally who is director of DPH's HIV and STI Prevention and Control Section of the disease prevention and control branch, told the B.A.R. that since Getting to Zero SF was started in 2014 "we set out a 10-year goal of a 90% reduction in new HIV diagnoses by 2025. We have seen a substantial decrease. The number of new HIV diagnoses has declined by more than 50% since that original date."
Indeed, in 2014 San Francisco saw 329 new cases; the 133 figure is little more than a third of that. To get to the 90% reduction from 2014, there would have to be 32 cases or fewer next year. Cohen acknowledged the 90% target was "an ambitious goal when we set it." Still, Getting to Zero SF is "continuing to strive to get to no new HIV infections in San Francisco," Cohen said.
Cohen stated that as the report shows, the primary transmission route since at least 2014 has been sexual intercourse between men. Among cis men, this only accounted for 84 infections in 2023.
"It's still the largest category," Cohen said, but it is representing a lesser portion of the total than it used to.
For 2023, people who inject drugs accounted for six HIV cases among cis men, while men who have sex with men and inject drugs accounted for 13 of the cases, according to the report. The previous year, those figures were eight and 17, respectively.
But contained in other city numbers, HIV diagnoses portend worrisome news: 35 people tested positive for antibodies to the virus year-to-date in 2024, compared to 27 year-to-date in 2023. This despite the number of tests being 1,998 and 1,941, respectively, according to the San Francisco Monthly STI Report for June 2024 released by DPH.
Asked about that, Cohen said, "I think people should be mindful that it represents a small sample."
"We do see people who are both San Francisco residents and who are not San Francisco residents at City Clinic," she said. "We definitely diagnose a number of people at City Clinic who live outside of the city and link them to care in their own counties, so it's kind of difficult to take these numbers and say how they apply to San Francisco specifically."
STIs still on decline
Through the first six months of this year, the three major bacterial STIs are continuing to decline, according to the recently released San Francisco Monthly STI Report for June 2024. The B.A.R. last month had reported on a drop in the numbers for the first four months of 2024, and that trend has continued in May and June.
By the end of June there were 2,216 gonorrhea cases in 2024 compared to 2,430 year-to-date in 2023 (though rectal cases were slightly up — 800 to 791).
Similarly with chlamydia, there were 2,139 cases in 2024 compared to 2,997 year-to-date in 2023 (a decline also shown in rectal cases — which went from 868 to 438). With syphilis there was also a decline, from 629 year-to-date in 2023 to 437 in 2024.
As for what is contributing to the declining STD cases, medical experts the B.A.R. has spoken with think the introduction of doxyPEP in late 2022 — a new way of treating bacterial sexually transmitted infections with the antibiotic doxycycline (a type of tetracycline) after unprotected sex — is the key to understanding what's happening.
DoxyPEP has only been approved for men who have sex with men and for trans women, which could explain the concurrent rise in cases in cis women even as cases go down generally. A study from Kenya found the drug didn't work with the cisgender women enrolled in it, likely due to low adherence, leading U.S. health officials to not include such women in the usage guidelines for doxyPEP they finalized in the spring, as the B.A.R. reported in June.
As for why gonorrhea isn't budging as much, tetracyclines aren't as effective against gonorrhea as against chlamydia and syphilis. A study of doxyPEP efficacy showed an 80% drop in syphilis and chlamydia but only a 55% drop in gonorrhea, according to findings presented by Dr. Annie Luetkemeyer of UCSF at the 2022 International AIDS Conference.
Dr. Oliver Bacon, a gay man who has been medical director at City Clinic for the past year and a half, told the B.A.R. that doxyPEP works "very well" against chlamydia and syphilis but "less well" against gonorrhea.
"One thing we're all hypothesizing is there's no resistance to doxycycline in chlamydia and syphilis. It's been used for decades for those two infections. Resistance has not arisen," he said in a September 23 phone interview. "Resistance to many antibiotics has arisen over time for gonorrhea. We know there are places in the world where the vast majority of strains of gonorrhea are resistance to doxycycline — France, the region around Paris, for example, eastern Africa. We don't use doxycycline in the United States to treat gonorrhea because depending on the city between 10% to 15% to 50% of isolates are resistant. So we didn't necessarily expect doxy to work particularly well against gonorrhea — it was actually a surprise in the doxyPEP trial we saw significant decreases."
Cohen stated DPH is now willing to say there is a connection between doxyPEP and this decline, saying the department tracked people receiving its services and how that has intersected with the roll out of doxyPEP.
"We are very encouraged by the citywide trends in bacterial STIs — particularly among men who have sex with men and trans women — and in particular, chlamydia and syphilis," she said.
Bacon said that City Clinic looked at rates among those in its PrEP clinic and compared the group that never took doxyPEP to the group that did during the same time period.
"We saw dramatic declines in chlamydia in folks who started doxyPEP and sizable declines in syphilis but not declines in gonorrhea," he said.
City Clinic bond
As the B.A.R. previously reported, Prop B, which will require 66.66% affirmative votes to pass on the November 5 ballot, includes $27 million for the relocation of City Clinic.
City staff led the B.A.R. on a walk-through of the clinic, which since 1982 has been located in a 91-year-old building in the South of Market neighborhood that was once a firehouse.
Judith Sansone, a nurse manager at City Clinic, told the B.A.R. that 75% of those served by the clinic are men who have sex with men and they rely on the sexual health services it provides. There were over 11,000 appointments made in 2023.
It has been on the frontlines of HIV, COVID, and the 2022 mpox outbreak, she said.
Thus, "we have a fairly robust research component to what we do," Sansone added.
Research at City Clinic led to the initial demonstrations of the effectiveness of PrEP and doxyPEP, Sansome said.
Jonathan Carlson, a microbiologist, said that the tiny size of the lab has made it hard to do the research the clinic is asked to participate in.
"It's kind of a big ask for a lab in this space to participate in national research," he said.
Christopher Ruiz, acting biomedical prevention coordinator for City Clinic, said the age of the building has negatively impacted the patient experience.
"In the summer months, when it gets very hot, it gets very hot — in the 80s" he said.
Carlson agreed that the heat can be a problem — machines in the lab run hot, he said, and if the temperature in the lab gets over 86 degrees they can't work in there.
In the wintertime, space heaters have had to be added to the clinic, which sometimes knocks out the power, shutting off computers, Ruiz said.
Ruiz also pointed to very small consultation rooms, where people sometimes learn they have HIV or the hepatitis C virus.
"You get a sense of how two people can be in this space," he said. "There's a lot of aspects that are really, really challenging. We're talking about intimate sexual health and I'm right here in your face."
There are six exam rooms and those, too, present a challenge.
Dr. Franco Chevalier, the clinic's deputy medical director, said that "sometimes we require certain equipment" and that equipment is unavailable because a room is being used. Further, rooms have to be kept available for those assigned female at birth to allow more privacy for pelvic examinations.
But what took the cake, Ruiz said, was that the clinic had to close for three days in July after a second-floor toilet leak led to tiles and sewage water falling from the ceiling on a first-floor hallway. He said there was a "good inch of water."
"Everything in here had to be replaced," he said in the (now clean) hallway. This, too, presented problems for patients because appointments had to be canceled.
Bacon said that "as much as we love our old firehouse, it's showing its age."
"I think people like to come to a clinic that is comfortable and they feel comfortable getting services in. It makes them feel good about the care they're getting," he said. "We have had numerous infrastructural failures over the years and in particular in the past year. We had a flood that closed us for two days. We had no heat in the winter. Those things made us scramble. Our building is not ADA compliant and we have staff who suffer because of that, patients who suffer because of that."
Dorsey told the B.A.R. September 20 that he's excited to boost Prop B.
"This is a major priority for me," he said in a phone interview. "We will be asking to move City Clinic to somewhere else in SOMA, contingent on a $27 million investment Prop B would authorize. Right now it's in a hundred-year-old converted firehouse. It's overdue for an upgrade, and I think we have to make sure we have a public health infrastructure to combat STIs and get to zero as well as to address public health challenges that may emerge, such as COVID and mpox."
The $390 million Healthy, Safe and Vibrant San Francisco bond also funds $25 million for the revitalization of Harvey Milk Plaza.
To view SFDPH's HIV annual report, click here.
Updated, 9/23/24: This article has been updated with comments from Dr.Oliver Bacon, medical director at City Clinic.
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