San Francisco’s New Approach to HIV Prevention


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Ronald Valdiserri

Dr. Ronald Valdiserri

With this post, we launch an occasional series, The Strategy in Action: Communities Respond to the National HIV/AIDS Strategy. In these posts, we will spotlight some of the ways that diverse communities from across the U.S. are undertaking efforts to support and implement the National HIV/AIDS Strategy.

This first post in the series features HIV prevention efforts currently underway in San Francisco, a city that holds a unique place in the history of our nation’s response to HIV. Not only was it one of the first and hardest-hit areas for HIV/AIDS, but San Francisco has always been be a leader in developing innovative strategies for preventing HIV and caring for persons living with HIV/AIDS. Recently, Dr. Grant Colfax Exit Disclaimer, Director of HIV Prevention and Research at the San Francisco Department of Public Health Exit Disclaimer (SFDPH), shared with us how his city has re-assessed and re-prioritized its HIV prevention efforts; Grant shared this information at a meeting with Federal and community leaders at the U.S. Department of Health and Human Services on March 16.

NHAS In Action

San Francisco, he explained, has had a fairly stable rate of new HIV infections in the past 10 years—between 500 and 1,000 per year. Leaders from the Health Department and the community recognized that if they were going to achieve the desired further reduction in the number of new HIV infections, they would have to make strategic changes in their prevention approaches. So the Department worked with its Community Planning Group over the course of a year to thoroughly and thoughtfully review and reprioritize the city’s HIV prevention plan. Last year, they released a 336-page five-year HIV prevention plan Exit Disclaimer. After analyzing their local epidemiology data, reviewing the scientific literature describing advances in prevention science, obtaining input from a variety of community sources, and considering their budget, they agreed they could do a better job if they targeted resources toward several priorities. These included:

  • A significant scale up of HIV testing to achieve greater HIV status awareness, particularly among the population groups bearing the highest burden of HIV in their community (identified through local epidemiology to include men who have sex with men, injecting drug users, and transgender women). As part of the effort to scale up testing, the SFDPH now urges all gay men and all injecting drug users to be tested every six months. They are working with many different providers to increase opportunities for HIV testing in venues ranging from doctors’ offices and emergency rooms to community-based organizations and mobile outreach vans.
  • Prevention with positives, which involves strategies and interventions that addresses the specific prevention needs of persons living with HIV. This reflects San Francisco’s deliberate and thoughtful linkage—or “marriage” as Grant called it—of prevention and care activities. Looking at prevention and treatment as a continuum rather than as two separate and distinctly administered activities has become a core component of the city’s response to HIV. The SFDPH now requires care programs to show that those who have been recently diagnosed with HIV and linked to care are on appropriate antiretrovirals (ARVs) and demonstrate a reduced viral load at 6 and 12 months after beginning treatment. Not only are lower viral loads associated with better health outcomes, they can also translate into a lower risk of transmitting HIV. San Francisco can monitor viral load at a “community” level because California requires reporting of viral load for all HIV-positive patients.
  • Addressing drivers of HIV through health education and risk reduction programs. Addressing drivers and cofactors of HIV through behavioral interventions is a critical component of San Francisco’s approach to HIV prevention. Drivers associated with the greatest number of new HIV infections in San Francisco include cocaine/crack, methamphetamine, poppers, gonorrhea, heavy alcohol use, and multiple partners. Using behavioral interventions targeting these factors among populations at high risk for HIV infection is likely to reduce HIV transmission and acquisition in the city. Indicators of success for programs focusing on such drivers include linkage to testing, linkage to care, and reduction in drivers.

These are just three of the priorities articulated in San Francisco’s thoughtful and ambitious five-year plan. Interestingly, though the San Francisco HIV Prevention Plan and the National HIV/AIDS Strategy were developed independently, they share a number of significant principles, priorities and actions. These include:

  • Intensifying HIV prevention efforts in communities where HIV is most heavily concentrated
  • Expanding targeted efforts to prevent HIV infection using a combination of effective, evidence-based approaches;
  • Expanding HIV testing to reduce new infections;
  • Expanding prevention activities with HIV-positive individuals;
  • Facilitating linkage to and maintenance in care;
  • Enhancing measurements of health outcomes;
  • Promoting a holistic approach to health that includes prevention of HIV-related co-morbidities such sexually transmitted infections (STIs), and hepatitis B and C; and
  • Engaging all levels of government, community partners, and people living with HIV/AIDS in the response to HIV/AIDS.

In the brief video below, Grant shares some of the San Francisco experience and lessons that might help other communities to achieve the goals of the National HIV/AIDS Strategy.



  1. David Harold Pass, Pharmacy Director, Lee Arrendale State Prison, Alto,Ga. says:

    Excellent and very useful information.

  2. “The SFDPH now requires care programs to show that those who have been recently diagnosed with HIV and linked to care are on appropriate antiretrovirals (ARVs) and demonstrate a reduced viral load at 6 and 12 months after beginning treatment.”
    While it is not mentioned in the above sentence or anywhere in the article, I hope SF’s 336-page 5-year prevention plan makes abundantly clear that an individual has a right to choose ART, and they have a right to NOT choose ART. I hope it is also clear that not all newly-diagnosed individuals are clinically indicated to begin ART.

  3. I think it very wise to address the “drivers.” Particularly the use of euphorics and depressants needs to be examined. The risk,incidence of exposure are greatly increased when we’re in an altered state, when through chemicals we feel invincible or worse, nihilistic. Two out of three gay men are chemically dependent; the possibilities are dreadful. Fifty percent of my clients state they contracted the virus under the influence of drugs. Thankfully, half of those are in AA & NA.
    Thank you for all your hard work,

  4. Former SF Resident says:

    I don’t know whether I have to believe in this article. I just got back from SF and heard about the direction of monopolizing HIV service delivery by few large organizations and leaving smaller organizations who have a long history and relationships with communities and the vulnerable population. The current programming in SF specifically presents a huge gap of services especially to youth, women and other minority groups (like API which is 30% of the city population, as well as Native American). It would be best to consult The HIV Planning Council of the city would as to whether the statements presented here are reflective of what the council feels.

  5. Consuelo Beck-Sagué, MD says:

    This is my first time at this blog, and I am just going to say I’m so very, very encouraged. Why isn’t this happening in Miami and Ft. Lauderdale? Why is getting tested in Miami still such a trip, with goofy consent forms and even “counseling” about the down sides of getting tested? But let me not start grouching… let’s leave it at what an encouraging blog!

  6. I think the coasts have a tendency to out pace us Midwesterners with their more progressive attitudes which in turn seed and cultivate the acceptance of a problem that’s necessary to do something about it especially one as stigmatized as HIV.

    How has San Francisco been able to reduce the stigma of HIV and get it into the category it belongs, namely a disease? My work with families around this issue often hinges on this one point.

  7. We as the article and other commentators mentioned HIV infections are very commonly linked to drug usage. in fact absent mimd altering cemicals very few people would ever consider making the decisions that ledo to their infections. Why is then thats we push push and push educational prevention plans? Will we ever get arround to the root of this epidemic? Lets talk about shame and depression, the two groups most at risk I’m no the US are gay men and african american women who partner with men on the DL. Now examine the demonstrated links between shame and drug use. As a population, by the age of 18, gay men have dealt with more shame and suffered more psycological damage than any population since before the civil rights movement and unlike those souls strugling in 1960s most go through ith alone. Worst amongst many problems are kids abandoned by their families nearly 100% will struggle with dependancy at some point ino life. Black men are so ostracized by their already long suffering community thats their only choice is to act “straight” abdul fulfill their basic human need on the “DL” which brings black women into the cycle. If this nation is serious about solving the hiv/aids crisis we must focus on ending the misguided “war on drugs”; focus on mental health and well being of our citizens; and finally end government sanctioned discrimination against gay men and women and take step to portray them as good and decent people just like everyone else. When we health the damage we will end stop the drugs and begin to end the hiv/aids crisis.

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