Sign of the times: San Francisco shifts delivery of AIDS care

Washington -- San Francisco has long been an epicenter in the fight against AIDS. Now, it again appears to be in the vanguard -- this time for beginning to shift the disease, in terms of city services, from its own separate office into the mainstream of public health.

The move is one concrete example of the changed thinking that surrounds HIV/AIDS. What used to be a diagnosis considered a swift death sentence is increasingly viewed as an illness with which people can live for years. Sometimes they also can face a range of other chronic conditions that can affect nearly anyone.

With the May 1 retirement of its director, Jimmy Loyce, the San Francisco Dept. of Public Health's AIDS Office will close and begin transferring at least some of its functions to other departmental divisions. But Loyce's job is the only one to go. The other workers will still be at their posts, they just may be in different offices.

And even if he hadn't been retiring, the reshuffling still would have taken place, because the timing is right. The city is moving away from the idea that AIDS stands alone, Loyce said.

San Francisco's action joins other activity signaling that the disease is moving into the mainstream. The Centers for Disease Control and Prevention recommended last September that everyone ages 13 to 64 be offered an HIV test, and reports indicate that many primary care physicians already treat patients with HIV.

Kima Taylor, MD, MPH, deputy commissioner of the Baltimore City Health Dept., can remember when only infectious disease specialists took care of people with HIV. But that's not the case today.

The changed treatment venue also reflects the aging of the AIDS population. Those reaching their 50s and 60s are affected by many of the same health issues as is everyone else -- hypertension and diabetes, for example. These patients also may be even more likely to have liver problems because of the powerful antiretroviral medications they have taken for years. Plus, these conditions appear to be developing earlier for this group than in other people, observers say, possibly as a side effect of those medications.

"All of us across the country really need to think about examining what it means to have a chronic disease where people are aging," Loyce said. "When we started this fight 26 years ago, people didn't age, they died."

Another consideration is a cut in funding from the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act that provides federal money to hard-hit localities. San Francisco's CARE grants have dropped over the last five years, and more cuts are expected in the next three, making economy of services even more attractive.

Pros and cons

Observers can see the pluses and minuses of the San Francisco decision.

"I think what San Francisco does is important and worth noting," said Kenneth Mayer, MD, professor of medicine and community health at Brown University's Warren Alpert Medical School in Providence, R.I.

The fact that San Francisco was so heavily impacted by the disease early on has led to a highly evolved public health model, said Dr. Mayer, who chaired a large HIV conference in Washington, D.C., last November and has studied the natural history of the disease since the start of the epidemic. Rather than "silo" a public health program, it makes sense to merge functions, he said. For example, some cities merge HIV programs with those on sexually transmitted diseases.

Although HIV is more stigmatized than other diseases, there are also efficiencies of scale when counselors are cross-trained to convey information on gonorrhea, syphilis and Chlamydia as well, he noted.

But San Francisco is not the rest of the country, Dr. Mayer cautioned. Other cities and states with limited resources and less professional training may want to think through the consequences of such a move, he said.

Other experts also agree that a city-by-city approach is still necessary.

A large number of people with AIDS in San Francisco are aging gay men, noted Christine Lubinski, executive director of the HIV Medicine Assn. of the Infectious Diseases Society of America, in Alexandria, Va. Some cities may be grappling with the problem of shared needles as the primary transmission mode.

In Baltimore, about the only merging that has taken place is between the HIV division and the sexually transmitted diseases division, Dr. Taylor said. The reason that city has not gone ahead with more integration of services is the stigma confronting people with AIDS -- "much to our chagrin," she said.

Mark Cloutier, MPH, director of the San Francisco AIDS Foundation and president of its international affiliate, the Pangaea Global AIDS Foundation, said there had not been a complete dismantling of AIDS services in his city's health department. It's still unclear how the delivery system will be redesigned or altered.

Still necessary is a "blue ribbon" panel that includes physicians of the caliber of Paul Volberding, MD, who started the AIDS program at San Francisco General Hospital, Cloutier said. Dr. Volberding and others like him would understand the epidemiology and what an optimal delivery system looks like, he added.

But Dr. Volberding, who is now chief of medical services at San Francisco Veterans Affairs Medical Center, hadn't heard much about the new plan and said he hoped that there was such a gathering of advisers.

He has mixed feelings about the move. "On the one hand, [the action] is understandable, since HIV has in many respects become a much more mainstreamed, chronic disease than we could have imagined in the early epidemic," Dr. Volberding said. "But on the other hand, I think it's a sad comment in the sense that the separate office maintains an identity and a focus for work that is still very important and about which the San Francisco health department does teach other organizations around the world some very important lessons."

The timing also might be unfortunate. The rollout of guidelines on the CDC's testing recommendations likely will generate discussions on ethical standards and the protection of individual rights, Dr. Volberding said. "It would be nice to have the AIDS office there and strong to deal with these concerns that arise."