Can San Francisco Become the First AIDS-Free City?

The city that was once the deadly AIDS epicenter of the world is now striving to be AIDS-free. What does that mean, and why is San Francisco poised to achieve this goal the way no other American city could?



Photographer: James Hosking

This all began with a visit to Ward 86, the nation’s oldest HIV/ AIDS clinic. Founded in 1983 at San Francisco General Hospital, Ward 86 was, for many years, a death camp with a dreamy view of palm trees and California sky. In the early ’80s, the average life expectancy of patients admitted there was 18 months—it was where people went to die. It was ground zero in America’s battle with AIDS, and where so much of the epidemic’s early iconography was crystallized: rag-and-bone bodies wasted from pneumonia or encephalitis, catatonia, seizures, bedside vigils. It seemed only appropriate to begin where the epidemic began. Jeff Sheehy, the ward’s communications director, is courteous but puzzled.

“There’s really nothing much to see,” he says. “It’s just a clinic.” Sheehy’s response would have been unimaginable 20 or 25 years ago, but something epochal has happened both in modern science and in the city of San Francisco. While there is still no cure for AIDS, and the rate of new HIV infections has remained relatively stable, the city is redoubling its assault on the disease that has claimed the lives of more than 19,000 of its residents. Inspired by Hillary Clinton’s 2011 speech at the National Institutes of Health, in which then-Secretary of State Clinton rallied for “an AIDS-free generation,” and emboldened by recent breakthroughs including PrEP and antiretroviral therapy (ART), San Francisco is committed to being the first city to reach zero—zero new HIV transmissions and zero AIDS patients.

There is fierce competition here, especially in the last decade as AIDS researchers have glimpsed a kind of epidemiological horizon. A cure seems all but inevitable. There’s the case of Timothy Ray Brown, the “Berlin patient” who was deemed functionally cured of HIV after receiving a 2006 stem cell transplant to treat leukemia. There’s the announcement, made at the 2012 International AIDS Conference, that 14 French HIV patients who started an ART regimen months after infection subsequently quit taking the medication with no surge in their viral loads. In April 2013, London’s Daily Telegraph reported that a team in Denmark was experimenting with strategies to rout HIV from human DNA for the purpose of nuking it with immunotherapy. These are all milestones, and cities across the country have positioned themselves as beneficiaries—and, in some cases, architects—of the cure. San Francisco is arguably the most determined.

No one knows this better than Dr. Diane Havlir. She began her career at Ward 86 in the 1980s, a time she describes, somewhat demurely, as “extraordinarily formative years.” Today she is head of the ward and one of the nation’s leading HIV/AIDS researchers. In 2012 she co-chaired the International AIDS Conference in Washington D.C., whose theme, “turning the tide together,” and official declaration called unequivocally for ending AIDS. “Now, for the first time ever—we’ve never really said this before—we think we can begin to end AIDS,” Havlir said shortly before the conference.

Her optimism hasn’t faded. “It’s an exciting time,” she says. “We’ve all been re-energized by a couple of things. First, by the prospect that with earlier treatment and with PrEP we can dramatically reduce the number of new infections, and secondly, by the fact that a cure—that it can even happen—has been proven.” The case of the 14 French patients bolstered by early exposure to ART was compelling enough that last year, Havlir and her col- leagues at San Francisco General launched RAPID, a citywide program aimed at getting HIV patients on ART the same day they’re diagnosed. In some cases this means that healthcare workers escort patients to Ward 86 in a cab—what I imagine must be the most frightening and tender ride anyone can take through the city’s pastel hills. “The data would suggest that people who start treatment immediately after they’re infected will reduce the reservoir of HIV in their body, so if a cure were to become available, they’d be in a better position to benefit from it,” Havlir says.

And there’s the c word again. It’s a subsonic hum beneath any conversation about AIDS. The prospect of a cure is both intoxicating and unnerving, namely because failure is not an option. When the subject is raised with Havlir, she hedges. “No one can predict it. The fact that there is investment and commitment means it’s going to happen faster than it would have before, when we weren’t even thinking about it.”

Although there was never a time when AIDS researchers weren’t thinking about a cure, Havlir’s response indicates the extent to which it will demand deep institutional pockets. UNAIDS and the World Health Organization estimate that curbing new HIV infections—reducing transmissions, not a cure— would cost $20-$30 billion over the next half-decade. That’s a sobering tally, and perhaps one reason why local public officials, policymakers, and researchers eagerly posit San Francisco as the incubator for AIDS innovation. There’s a torrential, largely untapped artery of funds awaiting whatever city or institution offers a viable blueprint for significantly slowing transmissions or, better yet, unveiling a cure.

Havlir sees the treatment cascade as one of the city’s biggest opportunities to tout benchmarks. Sometimes referred to as the “continuum of care,” the treatment cascade is best visualized as an upside-down pyramid identifying stages of HIV treatment where patients are most likely to go AWOL. Of the 82% of people with HIV who are diagnosed, only 66% are linked to care, while 37% are retained in care. Thirty-three percent are prescribed ART, and 25% become virally suppressed. In San Francisco, viral suppression stands at 50%, a number that’s double the national average, though it’s still underwhelming to Havlir. “We can do much better than that,” she says, and goes on to envision a city in which diagnosis, treatment on demand, and outreach services such as housing, substance abuse counseling, and mental health counseling are integrated under one umbrella of care.

If this sounds like a rehash of the vintage “San Francisco model” of AIDS policy, in which a full menu of health and social services are combined under one roof, it is. Thirty years after the epidemic first broke and the model was introduced, it remains the gold standard of HIV/AIDS treatment. Justin Goforth, director of community relations at Whitman-Walker Health in Washington, D.C., praises San Francisco’s method of fast-tracking patients to care. It’s one his clinic has adopted and rebranded as the “red car- pet entry” program. “Our goal is to link all newly diagnosed individuals or new HIV-positive patients to care within 24–48 hours,” Goforth says. “Most of our newly diagnosed patients actually have the first appointment with their provider and other members of their new care team the same day of diagnosis.” That protocol mimics San Francisco’s RAPID program.