Bay Area Reporter - November 30, 2006
Matthew S. Bajko, m.bajko@ebar.com

"After 25 years we do need to look at our model," said Jimmy Loyce, deputy director of the AIDS Office.

Over the last year a group of 13 people representing AIDS agencies, the health department, and people living with AIDS have met to strategize on how best to address the city's needs 25 years into the AIDS epidemic. Dubbed the San Francisco HIV Health Planning Work Group, the committee has yet to release any policy changes to the city's system of care. Instead, it issued a "call to action" in the form of a white paper in September and is preparing to hold public meetings in early 2007 with a variety of stakeholders to determine what changes to the system need to be made. [A copy of the white paper can be found at http://www.ebar.com/docs.]

"We've gotten some hits in the community from people who feel we are some 'Skull and Bones' group. We are not," said Positive Resource Center Executive Director Brett Andrews, a member of the work group. "People think we are shaping policy and we are not. We are just creating a document that really describes what the SF model has grown to be, which will inform a broader community process that will be assigned with really shaping what a model needs to look like."

According to the group's white paper, "It is time to reshape HIV/AIDS prevention, care, and support services to be responsive, flexible, and unsurprised by the forces that loom on the horizon." While the paper does not present any policy decisions, it does set an overarching directive that the SF model needs to change.

"We want to look forward to where it is ultimately the SF model ought to go but we can't answer that question," said Loyce. "If we answer the question then people living with HIV and people living with AIDS and a host of others, from providers and community leaders and those affected, will say, 'There you go imposing your will on us and not including us in the process.' It is why we are coming up with questions about the model."

The white paper does give some clues as to what changes may lay ahead. It expands HIV care to include the word health, using the term "HIV health" to describe "a complete range of activities, services, needs and supports" and insists that HIV health be part of a "fully actuated system of care." The work group says HIV health describes a "new San Francisco model, one which moves beyond separate foci on prevention, care, and support services into an integrated, realistic, optimistic and values-centered model for the future." It is how this new model is structured and how resources are allocated that remains to be determined, work group members said.

"All we've created is really a beginning document. We don't see ourselves as making policy and we are not trying to make the plan. We are trying to convene the community so that happens," said AIDS Emergency Fund Executive Director Mike Smith, who is also president of the HIV AIDS Provider Network. "What we have been struggling with since October is how to have the next steps and these discussions with other various stakeholders from consumers of services, people with HIV and AIDS to housing providers, senior services providers. And we are looking at other support networks not necessarily HIV-related in the city and engaging those service providers who may also be providing services for people with HIV and AIDS."

In its meeting with Katz, on the eve of World AIDS Day, the work group plans to request up to $50,000 in funding to hire a consultant to carry out the community meetings. If the funding request is approved, the work group hopes to hire the consultant in early 2007 and begin convening meetings in the spring or early summer.

Some have criticized the work group for not being more forthcoming about the process to date.

"I don't know what issues it is dealing with. I am just in the dark about it," said AIDS activist Michael Petrelis, who met with Loyce last week to voice his concerns. "There has got to be public involvement. I mean PWA involvement and hopefully PWAs who are not working for the AIDS groups to give some independent evaluation of the services."

Others have voiced concerns about the work group's slow pace. The Bay Area Reporter first reported on the work group in June, and at the time, Loyce had hoped to begin the public discussions this past summer.

"This process has taken too long and we need to speed it up," said San Francisco AIDS Foundation Deputy Director Steven Tierney, who joined the work group in August and wants to see public meetings begin in January or early February. "I just think when you have committees they take on a life of their own. This committee has done a good job and now it is time to move on. It is calling for a community process so let's get on with it."

Loyce said the fight over reauthorization of the Ryan White CARE Act, the government's main funding tool for AIDS services, forced many of the work group members to travel to D.C. over the summer to lobby Congress and diverted their attention from examining the city's model of care.

San Francisco officials, as well as lawmakers from other urban areas in the West and Northeast, have been vigorously fighting Republican proposed changes to the CARE Act, such as a requirement that 75 percent of funds cities receive must go toward medical care and elimination of what is known as a "hold harmless" clause, which factors in reductions in funding over five years, the length of time before the CARE Act expires. Without the clause, San Francisco had faced losing up to a third of the $28 million it receives from the CARE Act next March. Officials feared such a cut would devastate the city's AIDS service infrastructure.

To their relief, the Republican-controlled Congress failed to reauthorize the act, and it is unclear if lawmakers can push it through their lame duck session in December. Most observers expect the reauthorization process to be pushed back to January when the newly elected Congress reconvenes. At that time not only will Democrats be in control but San Francisco Congresswoman Nancy Pelosi will ascend to the House speakership.

"I do feel Democrats have the power and opportunity to look through that proposal and see how harmful it will be to urban [areas] across the U.S. I am encouraged by it," said Andrews. "Gaining that time really was a breath of fresh air. We now have an opportunity to strategize and lobby in a really effective way on Capitol Hill."

Drew Hammill, Pelosi's deputy press secretary, cautioned while, "there is a chance that Ryan White reauthorization will pass in the lame duck session" it is expected that "the hold harmless provisions will not be eliminated." He said that the primary issue facing the CARE Act is funding.

"Funding has declined each year and is now [assuming the fiscal year 2007 appropriations level is increased by $70 million] 36 percent lower in real terms per case than it was in 2001," wrote Hammill in an e-mail. "That is unacceptable and Speaker-designate Pelosi hopes in the next Congress to begin to increase funding in real terms per case as we did in each year of the Clinton administration."

Despite Pelosi's pledge, Loyce said local officials still expect San Francisco will see cuts in funding and the hold harmless clause will be eliminated. He said the only thing for certain "is the Republicans are not in charge."

"Even our friends have said to us we need to - as a national community - assess if hold harmless is still an appropriate mechanism for distributing Ryan White dollars," said Loyce. "All of us recognize at some point hold harmless is going to go away. The question is how does it disappear and what is the impact on San Francisco's and other urban areas' ability to deliver services the population says they need."

Tierney added that even with Pelosi in charge to safeguard the city from draconian cuts in funding, other leaders in Congress will be just as vocal about ensuring their districts receive funding.

"Ryan White CARE cuts are coming for sure. A lot of Democrats who just came into power are from the South and areas seeing a spike in infections," he said. "We do have reason to hope. Having the speaker of the house from our district means that we have a much more likely chance of being treated fairly and won't have any unreasonable cuts."

If anything, the party switch in D.C. has removed some of the urgency the San Francisco work group had been feeling earlier this year and given it more time to address the numerous issues already putting pressure on the SF model.

"I think it is natural that over time the resources the federal government can provide, regardless of who is in charge, are not going to be enough for cities with a caseload the size of San Francisco's. However, it seems that future seems a little further off than this coming March," said Smith. "San Francisco may still see a cut in March, but my guess is it will be much less than it might have been before the election. It doesn't solve the problem down the road. We can expect we can be seeing fewer and fewer federal dollars and we need to prepare for that."

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