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S.F. AIDS funding cut by $4 million




 

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 pandemic.

"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 institutions.

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 AIDS volunteers.

"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 Their Families."

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," he said.

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 near-universal appeal."



 


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Information in this article was accurate in January 10, 2005. The state of the art may have changed since the publication date. This material is designed to support, not replace, the relationship that exists between you and your doctor. Always discuss treatment options with a doctor who specializes in treating HIV.