HIV Breakthroughs, Persistent Inequities

With the help of researchers at UCSF, San Francisco has transformed HIV research into lifesaving public health interventions. Yet those advances have not reached every community equally, and new HIV cases continue to be reported each year. So why is HIV still spreading despite decades of research and innovation? 

San Francisco has played a central role in the history of the HIV/AIDS epidemic in the United States. In 1981, some of the country's earliest recognized cases of what would later become known as AIDS appeared among gay men in San Francisco, placing the city at the epicenter of an emerging epidemic. 

As cases mounted, clinicians at San Francisco General Hospital and UCSF helped build a new model of AIDS care, including the creation of Ward 86 in 1983, one of the nation's first dedicated outpatient AIDS clinics. Ward 86 became the center of what became known as the “San Francisco Model,” an interdisciplinary approach that brought medical care together with social, psychological and community-based services. The model was subsequently adopted beyond San Francisco and helped influence approaches to HIV care nationally and internationally.

The scientific response also changed rapidly. Researchers identified HIV as the virus that causes AIDS in the 1980s, while subsequent research clarified how the virus replicates and identified targets for treatment. The development of antiretroviral drugs, followed by combination antiretroviral therapy in the 1990s, transformed HIV care. What had often been a rapidly fatal disease increasingly became a manageable chronic condition for people who could access and remain engaged in treatment.

By the 2010s, prevention had entered another era. Pre-exposure prophylaxis, or PrEP, provided an effective biomedical method of preventing HIV acquisition, while improvements in antiretroviral treatment strengthened the role of viral suppression in preventing transmission. In 2014, San Francisco launched its Getting to Zero initiative, setting goals of reducing new HIV infections and HIV-related deaths while addressing stigma.

By the time Getting to Zero began, the conditions surrounding HIV in San Francisco were markedly different from those of the early 1980s. The city now had decades of clinical experience, established HIV services, community organizations, expanded testing, effective antiretroviral treatment and new prevention tools. As the biomedical possibilities changed, so did the central public-health challenge.

Ensuring that every community has access to HIV prevention and treatment is essential to Getting to Zero infections. Achieving that goal would reduce HIV transmission across the city’s entire population,benefiting all residents. Yet more than four decades after the epidemic began, that progress has not reached all San Franciscans equally. 

For T.J. Lee-Miyaki, a longtime HIV community advocate in San Francisco, one obstacle to closing this gap is a persistent misconception about who is at risk. Despite decades of advances in HIV prevention and treatment, he has encountered classmates who still perceive HIV as a disease confined to particular communities rather than a public-health concern that crosses sexual and demographic boundaries. 

“I overheard my classmates share that they didn't think they were at risk because they are not a part of the gay community,” Lee-Miyaki said. “We’re not going to get to zero new cases until everyone gets tested and uses safe sex practices. Until we break that barrier, we're going to have some level of new infections.”

Lee-Miyaki's observation reflects how the challenges surrounding HIV have changed over time. During the early epidemic, clinicians and researchers confronted a poorly understood disease for which effective treatments did not yet exist. Four decades later, many of the biomedical tools needed to prevent transmission are available, shifting greater attention toward questions of access, uptake and engagement with prevention and care.

This shift has made the distinction between biomedical efficacy and population-level effectiveness increasingly important. The existence of effective HIV prevention and treatment does not necessarily mean that testing, PrEP and sustained treatment are accessed at the same rates across populations. Patterns of healthcare access, risk perception, trust and engagement with public-health services can influence how biomedical advances translate into population-level outcomes.

Population-level improvements can also obscure differences among groups. Erin C. Wilson, a Senior Researcher with the San Francisco Department of Public Health and a UCSF professor, examines HIV prevention and health inequities among transgender populations, pointing to continuing disparities in treatment outcomes. She states that these persistent challenges reflect disparities that can be concealed beneath San Francisco's broader public-health successes.

“Health disparities exist in the treatment of HIV, especially for Black trans women,” Wilson said. 

Recent findings from the National HIV Behavioral Surveillance (NHBS) system reinforce that concern. 

“We are not meeting 95% goals for viral suppression in the recent NHBS cycle,” she said. 

The disparities are not explained by a single barrier. As HIV prevention and treatment have become more effective, access to their benefits has remained shaped by conditions outside the laboratory. Housing instability can make it more difficult to remain connected to care and adhere consistently to treatment. Stigma and discrimination can affect interactions with healthcare institutions, particularly for transgender populations. Differences in healthcare access and awareness of PrEP can influence who receives preventive medication, while perceptions about who is at risk for HIV can affect whether people seek testing or prevention in the first place.

These barriers can also reinforce one another. A person who lacks stable housing, for example, may face greater difficulty maintaining regular clinical appointments or medication access. Someone who does not perceive themselves to be at risk may never seek PrEP or routine testing. These conditions can create a gap between the availability of effective biomedical interventions and their consistent use across populations.

At the collective level, “we” encompasses all San Franciscans including patients, residents, researchers and students. In a city where public health is inseparable from community well-being, citywide progress is the most meaningful when it is shared across all communities.

The question is no longer whether HIV can be treated or prevented. Modern medicine has proved that it can. The challenge now is how those advances can reach people and whether our healthcare and public health systems can overcome the barriers that prevent those advances from reaching everyone who may who are likely to benefit from them. Getting to Zero new cases is a question of whether “we” truly means everyone.