Battered by government budget cuts, and strained by declines in
private giving, San Francisco's acclaimed network of AIDS
services is about to undergo its biggest overhaul since it was
assembled in the desperate early years of the epidemic more than
two decades ago.
Annual allotments of federal Ryan White Care Act dollars, a
benchmark for AIDS spending in the city, are dropping by $4
million this year, to $29 million. That is a body blow to
agencies that have been weathering a succession of lesser hits
since 1999, when such funding peaked at $38 million. As a result,
the system that is called the "San Francisco model" faces a year
of reorganization, consolidation and learning to make do.
In a bid to streamline the network, the city is restructuring it,
channeling the federal dollars into programs that provide a kind
of "one-stop shopping" for AIDS services so a newly diagnosed
patient could be enrolled at once into whatever available
services remain after the budget cuts.
The model may emerge stronger and more efficient. But many
participants fear they are witnessing the unraveling of a safety
net that once set the standard for community response to the AIDS
"It feels very much like a slow death," said Mike Smith,
executive director of the AIDS Emergency Fund and president of
the HIV/AIDS Providers Network, which represents about 50 groups
that serve city patients. "The system is withering."
The San Francisco model of AIDS care began in the early 1980s
during countless conversations around kitchen tables, in the
homes and apartments of stricken gay men. The desire to help a
roommate or friend who was sick or dying of AIDS spawned dozens
of small groups, which became large groups, which became
Using a blend of public and private resources, this network
offers comprehensive AIDS services -- from disease prevention and
treatment to nutrition, legal advice, housing and hospice care --
to thousands of patients who were poor to begin with or whose
incomes were consumed by their illnesses.
This year's budget woes are striking hard at some of the pillars
of the old San Francisco model.
Shanti, an organization that trains volunteers to care for sick
and dying patients, is losing $400,000 in Ryan White funding, and
on Saturday will close down its San Francisco program training
"This is the third or fourth year in a row where we've had to go
through this. Each year, we have to go back and beg," said Kevin
Burns, executive director of Shanti. This year, Shanti had a
signed contract to keep its city AIDS programs running through
July. But after San Francisco voters turned down Propositions J
and K in November, the programs were cut -- for good. Support
services that linked volunteers to 1,600 people with AIDS, most
of them minorities, will be gone.
Shanti will continue to rely on donations and remaining
government grants to keep a range of other programs running in
the Bay Area, including a program for poor women with breast
cancer, which will need a new infusion of money in June.
"We started off providing services to people with
life-threatening cancer in the early 1970s," said Burns. "Then,
we worked specifically on AIDS. Since 1998, we've been returning
to our roots."
At the heart of the forthcoming restructuring of San Francisco
AIDS services is the one-stop-shopping concept, which city health
officials are calling "Centers of Excellence."
James Loyce, director of AIDS programs for the San Francisco
Department of Public Health, likens the new system to food courts
found in shopping malls. "In flush times, none of us would choose
to eat lunch in a food court. We'd go to a restaurant," he said.
At new Centers for Excellence envisioned for the Bayview and
Tenderloin neighborhoods, AIDS patients with substance abuse
problems could be enrolled in Medi-Cal, offered drug treatment
and receive housing assistance from a variety of agencies housed
under one roof.
San Francisco AIDS patients today often have more complex medical
and social problems than did the young gay men who first came
down with the disease in the 1980s. Many are poor, some are
homeless, and high numbers of new patients suffer from mental
health and substance abuse problems. San Francisco has numerous
programs to deal with each of these issues, but they are
scattered geographically and operate independently -- lacking the
efficiency of a seamless system of care.
The one-stop-shopping idea has been tried before in San
Francisco. In 1991, the administration of Mayor Art Agnos opened
the Center for Positive Care on 18th Street, consolidating
operations of 16 different organizations. Barely one year after
it opened, the center closed its doors, a casualty of a budget
crisis, infighting among AIDS service groups, and lack of support
by the new administration of Mayor Frank Jordan.
Loyce maintains that the epidemic in the United States has
changed dramatically since the early 1990s, but the system for
dealing with it has not. "This is an opportunity to rethink what
we are doing, across the spectrum," he said. Dr. Edward
Machtinger views the impending change as a potential opportunity,
but does not know if his program for HIV-positive mothers and
their children will make the cut. "We are very much on the
edge," he said.
The UCSF program is applying for a Ryan White grant jointly with
seven other organizations in the city that offer AIDS services
for women. The goal is to pool AIDS programs from each
organization into a single "Center of Excellence for Women and
Machtinger said the center would be an improvement over the
current system, offering a more efficient way to process benefits
and provide care. But there is no guarantee their proposal will
win out in a competition with 22 other programs vying for a
smaller pool of Ryan White funds. The federal funding is named
for an Indiana teenager who died in 1990 after campaigning for
public understanding of AIDS.
Loss of the grant would force him to curtail services at his
clinic, Machtinger said, while other partners might have to close
down their AIDS programs. "If we lose, many of the women will be
forced to rejoin a system designed for men," he said.
Meanwhile, with funding for the current year running out in
February, and no guarantee it will be renewed, he's had to send
layoff notices to his staff, who will not know if they have jobs
until the grant-making process is completed.
Since the first AIDS cases appeared in 1981, the disease has
taken nearly 20,000 lives in the city alone. Successful but
ruinously expensive drug therapies have slowed the pace of dying
in the United States, but added to the cost.
The rollbacks in federal funding are not the only problems facing
the San Francisco model. Private support is faltering because of
the sputtering economy and the phenomenon known as "compassion
fatigue," where individual and corporate donors grow weary of the
relentless requests for cash.
Despite their tradition of support for city health programs, San
Francisco voters rejected the tax increases of Propositions J and
K, which Mayor Gavin Newsom said were necessary to keep these and
other city services afloat.
"Everybody is searching for alternative funds," said Bill Hirsh,
executive director of the AIDS Legal Referral Panel, which lost
$260,000 in Ryan White money. Until the election, it looked like
some of that money might be recovered with city funds.
A combination of layoffs and a campaign that raised $111,000 from
private donors took out some of the sting. But, Hirsh said,
"There are many organizations that are not going to be able to
withstand this level of funding reduction."
Dr. Jim Dilley, director of the UCSF AIDS Health Project,
scrambled to privately raise some $100,000 to keep psychological
support groups serving hundreds of HIV-positive gay men. Under
the new city guidelines that set policy for distribution of Ryan
White funds, the participants in those groups "make too much
money," Dilley said.
Although Dilley disagrees with decisions by the Ryan White CARE
Council, which sets spending priorities and has de-emphasized
emotional support programs, he acknowledged that programs and
priorities must evolve.
"The time has come, once again, for serious consideration to
reduce the number of AIDS organizations, and to look for
economies by reducing the number of administrative structures,"
At Project Open Hand, which got its start providing hot meals to
dying AIDS patients and now provides meals and groceries to
thousands of people laid low by a variety of illnesses, budget
cuts are only part of the problem.
"Romaine lettuce is up to $31.95 a case from $10 (after the
Florida hurricanes) and tomatoes have gone to $44.40 from $12,"
said executive director Tom Nolan. "Funding is really about the
same, but things cost more: food, vans, gasoline."
Nolan has had to lay off 25 staff positions but said the
organization's financial health remains sound. "Our backbone of
support has always been small, individual donors," he said.
"People really get the mission here. Meals for sick people has a