San Francisco Bay Guardian - March 7, 2002
Tali Woodward

But the roar from the right may be drowning out a more meaningful discussion about how HIV-prevention money is allocated in San Francisco. It's not only conservatives who think that programs here could be better evaluated and coordinated. Activists who are committed to an aggressive prevention approach allow that the city's overall strategy could use more scrutiny - and they say that as the hub of anti-AIDS efforts, San Francisco needs to take the lead on accountability.

Most government money for HIV programs comes from the feds. In 2000 federal funding for all HIV programs - including medical treatment and social services for people infected with the virus and roughly $800 million for prevention efforts - totaled $10.8 billion.

And there have been some pretty ugly stories about how some of the money has been spent.

The Washington Monthly ran a lengthy investigative piece on the misuse of HIV funds last April. It included details on how a doctor in Puerto Rico used $2.2 million in federal funds to buy luxury items like cars and jet skis, while severely neglecting the AIDS patients in his care. An AIDS clinic in Dallas charged the feds for purchases made at Neiman Marcus and calls to psychic hotlines. More than $20 million in grant money intended to help house AIDS patients was collected - but never spent - in Los Angeles.

So far no similar tales of fraud have surfaced about San Francisco.

But San Francisco prevention efforts, funded by roughly $10 million in federal dollars and another $5 million from the city and state, have nonetheless been under attack.

Last fall a memo from U.S. Department of Health and Human Services inspector general Janet Rehnquist criticized two workshops run by San Francisco's Stop AIDS Project - one called "Booty Call," the other "Great Sex" - for encouraging sexual activity and violating the standard of obscenity set forth in the 1973 Supreme Court case Miller v. California. When HHS secretary Tommy Thompson immediately called for an audit of all federally funded prevention programs nationwide, it wasn't hard to see the scuffle as the creation of right-wingers incensed by the public mention - or insinuation - of sex. (City officials told us recently that they have yet to be contacted by the HHS.)

The controversy got additional attention in November when Michael Petrelis, a frequent critic of the web of nonprofits that provides most AIDS services here, and David Pasquarelli, a member of ACT UP San Francisco who clings to the notion that AIDS is not caused by HIV, were arrested for harassing local reporters and city officials (see "Are These Guys Terrorists?," 12/26/01). It was Petrelis who originally got the HHS to investigate local prevention programs.

The newest shot in the funding wars came from a conservative group called Citizens Against Government Waste, which generally pushes a "market-driven" approach to fixing health care.

The February report, titled "AIDS Programs: An Epidemic of Waste," is peppered with illogical arguments. It criticizes the fact that more is spent fighting the spread of HIV than other, noncommunicable diseases. And it proposes the elimination of all federally funded treatment and social programs created for those who are HIV-positive - reasoning that "many of the most impoverished are also eligible for Medicare, Medicaid, and Social Security." Calls to CAGW were not returned by press time.

The report also lumps many San Francisco prevention programs - like the city's HIV Stops with Me campaign and various sexual health workshops - in the "waste" category. This is ostensibly because of their controversial content; the report never refutes the notion that they may be successful. Activists have rushed to defend these programs. They insist that the sexy marketing is needed to attract people - many of whom are simply tired of hearing about HIV.

"They pick apart the provocative language we use to get people in the door instead of the actual programmatic content," said Ernest Hopkins, the director of federal affairs for the San Francisco AIDS Foundation, which runs a program named in the report.

Everyone seems to agree that the attacks are rooted in squeamishness about gay sex. Hopkins, for one, told us that conservatives are bent on dismantling the nonprofit infrastructure because they see it as supporting "the gay agenda."

"AIDS programs in general have been audited and scrutinized at a level above any other federal programming," he said.

The attacks from conservatives, which have everyone "circling the wagons," as one activist put it, also seem to be distracting the community from the real prevention issues it faces.

The city's HIV-prevention program relies on dozens of nonprofits, many of which sprang up to deal with the AIDS epidemic in its earliest days.

Though there is still widespread commitment to the community-based model, there are frequent questions about accountability in such a diffused, fragmented system of public-private partnerships.

The San Francisco AIDS Foundation, for instance, is a powerful group that, according to its tax filings, received more than $5 million in government grants and another $15 million in private donations in 1999. It spends almost as much on salaries, fundraising, and other administrative expenses as it does providing services. "If we didn't have a professional staff, we wouldn't have been able to make the advances we've made," Hopkins said. But talk to most people in the city's gay community and you'll hear resentment concerning the lavish ways of many AIDS-related nonprofits.

Hopkins admitted that, in general, prevention programs are not evaluated for effectiveness very thoroughly. "Frequently data is collected, but it's often not analyzed in the way it needs to be," he said.

Dr. Steven Tierney, the director of HIV prevention for San Francisco's Department of Public Health, told us that each city contract for prevention services requires that 15 percent of the funding be used by the group to evaluate its own program - but that the process isn't very structured. Some say that San Francisco groups need to be particularly vigilant about monitoring, given the city's role in the HIV effort - and the fact that it receives more federal money per AIDS patient than any other community (because much of the money is doled out according to communities' total number of cases over time).

There are numerous debates about how to use limited prevention funds - such as whether it's better to fund needle exchanges or HIV screening for pregnant women. But it's hard to see how they will ever be resolved without overall evaluation.

Longtime activist Hank Wilson, who works at the Tenderloin AIDS Resource Center, said he is frustrated by the lack of attention to drug use among gay men in the city. "We have a raging speed epidemic that's fueling the AIDS epidemic - and people can't get into treatment. They're using these sexy titles to lure people into prevention programs, and then meanwhile, people with speed problems are knocking on the door." He said that often men do not yet have the virus when they get on a waiting list but are HIV positive by the time they get into treatment.

Tierney said that while prevention money cannot be used to provide clinical care, his office is setting up joint programs with other branches of the DPH that can provide treatment. "Providing a comprehensive range of services [continues to be a challenge]," he said, given the strict rules tied to most categorical health care funds.

Wilson emphasized that an epidemic as complex as this one requires constant fine-tuning. "I don't think anyone is claiming we have the solution - it's a moving target," he said. In the long run, he added, "the major concern is not the salaries - it's getting people through this epidemic, which is a very complex thing. Right now some people think it's a death sentence, while others are not concerned at all. We ought to keep our minds on getting people informed."

E-mail Tali Woodward at tali@sfbg.com.

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