Successes and Challenges Facing HIV Service Providers in San Francisco County
We spoke to Lance Toma, LCSW, who is the CEO of San Francisco Community Health Center.
Lance Toma: I’ve been CEO here 13 years, but I’ve been here for 20. Before that, I worked at the Chicago LGBT Center, now called The Center on Halsted. SFCHC is rooted in the Asian and Pacific Islander (API) community here. We started 32 years ago and were known as the Asian Pacific Islander Wellness Center. Over the past 10 to 12 years, we’ve expanded to meet the needs of the community here in the city’s Tenderloin area. We’ve built a reputation for serving the most marginalized and stigmatized—the transgender community, sex workers, substance users, the homeless or the marginally housed.
In 2015, we became a federally qualified health center (FQHC). In 2018, we rebranded to become the SFCHC.
Our annual budget is $8 million, primarily government money—mostly through San Francisco Department of Health HIV prevention and care funding, with some through the Ryan White CARE Act.
Our total staff is about 75. I would say at least 15% of the staff is HIV positive. A lot of our staff were formerly clients. About three-quarters are LGBTQ. It’s 50% cisgender male, 25% cisgender female, and 25% transgender or gender nonconforming. It’s 75% people of color, including eight of the nine people on the leadership team.
We have about 3,000 clients, close to 500 HIV positive, across all our programs. They’re about 70% people of color. Over half identify as LGB and a quarter as transgender or gender nonconforming.
Tim Murphy: Can you tell us about your spectrum of services?
LT: We offer very traditional HIV services—prevention, mobile testing, outreach in clubs, bars, on the streets. We do a series of drop-in programs for the HIV-positive community of the Tenderloin, and we have another drop-in program specifically for the trans community, which operates four afternoons a week.
We also do primary medical and behavioral health care for anyone who wants to access them, with a satellite clinic at the SF LGBT Center. We also integrate PrEP [pre-exposure prophylaxis] navigation into all our services, but we do have staff specifically focused on PrEP for the API and trans communities.
We do a Thanksgiving dinner for more than 100 people, with all the staff pitching in. We have a huge API community stage at SF Pride, and we help organize the Trans March here in SF. We also do a breakfast program run by clients every morning of the week. And we have a street medicine team in shelters and alleyways throughout the city.
TM: How would you paint the HIV picture in SF in 2019? It is widely seen as not only one of the main cities where HIV in the U.S. “began,” but also as the one to have made the most progress ending the epidemic in recent years due to a very concerted and robust response from both city government and the nonprofits.
LT: It’s true, SF has done an incredible job, because we’re a community that cares deeply about resources being invested. So we really pushed to increase our HIV safety net, even as federal dollars for us have decreased. We pushed the city to backfill those federal cuts, so we’ve been able to harness all the new biomedical advances [undetectable equals untransmittable (U=U), PrEP] in HIV prevention.
That’s why we saw fewer than 200 new infections in 2018.
But digging deeper, when we look at the fewer than 200 who’ve been recently diagnosed, the Latinx and African-American numbers are still increasing. So we’re aware there are still issues we have to deal with. There was an overall Black health report here recently with some very stark disparities in health and mortality rates.
Then look at our homeless situation. It’s alarming and visible, and really, in terms of income inequality [Ed: SF has become wildly richer and more expensive in recent decades due to the tech boom there], the gap here is widening by the second. And that directly relates to folks living on the street. Then of course in that population there’s substance use—meth, opioids—and mental illness. It’s true, we have many access points for needle exchange throughout the city.
There’s also the outflow of people leaving the city. We can’t claim we’ll get to zero on the HIV epidemic until the whole Bay Area gets to zero, because many folks can’t afford to live in SF proper. And part of why our own HIV numbers have decreased is the many people who’ve moved to not just Oakland but throughout all of Alameda County—and even beyond, as far as Sacramento.
TM: What successes are you most proud of?
LT: I think our transformation to a FQHC has been remarkable. Doing that is a way that a lot of HIV organizations are able to provide a more comprehensive array of services and also sustain themselves over time. The cultural competency [around serving vulnerable groups, such as people of color and/or LGBTQ people] we HIV/AIDS agencies have built across the country can be preserved that way. It adds so much value to the community-health clinic (CHC) world. In SF, there hadn’t been a new FQHC in over 30 years. We had to surpass a lot of barriers to achieve that status, because the CHC world can be a closed one, hard to get support from.
TM: Cool. What are other successes?
LT: We were partners with the SFDPH on two HRSA [federally]-funded special projects of national significance. One focused on transgender women of color who were newly diagnosed with HIV or out of care. The other focused on developing a street medical intervention for homeless people living with HIV. We had that federal funding for five years, and it showed such dramatic impact that we were able to have the city continue that funding for us. These programs have showed phenomenal success. For the trans program, we offer a drop-in clinic, and for the street program, we go out with a doctor, nurse, case manager, and social workers to give care on the street. The homeless population overall is achieving 33% viral suppression, but for our clients, it’s over 50%.
Also, the [federal] Centers for Disease Control (CDC) funded us to do capacity-building work in the Midwest, so we opened a Chicago office at Howard Brown [LGBT health center] and have a team there focused on HIV prevention. Our team provides technical assistance for clinics throughout the Midwest who want to implement more routine HIV testing and continue to do “Prevention with Positives” [helping HIV-positive people stay undetectable and hence untransmittable, or U=U].
TM: Where do you feel frustrated or stuck?
LT: With us being a FQHC, even four years in, it’s still one of the most challenging transformations here. Being a Medicare/Medicaid provider of medical and mental health care has required us to transform our board, staff, operations, and revenue. We’ve had to learn how to fit what we’ve always done into a more mainstream community health care model, where you are supposed to keep your visits to 15 minutes, even though it’s not a hard and fast rule. On the HIV side, that’s often not enough time. So how we bill for services and how we maintain the staffing levels—that’s enormous.
We’re competing with places like [California health care giant] Kaiser Permanente, which can sometimes pay providers two to three times more than we can. We’ve also had to refine our systems of compliance and quality improvement.
TM: What is the biggest sticking point on SF finally getting to zero new infections?
LT: The lack of housing. We’ve been pushing recently for increased housing stock, whether it’s long- or short-term, more shelter beds, more substance treatment beds. Just a few blocks away from us, a studio could cost $3,000 a month in rent. We have staff who can’t afford to live in the very city where they are taking care of folks. And the subsidies that are required to keep people housed are becoming more expensive.
TM: What about meth use among young men of color who have sex with men, is that a big issue in terms of HIV prevention?
LT: Definitely. And a lot of opioids on the street right now. We train all our staff on how to administer [overdose reversal drug] Narcan if they encounter anyone who needs it.
TM: What would you do with more money?
LT: Housing, including all the wrap-around support that people really need. The need for psychiatric services is tremendous and lacking citywide. There’s also a lack of access to workforce training and opportunities for our trans folks. We try to do as much as we can with very little money. The SF LGBT center has also spearheaded a Trans Employment Program over the past five or six years.
And I think we really could use money to think about how to build stronger bridges between organizations in San Francisco and Oakland, and beyond. That would make a huge impact. We have a lot of clients going back and forth depending on their housing situation.
TM: Any stories you want to share?
LT: Many of our clients are aging. One, K., is approaching 60. I’ve known him for 20 years. He’s always been on the edge of homelessness, and now he’s currently homeless. He comes to our programs every day because he gets connection here. He can get his meds, see his case manager. I see him become stronger in the moments when he’s here at our drop-in. We work really hard to get him housed, but he has a partner, and many housing situations don’t allow partners to stay, so K. has chosen to be on the street with him instead.
I also think of another client, M., a young African-American gay man living with HIV. He’s been on some of our client leadership councils, but he went through a really hard time healthwise and became hospitalized and was near death. We all went to the hospital to rally around him, and it took him three or four months to recover, but he’s now back in our program and doing well. It’s just one story of the resiliency I see in the clients we serve, who continue to inspire me.
In the past four months, we’ve also had five client deaths, so we had to grieve together as well. So even that K. and M. are alive is a success for me.
TM: How do you self-care?
LT: My leadership team is close, and we have fun together outside of work. I have a husband and an adult son I’ve raised over 20 years, so that helps ground and balance me. I also have a lot of close friends, and I try to travel. I also run. That’s my meditation.
Positive POV: Monica Paz
We spoke with Monica Paz, 38, of San Francisco, who is a clinic patient navigator at San Francisco Community Health Center. She was diagnosed with HIV in 2019.
Monica Paz: I identify as a transgender woman. I was born in El Salvador and came at the age of nine to Los Angeles. I moved to SF seven years ago, mainly because my very best friend, who never told me she was HIV positive, nearly passed away twice because she was so sick. Several friends kept saying to me, “Bring her up here [to SF] so we can save her life and keep her from prostitution and drugs.”
She didn’t want to leave without my coming, and I was also trying to get away from an abusive relationship, so I came with her.
Tim Murphy: Once you got to SF, what did you do?
MP: I was still prostituting and doing drugs, but I was happy when I saw that my friend got into a program and got sober and healthy. But it got bad for me. I had a lot of downfalls last year around this time [December 2018]. A good friend of mine overdosed next to me on Christmas Eve—I woke up and he was dead. Then I was arrested for something I didn’t even do and I spent New Year’s Eve in jail. I was released in January [of 2019] with no phone, no home. For the first time, I tasted what it was like to be homeless. I also got really sick, the flu, and ended up in the hospital. I decided that I couldn’t do [my current life] anymore. I promised myself that I’d change my life.
In the hospital, I was told I was HIV positive. I was shocked. I learned they’d actually tested me in jail but never told me the results.
So I came to the clinic here at SFCHC. I’ve had the best support system here. Everyone has been amazing. I was court-ordered to go to therapy, and my therapist motivated me to go to Walden House, a residential rehab. I was fed up with sleeping on the streets—it was raining and cold—so Walden took me in that same day, and I was there for three months. Then I went to Ferguson Place, a rehab center for people with HIV/AIDS. Then I went to live in SafeHouse, a residence for homeless women who’ve experienced abuse, prostitution, or sex trafficking. I live there now with my friend I came up here with from LA.
On the 14th [of December, 2019], I’ll be 10 months clean. I’m enrolled in school and working here—it’s a whole different world for me.
TM: What does this different world feel like?
MP: It’s an incredible feeling. I have a different perspective now on life. I have hope. I’m able to dream big again—something I wasn’t able to do for a long time. I was so insecure and unhappy, but now I have people who support, love, advocate for, and believe in me.
I’m about to graduate from the RAMS Leadership Academy at San Francisco State University, a peer certification program. Then I’ll do another certification at City College of San Francisco. I want to advance here and do more stuff and help more people. My supervisors here are the biggest motivators for me. I told them I’d like to advance to a case manager position and they told me the route to further advance my career.
TM: That’s awesome. How is life with HIV going?
MP: I have the best doctor, Dr. Royce Lin, a supportive, incredible man with such passion and commitment to all his patients. I’ve started HIV meds—one pill a day, and I have no side effects or adherence issues. My T cells are 1,150.
TM: What do you make of the current HIV situation in SF?
MP: People don’t die anymore from HIV—it’s from not taking care of yourself. We’ve come a long way. There are many programs in SF you can access because of your HIV status. There’s a lot of help and assistance.
TM: What do you think has to be done to bring down HIV rates among transgender women of color?
MP: It’s hard for many trans women of color to survive doing anything other than prostituting and drugs—that’s why they resort to it. You can only imagine what self-esteem issues they have. They can’t see a very good future for themselves. So they become depressed, and that’s why they don’t take care of themselves, which can lead to becoming HIV positive.
TM: So what’s the solution?
MP: There need to be more pathways to careers. We have to give trans women of color the opportunity to go to school and get an education so they can have decent-paying jobs. I went to LA recently for the first time in seven years, and I’m happy to see that the trans community has come a long way there, but they’re still a little behind SF, which has really tried to make it so that trans people are recognized and respected for who they are. It’s been a long time coming—and there’s still a lot of work to do.
TM: How would you sum up your life so far?
MP: I love my life! I’ve gone through so much. But my decision to change my life and my hard work is finally paying off, and I can honestly say I’m living my best life—the life I’ve always wanted to live. I can travel and meet my own expenses, and I’m able to help my friends and people whom I love.
TM: What do you do for self-care and joy?
MP: I love to travel and I love to shop, but I really love to help others, so I do a lot of community volunteering, from Crystal Meth Anonymous SF to the Coalition on Homelessness. I’m going to start going back to the gym. I love to eat, so I need to watch my weight. I had the best ribeye steak from a Peruvian place yesterday, but if you gave me shrimp along with that, that would be my perfect meal!