Uptick in HIV Cases Worries SF Officials

After six years of steady decreases in new HIV cases in San Francisco, the end of that trend in 2012 is causing concern among local health officials.

The city registered 413 new HIV diagnoses in 2012, a slight increase from the 406 reported in 2011.

While that may not appear significant, it is a troubling sign that the city's HIV prevention efforts may have reached a plateau. And it could prove problematic for reaching the city's goal of reducing new HIV infections among gay and bisexual men, as well as transgender persons, by 50 percent in 2015.

"We cannot say new infections are going up," said Tracey Packer, the health department's director of community health equity and promotion who oversees the city's HIV prevention efforts. "We can say we think the trend is going down and it is not."

The city will have a clearer picture of where the trend in HIV cases is headed later this year when the 2013 data is released.

Based on the most recent HIV/AIDS surveillance report, released in June 2013, there is some evidence to suggest that new HIV diagnoses either remained stable or decreased last year.

The quarterly report indicated that during the first half of the year the city recorded 159 new HIV diagnoses. That was down from the 176 new cases recorded in the June 2012 quarterly surveillance report.

"I think it is a really good time to look closely at all the data we have in combination. I don't think we have enough information yet to say it is not decreasing significantly," said Packer.

Nor do health officials know "what is causing the potential uptick," she added.

Presenting the most recent year-to-date figures to the city's HIV Prevention Planning Council last week, Henry Fisher Raymond, an epidemiologist with the Department of Public Health's Center for Public Health Research Branch, said the number of new HIV diagnoses in 2012 should have been below 400 for the data to indicate ongoing declines in HIV cases.

Instead, the uptick in cases "is really disconcerting," Raymond told the council, which prioritizes what HIV prevention strategies the city should be funding.

Raymond also pointed to an increase seen in the number of HIV cases among men who have sex with men between 2010 and 2011 as another troubling indicator. The city recorded 279 such cases in 2010 and 307 in 2011. In 2004 the number was 630 cases among gay and bisexual men.

"The overall trend from 2004 to 2011 is promisingly headed down. The question is whether the slight uptick from 2010 to 2011 is due to more infections or a result of more work being done to identify HIV cases through testing initiatives," Raymond told the Bay Area Reporter in an emailed response to questions following his presentation.

During the HPPC meeting Raymond was quick to emphasize that it remains unclear if "things are on the upswing again" or if the increased efforts to test people at risk of contracting HIV are behind the numbers.

"We are paying very much attention to if this is a welcome artifact of increased testing," he said.

Packer told the B.A.R. that HIV testing in the city has significantly increased since the implementation of what is known as a "test and treat" policy. The city has prioritized testing as many people at risk for HIV as possible and getting those who test positive into treatment soon after their diagnosis.

In 2010 there were 17,000 HIV tests administered by city-funded clinics; in 2013 that number had grown to 27,000 HIV tests, said Packer.

That has resulted in a decline in the number of people in San Francisco estimated not to know they are HIV-positive. In 2008 it was thought that 15 percent of people didn't know they were positive, said Packer, and in 2013 that estimate was down to 6.4 percent.

Nonetheless, the HPPC and health officials are re-examining their efforts to prevent the spread of HIV in the city.

"This is an opportunity to think about what has gone well and what needs to be rethought," Packer said.

One focus for health officials is eradicating HIV transmission among injection drug users. The HPPC set a goal of eliminating new HIV infections among IDUs by 2015.

The number of IDU HIV cases continues to decline, but it is unclear if the city will meet its goal. In 2011 there were 69 cases, dropping to 51 cases in 2012, according to the data Raymond presented last week.

"We are headed in the right direction but maybe not fast enough," he said.

Among the troubling signs in the data on IDUs, the proportion who do not know their HIV status "is quite high," said Raymond.

The number of users in 2012 who reported getting tested every six months was below 40 percent, down from a high of 60.7 percent in 2005. Just 52.2 percent of IDUs reported in 2012 having an HIV test within the last year, down from 74.5 percent in 2005.

"The big question is why are fewer IDUs saying they got tested in the last six or twelve months? I think we need to take a closer look there," said Raymond.

The use of clean needles has dropped slightly, going from 62.6 percent of IDUs saying they "always" did in 2005 to 60.4 percent in 2012. Over the same timeframe, 62.2 percent of IDUs reported engaging in unprotected intercourse, suggesting that sexual behavior "may be contributing" to new HIV infections, reported Raymond.

HPPC member Laura Thomas, the Drug Policy Alliance's deputy state director for California, renewed calls for the city to establish safe injection sites for IDUs as one way to help educate them about knowing their HIV status and providing easy access to clean needles.

"We've got to be doing more to make a bigger dent," said Thomas.

HPPC co-chair Jose Luis Guzman, the HIV testing services coordinator at Magnet, the gay men's health center in the Castro, agreed that the council needs to renew its efforts to reach the goal of bringing the number of new HIV cases among IDUs to zero next year.

"Let's do what we did with perinatal infections with IDUs," said Guzman, referring to the city's elimination of HIV transmission between pregnant women and their newborn infants.