San Francisco Covid-19 response may be guided by 1980s HIV experience

Molly Cooke and Paul Volberding

: Molly Cooke and Paul Volberding

Dr. Paul Volberding and Dr. Molly Cooke were among the hundreds of health professionals who unexpectedly found themselves on the frontline of the HIV epidemic in the 1980s. As young doctors in San Francisco, the couple treated some of the first patients with a mysterious – and very deadly – virus.

Now they take refuge in San Francisco, in the midst of another major epidemic.

This brings back a flood of memories.

Covid-19 is a very different type of virus from HIV, which progresses to AIDS. It is much less transmissible than Covid-19, much slower to develop and also much more deadly at its peak. But lessons learned from the epidemic have remained with many long-time residents of San Francisco, including its doctors.

In the 1980s, the city consistently had the highest per capita HIV rate. For this reason, residents say, it has created a line of communication between public health, doctors and the wider community that has never been broken.

“Going through this pandemic brings back visceral emotional memories of HIV,” said Barbara Welles Seegal, a longtime resident of San Francisco in her 60s. “Many of us have lost loved ones and I have lost a number of good friends. It never really goes away.”

For Welles Seegal, the HIV epidemic became personal when a close friend contracted the virus in the early 1980s. He died at the age of 30 in 1986, and his partner died a year later. At her friend’s memorial service, she talked about bringing her community of friends together the following year. “Some of them looked at me,” she recalls. “And they asked, will there be a next year for us?”

Welles Seegal and several of his fellow citizens watched city doctors work tirelessly to help these patients, knowing that there was little they could do.

The city eventually became internationally recognized for its efforts. Formerly zero in the epidemic, it now has only a few hundred new cases per year thanks to the creativity of the local health service.

Among other breakthroughs, San Francisco launched the idea that HIV patients should start antiretroviral drugs as soon as they are positive, rather than waiting for the immune system to be affected.

“I love the San Francisco model,” said Dr. Anthony S. Fauci, director of the National Institute of Allergies and Infectious Diseases, to the New York Times. in 2015. “If he continues to do what he does, I have a strong feeling that they will succeed in ending the epidemic as we know it.

Welles Seegal knows this story well, which remains a source of pride. “We have this heritage as a city,” she told me. “And that left us with immense respect for our health service.”

Not submerged – at least not yet

In 2020, while the country is fighting coronavirus, San Francisco is doing better than many other American cities. New York now has about 10 times more cases of Covid-19 than the whole state of California, even if the two cities were neck and neck in early March.

Manhattan is larger and denser, but another factor, according to some public health experts, is that policymakers in San Francisco issued on-site placement orders relative to the rest of the country early on. And its inhabitants seem above all to stay with them.

A man walks his dog in front of a sleeping homeless man under a painted message on a closed shop in San Francisco, California, April 1, 2020, during the new epidemic of coronavirus.

Josh Edelson | AFP | Getty Images

Now, as other parts of the country rush to reopen, San Francisco is slowly and carefully breaking free from restrictions, guided by the advice of public health experts and epidemiologists. Polls show that citizens widely support policies: 11% of the inhabitants of the city see an urgent need to end the shelter on site.

There are always new Covid-19 cases every day in San Francisco, but the numbers are not yet overwhelming in hospitals.

This is a fact that has not escaped the generation of doctors who have treated HIV-infected patients, including Dr. Volberding, who is now the director of the AIDS Research Institute.

“Many doctors in San Francisco have started to help with HIV,” he said. “And now we get a good reputation for being quick to react to the current crisis.”

Take confidentiality seriously

Another great lesson from the HIV epidemic has been how public health has integrated the perspectives of civil liberties and privacy rights groups.

In the United States, AIDS has primarily affected marginalized groups, particularly gay men and intravenous drug users. It was therefore extremely important that health professionals remain anonymous as much as possible.

This reflection resulted in “HIV exceptionalism,“a term that academics like Ronald Bayer’s Mailman School of Public Health at Columbia University have used to describe the notion that a good privacy policy and a good public health policy were one and the same thing during the HIV epidemic.

“In the early years of the HIV epidemic, before there was very effective treatment, there was great fear that surveillance would be counterproductive,” said Professor Bayer. “There was concern that if people thought they might be reported to public health by name, they might be reluctant to go to a doctor and get tested.”

An image of the HIV virus taken by transmission electron microscopy.

BSIP / UIG | Getty Images

Many doctors treating patients with HIV remember that they have taken steps to protect the privacy of patients. Dr. Cooke and Dr. Volberding remember that San Francisco developed a comprehensive system around anonymized testing, which was a breakthrough given that some patients were reluctant to see a doctor – fearing that they would be excluded from the process. “Those of us in the epidemic were really sensitive to this,” said Dr. Cooke. “It was almost a fault. Looking back, we could have worked more with public health.”

“We were really aware of confidentiality, really for the first time in my medical career,” recalls Dr. David Brown, professor of medicine at the University of Washington in St. Louis, who has treated patients HIV in San Francisco in the 1980s. “By reporting the test results before that, we would leave a message on voicemail. But we learned to take privacy much more seriously during HIV.”

All of these problems – which surfaced during the Covid-19 crisis – have forced public health and civil liberties groups to work together and find mutually satisfactory solutions. For the city of San Francisco, which defends civil liberties, doctors and public health services have learned to balance the two sides.

“I am not aware of a single case where the name of a patient reported to the CDC has been misused,” said Dr. Volberding. “They did a good job.”

“The scars we still have”

Dr. Bob Wachter, who is now the chair of the department of medicine at UC San Francisco, began treating HIV-infected patients in 1983 when he arrived in town to begin his residency in internal medicine. He wrote a lot how it affected him personally, and how it has transformed medical education more broadly.

Almost thirty years later, he is currently working on the UCSF response strategy to Covid-19. He acknowledges that the city’s health systems have not yet been inundated with cases. In his opinion, this is largely because city lawmakers were ready to listen to the scientific experts who warned them against Covid-19 from the start.

“I think it’s partly the scar that people here still have about what a viral disease can still do in a community,” he said. “The cornerstone of the Bay Area, which we applied long ago in the 80s and 90s, is to take data and use it to make informed decisions.”

It is an experience that has not been forgotten in the medical community, even to this day.

“The whole city knows what it will look like if a virus takes off – and I suspect it has given courage to our political leader,” said Dr Wachter. It was not a theoretical risk. “


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