For the first time, gay and bisexual men who don’t inject drugs accounted for less than half of new HIV cases in San Francisco last year. But total diagnoses in 2021 saw an uptick that could be due to changes in testing in the wake of COVID-19, according to the latest epidemiology report from the city’s Department of Public Health released September 13.
HIV care indicators have generally improved or remained stable, found the annual report, but disparities persist.
“The good news is we’re seeing some recovery from COVID, but we still see disparities, particularly for African American and Latinx individuals, people experiencing homelessness, and people who inject drugs,” Dr. Susan Buchbinder, director of DPH’s Bridge HIV and co-chair of the San Francisco Getting to Zero steering committee, told the Bay Area Reporter in an interview.
The new report shows a 16% increase in new HIV cases, departing from the downward trend since 2012. The number of new diagnoses rose from 138 in 2020 to 160 in 2021 but remains below the 173 new cases reported in 2019.
According to the report, gay and bisexual men who did not inject drugs accounted for 49% of new HIV cases last year. The report includes a separate category for men who have sex with men and inject drugs, which accounts for 14% of cases.
The share of cases among women is similar to 2020, but up from 8% in 2019. No children have been diagnosed with HIV in San Francisco since 2012. People who inject drugs accounted for 27% of new cases, up from 21% in 2020, and 24% of newly diagnosed people were homeless — the highest level ever.
Latinos made up the largest share of new cases, at 38%, followed by whites (33%), Blacks (16%), and Asians and Pacific Islanders (9%). But Latino and Black individuals have disproportionately high HIV rates relative to their share of the population. Diagnosis rates in 2021 were 3.3 times higher for Black men and 2.8 times higher for Latino men compared with white men.
This brings the number of San Francisco residents living with diagnosed HIV to 15,631 at the end of 2021, accounting for 11% of all people with HIV in California. Nearly three-quarters are gay or bisexual men, though cases among other groups are rising faster. And the HIV population continues to age: 73% are now 50 or older.
However, this year’s statistics are influenced by COVID disruptions. In the spring of 2020, both HIV screening and viral load testing dropped dramatically. HIV testing at medical sites fully recovered in 2021, but testing at community sites still lags. Health officials suspect the low number of new cases in 2020 might have been an underestimate due to decreased testing. Despite the decline in testing, the number of people diagnosed with late-stage HIV, after they had already progressed to AIDS, remained stable.
The number of deaths among people with HIV rose to 286 in 2020 (the last year with complete data), continuing an upward trend since 2016. While the number of HIV-associated deaths is still on the decline, accidental deaths — which include drug overdoses — are rising.
In 2020, nearly three quarters of deaths among HIV-positive people were due to non-HIV-related causes. Looking at the 2017-2020 time period, 29% of deaths were HIV-related, but accidents overtook non-AIDS cancers as the second leading cause of death. Drug overdoses were responsible for 15% of deaths during this period. But deaths due to advanced liver disease declined sharply, likely thanks to effective new hepatitis C treatment.
“The increased death rate we’re seeing is of great concern and we really need to focus on overdose deaths,” Buchbinder said. “We still need to work on getting the number of HIV-associated deaths down, but we also need to look at other causes. It’s really about whole-person care.”
HIV care indicators
Despite COVID disruptions, HIV care indicators are generally holding up. The report shows an improvement in linkage to care for newly diagnosed people, a high rate of antiretroviral treatment, and increased PrEP use, but viral suppression hasn’t caught up.
“We’re doing pretty well in terms of getting people onto antiretrovirals quickly — that’s stayed pretty stable or is improving, but we’re still not seeing quite as good a viral suppression rate,” Buchbinder said. The rate among the homeless people “is better, but it’s still really low and needs to be addressed.”
Most people newly diagnosed with HIV in 2021 (94%) entered care within one month, approaching the pre-COVID level, and most of those started antiretroviral treatment. What’s more, the time from diagnosis to treatment initiation continues to shorten, with a majority starting antiretrovirals the day they’re diagnosed. But the proportion of people who achieved viral suppression within six months fell to 75% in 2021, down from 77% of those diagnosed in 2020 and 80% of those diagnosed in 2019.
Here too, disparities persist. Overall, 72% of San Francisco residents living with HIV had an undetectable viral load according to their most recent test in 2021, but viral suppression rates were lower for Black people (68%), women (66%), and people who inject drugs (64%). People experiencing homelessness were least likely to have an undetectable viral load, at just 27%, though this is an improvement over the 20% rate in 2020.
In an effort to reduce these disparities, DPH has developed Health Access Points for seven priority populations. Operated in conjunction with Zuckerberg San Francisco General Hospital and Trauma Center’s Ward 86 HIV clinic and community groups, including Glide and the St. James Infirmary for sex workers, the access points provide HIV, sexually transmitted infection, and hepatitis C testing and care, harm reduction services and substance use treatment, and primary medical and mental health care, as well as food and housing services.
Project OPT-IN, a team of DPH staff and community partners, works to provide access to these services, while the LINCS (Linkage, Integration, Navigation and Comprehensive Services) program ensures that people newly diagnosed with HIV are rapidly linked to care and provides support for people experiencing homelessness and others who have fallen out of care.
“It is welcome news that more people are able to access lifesaving HIV testing and are being linked to care,” gay San Francisco Health Director Dr. Grant Colfax said in a statement. “However, we are seeing health disparities among BIPOC communities and people experiencing homelessness that are deeply concerning. We must continue to focus our efforts on delivering services and outreach to people most affected through collaborations with community groups in providing low-barrier, stigma-free approaches to care.”
Expanded PrEP data
This year’s report includes an expanded section on PrEP. Among HIV-negative men who have sex with men seen at San Francisco City Clinic, PrEP use increased each year from 2014 to 2021. PrEP use in 2021 was high and stable for white, Latino, and Asian gay and bi men (69%, 70%, and 71%, respectively), but lagged for Black men, at 57%.
Looking at PrEP screening across five community-based organizations serving people of color or youth, 215 clients were screened for PrEP, 68% of them scheduled a PrEP appointment, and 61% took their first dose, but only 25 people (12%) were still on PrEP six months later.
At the San Francisco AIDS Foundation, the number of clients who were screened for PrEP increased to 1,852 in 2021, and 44% of them enrolled in PrEP services. About a third (29%) were still in the PrEP program three months after enrollment. Latino men were most likely to enroll (50%) while Black men were least likely (40%). The proportion of trans women who enrolled after screening rose to 41% from 30% in 2020.
Overall, 81% of SFAF’s 2020 enrollees used daily PrEP pills while 19% used on-demand PrEP before and after sex (known as PrEP 2-1-1). While two-thirds of all enrollees were still on the same regimen six months later, Black and Latino gay men and those under age 25 were more likely to stick with on-demand compared with daily PrEP.
So far, few people in SF are using long-acting injectable cabotegravir (Apretude) for HIV prevention, but DPH and partner organizations are “working to make [it] available and accessible,” Buchbinder said.
Regardless of the regimen, PrEP uptake among women and people who use drugs has been low, according to Buchbinder. “We really need to make it clear to people and have them be knowledgeable about PrEP,” she said. “People think of it as something for men who have sex with men, but it works very well for women.”
The full HIV Epidemiology Annual Report 2021 is available here.
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