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?



Goforth also mentions the role his clinic takes in crafting HIV campaigns that herald the not-too-distant day when D.C. is AIDS- free. “The newest prevention messages no longer include the word AIDS and speak only of HIV infection,” he says. Likewise, Randall H. Russell, CEO of the Seattle-based clinic Lifelong, frames his facility’s mission as making Seattle “an environment that will perpetuate an AIDS-free city.” Major HIV/AIDS organizations in Chicago, Los Angeles, and New York—and indeed all across the country—share the same goal. While finding a cure is a global, collaborative endeavor, wherever it happens is likely to become a tinderbox of enormous economic, political, and cultural capital. So why is San Francisco primed to take the jackpot?

According to Neil Giuliano, CEO of the San Francisco AIDS Foundation, the city’s notoriously liberal outlook is more congenial to progress. “We still have a ways to go in dealing with shame and stigma,” he says, “but I would venture to say we have gone much further than most other urban, and certainly suburban, communities in this country.” To prove his point, he hands me a sheaf of posters promoting the foundation’s various public forums. F*CK WITHOUT CONDOMS EVER? LET’S TALK ABOUT IT, reads one. RAW SEX—ARE THE RULES CHANGING? blares another in a burly, biohazard-colored font. “These are probably not posters that could go up in many communities around the country. It wouldn’t work in San Francisco if we tried to do any- thing that was other than very open, very honest.”

Giuliano is a relative newcomer to HIV/AIDS public policy. His résumé includes four terms as the openly gay Republican mayor of Tempe, Ariz.; four years as president of GLAAD; authoring a motivational memoir-cum-campaign-bio; a midlife conversion to the Democratic Party; and, since 2010, serving as CEO of the San Francisco AIDS Foundation. More recently, he’s moonlighted as the Great White Hope of Arizona politics. He seems to relish playing coy with the state’s media about a potential gubernatorial run. When I meet him at his office four stories above Market Street he’s rebounding from a nasty flu, which may explain his affable but somewhat prerecorded demeanor. He is accompanied by James Loduca, the foundation’s PR head, who chaperones our conversation.

“This was the first community where HIV was an epidemic in the United States,” Giuliano says. “It was in San Francisco, in the Castro neighborhood on Castro Street, where people literally dropped dead while walking down the street. We believe it will be in San Francisco, in the Castro neighborhood on Castro Street, where we will be able to say a new HIV infection is incredibly rare and we’re caring for people who have HIV. That’s it for us. That’s what we’re all about.”

In practice this means exceeding the goal established by the foundation’s board in 2010 to cut new HIV infections by 50% over five years. This target doubles that of President Obama’s National HIV/AIDS Strategy, also instituted in 2010, which calls for reducing new infections by 25%. San Francisco halved its number of new infections between 2004 and 2011, and now reports a little more than 300 new cases per year. The city hopes to trim that number by a further 25% this year. It’s an ambition many veteran HIV researchers dismiss. Dr. Matthew Golden, director of Seattle’s HIV/STD Control Program, deems such a downsizing in new infections as extraordinary. “Could San Francisco go down another 25% in the next five years? Maybe. In the next one year? No way,” he tells me.

Giuliano sympathizes with the skeptics. “We have an obligation to be aspirational,” he says. “Do I know that we’re going to hit that goal by 2015? I don’t know that we’re going to do that. One of the things I’ve learned in life is if you don’t set a high enough goal, you’ll certainly never come close to it.” (Behind him, a copy of Benjamin Barber’s If Mayors Ruled the World is displayed on his desk. In a 2012 interview with the Bay Area Reporter, Giuliano quipped, “Being mayor of San Francisco is a great gig, I wouldn’t mind that.”)

The centerpiece of the SF AIDS Foundation’s 2014 plan will be the ribbon-cutting for a new, $10 million gay men’s health and wellness center in the heart of the Castro. An architectural rendering is propped against the whiteboard in Giuliano’s office. It shows a glass-fronted cube inviting passersby into an interior of recessed lighting and Scandinavian furniture.

The facility, at 474 Castro St., will consolidate three separate agencies: Magnet, a sexual health clinic; the Stonewall Counseling Center; and the STOP AIDS prevention office. Its location in the Castro is a tactical move that acknowledges the city’s disproportionately high percentage of HIV-positive gay and bi men: 80% of the total HIV-positive population, by some measures. “There’s still a balance of maybe 60/40 gay and bi men to the general population in most other urban areas,” Giuliano says, a ratio that makes it difficult for other cities to hone treatment strategies. This is another reason why San Francisco has an edge when auditioning outreach initiatives: It’s a lot easier to monitor medical and behavioral intervention if your clientele is homogenous.

Still, neither the San Francisco AIDS Foundation nor the city itself denies that a variety of factors—including crystal meth and bareback sex—continue to spur infection in new communities. The average profile of a new HIV case in San Francisco is a gay, 34–35-year-old white man, but African Americans are increasingly at risk. That said, the city’s population is only 6% black, so that risk must be kept in perspective. San Francisco is nowhere near the emergency levels of Baltimore, Atlanta, or Washington, D.C., cities where black women in particular contract HIV at rates five times the national average. For Giuliano, the only plan that makes sense is a holistic health and wellness model that precludes fear. “The approach 10 years ago was ‘wear a condom, wear a condom.’ We’re way beyond that now,” he says.