This week, the San Francisco Department of Public Health released the most recent HIV epidemiology annual report—a comprehensive summary of current HIV data and trends in San Francisco. Although the number of HIV infections happening every year continues to decline, disparities remain among African Americans, Latinos, men who have sex with men, trans women, people experiencing homelessness and people who use substances in our city. As San Francisco moves toward its Getting to Zero goals, these lingering disparities highlight the need for continued investment in programs and resources that target our city’s most marginalized communities.
People living with HIV
As of December 31, 2016, there were 16,010 San Francisco residents who were diagnosed and living with HIV (2% of all people living with HIV in the U.S.). Most (92%) were male, 6% were female and 2% were trans women. The majority were white (59%), 19% were Latino, 12% were African American, 6% were Asian/Pacific Islander, 3% identified as multi-race and <1% were Native American.
More than half of all people living with HIV (63%) were over age 50, and the majority (89%) were men who have sex with men (74% were men who have sex with men, and 15% were men who have sex with men who also used injection drugs).
“We have more people in San Francisco living with HIV than ever,” said Supervisor Jeff Sheehy. “Normally, in infectious disease, [this] would lead to more transmissions, yet our transmissions are falling. The collective effort that the Getting to Zero consortium has—bringing together all different sectors of people involved in fighting this disease in our community—has been enormously successful.”
Decline in new HIV diagnoses
The number of annual HIV infections reached a new low last year, with 223 San Francisco residents diagnosed in 2016. This represents a 51% decline in HIV infections since 2012 (when there were 453 infections).
“We’re very happy to report that we had a 16% decrease in new diagnoses from last year,” said Susan Scheer, co-director of the HIV Surveillance Unit at San Francisco Department of Public Health. “That means we’re down to 223 new diagnoses—the lowest number ever recorded in San Francisco. It’s quite remarkable. Last year, it was a 15% decrease, and we were worried that we would start stalling out, but it’s continuing.”
This decline can be attributed to a number of innovative programs and services: a ramp up in PrEP services and access since 2012; city-wide uptake of same-day antiretroviral therapy start for people newly diagnosed with HIV through the RAPID program since 2010; navigation programs that help people living with HIV remain or re-engage in HIV care; and other collective-impact initiatives by the Getting to Zero consortium.
The breakdown by HIV risk category was similar to that observed in recent years. Most new cases of HIV were among men who have sex with men (70%), 9% were among people who use injection drugs, 9% were among men who have sex with men who also use injection drugs, and 6% were among heterosexuals (5% had unidentified risk factors).
In 2016, there were fewer HIV infections among people who identified as African American and Latino compared to the previous year (although the overall rates of infection were higher for these populations than whites).
“This year, new diagnoses have declined in almost every population, including African Americans and Latinos. That’s not something we saw last year,” said Scheer.
Transgender people represented 2% of new HIV diagnoses in 2016, a proportion which has been fairly stable for the last ten years.
Since 2011, the proportion of new HIV diagnoses among younger people age 18 – 24, 25 – 29 and 30 – 39 has increased (from 10% to 14%; 16% to 24% and 27% to 33%, respectively). The proportion of new diagnoses among people age 40 to 49 has decreased by more than half: from 31% to 15%.
Sheer was optimistic when asked whether these data indicate if San Francisco might reach its Getting to Zero goals by the year 2020. “They are aspirational goals. I think we’re getting better every year, and I think we are on track,” said Scheer.
Decline in HIV deaths & late diagnoses
The number of deaths attributed to HIV has declined 21% from 327 in 2006 to 257 in 2015 (the number of HIV/AIDS deaths in 2016 is still not known due to reporting delays).
Survival with AIDS has improved steadily over time. For people diagnosed with AIDS, the survival probability is 90% at three years and 87% at five years.
Late-stage HIV diagnoses, where the person is diagnosed with AIDS within three months of their HIV diagnosis, are also on the decline. In 2012, 21% of HIV diagnoses were late-stage diagnoses; in 2015, 16% were late-stage diagnoses. People who are diagnosed earlier in their infection, who access HIV treatment, have better health outcomes and also are less likely to transmit HIV to others.
Engagement in care and viral suppression
For people newly diagnosed with HIV, early HIV treatment is prioritized through the City’s RAPID Program, which provides people with antiretroviral medications on the day of diagnosis (if the person is willing to start therapy immediately). The report revealed that, in 2016, most people newly diagnosed with HIV (84%) were linked to care within one month of diagnosis. A little more than three-quarters of people diagnosed in 2015 (77%) were virally suppressed within a year of diagnosis (2015 is the last year that data are available for this measurement).
Among all people living with HIV, 81% were engaged in care (as measured by having one or more lab tests in 2015) and 73% were virally suppressed.
Disparities by HIV transmission category, gender, race, age and housing status emerged in the report.
Women and trans women had lower viral suppression rates than men. African Americans and Latinos had lower viral suppression rates than white people and Asian/Pacific Islanders. Younger people, between the ages of 13 to 39 had lower viral suppression rates than people over age 40. People over age 60 had the highest rates of viral suppression (82%).
Men who have sex with men had the highest rates of viral suppression (76%). People who used injection drugs, MSM who used injection drugs, heterosexuals and people with unidentified risk factors had lower rates of suppression.
Worse outcomes for people experiencing homelessness and people who use substances
“Of particular concern this year are the homeless population, which had much lower prevention and care outcomes,” said Scheer.
Startlingly, less than a third of people (31%) who reported being homeless were virally suppressed.
“The homeless population, which has been relatively stable, is increasing in HIV infections,” said Sheehy. “We’re not going to get there [reach Getting to Zero goals] unless we address all of the disparities that drive this. This is a city-wide problem, but we have to prioritize people who are HIV-positive who are homeless for services.”
San Francisco AIDS Foundation CEO Joe Hollendoner, MSW, advocated for safer consumption spaces, PrEP access and other health services for marginalized populations including people who are experiencing homelessness and people who use substances.
“If San Francisco is to achieve our ambitious goal of getting to zero new HIV infections and zero AIDS-related deaths, we must eliminate disparities associated with sexual orientation, race and ethnicity, gender, housing status and substance use,” he said.
The foundation, through the Harm Reduction Center in the SOMA/Tenderloin neighborhood, provides people experiencing homelessness and people who use substances with harm reduction supplies and drop-in health services.
“We’re engaging people who inject drugs,” said Hollendoner. “These folks have the worst rates of viral suppression of any risk category, and there is no doubt that this is related to the shame and stigma our society perpetuates for these individuals. We believe that efforts like creating safer consumption facilities and treating substance use as an illness rather than a crime will enable people living with HIV who inject drugs to access treatment and other support services.”