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Tag: Harm reduction

People often equate harm reduction with syringe access services— providing people who inject drugs with the supplies and resources they need to prevent HIV, hepatitis C, other blood-borne infections, abscesses and skin infections.

I’m here to tell you that it’s so much more than that.

Harm reduction is an expression of love and empathy for all who use drugs, who have sex, who engage in sex work or do other things that can result in harm. That means that all of us, at different points in time, practice harm reduction as a way to take care of ourselves and the people we love.

When applied to drug use, harm reduction strategies exist on a spectrum anywhere from safer techniques (like testing your drugs for fentanyl or using with friends who have Narcan), to managed use, to abstinence. It can include limiting when we use drugs, or changing how or what we use. Harm reduction recognizes that there are reasons why we use drugs, and reasons why we don’t or can’t stop. Harm reduction creates opportunities so that we can be as safe as possible.

When we practice harm reduction, we work to create spaces and conversations that heal the harms caused by a racist drug war. It’s a lens through which we can look at social inequities and the way they impact the harms we are vulnerable to. 

If you have money and resources, the risks you experience from drugs will look very different than those you might encounter if you’re unhoused and using outdoors. If you don’t have access to showers or hygiene supplies, or if you’re trying to use under your coat in a public place and you’re rushing because people are walking by and you feel shame and stigma, you may be exposed to more risk. 

Add to that how factors like race, gender, sexuality, immigration status and disability can influence how much money you make, your risk of experiencing homelessness, and how likely the police will be to confront you. Harm reduction recognizes–and works within–the structural inequalities that we face that intersect with drug-related stigma and the harm it causes.

Standing squarely in the way of harm reduction is the war on drugs. 

The drug war has shaped a collective societal view of certain drugs as inherently bad or evil. Drugs can’t be bad, nor can they be good, because they are just a thing that can be used for many different reasons. When we see those drugs as bad, then we start to look at the people who use them as bad–as opposed to people who use drugs for reasons of their own.

This mindset leads to people in power operating from a punitive space—coming at the problems caused by drugs with hurt as opposed to health. There are a lot of people with really good intentions who think, ‘I need to punish you because that’s how you get better.’ But if you’re coming at someone who uses drugs with that perspective, it means you’re not listening to that person. You’re not including that person. You’re trying to tell them what’s best for them (abstinence) without listening to them about what they need to be healthy and whole.

It’s important to acknowledge that most people have trauma around drug use, something that my colleague Miss Ian, the executive director of the San Francisco Drug Users Union has reminded me. We’ve been affected by our own use, the use of our family or friends, or what we’ve seen in our community growing up. This is one reason why it can be difficult to prevent any negative feelings about drugs from setting expectations about what people who use drugs should or shouldn’t do. But we must try.

Harm reduction is one way to help process some of these experiences of trauma.

We don’t minimize, ignore or overlook the real or tragic harms that can come from licit or illicit drug use. In fact—we have to be pragmatic, realistic and informed in order to find solutions to minimize or prevent these harms. We know that people die every day from opioid overdose. That’s why we’re proponents of overdose prevention—testing drug supplies, using with other people, being trained on and having Narcan—strategies that have been proven time and time again to save the lives of people who use drugs.

For all the drug users who feel overlooked, discounted or on edge—we see you. We’re here to meet you where you are with love and support.  

Harm Reduction Coalition

Harm Reduction Coalition is a national advocacy and capacity-building organization that works to promote the health and dignity of individuals and communities who are impacted by drug use, challenging the persistent stigma faced by people who use drugs and advocating for policy and public health reform. 


More info

Looking for drug and alcohol use support?

Find out more about the harm reduction-based substance use services at San Francisco AIDS Foundation. We help people who use drugs to pick evidence-based strategies to reduce the harm that drugs and alcohol can cause.


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About the author

Charles Hawthorne

Charles Hawthorne

Charles Hawthorne is a trainer for the Harm Reduction Training Institute and Outreach Project in partnership with the San Francisco Department of Public Health, working passionately to deliver training and technical assistance to organizations in the Bay Area and the greater San Francisco region that impacts the lives of PLWHA, PWUD, PWID and LGBTQ+ communities.

Charles works to foster partnerships with other organizations in the Bay Area that do social justice and harm reduction work while helping to expand reach and capacity to communities experiencing disproportionately punitive impacts of racialized drug policies.
Harm reduction

Relaunched Tweaker site tightens ties to substance-use support group

What began as a campaign exploring STI transmission is now an international resource for drug-use safety. SFAF’s Jen Hecht shares the importance of accessible sexual health information and the evolution of drug language.

Since its inception 22 years ago, tweaker.org has been a resource for people seeking tips on using crystal meth more safely. After a design update this spring, the site is now configured to better serve the community.

In 1997, STOP AIDS Project surveyed some of San Francisco’s gay male community about issues around HIV and crystal meth was identified as a large driver for transmission. Thus, a social marketing campaign was born to address how meth affects sexual health and overall wellbeing.

The ad campaign appeared around San Francisco and tweaker.org was launched that summer, continuing for two years before its funding was canceled, leaving a static and dormant web address.

Stonewall Project, a harm reduction counseling group for gay, bisexual, queer and trans men interested in changing their relationship to drugs and alcohol, resurrected tweaker.org in 2001 as an additional outreach tool. Then, a decade after its debut, tweaker.org became part of San Francisco AIDS Foundation along with the Stonewall Project.

Jen Hecht, senior director of program strategy and evaluation at SFAF, has over 20 years of experience in public health with a focus on HIV and STIs. Now overseeing the relaunch of tweaker.org, which was updated this year to incorporate new mobile technologies and easier site navigation, Hecht spoke about the importance of access to sexual health information and the evolution of drug language.

How is tweaker.org different from other websites that offer harm reduction tips?

Jen Hecht: The fact that it’s not coming from an abstinence-only focus is huge. [The language is] non-judgemental and it’s in a tone that’s for the person who’s using. People have struggles that they’re facing and being able to learn how to really deal with them is essential.

What are the goals of tweaker.org?

The number one focus is to make sure people have access to accurate information. Secondly, and almost as important, is that people have access to communities of other users and peers, and feel that they’re not being judged. This site has been around for a lot of years and there has been a lot of activity with people supporting each other with information they’ve learned from their own experience.

Why is tweaker.org important to you?

It’s important because there are lots of people who are using and want to be able to use safely. [They] want to be able to take care of their friends, family, or partners who are using. They can be on their phone on the street and access that information. They don’t have to walk into a service provider or into a place that has a name on the front of the building that they might not feel comfortable with or be judged for. There’s any number of different scenarios where someone might not be in a position to walk into a treatment space, and that is completely fine, but they should still be able to access the information.

How have you seen drug language evolve over time?

There are terms that evolve and terms that, over time, acquire a certain stigma or negative association that we then want to move away from. While we’re based in San Francisco and a lot of the tweaker.org language is influenced by that, the website itself is accessed by people around the world. We recognize that regionally these things can be very different and that language may not be as on-point in other parts of the country or the world, but hopefully it’s at least clear.

How does tweaker.org intersect with the harm reduction values of the foundation?

We want to make sure people feel safe and welcomed into the [digital] space, and that they can get the information they want and not feel judgement.

In this new relaunch, we tightened the connection to Stonewall Project who runs tweaker.org. They have so much knowledge and expertise to share. We’re trying to make it easier for people who want to get support to be able to find it; there’s no pressure around it. The door’s open if that’s what you want, and if it’s not, here’s some information that will hopefully make using as safe, joyful and pleasurable as possible.

Try it! Access the relaunched tweaker.org from your mobile device for tips on using crystal meth more safely.

About the author

San Francisco AIDS Foundation

San Francisco AIDS Foundation

San Francisco AIDS Foundation promotes health, wellness and social justice for communities most impacted by HIV through sexual health and substance use services, advocacy, and community partnerships. Each year more than 25,000 people rely on SFAF programs and services, and millions more access SFAF health information online.
Harm reduction

How do meth and other stimulants affect viral suppression?

For many years, researchers have observed that people using stimulants (such as meth, powder cocaine, and crack-cocaine) who are living with HIV are less likely to stay engaged in HIV care, are more likely to have higher viral loads and are more likely to experience faster disease progression. But in the age of universal HIV treatment with powerful and effective antiretrovirals, the impact of stimulant use on HIV treatment appears to be less significant than it once was.

Adam Carrico Headshot
Adam Carrico, PhD

Adam Carrico, PhD, from the University of Miami, joins BETA to discuss new research his team published about the impact of stimulant use on viral suppression, and share some take-aways from his research to improve the health of people living with HIV who use stimulants like meth.

BETA: Thanks for sharing information about your research, Adam. Could you start by talking a little bit about why it’s important to understand the effects that stimulants have on HIV health and viral suppression?

Adam Carrico, PhD: This work is important for a couple of reasons. For one, viral suppression is just as important for people who use stimulants as it is for anyone else. Having a better understanding of the challenges that people who use stimulants may face in becoming undetectable will may ultimately help us increase rates of viral suppression in this high-priority population.

People who use substances, particularly people who use meth, are also more likely to engage in sexual risk behaviors including HIV transmission risk behavior. If people are able to stay undetectable, this is one of the best tools that we have for preventing the onward transmission of HIV. All of this work is nested in the double benefit of HIV treatment as prevention by optimizing the heath of people who use stimulants and reducing risk of onward HIV transmission.

What effect did stimulants have on viral suppression for people living with HIV in your research?

In collaboration with a team of investigators at the University of California, San Francisco (UCSF), the study published recently in JAIDS compared the rates of viral suppression between people who used stimulants (meth, powder cocaine, crack-cocaine or cocaine injection) and people who didn’t use stimulants.

We included 1,635 people living with HIV who were part of the SCOPE clinical cohort at Zuckerberg San Francisco General Hospital, which began enrolling people in the year 2000. Basically, we looked at rates of viral suppression and compared people who reported no stimulant use, those who reported stimulant use at half of the study visits, and those who reported stimulant use at every visit. We also looked at the differences in rates of viral suppression between these groups in the years before universal HIV treatment (2000 – 2009) and following the advent of universal HIV treatment (2010 – 2016).

Across all of the years, people who used stimulants were less likely to be virally suppressed than people who did not report stimulant use. But these differences were diminishing in the era of universal HIV treatment. Basically, our research found that stimulants seem to be affecting rates of viral suppression less in the current day and age than in previous years. By no means is the problem solved, but things appear to be better than they used to be.

Why do you think stimulant use seems to be having less of an effect on viral suppression these days compared to previous years?

This isn’t something that we collected data on in this study, but we do know that over the years HIV medications have gotten better. You can take one pill once a day now. The medications are also more forgiving of non-adherence—people can get virally suppressed even at moderate levels of adherence. That is likely one reason why we see that people using stimulants are more likely to be virally suppressed in recent years.

Another reason may be that people are more motivated to become undetectable now that we know that undetectable equals untransmittable (U=U). People are motivated to be undetectable knowing that they can meet romantic and sexual partners without having to worry about onward HIV transmission.

What message do you have for people living with HIV who use stimulants?

After working with guys in San Francisco who use meth and also women in Miami who use cocaine, I would say that just because you’re using stimulants doesn’t mean you can’t take your HIV medications. Even if you’re partying, make sure to take your medications so you can be undetectable.

The other major take-home is that viral suppression isn’t the only thing to consider health-wise. It’s great if you’re undetectable. Research by my team and others shows that stimulants may be detrimental to the immune system even if people are undetectable. Stimulants can still damage the immune system in important ways that can increase risk for negative health outcomes. Viral suppression is just one metric. So, reducing or abstaining from stimulant use can improve your health even if you are already undetectable.

Can you tell us more about the focus of your research now and in the future? What more is there to find out about stimulant use and HIV health?

My team is developing and testing interventions that amplify or accelerate the benefits of HIV treatment as prevention in people who use stimulants like meth. We’re testing approaches that help people get a handle on their stimulant use in the hopes that it will also have benefits for people’s ability to manage HIV medications and be undetectable.

One intervention we developed is a brief therapeutic intervention that helps people in substance use treatment focus on positive affect like happiness or gratitude to find ways that life is rewarding and pleasurable outside of their substance use. This research was conducted in partnership with the Positive Reinforcement Opportunity Project (PROP), which is administered by the Stonewall Project at San Francisco AIDS Foundation.

Inspired by harm reduction, the orientation of the positive affect intervention is very different than mainstream substance use treatment approaches—which tend to focus on avoiding triggers or demanding abstinence. Instead of focusing on taking things away, we’re helping people add something positive to their lives, so that hopefully the substance use becomes less of a dominant focus. It’s about how to find pleasure outside of substance use, and making your life more rewarding and meaningful. Our recent findings show that this approach reduces methamphetamine craving and self-reported stimulant use in HIV-positive, meth-using men and trans women receiving services at PROP.

Source

Carrico, A. W. and colleagues. Stimulant use and viral suppression in the era of universal antiretroviral therapy. JAIDS, January 2019.

Want to talk to someone about drugs or alcohol?

The Stonewall Project is here to help. Stonewall offers free harm reduction counseling to gay, bi and trans men who want to assess their substance use and are thinking about making changes. For more information and to seek services, visit stonewallsf.org or call 415-487-3100.

People in the San Francisco Bay Area who are interested in reducing or quitting use of crystal meth, cocaine or other stimulants are welcome to find out more about PROP. PROP is a supportive, incentivized program for gay, bi and trans men, men who have sex with men, and trans women. People interested in enrolling may call Rick at 415-487-3115 or may visit the PROP website at San Francisco AIDS Foundation for more information.

About the author

Emily Land, MA

Emily Land, MA

Emily Land, MA is the associate director of communications & editorial services at San Francisco AIDS Foundation.

Methamphetamine (meth) is a powerful stimulant that in the short-term can improve mood, energy levels and alertness—but when used long-term can lead to depression and other mental health concerns. Some people who use meth and want to make a change to their substance use opt for complete abstinence, through programs such as Crystal Meth Anonymous (CMA) with the belief that stopping substance use is the only way to “recover” from addiction. New research, published in JAIDS, is the latest in a long line of studies over many decades which shows that people struggling with substance use can experience significant improvements without abstinence.

I’ve been working in drug and alcohol counseling for about 8 years, and the take-home message from this study for me is that harm reduction works. A lot of people say that you have to quit meth to have any hope—but that’s just not true.

Many people are able to successfully use drugs, and many people who make changes to their substance use don’t do it with complete abstinence.

Details of the study

The study included 9,905 people living with HIV who reported the frequency that they used drugs including crack/cocaine, amphetamine-type substances (e.g., meth), illicit opioids and marijuana every six months. The researchers assessed depressive symptoms using a measurement tool called the Patient Health Questionnaire.

Most of the people in the study were men (84%) and 40% reported using a substance at the beginning of the study. A total of 1,016 reported meth use, 728 reported cocaine/crack use, 290 reported illicit opioid use and 3,277 reported marijuana use during the study. The researchers examined associations between changes in the use of individual drugs and depressive symptoms.

Over time, substance use reduction and abstinence were associated with improvements in depressive symptoms.

Changes in meth use were associated with the greatest improvements in depressive symptoms: Reducing meth also led to a significant decline in depressive symptoms (on average a decline of 1.7 points). Abstinence from meth reduced the depressive symptoms score on average 2.2 points (compared to people who continued to use).

Depressive symptoms

 

For other drugs, the impact of abstinence and reduced use on depression was more subtle.

Stopping marijuana decreased the average depressive symptoms score by 0.5. Reducing marijuana was associated with a decrease of 0.4.

Stopping cocaine/crack decreased the depressive symptoms score by 0.8, but reducing use did not lead to a significant decrease in depressive scores.

Stopping or reducing use of opioids was not significantly associated with a reduction in depressive symptom scores.

“Reducing [amphetamine-type drugs] was more strongly associated with alleviation of depressive symptoms, perhaps suggesting that it has greater detrimental clinical impact, including on depression, than other drugs in this population,” the researchers speculated.

The intertwined effects of meth and depression

The results of this study closely align with what I see working with clients every day.

Depression and meth use are tightly intertwined. People who experience depression are more likely to seek out meth as a way to self-medicate, and people with no history of depression are more likely to experience depression after taking meth regularly.

The reasons are pharmacological.

Meth, a stimulant, can be an incredibly effective solution to depression in the short-term. People with mental health issues often use drugs as a way to self-medicate—seeking out the particular types of drugs that solve their mental health concerns. People who are anxious are more likely to use alcohol, benzodiazepines, marijuana and other depressants; people who are depressed are more likely to seek out stimulants like meth.

A lot of people that use stimulants, in particular, have pre-existing depression. And when they discover their stimulant of choice, they feel like, “Oh my god! I finally feel normal.” Meth floods your brain with dopamine, and also prevents the re-uptake of it. In the short-term, it can blow your depression out of the water.

The problem is that it’s next to impossible to regulate meth use (or any illicit substance) in a way that mirrors the precision of pharmacological therapy. People taking meth flood their system with high doses that spike dopamine levels and lead to dramatic crashes. Drug supplies are unreliable and can be filled with adulterants. People taking frequent, high doses develop tolerance. With time, the brain loses the ability to naturally produce endogenous dopamine, which makes it even harder to stop using. The self-medication benefits from meth use stop working over the long-term.

Long-term meth use also makes people more susceptible to depression, by changing the amount of endogenous dopamine produced by the brain.

These changes mean that it can be incredibly difficult to stop using meth cold turkey. Withdrawal and post-acute withdrawal, which people experience as depression, irritability, intense fatigue and more are the effects of the body and brain adapting to the loss of dopamine.

Many people opt to reduce their use of meth, as a way to reduce the negative impacts that meth can have while lessening the withdrawal symptoms that may come from stopping use outright. And this study shows that reducing your use—even if you don’t quit altogether—can lead to significant, measurable improvements.

Reducing use and other harm reduction strategies

Reducing substance use is one way to reduce the negative impact that drugs can have on your life, but it’s not the only way.

Substitution strategies involve understanding what one is getting from a drug, and then trying to find other less harmful drugs or non-drug related activities to fulfill those same needs. For example, many clients find that they can use cannabis to help reduce social or sexual inhibitions instead of using meth in social or sexual situations.

You can also change how you administer or use your drugs. Some clients find that injecting is more problematic for them than smoking, snorting or booty bumping. Some people believe that once you have injected, it is difficult to revert to a different mode of administration, but people make this change frequently and successfully.

Improving your safety when you use drugs is also a harm reduction priority. Even if you do not significantly change your quantity of use, you can do things like only invite people you know for party and play in your room. Or you can always let a close friend know where you are and ask them to check in with you after a certain amount of time to ensure that you are safe.

Another key strategy is timing your meth use strategically. You can make sure to eat, pay rent and bills, and make it to a medical appointment BEFORE starting to use meth. A person with a job may set boundaries such as only using on weekends, or cutting off their use at a certain time and trying to get at least a few hours of sleep. Some people also find it helpful to set alarms for times when they need to take medications, or strategically place water, lube or other safer supplies in places they will likely be when using.

The take-away message is that many people can use meth and still maintain a quality of life that is commensurate with their values.

Want to talk to someone about drugs or alcohol?

The Stonewall Project is here to help. Stonewall offers free harm reduction counseling to gay, bi and trans men who want to assess their substance use and are thinking about making changes. For more information and to seek services, visit stonewallsf.org or call 415-487-3100.

Source

Delaney, J.A. and colleagues. Brief Report: Reduced Use of Illicit Substances, Even Without Abstinence, Is Associated With Improved Depressive Symptoms Among People Living With HIV. JAIDS, November, 2018.

 

About the author

Jeremy Prillwitz, MA, LAADC

Jeremy Prillwitz, MA, LAADC

Jeremy Prillwitz, MA, CATC, has been a counselor at the Stonewall Project since 2012. He is a frequent presenter on harm reduction at conferences and trainings. He is currently writing a book challenging the abstinence-only treatment monopoly in the U.S., and highlighting the positive and pro-social aspects of drugs.
Harm reduction

How an overdose prevention site will reduce public injecting

Overdose prevention sites reduce public injecting and prevent discarded syringes, save cities money, and improve the health of people who inject.

Public injection drug use in San Francisco is not a new issue, but it’s one that’s reaching new levels of concern by public health agencies, business owners and the general public alike. If you have spent time walking the city, you have likely seen the tell-tale signs of public drug use—improperly discarded syringes or drug use paraphernalia—if not people injecting or using drugs outright.

It’s not that people who use injection drugs enjoy doing so in public—more often than not people use in public simply because they have nowhere else to go.

San Francisco Mayor London Breed speaks about overdose prevention sites at a community event (Photo: San Francisco AIDS Foundation)
San Francisco Mayor London Breed speaks about overdose prevention sites at a community event (Photo: San Francisco AIDS Foundation)

“Continuing with the status quo and just hoping that things will get better is not an option. Substance abuse is not simply going away because we don’t want to see it,” said San Francisco Mayor London Breed at a press conference in August.Pending the Governor’s approval of AB 186, San Francisco may soon be able to open overdose prevention facilities where people who inject drugs can do so in a clean, sterile environment away from the public eye and under supervision of trained professionals. How will these facilities change the landscape?

Fortunately, we don’t have to guess. San Francisco benefits from rigorous research on overdose prevention sites that have been operating across Europe and in Canada for many years. Numerous studies have shared the positive impact that overdose prevention facilities have on cities (not to mention disease transmission rates, the health of drug uses and rates of overdose).

Overdose prevention facilities decrease public injecting

Studies of Insite, an overdose prevention/safe injection facility (SIF) that opened in Vancouver in 2003, show that public injection significantly decreased in the area surrounding the facility after it opened.

 

A volunteer for the Glide overdose prevention facility demonstration, Safer Inside, shows harm reduction supplies that would be provided to visitors at an overdose prevention site.
A volunteer for the Glide overdose prevention facility demonstration, Safer Inside, shows harm reduction supplies that would be provided to visitors at an overdose prevention site. (Photo: San Francisco AIDS Foundation)

In a study conducted in the six weeks before the facility opened through the 12 weeks after opening, researchers measured public injection drug use, publicly discarded syringes, injection-related litter and suspected drug deals in the 10-block radius surrounding Insite. Specifically, ethnographers walked through pre-determined areas at set times to count instances of each during the study.

With more than 500 people visiting the facility after its opening, the researchers said it was “not surprising” that public injection significantly decreased in the weeks after Insite opened. During data collection times, the mean number of people injecting in public areas near the SIF every day fell from 4.3 before Insite opened to 2.4 in the weeks after opening.

“A commonly reported reason for public drug use is the lack of an alternative place to inject,” the authors said. “[People who inject drugs] who go to safer injecting facilities are often homeless or marginally housed.”

Reports from people who inject drugs as well as community residents bolster this finding. A separate study with people visiting an overdose prevention/safer injection facility in Copenhagen, Denmark, found that drug users themselves reported public injecting less frequently. More than half (56%) of people surveyed in the study said that they injected outdoors less often after the facility opened.

A long-term study of an overdose prevention facility’s impact in Australia found that residents and business owners noticed a similar impact on public injection.

An example of what an overdose prevention facility set up might look like, by Glide.
An example of what an overdose prevention facility set up might look like, by Glide. (Photo: San Francisco AIDS Foundation)

In Kings Cross, Sydney, telephone surveys were conducted with local business owners and residents before and in the years following the opening of an overdose prevention facility. There was a 50% decrease in the number of residents who reported observing public injecting in the past month from 2000 (before the site opened) to 2010. Similarly, the percentage of business owners who reported seeing public injection in the previous month declined from 61% before the facility opened to 22% ten years later.

This same study found that a majority (92%) of clients surveyed agreed with a statement that the facility “helped [them] to reduce injecting in public places.”

Overdose prevention facilities decrease improperly discarded syringes and injection litter in public spaces

Syringe access programs in San Francisco help ensure that people who use injection drugs have access to the supplies they need. Syringe access sites are also the top disposers of used injection equipment. But, used injection equipment too often winds up on sidewalks and in other public spaces. The good news is that overdose prevention facilities give people a convenient place to dispose of used injection equipment, which significantly reduces the amount of syringes and injection litter that wind up on the street.

Currently, San Francisco AIDS Foundation staff conduct regular sweeps to pick up improperly discarded syringes. Overdose prevention sites reduce the amount of public injection and the amount of improperly discarded syringes.
Currently, San Francisco AIDS Foundation staff conduct regular sweeps to pick up improperly discarded syringes. Overdose prevention sites reduce the amount of public injection and the amount of improperly discarded syringes. (Photo: San Francisco AIDS Foundation)

In Vancouver, researchers studying the impact of Insite found that the amount of improperly discarded syringes and injection litter decreased dramatically after the site opened. In the 10-block radius around the facility, publicly discarded syringes and injection-related litter dropped by about 50% in the 12 weeks after opening compared to the six weeks before opening: The mean number of discarded syringes dropped from 11.5 to 5.4, and the amount of injection litter from 601 to 310 (which were both statistically significant reductions).

Reports from people who use overdose prevention facilities support these findings. A study in Copenhagen found that people who used an overdose prevention facility reported significant changes in syringe disposal practices after they started using the facility. The percent of people surveyed who reported returning needles to the needle exchange or overdose prevention facility increased from 34% to 88%, and a large percentage of people surveyed (62%) reported that their syringe disposal practices changed from “not always disposing safely” to “always disposing safely.”

“Establishment of the [overdose prevention] facility has resulted in measurable improvements in public order,” said Evan Wood, MD, PhD and colleagues in an article describing Insite’s impact on the community. “This in turn may improve the livability of communities and benefit tourism while reducing community concerns stemming from public drug use and discarded syringes.”

Overdose prevention facilities do not increase drug-related crime or drug dealing

One oftentimes cited concern about overdose prevention facilities is that they will increase drug dealing, drug-related crime or other criminal activity in the area. Studies of crime data in areas before and after the opening of overdose prevention facilities refute this assumption—showing that these facilities do not lead to increases in drug dealing or other neighborhood crimes.

In Vancouver, a group of researchers analyzed Vancouver police data of the year prior to and the year after InSite’s opening. Rates of drug trafficking, assaults and robbery in the Downtown Eastside neighborhood remained steady and rates of vehicle break-ins and theft declined.

“Our overall findings suggest that the [overdose prevention facility] was not associated with a marked increase in drug-related criminal activity,” said Evan Wood, MD, PhD and colleagues.

A similar study of crime data from Kings Cross, in Sydney, found that rates of robbery, theft and drug dealing did not increase in the nine years after the overdose prevention facility opened. In fact, rates of robbery and theft fell dramatically in the neighborhood (similar to trends across Sydney). Rates of dealing cocaine, narcotics and amphetamines remained stable from 2001 to 2010.

“Overall, these analyses show no evidence that the [overdose prevention facility] has had a negative impact on property crime or incidents of drug dealing or possession in Kings Cross,” said Jacqueline Fitzgerald and colleagues.

An overdose prevention facility could save San Francisco millions

In an innovative mathematical modeling analysis, Amos Irwin, MD and colleagues compared the estimated cost of operating an overdose prevention facility in San Francisco to possible city savings. They asked the question: Would a facility in San Francisco be an effective and efficient use of financial resources?

The researchers used existing data from overdose prevention facilities around the world to estimate how many HIV and hepatitis C infections, overdose deaths, and skin and soft tissue infections could be averted with a single San Francisco overdose prevention site. They also estimated the impact a site could have on the number of people entering substance use treatment. These averted infections and benefits to health for people who inject drugs would provide a net savings of $3.5 million every year.

“Our cost-benefit analysis supports the establishment of an [overdose prevention facility] in San Francisco, as we find that it would significantly reduce costs associated with health care, emergency services, and crime,” the authors said.

Get involved

To be part of the San Francisco AIDS Foundation HIV Advocacy Network, and advocate for causes such as overdose prevention sites, text SFAF to 52886.

Sources

Fitzgerald, J. and colleagues. Trends in property and illicit drug crime around the medically supervised injecting centre in Kings cross: an update. Crime and Justice Statistics, 2010.

Irwin, A. and colleagues. A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco, California, USA. Journal of Drug Issues, 2016.

Kinnard, E. N. and colleagues. Self-reported changes in drug use behaviors and syringe disposal methods following the opening of a supervised injecting facility in Copenhagen, Denmark. Harm Reduction Journal, 2014.

KPMG. NSW Health Further evaluation of the Medically Supervised Injecting Centre during its extended Trial period (2007-2011).

Wood, E. and colleagues. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. CMAJ, 2004.

Wood, E. and colleagues. Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime. Substance Abuse Treatment, Prevention, and Policy, 2006.

 

About the author

Emily Land, MA

Emily Land, MA

Emily Land, MA is the associate director of communications & editorial services at San Francisco AIDS Foundation.
Prevention

Getting syringes off San Francisco streets

In April 2018, San Francisco AIDS Foundation received funding from the city to expand syringe disposal efforts. With the support of a grant from the Department of Public Health, our syringe access and disposal team has been able to design a new program and hire staff who focus on looking for and properly disposing of syringes and other drug use paraphernalia discarded on city streets and in public areas.

“The City’s increased investment will allow us to build upon current disposal efforts which result in the collection and disposal of more than 275,000 used needles per month,” said Joe Hollendoner, CEO of San Francisco AIDS Foundation.

“These new positions will increase our capacity to remove used syringes from circulation, ensure their safe disposal to prevent syringe sharing and re-use, and clean up syringe litter on our city streets,” said Terry Morris, director of syringe access and disposal services and the 6th Street Harm Reduction Center at San Francisco AIDS Foundation.

“Most importantly, this programming will allow us to dispatch staff to quickly respond to neighbor and merchant requests for syringe cleanup seven days a week for a total of 72 hours per week.”

The new positions will supplement existing safe syringe disposal and street clean-up efforts. Currently, San Francisco AIDS Foundation staff and volunteers search the City’s streets, alleys, parks, plazas and BART stations for improperly discarded syringes, offer safe disposal services at all syringe access sites, provide clients and community members with safe disposal equipment, and provide safe disposal education to program participants. In May 2018, staff and volunteers in existing programs picked up 8,000 improperly discarded syringes, said Morris.

“For the last five years we have made an extra effort to improve the pickup of needle litter,” said Barbara Garcia, director of health at San Francisco Department of Public Health. “This is an environmental health issue that affects everyone in the city, and it is a problem for cities all over the world. By increasing our response capabilities we expect to see a significant reduction in needles on the streets.”

Syringe access programs distribute clean syringes and other safe injection equipment to combat the spread of infectious diseases including HIV and hepatitis C. User-defined syringe distribution programs are the most effective way to curb disease transmission, and syringe access sites are the collecting the largest share of used syringes compared to all the other means of collection. While no HIV infections have resulted from needle sticks from improperly discarded syringes, needle litter is a concern when syringes left on the street become a nuisance or pose safety concerns.

Although people who inject drugs are most often proponents of safe disposal, difficult life circumstances and structural barriers can stand in the way of safe disposal. People without stable housing may not have a choice about how long they can stay at a certain location and what happens to their property, explained Morris.

“You can’t disconnect the issue of homelessness and syringe disposal,” Morris said. “If people had better options about where they could go and safely inject, we would see less injection equipment left on the street.”

Want to make a difference in your community? Find out how you can volunteer with Syringe Access Services and other programs at San Francisco AIDS Foundation.

See a needle on the street? Don’t touch it or try to pick it up without proper training and equipment. Report it to our Pick Up Crew using our online tool, or text a photo and location to 415-810-1337. You may also call 311 to report the location. A team will be dispatched to the location to pick up and dispose of the syringe safely.

About the author

San Francisco AIDS Foundation

San Francisco AIDS Foundation

San Francisco AIDS Foundation promotes health, wellness and social justice for communities most impacted by HIV through sexual health and substance use services, advocacy, and community partnerships. Each year more than 25,000 people rely on SFAF programs and services, and millions more access SFAF health information online.
Harm reduction

Alcohol & HIV: What You Need to Know

“We are not here to wag fingers at bars or people who drink. We are here to provide information and resources so that everyone has the knowledge to make the best possible decisions about their health.”

—Neil Giuliano
CEO, San Francisco AIDS Foundation

On February 16, 2012, San Francisco AIDS Foundation held a public HIVision forum titled, “Alcohol & HIV: Current Thinking about Drinking.” In his introduction, foundation CEO Neil Giuliano observed that alcohol use in our community is pervasive—so much so, that “the line between drinking and drinking too much often gets blurred. And when we cross that line, many of us don’t have the tools to recognize it and know where to get help.” According to the Centers for Disease Control and Prevention (CDC), Giuliano said, one in six U.S. adults binge drinks, defined as consuming five or more drinks within two hours for men, and four or more drinks within two hours for women. Excessive alcohol use contributes to car crashes, violence, and sexually transmitted infections like HIV and is implicated in nearly 80,000 deaths per year.

San Francisco AIDs Foundation CEO Neil Giuliano with Hivision panelists“So,” asked Giuliano, “is drinking bad for us?” Not necessarily, given research showing cardiovascular benefits of moderate drinking. In addition, he said, “we want to recognize the important role that our bars and clubs—and the LGBT merchants and allies who run them—play in creating a very strong sense of community” here in San Francisco. Giuliano’s opening remarks highlighted some of the complex health and social issues surrounding alcohol use and laid the groundwork for a lively panel discussion.

Invited panelists included Susan Buchbinder, MD, director of research for the HIV Prevention Section at the San Francisco Department of Public Health and assistant clinical professor of medicine, epidemiology and biostatistics at the University of California, San Francisco (UCSF); Michael D. Siever, PhD, director of behavioral health services at San Francisco AIDS Foundation; and Chris Hastings, owner of LOOKOUT bar in San Francisco’s Castro neighborhood. The panel was moderated by E. Maxwell Davis, PhD, MSSA, assistant professor of human development and women’s studies at California State University, East Bay.

The purpose of this forum was to begin a frank dialog about the intersection of alcohol use, HIV risk, and HIV health. Following is a summary of key questions and issues that emerged during the panel and audience discussion.

To put alcohol in perspective, how is it similar to and different from other drugs?

“Alcohol affects virtually every part of the body if it’s used in excess. . . . It may be similar to some drugs, but rather than a focused or concentrated negative effect, it has a very widespread effect.”

—Susan Buchbinder

Alcohol is an intoxicant and central nervous system depressant like many other substances of abuse, but it is legal, readily available, and widely socially accepted. Like other drugs, alcohol alters the way we think about, perceive, and react to things, but as Dr. Susan Buchbinder noted, excessive alcohol use has broader effects throughout the body. Buchbinder also explained that alcohol can alter the way medications are metabolized in the body, which may reduce their effectiveness or cause unwanted side effects.

Unlike some more addictive substances, there is “a spectrum of people who are more susceptible or less susceptible to becoming addicted to [alcohol],” Buchbinder observed. “It’s not necessarily a very addictive substance, but for some people, it probably is.” Dr. Michael Siever emphasized that although not everyone who drinks becomes addicted to alcohol, it is a drug. “One of the phrases that a lot of us in the substance-abuse field use pretty frequently is ‘alcohol and other drugs,’ the emphasis on ‘other.’ . . . When you ask people what drugs they do, they generally are not going to talk about alcohol.”

And yet, Siever continued, overuse of alcohol can have consequences as deadly as any other form of substance abuse. “There are regularly stories about . . . ‘hazing’ events where people are encouraged to down a fifth of vodka in one gulp. That can kill you. So it’s a serious drug, but we don’t think of it that way.”

Buchbinder agreed. “I would say that we see many, many more diseases that are related to alcohol use, deaths related to alcohol use, and hospitalizations related to alcohol use than probably all of the other drugs put together”—most likely, she said, because more people drink alcohol than use other drugs and because alcohol affects every organ in the body when overused. “If you’ve already got disease in an organ—the brain, the liver, the heart, the kidneys—alcohol can make that worse.”

“Frankly,” added Siever, “alcohol is much harder on your body than heroin!” Siever acknowledged research indicating the health benefits of moderate drinking, but cautioned that “it’s pretty easy to tip over into the territory where it’s really not a positive effect on your body.”

Given alcohol’s wide social acceptance, how do we define and recognize problematic alcohol use?

“Obviously, it’s about when your drinking is starting to cause problems. That’s easy to say, but the problem is we don’t always recognize when our drinking is causing problems.”

—Michael Siever

According to Siever, drinking is widely considered a cultural “norm”—a view that obscures the real range of ways people use (or don’t use) alcohol. “We tend to think either [your drinking] is fine or you’re an alcoholic, and there’s nothing in between. That’s a major problem in terms of how we think and talk about it.” Rather, there is a continuum of alcohol consumption, from total abstinence and non-problematic use to problematic overconsumption, alcohol dependence, and alcoholism.

Siever mentioned a CDC survey showing that only 50% of American adults drink regularly—although, he noted, the survey “defined a ‘regular drinker’ as someone who drinks 12 or more drinks a year, so that’s a pretty hazy definition.” To moderator Dr. E. Maxwell Davis, this definition further demonstrated how alcohol is viewed differently from other drugs: “If I tell someone that I use crack casually, they probably automatically tell me I have a problem, right? . . . There’s no level of socially acceptable use for a lot of other substances.”

Chris Hastings offered two perspectives on problematic alcohol consumption. “As a member of the community and as a friend, I would say problem drinking is something that’s going to negatively impact someone’s life; it’s going to cause them to make decisions that maybe they wouldn’t otherwise. Maybe that’s on the scale of an evening, or it could be bigger—something that’s going to affect their job or [relationships].” As the owner of a local bar, he has another take: A sign of problem drinking could be “someone just being loud and rude and annoying the patrons around them, or it could be something more serious so that they hurt themselves. There’s a pretty big spectrum of what could be considered a problem.” At his bar, Hastings takes these warning signs seriously: “I think it’s really important for me and my staff to recognize and see those things before they become big problems.”

Siever added that “drinking can cause problems in a lot of different ways, whether it’s physical health or mental health or becoming belligerent or unpleasant. There are also people who quietly drink and it’s not so obvious, but it’s causing problems for them also.” Continuing to do something despite the negative consequences is key to some definitions of addiction, Siever explained. “If you’re having negative consequences yet you continue to do the same thing, that’s a problem.”

Buchbinder identified specific signs of problem drinking, including driving while alcohol-impaired. Drinking among young adolescents is also problematic, she said, as is heavy alcohol use by people over age 65. Among older adults, overconsumption is “going to be a problem particularly, because they are going to be more susceptible to infections [and] to cancers.”

In a clinical setting, Buchbinder said, doctors start asking patients about their alcohol use “when we do blood work and we see a particular pattern of liver dysfunction; we know that that’s from alcohol.” She also described the “CAGE” score, a mnemonic device to remind clinicians to ask patients a series of questions about their alcohol use: Have you ever felt like you need to cut down on your drinking; have you annoyed people with your drinking; do you ever feel guilty about your drinking; and do you ever need an eye opener—that is, do you need a drink in the morning to be able to function? “If people say ‘yes’ to any of those questions, then that’s a trigger to start to ask more questions.”

How does alcohol use affect the health of people living with HIV?

“Probably the biggest issue is that when people are drinking too much, they’re not taking their meds.”

—Susan Buchbinder

Susan BuchbinderBuchbinder emphasized that people with HIV don’t necessarily need to abstain from alcohol unless they have a comorbid condition, such as hepatitis C or other liver disease, that would be worsened by alcohol use. But, she continued, “HIV and alcohol act synergistically, so that there’s more brain tissue disruption. There’s a new understanding of how HIV causes disease by causing these inflammatory reactions, and alcohol also increases that.”

In addition to the risk of increased inflammation—and the resulting higher risk for neurological and cardiovascular problems—alcohol use may interfere with HIV-positive people’s ability to adhere to their antiretroviral treatment regimen. “In talking with colleagues, they say that they can get most of their patients down to an undetectable viral load, including sometimes their meth users, their crack users, their injection drug users, but not their alcoholics,” related Buchbinder. “It’s just so destructive to the rhythm of people’s days that it’s really challenging to help people to use meds effectively. If you aren’t using them effectively, you may be developing resistance, and you may be eliminating your future options.”

Alcohol use can also have negative consequences for mental health, Siever noted. Not everyone who turns to alcohol during times of stress or sadness realizes it is, in fact, a depressant. “For those of us living with HIV, depression is one of the things that we struggle with,” he explained. “Drinking, although initially or in the moment seems like it’s helping, probably isn’t helping—and in some ways it probably makes [depression] worse. That’s another way that it interacts with HIV disease.” Siever also noted that, “along with depression, isolation is a real issue for a lot of people—in general, but also for people with HIV. It’s a well-known fact that for people who have problematic drinking or other drug issues, over time, isolation tends to be a result of that.”

Drawing from her own research on HIV and alcohol, moderator Davis mentioned that heavy alcohol use can interfere with important self-care behaviors. “I remember people saying [in interviews], ’It’s not so much what I do if I’m drinking a lot, it’s what I don’t do. I don’t go have coffee with my good friend who is supportive of me, I don’t go to the gym, I don’t do my laundry and such. . . . I don’t do the things that I need to do to live successfully with this disease, because there are times when my drinking is getting problematic.’”

Buchbinder also brought up the challenges of aging with HIV in relation to alcohol. “A lot of the negative impacts of alcohol may accumulate over time, so what might not seem problematic now could be problematic later on,” she observed. As people with HIV live longer, “we might be dealing with the consequences of alcohol at a later time when it’s had an opportunity to cause more disease.” Siever offered his own perspective: “For a lot of us who’ve been living with HIV for a long time, there’s this whole history and accumulation of all the things we did when we thought we were about to die. . . . What impact did that have? What’s our relationship with alcohol and other drugs now? It’s a complicated trajectory over the last 30 years.”

The San Francisco Department of Public Health has identified alcohol as a driver of new HIV infections. In what ways does alcohol contribute to HIV transmission and acquisition risk?

“There’s a lot of data to suggest people are not as safe when they’re under the influence of alcohol. It’s probably partner choice, it’s probably what you’re doing—it may even be how you’re doing it. It’s a combination of all of those things.”

—Susan Buchbinder

Buchbinder explained that the Department of Public Health defines a “driver” of HIV infection as something that is both independently related to HIV acquisition (all other things being equal, that particular factor, in this case alcohol, increases the risk of becoming HIV infected) and is common (that is, at least 10% of the population has that particular risk factor). “Alcohol meets both of those requirements,” she said.

“In terms of becoming HIV infected,” she continued, “it’s probably about what you choose to do sexually” while under the influence. “It’s not clear that [alcohol] is really affecting biologically what’s happening to you; it’s more likely that it’s affecting your judgment, your sexual practices, your choice of partners at the time, those kinds of things.” Added Siever, “in the context of HIV transmission, you don’t have to be an alcoholic or addicted to a drug to have done enough so that you’re not thinking very carefully about what you do.”

Not surprisingly, the disinhibiting effect of alcohol contributes to its role in HIV transmission and acquisition: “We tend to be disinhibited and not think about the consequences of our actions or take responsibility for our actions when we’re a little toasted,” Siever remarked. “And in this culture, it’s also sort of an absolution—like ‘Oh, I was drunk’ is going to absolve you of any responsibility for what you do. I think there are lots of complications about how we think about drinking that make it really problematic in terms of public health.”

Also, Buchbinder noted, if heavy alcohol use prevents people from taking their antiretroviral regimens effectively, there can be potential consequences for both their own health and that of their sex partners. Current research indicates that HIV treatment doubles as HIV prevention by reducing viral load: Less virus in the body means lower likelihood of passing it on through unprotected sex.

Indeed, getting HIV-positive people into medical care and on appropriate treatment is now considered a public health strategy for HIV prevention. “Alcohol probably is the leading risk factor for lack of adherence,” said Buchbinder, “and that will fuel the epidemic—and, more unfortunately, yield an epidemic that has a lot of resistant HIV so that people who are getting newly infected don’t have treatment options either.” To combat this problem, she suggested developing better systems of support for people who are struggling with alcohol and medication adherence. “People should be able to choose whether or not they go on meds,” she stated, “but if they’ve chosen to go on meds, then we want to be sure we have those support structures in place.”

Even after discussing the potential dangers of drinking in the context of HIV health and HIV risk, the panelists agreed that alcohol and bars have an important function in San Francisco. Said Siever, “I’m old enough to remember when gay bars were really the only place you could go to meet other gay people.” Buchbinder added, “that’s the challenge of alcohol, because a little bit of it may be a good thing for some people, right? We don’t want to shut down people’s social interaction.” Hastings agreed, noting that bars have offered “a place where people could come and feel safe when there weren’t other places to go. For a very long time, that was built into what it means to be a part of our community.” And, he continued, “it’s really important for bars to still take on that role. That’s something I try really hard to have LOOKOUT do: really be a part of the fabric of the community that we’re in.”

Can we create effective interventions without addressing the complex relationships between problematic alcohol use and other psychosocial factors like HIV stigma, homophobia, and lack of social support?

“In interviews, folks would tell me, ‘In my family, in my world, on my block, it is so totally unacceptable to be gay, it’s totally unacceptable for me to have HIV—so frankly, I’d rather they think I’ve become an alcoholic.’”

—E. Maxwell Davis

E Maxwell Davis at podiumLike HIV infection, alcohol use and abuse occur in a social context and are driven by a wide range of psychosocial factors, including homophobia and stigma. Siever explained that unease with sexuality and sexual relationships can increase the appeal of using alcohol before engaging with potential partners. “We all think we’re very liberated,” he joked, “but we all struggle with that stuff.” He recalled a conversation with a group of gay men coping with substance-use issues: “I said, ‘How many of you have ever had sex with anyone not under the influence of anything—stone-cold sober?’ And not one of them ever had.”

Buchbinder added, “it’s really clear that the epidemic is driven by a number of upstream issues—stigma, homophobia, poverty, all kinds of things. We definitely do need to address those…but I don’t think those are going to be simple solutions.” Siever suggested harm reduction, a counseling and treatment model that addresses the negative consequences of substance use without requiring a commitment to abstinence from alcohol or other drugs. “Even if you have a problem in terms of your alcohol consumption,” said Siever, “abstinence isn’t necessarily the only answer.”

Stigma around alcohol dependence can prevent people from seeking help, he added: “I think there’s a reluctance to talk very honestly about some of these issues for fear of being labeled as an alcoholic.” Siever highlighted The Stonewall Project, a family of counseling, treatment, and support programs (and part of San Francisco AIDS Foundation) that offers “services people can access regardless of where they’re at with their alcohol use and to what extent they think they do or don’t have a problem with drinking.” He explained, “you don’t have to have already decided or know that you’ve got a problem to be able to come and talk with someone.”

Hastings offered a different take on the psychosocial factors implicated in alcohol use and its interaction with HIV. “I feel like it is possible to address those issues, but I don’t feel like it’s necessary,” he said. Rather, “we should be looking at [having] an impact on decision-making, and the point at which people are making those poor decisions. I feel like that’s a simpler approach to take rather than trying to dissect how complicated and how intertwined alcohol is into our culture, especially in the gay community.” Hastings’ is one of a handful of bars in the Castro and South of Market area participating in the PACE study, short for “Pacing Alcohol Consumption Experiment,” conducted by UCSF and Stop AIDS Project (part of San Francisco AIDS Foundation). Patrons exiting bars opt to take a five-minute survey and use a breathalyzer to gauge their blood alcohol level, and can complete a follow-up online survey about what they did after leaving the bar. The researchers hope to shed light on patterns of alcohol use and related activities, as well as community norms around drinking.

What strengths can we capitalize on in order to address the interaction of problematic alcohol use and HIV/AIDS in our community?

“I think the biggest strength that I’ve seen in the community since I’ve taken over the business is how people band together . . . and how strongly we support each other.”

—Chris Hastings

The discussion ended on a forward-looking note as the panelists turned to the strengths our community can draw on to deal with challenges around alcohol and HIV. Hastings called for greater community awareness of the role of alcohol in San Francisco’s HIV epidemic. “Unfortunately, people don’t at this time see us in being in a crisis mode with this,” he said. In a similar vein, Buchbinder recalled the early AIDS crisis in San Francisco, when people took care of those in need and educated and supported each other in preventing the spread of the disease. “Nothing that we’ve ever done to try to prevent HIV even comes close to what the community did to reduce the rates of infection of HIV,” she said. “I don’t think we could ever hope for a vaccine that would be as effective as the community was.” (She was quick to add, “Hopefully we’ll get a vaccine!”)

Buchbinder also highlighted a need for “expanding that community so that it isn’t just necessarily geographically limited to the Castro.” HIV and alcohol collide in other San Francisco neighborhoods hard-hit by the epidemic; for example, as observed by one audience member, a self-described AIDS survivor, “where I stay, in the Tenderloin, we have four liquor stores to every block.”

To Siever, the word “community” is sometimes overused: “I’ve often complained about how easily we use the word ‘community’ and go around as if it means something, and it doesn’t always.” But, he continued, “part of the meaning of that word to me is that . . . we do take care of each other and look out for each other. I think that does happen a lot, and that is one of our strengths, but it doesn’t always happen.” He emphasized the role of individuals: “If one of our friends is drinking too much, . . . it’s part of being a community and part of being a friend to say something to them.” Concluded Siever, “we’re all in this together.”

About the author

San Francisco AIDS Foundation

San Francisco AIDS Foundation

San Francisco AIDS Foundation promotes health, wellness and social justice for communities most impacted by HIV through sexual health and substance use services, advocacy, and community partnerships. Each year more than 25,000 people rely on SFAF programs and services, and millions more access SFAF health information online.