Bay Area Reporter - November 10, 2005
Matthew S. Bajko, m.bajko@ebar.com

Combining both the HIV and STD branches has been floated in the past, not only as a cost-saving measure but also as a recognition that often treating and controlling STDs goes hand in hand with stopping the spread of HIV. Opinions differ, with some arguing that the constant financial strains on the health department's budget require officials to reexamine the current structure of having separate directors and staff for both units. Others argue the two sections' approaches are so dissimilar - the STD unit actively pursues partners of infected patients to notify them they could be carrying a venereal disease while no such aggressive steps are taken with newly infected HIV patients - that there should be a firewall of sorts between the branches.

"Every time there are key positions that open up it is time for reassessment. But that is a role for the health department director and health commission," said Dr. Jeffrey Klausner, director of the STD control section.

Responding to questions via e-mail, Health Director Dr. Mitch Katz said that at the current time the department is not pursuing this option, but he wouldn't rule it out in the future.

"Merging HIV prevention with STD prevention has both gains and losses in terms of synergy. Clearly, good HIV prevention programs prevent STDs and vice versa. Effective substance abuse programs would affect both," wrote Katz. "However, there is also a gain in having all of the programs focused on preventing HIV or caring for people with HIV in one office. We have learned through the campaign 'HIV Stops with Me' how strong the link is between providing care and preventing infections."

Supervisor Bevan Dufty, who intends to speak to Katz about the department's search for a new HIV prevention director, said he would like to discuss the option of merging the two sections.

"I want to find out if it is not necessarily important to keep those separate. We must recognize with the certainty of declining federal funds that we can't, on the one hand, look to providers and encourage consideration of consolidation without looking internally at how we can better structure programs," said Dufty.

Others contend it is essential that the two units be separate but work in collaboration with each other on such areas as continuing to reduce the city's rates of syphilis, a venereal disease known to increase a person's risk for HIV, and alerting gay men to the dangers of crystal, a drug researchers have shown increases a person's chances of seroconverting and plays a large role in the continued transmission of STDs.

"It is a good question. I am not sure on merging the two sections," said Jeff Sheehy, Mayor Gavin Newsom's adviser on HIV and AIDS policy. "I think closer integration between STD control and HIV prevention is just a no-brainer. That is not to say Steven [Tierney] and Jeff [Klausner] haven't been working together. The kind of pressures we are seeing on the budget side suggests we ought to look for ways to better integrate. Basically, we are targeting the same population, to a large degree."

Sheehy, who said he also would be interested to see where Katz stood on the concept, said at the same time he worries about the consequences of pushing forward such a change in the department's structure.

"My fear would be to push for some integration when we have a strong STD control person and a strong HIV prevention person. It does make sure neit her side is going to lose because both of them are able to weigh in," said Sheehy. "It was an interesting thing to talk about closer integration with Steve and Jeff. I wouldn't want to set up something that might interfere with our ability to hire a really first-class director of HIV prevention."

San Francisco Health Commissioner Jim Illig said he believes it is important the department provide both sections but that the two directors work together.

"They can't not talk. They can't be silos in preventing diseases and caring for people who have the disease," said Illig.

Jimmy Loyce, the deputy director for health who oversees the AIDS office, which includes the HIV prevention unit, said he is not focused on changing the parameters of the HIV prevention directors' job.

"I have not thought about that at all. What I have thought about is a replacement for Steven," said Loyce. "I would not be opposed to it if folks from the city said it was a good idea. Internally, the discussions have to start with Mitch. We will do some dialogue about it and come out and say this is our thinking on this, what do you think?"

Though Loyce added, "To be very clear, it is not something I had thought about."

Hire a gay man - or not

Tierney said he hopes whomever replaces him continues to reach out to the other sections in the health department, such as the STD section, behavioral health, and substance abuse, to work on joint projects.

"Rather than the rumored tradition of folks being in their own bunker to protect their budget, my hope is whomever comes in next works well with the other departments on developing services based on client need rather than sources of funding," said Tierney.

Due to San Francisco's HIV epidemic overwhelmingly impacting the city's gay community - 72 percent of the people living with AIDS in San Francisco are gay and bisexual men and men account for 82 percent of all new HIV infections - many leaders expressed the need for a gay man, whether HIV-positive or -negative, to fill the role of HIV prevention director.

"Yes it is important to hire a gay man for that job. That is still who makes up an overwhelming number of HIV infections," said Sheehy, who is gay and HIV-positive. "I don't think you have to be gay but I think it is pretty helpful."

"I can't imagine someone having the requisite skills not coming from our community," said Dufty, himself an openly gay man. "I think Steven's success was predicated on who he was as someone who is in recovery, a gay man who has lived through all of this epidemic, and an incredible human being with a wealth of compassion and one of the sharpest wits around."

Illig, who is gay, also said he supports seeing a gay man succeed Tierney.

"I think in this town, yes. That is where the disease is here, which is not necessarily true of other places," he said. "Certainly, we need someone who understands the population we are targeting and understands the emerging populations in San Francisco too, such as the meth stuff and African American men on the down low."

While Tierney said it makes sense for the person in that role to be gay, or even HIV-positive, what truly matters is finding someone "who understands the funding component and building coalitions that are truly open. It is really important to find someone who understands the community at risk."

Steven Gibson, director of Magnet, the gay men's health center in the Castro, disagreed with the notion that only applicants of the male gender possessed those characteristics. Gibson previously co-led the Stop AIDS Project with Darlene Weide, who went on to become the agency's sole executive director, and only had praise for Tracey Packer, who will become interim director of HIV prevention when Tierney steps down on December 1.

"No. I don't think it is important to hire a gay man for the position. I think it is important to hire somebody doing community-based HIV prevention," said Gibson. "Community organizing policies and HIV prevention procedures are not uniquely understood by all gay men. A straight man or woman can understand prevention."

"Steven as a gay man did a good job with his knowledge of the community to turn the HIV prevention department to where it is now, but I don't think that is unique to gay men," added Gibson. "I have worked with Tracey for about six years in my role on the HIV Prevention Planning Council. She is the unspoken person behind Tierney and she understands the essentials and contracts of funding streams."

Katz agreed with Gibson, stating gay men do not have a lock on knowing the best way to prevent HIV.

"Understanding the various communities of men who have sex with men is clearly important. Unfortunately, being gay is no guarantee of such an understanding," he wrote.

Loyce said he plans to convene a panel with broad representation from the city to help him with the selection process for Tierney's successor. Due to the city's civil service guidelines and the vacancy occurring during the holiday season, the process is expected to be lengthy.

"I want to find a successor to Steven and find one as quickly as possible. But given I live and work in the civil service system, nothing happens in a short time," said Loyce, who will share duties with Packer until a permanent director is named. "My goal is to recruit and to find the best and the brightest, as the mayor often says, to be in the candidate pool as his replacement. I will not do this by myself. I will have representation from the HPPC, provider community, consumer community, and also some folks from the department, not necessarily from the AIDS office but a public health type person."

Loyce said he hopes to convene the selection committee for its first meeting after the first of the year.

"Getting people to sit in on panels and come in for interviews for jobs, as wonderful a job as it may be, is going to be hard when you are rolling up against the holidays. But I don't want to be waiting until February or March to develop the panel," he said.

A challenge

No matter who eventually is selected for the position, most everyone interviewed for this article agreed finding someone to replace Tierney poses a challenge.

Loyce said finding the right person with the professional skills and community investment and involvement that Tierney had is a huge task.

"This is a huge loss both professionally and personally for me. I don't know how you fill those two things immediately," he said.

The hiring for the position has always posed a challenge. When the city hired Tierney in 2000, it took nearly a year and a national search before health officials settled on him as the person for the job. At the time, Tierney had been working at a community clinic outside Boston.

"The city and community have very high expectations for a leader in HIV prevention. It is very difficult to find the right person with the appropriate experience and expertise," said Klausner.

"They will need to be able to ride the politics. We are constantly fighting with the CDC, which was another thing he did quite well, in my mind. It is going to be quite a challenge," said Illig.

Many said they believe this next search process will be able to find the right hire closer to home.

"I just think Steve put together a really good group of people, so it may be an internal hire is most appropriate," said Sheehy.

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