Rethinking the San Francisco Model of HIV Care

This edition of OUTReach comes at a time when San Francisco has received yet another cut to its Ryan White CARE Act award for fiscal year (FY) 2006. This year, San Francisco will receive just under $28 million to provide medical care and related support services to the estimated 20,000 people living with HIV/AIDS in our community. This is $333,000 less than the amount received in FY 2005. While this reduction was lower than expected and will not cause significant service disruption, San Francisco is likely to face far more serious cuts in the future.

Federal CARE funding that comes to the San Francisco metropolitan area (which includes San Mateo and Marin counties) has been dropping for several years now. In the mid and late 1990s, the City received over $36 million annually in direct CARE Act funding-- nearly $10 million more than it receives today.

Sadly, cuts to San Francisco's CARE award are likely to accelerate in the years ahead. The legislation that authorizes the CARE Act expired last September and must be renewed by Congress in the coming months. Changes to the authorizing legislation will likely result in even greater reductions to San Francisco's funding levels. As a result, the City's CARE award will continue to drop significantly over the next five years.

These ongoing reductions in federal support will further destabilize the system of HIV care in San Francisco and result in significant reductions in essential services. In order to better plan and prepare for these future funding cuts, I believe it is time for us to rethink the much praised but outdated "San Francisco Model" of HIV care.

The publicly-funded health and social service system for people with HIV requires overhauling in an effort to improve efficiency, focus on quality of care, increase cost effectiveness and ensure cultural competency. This overhaul will likely lead to questions that strike at the heart of the San Francisco model and will undoubtedly raise concerns about equity among groups and subpopulations affected by the disease. It will also force us to question the wisdom of providing HIV-specific services that are separate from established systems of care for people with other chronic medical conditions.

We need to preserve critical services-- such as primary care, case management, housing, mental health and substance abuse interventions-- that support HIV health. But reductions in CARE funding and the inability to make up all of those losses with local resources mean that we will have to provide more services to more people with less funding. Such circumstances demand that we look at the whole system of care, taking into account all funding sources, including local funds, CARE Act dollars, Medi-Cal and Medicare resources, and other related funding streams.

We can no longer react to each round of cuts on a year-to-year basis. Doing so has already created a fragmented and disjointed system of care. Instead, we need to devise a blueprint for developing a sustainable system of care for HIV-infected San Franciscans who rely on publicly-funded care.

The San Francisco AIDS Foundation will continue to work with its advocacy partners around the country to increase federal AIDS funding and avoid cuts in essential HIV support and medical care services. We also look forward to engaging in local planning efforts with the community, health department, and other service providers to preserve the legacy of San Francisco's commitment to being a model in providing innovative care and services.