As San Francisco faces a looming budget deficit, HIV/AIDS advocates and their supporters have set a goal this year to keep existing services funded. It could be a hard ask of city officials, though, who have been warning about the dire fiscal situation since last year's budget negotiations.
The San Francisco AIDS Foundation's HIV Advocacy Network is gearing up for budget season — discussing what it plans to ask of San Francisco supervisors and Mayor London Breed in the coming months. But even dyed-in-the-wool advocates — including Honey Mahogany, the new head of the city's Office of Transgender Initiatives — have conceded new funding will be hard to come by.
"Every single person in City Hall has been calling this a challenging budget year, or a very bad budget year," Laura Thomas, senior director of HIV and harm reduction policy at the AIDS foundation, said during a May 6 teach-in at its Strut health center at 470 Castro Street titled "Queering the San Francisco Budget." About three-dozen people attended the forum.
"The city's revenues are lower than what is currently in our budget to spend so if you're not bringing in as much as you're spending, that's when you bring out the credit cards or cut back on what you're spending money on," Thomas added. "So, the city doesn't have a credit card like that, so they're figuring out what to cut back on."
Typically, the budget is introduced by the mayor in May and submitted to the Board of Supervisors, which holds hearings in June to analyze the budget, hear feedback from the public, and make changes. In July, the budget is finalized and approved by the supervisors and the mayor.
Already expecting challenges, Breed last December asked city departments for 10% cuts across the board. A deficit of about $800 million is expected over the next two fiscal years, and Breed has said it could reach $1 billion by Fiscal Year 2028.
Thomas said Breed had also asked department heads to come up with 5% in potential additional cuts.
"Unsurprisingly, the very first priority is to protect existing services, protect the safety net, and try to be sure we're not losing any valuable services this year," Thomas said.
Mahogany, who started May 6 in her new role, said in an interview last week that she, too, is fighting to prevent cuts.
"This is going to be an incredibly difficult budget year," said Mahogany, who's a trans person and has years of experience dealing with budgetary matters.
She previously worked as an aide to Assemblymember Matt Haney (D-San Francisco), first when he was District 6 supervisor then as his district director after he was elected to his Assembly District 17 seat representing the west side of the city.
"Part of my job is to work with the mayor's office and the Board of Supervisors to protect the most vulnerable," Mahogany said of her new job overseeing the trans initiatives office. "Certainly, the trans community is imperiled on a variety of levels, whether it be homelessness or suicidality. While we're trying to solve the issues we are working on in San Francisco, we want to make sure trans people are part of that conversation. I don't want to see any services for the trans community cut right now. I want to make sure we are staying true to our word."
But changes in the federal government's allocation of HIV/AIDS funding are likely. Thomas noted at the teach-in that the Centers for Disease Control and Prevention "has already let San Francisco know we're going to get a cut in our federal HIV prevention dollars, and it will probably be $500,000-$800,000 in a cut. We don't know exactly yet, but we should know in the next couple of months."
The good news is that "one of the things we have done historically throughout the years is we have been very successful in getting the city to backfill those cuts and invest San Francisco general funds into those services," Thomas continued. "We have not lost HIV services because of federal cuts, and that is our goal this year."
The mayor's office did not return a request for comment for this report.
2024-2025 budget proposal
The network — a group of HIV and LGBTQ activists in the Bay Area — has a detailed budget proposal for San Francisco for 2024-2025: $509,000 to preserve existing services in the HIV care safety net, $500,000 to support HIV care organizations (including a small increase to account for some of the inflation of recent years), and $3.6 million for 200 additional housing subsidies for people living with HIV.
The network's proposal also includes $1 million for additional mental health services for long-term survivors, $500,000 for intensive case management, $500,000 for PrEP and PEP for Black and Latino communities, and $1-$2 million to open and fund supervised injection sites. City officials have recently been reluctant to fund the sites, which are a form of harm reduction that allow people to use their own drugs under the supervision of trained staff. That's mostly due to federal legal obstacles and, if such a site were to open, a nonprofit would have to house and operate it.
As the B.A.R. previously reported, last year's budget included $1.25 million for housing subsidies for people living with HIV for 2023-24 and $500,000 for 2024-25. The budget also included $500,000 to help HIV/AIDS nonprofits with rising costs. The funding was far short of the $7 million requested by HIV advocates.
According to Paul Aguilar — a gay long-term survivor who has been living with HIV since 1988 and who was a community grand marshal in last year's San Francisco LGBTQ Pride parade — people living with HIV are two to four times more likely to develop major depressive disorder, highlighting the need for additional mental health services. There's a need for culturally competent care, he stressed.
"People didn't necessarily want to speak with someone professionally trained, but someone who had been where they've been, who's walked that path," Aguilar said. "Trans folks and others would walk in and there wasn't representation."
Vince Crisostomo, a queer Chamorro man who's the director of aging services at the AIDS foundation, said that there's an increase in the need for case management.
"Particularly for long-term survivors, they need case management because our care becomes more complicated and nobody coordinates those services," he said.
Crisostomo said that the case management system is "kind of in shambles," but there are stand-outs.
"The San Francisco Community Health Center is probably the most functional of all the case management systems. They have five tiers and they will work with you — they're very good at responding very quickly and are good at offering limited mental health services," Crisostomo said. "Ward 86 [at Zuckerberg San Francisco General Hospital and Trauma Center] has a team of case managers, social workers."
PrEP and PEP
Jonathan Salinas and Alton Lou, community chair and outreach co-chair of the network, respectively, discussed preventative care disparities. As the B.A.R. previously reported, the budget deficit may imperil the city's ability to respond to the fact that Latino cisgender men now make up the highest rate of new HIV diagnoses in San Francisco, and data that showed that Latinos were the only group to see an increase in new cases (67 of 157 cases, or 43% of new diagnoses, up from 36% in 2021).
Among cis men the rate of diagnoses surpassed all other racial or ethnic groups measured.
PrEP, or pre-exposure prophylaxis, refers to the use of antiviral drugs to prevent people exposed to HIV from becoming infected. The pill Truvada was first approved for PrEP use in 2012 by the federal Food and Drug Administration; since then the FDA has also approved the pill Descovy for some groups, and the drug Apretude as an injectable treatment. According to CDC statistics, only 25% of the approximately 1.2 million Americans who could benefit from PrEP had prescriptions in 2020. PEP, or post-exposure prophylaxis, refers to taking HIV medicines within three days after a possible exposure to prevent HIV infection.
Salinas said that according to data from the Magnet clinic at Strut, "we are seeing a big gap as to who is getting access, who is allowed access, for prevention, and who is affected by transmission."
"The largest group of people accessing PrEP here at the foundation are white people," he said, sharing data showing white Americans account for 36% of people in the PrEP program, while Black Americans account for 4.5%, Latino Americans account for 23.5% and Asian Americans 17.6%. (Based on 2020 census data about San Francisco's population, this would mean Black and Asian communities are underrepresented while white and Latino communities are overrepresented.)
"We're asking for half-a-million to insure rates of HIV transmission do not continue to rise for the Latinx and Black communities," Lou said. "We must invest in cultural competency and bilingual staff for PEP and PrEP programs."
Life Day of Action
Ande Stone, senior community mobilization manager at the AIDS foundation, said that there are opportunities for advocacy coming up; for example, the Life Day of Action on Friday, June 7, which will consist of a teach-in at 11 a.m. at Civic Center Plaza, a noontime lunch, and meetings with members of the Board of Supervisors from 1:30 to 5 p.m.
"We're going to be visible; we're going to be out, loud, and proud about all the things we're fighting for right at the seat of government," he said.
Further, "we are asking people to email the mayor and the Board of Supervisors asking them to prioritize this crucial funding," he added.
The May 6 teach-in ended with Aguilar sharing memories of the late Randy Leo Dudley, a queer man who'd been involved with the network.
Aguilar shared words written by Dudley about the LGBTQ community, poignantly including the line "the rainbow that connects us is glistening like the stars we all are."
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