Bay Area Reporter - October 19, 2000
Terry Beswick

Of the five items on the Thursday, October 12 agenda for the group appointed by Health Director Dr. Mitch Katz under mandate of federal regulations from the Centers for Disease Control and Prevention, four items are identified by DPH as relating "to CDC role #11: attend to the HPPC process and business issues necessary to ensure an efficient and effective council."

("CDC role #11," it should be noted, is not among the responsibilities of the advisory group mandated by the CDC, but rather was added by the HPPC advisory group itself.)

The last of these four items - following a DPH presentation recommending that gay and bisexual men should "wash before and after sex" to prevent shigella infection - was a presentation by Katz on his 11-point action plan. (see http://hivinsite.ucsf.edu/ari/HIVEstimatesReport8900.html) Katz spent a good portion of his allotted time talking about process himself, describing his reasoning behind a recent restructuring of the embattled department, putting his new AIDS deputy Jimmy Loyce in charge of three separate AIDS offices that previously reported to intermediaries.

But once he waded into a justification for releasing his 11-point plan prior to consulting with the HPPC - which is in the midst of developing its own new plan for HIV prevention in San Francisco - Katz took some heavy criticism from many of the HPPC members present.

Revisiting the plan

The HPPC helps the department to prioritize budgeting for $10 million in annual CDC funding of the $16 million that the city spends on HIV prevention. Before granting its approval last month of the DPH's cooperative agreement application to the CDC for fiscal year 2001, the HPPC had voted to delete all the department's references to Katz's 11-point action plan as a condition of its approval of the document.

The department also undergoes a separate budgeting process overseen by the mayor and the Health Commission that includes all of the $16 million budgeted for HIV prevention in the city.

"I feel that my job as health director is to try to forge good policy that will then be adopted by the formal governing body. That would be the Health Commission, and also the HPPC and also the CARE Council and other advisory bodies," Katz told the approximately 20 members of the HPPC in attendance last Thursday. "But I feel that it is my job to respond. That doesn't mean that because I make a response that I assume that everybody is going to think it's the best response, but I think that's part of how a good health department functions.

"So I feel quite happy with the response. I feel that people have been talking about, 'Well is this recommendation, speaking of the 11-point plan, a good one or a not good one, do we want to change it, do we want to tweak it in a particular way to make it more powerful?' And that was my goal and why I think it has been successful, to move this, the discussion, from a more amorphous 'We need to do something, we don't really know what to do,' to the Health Department having a concrete proposal."

John Newmeyer, an epidemiologist with the Haight-Ashbury Free Clinic who has previously expressed concern that community members may begin to call for resignations from the department and the HPPC in the face of reports of escalating rates of HIV infection among gay men, was the first to assault the director's plan on a substantive level.

"The two main problems with the plan are, first that its not concrete," said Newmeyer. "Sounds great, but it's very vague. The second problem is that it's a slow response to a rapidly developing problem.

"But the concreteness most bothers me," continued Newmeyer, referring specifically to two items in the plan that prioritize "condoms for HIV-positive tops with HIV-negative bottoms" and expansion of drug treatment programs.

"One's eyes glaze over because we've heard that for 15 years," Newmeyer said.

"I have to say that I was a little disappointed when this 11-point plan was announced without even the notification of the HIV Prevention Planning Council," commented HPPC member Al Cunningham. "I hear your explanation, which seems to be that this is within your purview and you thought it to be appropriate.

"But I agree with John Newmeyer that it's vague and doesn't really say who's going to take responsibility for doing any or all of these things," Cunningham continued. "And it takes on a much stronger characteristic than a recommendation when the press is invited and so forth. à You might want to correct me if I'm wrong, but this is all designed to deal with the issue of gay men and I would hope that it's designed to deal with the issues of all of San Francisco, gay, bisexual, male, female. I would just like to know where you à prioritize the input of this council in terms of your decision-making process."

There are other action plans

"I do see this plan as being about men who have sex with men," Katz replied. "I think that there are other action plans that deal with other populations. à It's not meant to be an action plan for [injection drugs users], It's not meant to be an action plan for other groups."

Katz objected to the statement that the HPPC had not been consulted prior to the July unveiling of the plan, when it was introduced by Mayor Willie Brown in a surprise announcement just prior to a scheduled hearing of the Board of Supervisors Finance Committee chaired by Supervisor Tom Ammiano that he called to discuss the new HIV estimates.

"We did have meetings with councilmembers and other community people at a briefing prior to the press briefing, so I don't know if you were aware of that Al, but that did happen with the HPPC co-chairs," Katz stated.

HPPC co-chair Michael Discepola later corrected Katz however, saying he had never been invited to a briefing, and had read about the plan in the press.

Katz continued to defend his plan against such oversights as inclusion of the federally-mandated diverse membership of the HPPC in its development and - rather than take on the substantive criticisms of exclusion of populations targeted by the HPPC for prevention work, or of the lack of specificity - the director chose to take on the process issues.

"That still doesn't change whether or not you think its appropriate for the director of health, of the Department of Public Health, to raise a plan," Katz said. "I think, Al, that maybe we should leave it that your feeling is that 'no, that any kind of plan about prevention would need to start here [at the HPPC].' And my view is that at times it would be appropriate for a health department to present a plan. I think it would be inappropriate for the Health Department to present a plan and [then] say that 'we don't care if you like it or don't like it. This is the plan.

We're not interested in your opinion, we're not interested in improving it; this is the plan.' I feel that would be inappropriate. I don't think it's inappropriate for a health department to respond to an increase in infections. I think that one, though, has to be careful that the response allows people to contribute.

"I would think throughout the discussion it's good to raise those [issues], but the problem with the plan can't be that the process is wrong. I mean the process can be wrong, but that's to discuss, and then people can talk about process.

"But the process itself can't determine whether or not it's a good plan or a bad plan. You have to determine whether or not you think it's a good plan based upon what the plan is. And John has already raised what he feels are objections to the plan."

Katz said it is fair to be critical of both the plan and the process, "But it's important to be critical of the things separate. So there's two things: there's "hated the process; liked the plan," [and] "hated the process; hated the plan," though all four are possible."

Co-chair Maria Rinaldi, who noted that Katz had last year overruled the HPPC when it recommended that he lift San Francisco's de facto ban on bathhouses serving the gay community, objected to the director's assessment of the way things should be done in San Francisco, and suggested that the process and the outcome are intricately linked. Plans issued without involving all the stakeholders in their development, she said, "are never good plans."

Several other HPPC members, most of whom are either actually employed by the Health Department or its contractors, also complained about the exclusion of transgenders from the plan. One HPPC member - Janetta Johnson - walked out in disgust over the issue.

Katz refused to take questions during the meeting from the press or others who were not on the HPPC.

For more information on future HPPC and subcommittee meetings, which are open to the public, call DPH prevention director and HPPC co-chair Steven Tierney at (415) 554-9998, or visit www.dph.sf.ca.us/HIVPrevPlan/hppchome.html.

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