Early in this decade, the state government of Indiana achieved a long-running goal among some conservative family-values crusaders and deficit hawks: It defunded Planned Parenthood. The ostensible purpose was to reduce the number of abortions, but because Planned Parenthood provides a wealth of health services, there were ancillary effects. Among them, southern Indiana lost its only HIV-testing site.
Scott County is an economically depressed area with an opioid-abuse problem that morphed into a heroin-abuse problem. Rural poverty and a general sense of anomie and despair combined with the withdrawal of services to create a sort of spasm of public-health infrastructure. The result was the worst localized outbreak of HIV in America since the 1990s.
Scott County saw only three new HIV cases from 2009 to 2013, but in the two years after that, it recorded 124. More than 200 people eventually became infected, at one point at a rate of 20 per week, before epidemiologists brought things under control — although it took months to convince the governor to permit a temporary needle-exchange site for intravenous drug users.
That governor was a former congressman who’s now the vice president of the United States: Mike Pence.
This is not to impugn the moral character of a public figure who has described himself as “a Christian, a conservative, and a Republican — in that order.” It is to emphasize the fragility of the gains made in a fight against a stubborn enemy. Some 35 years after researchers first isolated the human immunodeficiency virus and 29 years after the Surgeon General mailed a candid pamphlet about AIDS to every household in America, HIV’s fortunes continue to rise and fall on abstract and occasionally remote public-health policy decisions.
Friday, Dec. 1, is World AIDS Day, when governments and organizations acknowledge the 40 million lives the disease has claimed. In San Francisco, where new HIV transmissions have fallen to their lowest level in decades, a sudden, Indiana-style retreat from the fight is practically unthinkable. The introduction of PrEP — or pre-exposure prophylaxis, a once-a-day pill regimen marketed under the name Truvada that cuts the likelihood of HIV infection by up to 99 percent — has also improved the outlook considerably. But the city’s Department of Public Health and a constellation of nonprofits face a challenge that’s arguably even steeper than Scott County’s. If, after millions of dollars and decades of aggressive public-health campaigns, 223 San Franciscans still contracted HIV in 2016, what will it take to get that figure to zero?
One of the most symbolic moments in San Francisco’s fight against HIV/AIDS came almost 20 years ago. The Aug. 13, 1998 issue of the Bay Area Reporter, a newspaper oriented to the LGBTQ community, ran a mordantly ecstatic headline: For the first time in years, the BAR had no obituaries. It was bittersweet in that advances in treatment prolonged the lives of HIV-positive people, but the city’s gay population had also been so decimated that, statistically speaking, there were simply fewer sick people left to die.
Twenty years later, the stakes have changed. Deaths from AIDS-related complications have become rare, although certainly not unheard of; Michael Friedman, the playwright who wrote Bloody Bloody Andrew Jackson, died of AIDS in 2016 at age 41. But San Francisco’s goal of reaching zero by 2020 doesn’t refer only to zero deaths. It also means zero new transmissions and zero stigma.
The statistics are trending in the right direction. According to the S.F. Department of Health’s 2016 annual report, released in September, there were 16,000 San Franciscans living with HIV. That figure represents just under 2 percent of the city’s population (875,000) and the total number of HIV-positive Americans overall (973,000). But it also means the city is home to approximately six times as many HIV-positive people as the national average. We remain a locus of the larger battle.
In the broadest sense, the demographic terms of that battle have not shifted much. Of the San Franciscans who contracted HIV in 2016, 88 percent fell into one of three categories: MSM (men who have sex with men), PWID (people who inject drugs), and the combined MSM-PWID. Happily, however, that total figure — 223 new cases — represents a drop of just over half since the most recent peak, when 453 people became infected (in 2012).
Progress in several areas is real and sustained. By most metrics, S.F. outperforms California and the United States at treatment. The number of HIV-positive people who know their serostatus is higher, as is the percentage who are in care, and the percent of people diagnosed with late-stage HIV is lower. Since 2009, the median time between diagnosis and antiretroviral treatment has fallen from eight months to one, and the time between diagnosis and viral suppression has fallen from 11 months to three. From 2015 to 2016 alone, HIV mortality in San Francisco dropped sharply.
Numbers don’t lie, but they can conceal. For instance, 15 percent of new HIV transmissions in San Francisco were among African-Americans, a stable figure year-over-year that’s considerably lower than the 42 percent figure at the national level. However, the percentage of San Franciscans who are Black has fallen below 6 percent and likely continues to drop.
Perhaps more importantly, underlying those numbers is a city in flux. As in Indiana, HIV in San Francisco is linked to intravenous drug use, but the extraordinary cost of living complicates things even further. The median monthly rent of a one-bedroom apartment in San Francisco is $3,390 — an astounding figure that was celebrated as a slight drop. Our eviction crisis ebbs and flows, as do the tent encampments under overpasses and on sidewalks, but the criminalization of homelessness endures — and this has effects on the fight against HIV.
So does the War on Drugs. Supervised-injection sites present an opportunity to disentangle substance abuse from the criminal-justice system and reorient it within the public-health sphere where addiction treatment belongs, but the proposal is also a very easy subject for demagogues to rail against. (When the state legislature debated it earlier this fall, one Republican called such sites “sanctioned shooting galleries for street heroin,” and the measure subsequently died.)
However, Board of Supervisors President London Breed has signaled an openness to the idea, citing the loss of her sister to addiction. According to Laura Thomas, interim California state director of the Drug Policy Alliance, Vancouver has proven that supervised-injection sites succeed at reducing overdose deaths and HIV transmissions, supplying hard data that provided momentum for jurisdictions elsewhere in Canada to adopt them. Barbara Garcia, S.F.’s director of public health, is committed to opening such sites in the city in the next eight to 12 months, Thomas says. And in a city where NIMBY passions run high and homeless-navigation centers prove difficult to situate, hostility to injection sites ran low.
“At the Board of Supervisors meeting, a lot of people turned out to provide comment but not a single person came out in opposition,” Thomas says. “People from churches to small businesses to nonprofits, people who use drugs, people from the Democratic Socialists of America — a broad section of folks [voiced support] and no one was there to speak against it.”
Still, persistent homelessness and citations against tent-dwellers contribute to a climate that makes keeping people in treatment that much harder. And you can’t quantify vituperation.
“It’s clear to a lot of people who work in both substance abuse and HIV that much of the problem we’re having in San Francisco is a housing problem more than it is anything else,” Thomas says. “It’s much easier to get HIV treatment than housing if you’re a homeless person living with HIV, and housing is what makes those other kinds of treatment more effective and more sustainable and more cost-effective.
“Until we can fully meet the needs of all folks, we’re not going to get to zero,” she adds. “When you combine homelessness and substance use and HIV, and wrap that all up, that’s a set of people who are facing enormous stigma and hatred and vitriol in the comment section of any newspaper — or anywhere else.”
Mike Discepola is senior director of Behavioral Health Services & Stonewall Project at San Francisco AIDS Foundation, and he sits on several of DPH’s task forces. The medical establishment has perpetuated certain stigmas, he believes, with the consequence that the populations who are hardest to reach are also the ones to fall “out of care” first: unhoused individuals, the marginally housed, and intravenous drug users.
“Systems of care are not designed to meet their needs,” he says.
The foundation’s Sixth Street Harm-Reduction Center combats this through what Discepola characterizes as “super low-threshold services” like not requiring that people be clean and sober for 30 days before they can meet with a psychiatrist. Just affording people a respite from the hustle of the sidewalk, or providing a dignified setting to shower and use the toilet, can have a measurable impact. So can allowing people to enter if they have drugs on their person (although it’s certainly OK to ask them not to use them on site).
It’s starting to change, Discepola says, but “a lot of the shelters in this city, if you’re discovered with drugs, you get kicked out for 90 days. That just doesn’t work.”
Post-Proposition 64 San Francisco may be set to legalize adult-use cannabis in barely a month, but decriminalization has momentum. Psilocybin, the psychoactive chemical in “magic mushrooms,” has enough potential as a treatment for depression and PTSD that it may be next. In light of the current administration and America’s penchant for over-incarceration, the prospect of total decriminalization of drugs sounds like a pipe dream, but one country has already done it.
“Portugal decriminalized personal drug use, and as a result of that saw a dramatic reduction in HIV transmission in people who use drugs,” Thomas says, pointing out that the gains augment one another. “More people die of overdoses now than of HIV — that’s true of San Francisco, true of California, and the U.S. as a whole. Overdose is one of the leading causes of death for people with HIV.”
While the stigma against being LGBT has waned over the years, it has not disappeared — not even in the gay capital of planet Earth. Trans and gender-nonconforming people are murdered at disturbingly high rates, for one, and they experience widespread economic insecurity. Among gay men, candidly discussing one’s own promiscuity only to slut-shame others as “Truvada whores” in the next breath isn’t uncommon. Michael Weinstein of the AIDS Healthcare Foundation — the influential Los Angeles nonprofit that runs a Castro pharmacy and the Out of the Closet thrift shops — caused a stir in 2014 when he dismissed Truvada as a “party drug.” That flip, irresponsible remark was also medically incorrect in two senses, as Truvada is demonstrably effective at preventing HIV transmission, and it has no intoxicating side effects. (If anything, people report occasional nausea and diarrhea.)
Discepola declines to name any names, but says “that type of jargon is dangerous.”
“Not just communities but also providers need to understand that when someone makes a decision to go on PrEP, it may not be a lifetime decision,” he adds. “There are periods and seasons of risk in a person’s life. For instance, someone who just got out of a relationship or they’re trying to figure out who they are as a sexual being.”
Noting that many PrEP users are HIV-negative individuals with HIV-positive partners — people who may well be monogamous — Discepola adds that condoms might not always be the most feasible means of preventing HIV transmission.
“They’re using condoms but they’re having some challenges using condoms 100 percent of the time,” he says of such folks. “PrEP is a very important piece — but not the only piece. Fortunately for us, we don’t have one option only: that of ‘use condoms every time.’ ”
Still, when PrEP rolled out several years ago with great fanfare, it was not a case of a rising tide lifting all boats. Most gay-identified men who began taking their little blue pill were employed and insured — and some communities of color were left out. As Discepola notes, there needed to be programs “designed specifically to speak to and from the voice of men of color to talk about why PrEP might be an option. There’s reasons why men of color don’t trust medical systems.”
Terrance Wilder is the program coordinator for San Francisco AIDS Foundation’s DREAAM Project (Determined to Respect and Encourage African American Men), and he’s put on several events at Strut, the foundation’s sexual-health services center in the Castro.
The DREAAM Project has created a “one-stop shop where we address family trauma, childhood trauma, STI issues, PrEP, a series of things that Black men and other people of color go through on their journey in the LGBTQ world,” Wilder says.
Drawing people in with games and drag performances, they can then get tested and speak to experts to obtain information about Truvada. Many clients were uncertain whether the pill was for them, Wilder says.
“When PrEP came out, you didn’t see Black faces or people of color in the media,” he says.
It’s been quite successful, with turnout at “Gaymer Nights” and “PrEP Rallies” more than doubling to 150. Since November 2015, San Francisco AIDS Foundation has enrolled more than 3,100 people on PrEP, and while they don’t have specific numbers to attribute specifically to the DREAAM Project, there has been a marked increase in the number of clients who identify as African-American, Asian-American, and Latino.
Another impetus for greater racial equity has come from the city itself. The “Our Sexual Revolution” campaign launched in late June 2016, on the eve of Pride, with a series of posters that depicted PrEP use in an uplifting way.
“Our Sexual Revolution was a social-marketing effort to reach the populations that were disproportionately affected by HIV,” says John Melichar, HIV prevention program manager at the Department of Health. “We know that in the last five years, we have been very successful in halving the number of new HIV infections. However, that success has not been shared equally across different populations.”
With young people, African-Americans, and transgender women in mind, DPH worked with a vendor to create 13 concepts, from which they ultimately chose several based on responses from the targeted demographics.
“I think what resonated with people was the celebratory nature of it, that PrEP was an opportunity,” Melichar says.
If the idea of composite images of smiling faces sounds perilously close to fulfilling the misperception of Truvada as a “party drug,” text on the posters also encourages condom use to prevent the transmission of other sexually transmitted infections.
Our Sexual Revolution lasted six months, and DPH has another campaign in the works, to debut in 2018.
“We have selected another vendor, and we are looking at another campaign like this with a different approach, an ethnography approach,” Melichar says. “They’ve been looking at what’s happening online with those same populations, working with neighborhood organizations so we’re really getting the input from the ground up, rather than from the top down.”
World AIDS Day happens to fall only four days after another somber memorial: the 39th anniversary of the assassination of Mayor George Moscone and Sup. Harvey Milk. HIV, researchers have come to understand, was already present in San Francisco in the late 1970s, and it’s arresting to ponder how the timeline of the AIDS crisis might have played out differently had queer San Francisco’s most visible advocate lived to grapple with it. Would “You gotta give ’em hope” have filtered up to the Reagan White House if Milk had stood there alongside his friend and fellow advocate Cleve Jones at the unveiling of the AIDS Memorial Quilt, nine years after Milk’s death?
Decades on, LGBT San Franciscans are solidly enmeshed in the city’s — and, increasingly, the country’s — power structure, and panels of the quilt have hung in Grace Cathedral on Nob Hill for weeks now. San Francisco AIDS Foundation’s Discepola maintains that S.F.’s commitment to the three zeroes remains a model for other cities to follow — but complacency is a force that’s not to be underestimated.
It’s safe to say that all the low-hanging fruit has been cleared, and that reaching the remaining vulnerable populations and keeping them in treatment will be challenging and costly. Thomas, of the Drug Policy Alliance, is candid that sustaining the political will could prove difficult. Still, she remains hopeful.
“I’m an optimist, and we will be able to do a better job at providing housing and addressing homelessness,” she says. “We will be able to open supervised-consumption services, and we will be able to make more of these service available. I know that’s going to come at a cost and people are going to lose their lives before we get there — and people who would otherwise be able to provide a lot to San Francisco will be forced out by then. But I do think there are a lot of people who are working really hard to try to hold on to the core values of San Francisco, which are the things that made a lot of us move here.”
“This is one of those situations where we don’t want to be punished for our success,” Melichar says. “Decreasing the number of new infections doesn’t mean we need to decrease our efforts. We probably need to scale up our efforts to reach those people we have not been reaching, and sometimes that takes more resources.
“We need to reach out to their communities and not just those individuals who are affected by HIV,” he adds. “The struggle isn’t finished.”