Soon San Francisco will face some of the biggest changes in the ways that HIV prevention programs have been funded for decades. In its 2010 document, "New Directions in HIV Prevention," the San Francisco Department of Public Health outlines its plans to restructure, refinance, and refocus the ways that HIV prevention services are provided. While SFDPH has not been transparent to the public about the plans or reasons behind the shift, HIV prevention workers have been told that the changes threaten to defund culturally competent, peer-led, and participant-driven programming, while sending money to large agencies with a focus on wide-scale testing and medication compliance. SFDPH also intends to implement aggressive and widespread HIV screening and treatment based on the idea that, on medication, poz people are less likely to transmit the virus.
Currently, HIV prevention funds support a huge network of unique, culturally competent services that are often led by those most impacted by HIV within the communities they serve. Agencies like Bay Area Young Positives, Homeless Youth Alliance and El/La have used HIV prevention funds to creatively address the multiple, complex roots of HIV such as stigma, poverty, trauma, racism, and transphobia. This has resulted in HIV agencies forming a safety net of services for SF's most vulnerable and marginalized – case management, culturally relevant community building, health education, housing assistance, peer counseling, food, clothing, and more. These services empower participants to make positive changes in their lives. They also create spaces, resources, jobs, and volunteer opportunities that under-served communities can use to support themselves.
Although difficult to capture by the type of research SFDPH uses to shape its policies, HIV agency staff and participants know that effective prevention takes way more than pills and doctor visits. The current San Francisco model has already proven successful. HIV has decreased over the last decade with a 30.8 percent reduction in rate and a 24.6 percent reduction in number (see H. Fisher Raymond's HIV Update 2011). Herein lies the crux of the question: why the switch to a test and treat model? HIV intersects with some of the most complex needs of SF's most vulnerable and marginalized communities. Doctors are trained to fix health issues. As a highly stigmatizing and complex social issue, HIV cannot simply be "fixed."
So we must ask: under the new paradigm will doctors be able to perform the community building, essential crisis interventions, and the innovative case management currently performed by peer counselors and advocates? Currently, San Francisco residents have access to non-judgmental, harm reduction-based support. HIV workers have the time to listen, develop trust, advise, and bear witness – all crucial elements of behavior modification. When medical professionals are given primary responsibility for HIV testing and prevention, as is the push, will they also take on transforming the root causes of HIV? When organizations like BAYPoz, HYA and El/La lose their funding, these issues will still need to be addressed.
While SFDPH's "New Directions" may seem tantalizing in its promise to reduce new HIV cases, it opens the doors for coercive and non-consensual testing and treatment. The SFDPH is developing the PHAST program as part of this new paradigm, the stated purpose of which is to connect new positives to medical care and to facilitate increasingly vigilant partner disclosure. In 2010 the recommendations to start antiretrovirals changed to no longer depend on an individual's general health, their viral load, or their CD4 and T-cell counts. People are now being encouraged to start meds immediately after testing positive. Easily accessible medical care for all positive people is imperative, however, we are concerned that PHAST will mean coercive pressure for poz people to go on meds. Based on hearing clients' stories, we are also concerned that the SFDPH's partner disclosure tactics could bend standards of confidentiality through invasive attempts to notify sex partners. This is reminiscent of a quarantine – it institutes a paradigm of treatment for the good of the public while the individuals most impacted pay the highest cost.
SFDPH is engaging in risky behavior! It wants to put Band-Aids on poz people and money in the pockets of the pharmaceutical industry, but SF deserves more. If it abandons an essential network of San Francisco's social services and sets the stage for a paradigm that fails to combat the root causes of HIV, the results could be disastrous. Vital elements of HIV prevention must include culturally competent, peer-based services and non-medical spaces that address the complicated ways that HIV spreads.
There will be a forum for questions and comments regarding SFDPH's plans on Monday, August 1, from 6:30 to 8:30 p.m. at the SF LGBT Community Center, 1800 Market Street (resource tables will be available a half-hour preceding and following the forum). Please attend! Help to re-center the voices of the people most affected by HIV, instead of leaving it to bureaucrats to decide where our funding goes.
Through the past decade, Billay Tania has been a client and a service provider at many San Francisco mental health, substance use, and HIV prevention services. He is currently an MSW student at UC Berkeley and works with Off the Grid, a rebellion of HIV prevention workers, activists, and backroom divas who want widespread AIDS activism back in the Bay Area. Members of Off the Grid also were involved in writing this piece. Contact them at [email protected].