2010 San Francisco HIV prevention plan

2010·18 MB·English

by  San Francisco (Calif.). HIV Prevention Planning Council

SANFRANCISCOPUBLICLIBRA
3 1223 08679 4881
IV Prevention Plan
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Dedication
As the city ofSan Francisco embarks on a period oftransition and
change, we, as HPPC, once again committo fighting the epidemic.
We believe that our success is tied to collaborating with and
supporting various communities ofSan Francisco also committed
to this fight, including people living with HIV, people at greatest
risk for infection, and people supporting these groups. We cannot
move forward without acknowledging the thirtyyears ofwork that
precedes this Plan. Today's HPPC embodies the passion, integrity,
and initiative ofthe men, women, and transgender communities
who have and continue to shape San Francisco into a leader of
cutting edge HIV prevention and education strategies.
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Introduction
1
Chapter 1: Epidemiologic Profile
ChapterOutline 10
Introduction 11
SectionI:Demographic CharacteristicsofSanFrancico 15
SectionII:Scope oftheEpidemic 23
SectionIII:IndicatorsofRisk 43
SectionIV:ServiceUtilizationandAccesstoServices 49
Chapter 2: CommunityAssessment
ChapterOutline 60
Introduction 61
SectionI:Populations 62
SectionII:Drivers 115
SectionIII:Cofactors 125
Appendix 1:ResourceInventory 147
Chapter3:Priority Setting
ChapterOutline 150
Introduction 151
SectionI:TheCurrentModel andItsHistory 152
SectionII:Prioritiesfor2010 153
SectionIII:BackgroundandRationale 158
Appendix 1:ChangesinBehavioralRiskPopulationsfrom2004 to2010 165
Appendix2:ProcessforDeterminingDrivers,PrioritySubpopulations
andCofactors 166
Chapter4: Strategies & Interventions
ChapterOutline 170
Introduction 171
SectionI:SanFrancisco'sApproachto HIVPrevention 173
SectionII:HIVStatusAwareness 177
SectionIII:SyringeAccessandDisposalPrograms 185
SectionIV:HealthEducationandRiskReduction 190
SectionV:PreventionwithPositives 192
SectionVI:Structural Change 195
SectionVII:GuidetoStrategiesandInterventions 198
Appendix 1:SummaryofCaliforniaLaws andRegulationsforHIVTesting 275
Appendix2:NewPreventionApproaches inDevelopment 278
Chapter 5: Evaluation
ChapterOutline 282
Introduction 283
SectionI:HIVPreventionEvaluationinSanFrancisco 284
SectionII:The HIVPreventionEvaluationCycle 290
SectionIII:RolesandResponsibilities 298
SectionP/:AchievementstoDate andFuture Objectives 302
SectionV:Conclusion 304
Appendix 1:HowSTOREEWasDeveloped 304
Appendix2:EvaluationTips andResources 305
Appendix3:GeneralEvaluationToolkits,ManualsandOtherResources 306
Appendix4:EvaluationofStructuralInterventions andApproaches 306
Appendix5:Acknowledgments 307
6:References, Index &Acknowledgments
ChapterOutline 310
References 311
Index 329
Acknowledgments 335

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Introduction
Background
NearlythirtyyearsintotheU.S.HIVepidemic,SanFranciscocontinuestodevelopinnovative
strategiesandinterventionstopreventandtreatHIVAsoneofthefirstandhardest-hitcentersof
HIV,SanFranciscoholdsauniqueplaceinhistory,fromourcommunity'sunprecedentedmobili-
zationinthe 1980stoaddresstheepidemic,tothedevelopmentofpreventionandcaremodels,
toourcontinuedcommitmenttodevelopingevidence-based,cost-effective,andcommunity-
supportedpreventioninterventions.In2010,thereisanongoingneedtoemphasizeHIVpreven-
tion:infectionratesamongmenwhohavesexwithmen(MSM),transfemales,andinjectiondrug
users(IDUs)remainunacceptablyhigh.Whilenewinfectionsamongnon-injectingheterosexual
menandwomenandpennataltransmissionremainrelativelyrare,wemustcontinuetobevigilant
toensurenoHIVresurgenceamongthesegroups.InpreparingthisPlan,theHIVPrevention
PlanningCouncil(HPPC)membersexhaustivelyreviewedlocaldata,heardhoursofcommunity
testimony,andhavebroughttheirownexperiencesinaconcertedefforttodeterminehowbestto
reducenewHIVinfectionsmSanFrancisco.ThisPlanrepresentsthiscommitment.
Ourcurrentcommunityplanningprocessisaconceptthatcameofagehereintheearly
daysoftheepidemic.SanFranciscoinitiatedanefforttoensurethatcommunityplanningwas
formalizedinfederallegislationandadministrativeguidance.Theresultwastheissuanceofthe
CentersforDiseaseControlandPrevention's(CDCs)guidanceoncommunityplanning,which
requireshealthdepartmentstoworkcollaborativelywithcommunityplanninggroupstodesign
localpreventionplansthatbestrepresenttheHIVpreventionneedsoftheirrespectivejurisdic-
tions.Thus,in 1994,theSanFranciscoHPPCwasformed.Sincethen,theHPPChasbeena
consistentandclearvoicerepresentingthecommunitiesaffectedbyHIV
Fromtheearlydaysoftheepidemic,theroleofcommunityplanninghasbeenmulti-faceted.
CommunityplanninghelpedidentifythegroupsathighestriskforHIVinfection.Ithelpedem-
powermanypopulationsthatpreviouslyhadlimitedornovoiceindeterminingthedesignand
deliveryofpreventionandcareservices,includinggaymenandotherMSM,transpeople,injection
drugusers,youth,andimmigrants.Itcreatedapublicforumforanyonetoexpressideasandcon-
cernssurroundingHIVTheprinciplesofparity,inclusion,andrepresentationthatguidecommu-
nityplanningensurethatallaffectedcommunities,includingpeopleofvarioussexualorientations,
racial/ethnicbackgrounds,incomes,genders,andlifeexperienceshaveaplaceatthetable.Our
communityplanningprocesshasalwaysbeenbasedonthebeliefthatdeterminingthebestwayto
respondtolocalHIVpreventionprioritiesandneedsisthroughlocaldecision-making.
What Has Changed Since the Last Prevention Plan
SincethelastHIVPreventionPlanwaspublishedin2004,therearereasonsforoptimismwith
regardtoHIVinSanFrancisco:TheincreasingtrendseeninnewHIVinfectionsattheturnof
themillenniumappearstohaveleveledoffandmayevenbeonadownwardtrend;simplerand
effectivetreatmentoptionsarenowavailablelorpersonslivingwithHIV;andAlDS-relateddeaths
continuetodecline.Thereisgrowingrecognitionthatbothpreventionandtreatmentmustgo
hand-in-handandwithfurtheremphasisonintegrationofHIVpreventionwithotherservices
neededbyhigh-riskgroups.Theseservicesincludetestingandcarelorothersexuallytransmitted
infections(STls),substanceuseireatment,housing,andmentalhealthservices. Effortstodevelop
innovativepreventioninterventionsconsidereduntenablebymanyjustafewyearsagoarenow
underway,includingthosedeterminingwhethertakinganttrctroviralsonaregularbasisbefore
exposuretoHIV(knownaspre-exposureprophylaxis)isaneffectivepreventionstrateg) At 1In-
federallevel,thereisalsoreasonlorhope. IheelectionolaPresidentcommittedtohealthcare
reformrepresentsthemostpromisingopportunityinmanyyearstorevitalizehealthpromotion
andpreventioneffortsnationallyThePresidenthasendorsedthedevelopmentolanational
H1V/A1DSstrategythatcould profoundlyaffeel howHIVpreventioneffortsaresupported
Nevertheless,optimismmustbetemperedbylesspromisingdevelopments Withthe(ui
renteconomiccrisis,HIVpreventionprograms/activitieshaveexperiencedsubstantial hudgetan
cuts,andcomparedto2004,ourpublichealthdollarsarereduced,challengingustoprioritize
programsandtaigei preventionefforts Integrationol HIVpreventionwithotherservicesmust
noi result initsbeinglessemphasized (hitheresearch front,multiplepotentialprevention
interventions,includingseveralvaccinecandidatesandintensivecounselinginterventions,have
shownnoefficacyincontrolledresearchstudies.WhiletheestimatednumberofnewHIVinfec-
iuwiseachyearhasgonefrom 1,082in2000to975in2006,wearenowhereneareradication
.'I inu HIVinfections,andHIVprevalencecontinuestoincrease.Givenourcurrentestimates
ofriskbehaviorandHIVinfectionrates,itisestimatedthata20-yearoldWhitegaymaninSan
Franciscohasa60%chanceofbecominginfectedbytheageof60;foranAfricanAmerican
20-yearoldgayman,theriskis80%.Suchstatisticsareunacceptable;oursocietymustrallyits
resourcesandreinforceitscommitmenttopreventingandtreatingHIV Indoingso,wemust
notfunctioninavacuum.Tobesuccessful,HIVpreventionmustbeintegratedinthecontin-
uedstruggletoenddisparitiesandachieveequalityforall.Suchworkisparticularlypertinent
amonggroupsmostaffectedbyHIV,includinggaymenandtranspeople.
Whatistheroleofcommunityplanninginthesechallengingtimes?Itremainscriticallyim-
portantlocally,nationally,andinternationally.WithinSanFrancisco,threepeopleperdaybecome
infectedwithHIV;intheU.S.,anewHIVinfectionoccursevery9.5minutes.Withnationaldata
—
showingconsistentlyhighralesofnewinfectionsintheU.S. especiallyamongMSMandpersons
—
ofcolor communitiesmustbefullpartnersaswefacethechallengingtaskoftreatingandpre-
ventingHIVInSanFrancisco,theHPPCplaysakeyroleinilluminatingcommunityvoices,pro-
vidingtrainingandsupportinthearticulationofneeds,andadvocatingfortheresourcesnecessary
tomeetthoseneedswithappropriate,effective,andcost-efficientcareandresources.
ThisPlanistheresultoftheworkoftheHPPCanditscommitteesfrom2004through2009.
AbroadspectrumofSanFranciscocommunitymembershavedebatedtheprinciplesandapproach-
escontainedinthePlan.TogethertheHPPCandSFDPHHrv*PreventionSectionhaveestablished
prioritiesforHIVpreventioninSanFrancisco,andtogetherwerecommendstrategiesandinter.-en-
tionstomeettheneedsofourcommunities.Webelieveandfullysupportworkinginpartnership
withotherstakeholdersinthecommunity,whethertheybefederal,stateorlocalgovernments,
electedofficials,communitymembers,community-basedorganizations,schools,privatefoundations,
privateorpublichospitals,companies,orvariousotherorganizations.Togetherwecandevelopand
implementasharedvisiontorecommendandpro\-idesen-icesasarticulatedbythoseatriskforor
livingwithHIV,andtheirfamiliesandfriends.Wearecommittedtoendingthisepidemic,eliminat-
ingthehealthdisparitiesunderl)ingtheepidemic,andpromotinghealthandwellnessforall.
San Francisco's Current HIV Epidemic
Acumulativetotalof28,114personshavebeendiagnosedwithAIDSinSanFrancisco.Asof
December31,2008,atotalof18,866deathshaveoccurredamongSanFranciscoresidentsdiag-
nosedwithAIDS.Approximately15,757personsareestimatedtobelivingwithHIV/AIDSinthe
city.NewHIVinfectionspeakedaround 1982,followedbyaperiodofrapiddeclinethatlasted
intotheearly 1990s,whentherateofnewinfectionsstabilizedatapproximately500peryear.
Fromthemid-1990stotheearly2000s,ralesofnewinfectionsroseagain,toanestimated1,082
peryearby2000consensusestimates.Themostrecentconsensusin2006estimated975new-
infectionsannually.AnewermethodofcalculatingnewinfectionsinSanFranciscofoundthere
wereapproximately792newinfectionsin2007,althoughtherangeisaslowas552toashighas
1.033(SFDPH2008b).Takingintoaccounttheoverallestimatedtrends,theresurgenceininfec-
tionrateswewitnessedattheturnofthemillenniumappearstohaveplateaued,andthereissome
indicationthatraleshavedeclinedsomewhatinihelastfewyears.However,thisisnocausefor
Iorhplaiency ilcurrentbehavioralandbiologicindicatorsholdsteady,wemustnowconsiderHIV
tobeendemic(persistentandestablished)inSanFrancisco,withHIVprevalenceincreasingevery
yearduetolongersurvivalandarateofnew infectionthaimorethanreplacesdeathsduetoAIDS.
Inourmostseverelyaffectedpopulations,suchasMSMandtransfemales,HIVmaybeconsidered
"hyper-endemic"withprevalenceratesrivalingmanyotherinfectiousorchronicdiseases.While
"endemic"and"hyper-endemic"areimportantepidemiologicterms,historicallythephrase"HIV
epidemic"hasbeenappliedindescribingHIVinSanFrancisco,andwewillcontinuetousethis
phraseinthePlantodescribepatternsofHIVratesinthecity.
WhileHIVandAIDSremainconcentratedamonggaymalecommunities,whichrepresent
approximately80%ofnew-HIVcasesannually,itisimportanttorememberthatothergroupsare
alsodisproportionatelyaffectedbyHIV.From2006estimates,newHIVinfectionratesappear