San Francisco's Citywide COVID-19 Response: Strategies to Reduce COVID-19 Severity and Health Disparities, March 2020 Through May 2022

San Francisco implemented one of the most intensive, comprehensive, multipronged COVID-19 pandemic responses in the United States using 4 core strategies: (1) aggressive mitigation measures to protect populations at risk for severe disease, (2) prioritization of resources in neighborhoods highly affected by COVID-19, (3) timely and adaptive data-driven policy making, and (4) leveraging of partnerships and public trust. We collected data to describe programmatic and population-level outcomes. The excess all-cause mortality rate in 2020 in San Francisco was half that seen in 2019 in California as a whole (8% vs 16%). In almost all age and race and ethnicity groups, excess mortality from COVID-19 was lower in San Francisco than in California overall, with markedly diminished excess mortality among people aged >65 years. The COVID-19 response in San Francisco highlights crucial lessons, particularly the importance of community responsiveness, joint planning, and collective action, to inform future pandemic response and advance health equity.

Uniting for Ukraine Tuberculosis Screening Experience, San Francisco, California, USA

Ukraine surveillance data suggest high tuberculosis (TB) incidence, including multidrug resistance. Of 299 newcomers from Ukraine screened in San Francisco, California, USA, by using an interferon-γ-release-assay (IGRA) and chest radiograph, 7.4% were IGRA positive and 1 had laboratory-confirmed pansusceptible TB. Screening with IGRA and chest radiograph can help characterize TB risk.

Implementation of a novel program to support colorectal cancer screening in a community health center consortium before and after the onset of COVID-19: a qualitative study of stakeholders' perspectives

BACKGROUND

In 2017, the San Francisco Cancer Initiative (SF CAN) established the Colorectal Cancer (CRC) Screening Program to provide technical assistance and financial support to improve CRC screening processes, and outcomes in a consortium of community health centers (CHCs) serving low-income communities in San Francisco. The purpose of this study was twofold: to evaluate the perceived influence of the support provided by the CRC Screening Program's Task Force on CRC screening processes and outcomes in these settings and to identify facilitators and barriers to SF CAN-supported CRC screening activities before and after the onset of the COVID-19 pandemic.

METHODS

Semi-structured key informant interviews were conducted with consortium leaders, medical directors, quality improvement team members, and clinic screening champions. Interviews were audio-recorded, professionally transcribed, and analyzed for themes. The Consolidated Framework for Implementation Research (CFIR) was used to develop the interview questions and organize the analysis.

RESULTS

Twenty-two participants were interviewed. The most commonly cited facilitators of improved screening processes included the expertise, funding, screening resources, regular follow-up, and sustained engagement with clinic leaders provided by the task force. The most salient barriers identified were patient characteristics, such as housing instability; staffing challenges, such as being understaffed and experiencing high staff turnover; and clinic-level challenges, such as lack of ability to implement and sustain formalized patient navigation strategies, and changes in clinic priorities due to the COVID-19 pandemic and other competing health care priorities.

CONCLUSIONS

Implementing CRC screening programs in a consortium of CHCs is inherently challenging. Technical assistance from the Task Force was viewed positively and helped to mitigate challenges both before and during the pandemic. Future research should explore opportunities to increase the robustness of technical assistance offered by groups such as SF CAN to support cancer screening activities in CHCs serving low-income communities.

Somewhere to go: assessing the impact of public restroom interventions on reports of open defecation in San Francisco, California from 2014 to 2020

BACKGROUND

Open defecation due to a lack of access to sanitation facilities remains a public health issue in the United States. People experiencing homelessness face barriers to accessing sanitation facilities, and are often forced to practice open defecation on streets and sidewalks. Exposed feces may contain harmful pathogens posing a significant threat to public health, especially among unhoused persons living near open defecation sites. The City of San Francisco's Department of Public Works implemented the Pit Stop Program to provide the unhoused and the general public with improved access to sanitation with the goal of reducing fecal contamination on streets and sidewalks. The objective of this study was to assess the impact of these public restroom interventions on reports of exposed feces in San Francisco, California.

METHODS

We evaluated the impact of various public restroom interventions implemented from January 1, 2014 to January 1, 2020 on reports of exposed feces, captured through a 311 municipal service. Publicly available 311 reports of exposed feces were spatially and temporally matched to 31 Pit Stop restroom interventions at 27 locations across 10 San Francisco neighborhoods. We conducted an interrupted time-series analysis to compare pre- versus post-intervention rates of feces reports near the restrooms.

RESULTS

Feces reports declined by 12.47 reports per week after the installation of 13 Pit Stop restrooms (p-value = 0.0002). In the same restrooms, the rate of reports per week declined from the six-month pre-intervention period to the post-intervention period (slope change = -0.024 [95% CI = -0.033, -0.014]). In a subset of restrooms, where new installations were made (Mission and Golden Gate Park), and in another subset of restrooms where restroom attendants were provided (Mission, Castro/Upper Market, and Financial District/South Beach), feces reports also declined.

CONCLUSIONS

Increased access to public toilets reduced feces reports in San Francisco, especially in neighborhoods with people experiencing homelessness. The addition of restroom attendants also appeared to have reduced feces reports in some neighborhoods with PEH. These interventions should be audited for implementation quality, observed utilization data, and user experience at the neighborhood level in order to tailor sanitation interventions to neighborhood-specific needs.

Socioeconomic status and colorectal cancer screening behaviors in a vulnerable multiethnic population

OBJECTIVE

Despite some progress in recent years, colorectal cancer (CRC) screening adherence in the United States is still suboptimal, particularly among disadvantaged groups. In this study, we assessed the association between socioeconomic status (SES) and self-reported screening non-adherence (SNA) in a sample of racial/ethnic minorities living in San Francisco, California.

DESIGN/METHODS

A total of 376 participants of the San Francisco version of the Health Information National Trends Survey (SF-HINTS) with ages 50-75 years were included in this cross-sectional study. SNA was defined as not reporting blood stool test within the past year and not reporting sigmoidoscopy/colonoscopy within the past 10 years. Poisson regression models with robust variance estimators were used to evaluate the relation of SES with SNA, adjusting for measured confounders. Results are reported as prevalence ratios (PR) and 95% confidence intervals (95% CI).

RESULTS

Overall SNA was 40%. In multivariable models including all respondents, retired participants had significantly lower SNA prevalence than employed participants (PR = 0.46, 95% CI = 0.26 0.83). In stratified analyses by race/ethnicity, Black respondents with less than high school (PR = 1.93, 95% CI = 1.09, 3.43) and those with high school or equivalent (PR = 1.88, 95% CI = 1.16, 3.04) had significantly higher SNA prevalence than those with at least some college. Among non-Hispanic Asian/Pacific Islanders, those disabled had significantly higher prevalence of SNA as compared to employed people (PR = 4.26, 95% CI = 2.11, 8.60). None of the SES indicators were significantly associated to SNA among Hispanics.

CONCLUSIONS

Participants with lower SES characteristics were less likely to adhere to CRC screening guidelines and being retired was a predictor of compliance. There was evidence of heterogeneity in associations between SES and CRC screening by race/ethnicity. Life circumstances of retired people could provide insights for designing interventions aimed to improve CRC screening uptake in these priority groups. Future efforts should consider mechanisms underlying differences by race/ethnicity.

Cancer Risk Behaviors, Cancer Beliefs, and Health Information Seeking Among Under-Represented Populations in San Francisco: Differences by Sexual Orientation and Gender Identity

Purpose

Sexual and gender minority (SGM) individuals in the United States are at increased risk of cancer compared to the non-SGM population. Understanding how SGM persons perceive cancer risk and their practices and preferences for accessing health information is key for improving the preventive and health care services they receive.

Methods

In this cross-sectional study, we analyzed data from the San Francisco Health Information National Trends Survey. SGM individuals were identified by self-report. Differences in cancer risk factors, cancer beliefs, and health information seeking were evaluated by SGM status using multivariable logistic regression models.

Results

Out of 1027 participants, 130 (13%) reported being SGM individuals. Current smoking (odds ratio [OR]=1.93, 95% confidence interval [CI]=1.24-3.01) and alcohol use (OR=1.69, 95% CI=1.10-2.59) were more common among SGM persons than among non-SGM persons. No differences by SGM status were observed in health information seeking behaviors, preferences, and cancer beliefs, but SGM participants reported significantly higher odds of feeling frustrated (OR=1.78, 95% CI=1.20-2.64) and having concerns about the quality of the information (OR=1.54, 95% CI=1.03-2.31) during their most recent health information search.

Conclusions

Intervention efforts aimed at SGM individuals with current use of tobacco and/or alcohol should be expanded. SGM communities also need improved access to consistent, reliable, and accurate sources of health information. Their increased frustration when seeking health information and concerns about the quality of the information they find have important implications for SGM health and care, and the drivers of these differences merit further evaluation.

Experimental validation of otolith-based age and growth reconstructions across multiple life stages of a critically endangered estuarine fish

Background

The application of otolith-based tools to inform the management and conservation of fishes first requires taxon- and stage-specific validation. The Delta Smelt (Hypomesus transpacificus), a critically endangered estuarine fish that is endemic to the upper San Francisco Estuary (SFE), California, United States, serves as a key indicator species in the SFE; thus, understanding this species’ vital rates and population dynamics is valuable for assessing the overall health of the estuary. Otolith-based tools have been developed and applied across multiple life stages of Delta Smelt to reconstruct age structure, growth, phenology, and migration. However, key methodological assumptions have yet to be validated, thus limiting confidence in otolith-derived metrics that are important for informing major water management decisions in the SFE.

Methods

Using known-age cultured Delta Smelt and multiple independent otolith analysts, we examined otolith formation, otolith-somatic proportionality, aging accuracy and precision, left-right symmetry, and the effects of image magnification for larval, juvenile, and adult Delta Smelt.

Results

Overall, otolith size varied linearly with fish size (from 10–60 mm), explaining 99% of the variation in fish length, despite a unique slope for larvae < 10 mm. Otolith-somatic proportionality was similar among wild and cultured specimens. Aging precision among independent analysts was 98% and aging accuracy relative to known ages was 96%, with age estimates exhibiting negligible differences among left and right otoliths. Though error generally increased with age, percent error decreased from 0–30 days-post-hatch, with precision remaining relatively high (≥ 95%) thereafter. Increased magnification (400×) further improved aging accuracy for the oldest, slowest-growing individuals. Together, these results indicate that otolith-based techniques provide reliable age and growth reconstructions for larval, juvenile, and adult Delta Smelt. Such experimental assessments across multiple developmental stages are key steps toward assessing confidence in otolith-derived metrics that are often used to assess the dynamics of wild fish populations.

Design of a population-based longitudinal cohort study of SARS-CoV-2 incidence and prevalence among adults in the San Francisco Bay Area

Purpose

We describe the design of a longitudinal cohort study to determine SARS-CoV-2 incidence and prevalence among a population-based sample of adults living in six San Francisco Bay Area counties.

Methods

Using an address-based sample, we stratified households by county and by census-tract risk. Risk strata were determined by using regression models to predict infections by geographic area using census-level sociodemographic and health characteristics. We disproportionately sampled high and medium risk strata, which had smaller population sizes, to improve precision of estimates, and calculated a desired sample size of 3400. Participants were primarily recruited by mail and were followed monthly with PCR testing of nasopharyngeal swabs, testing of venous blood samples for antibodies to SARS-CoV-2 spike and nucleocapsid antigens, and testing of the presence of neutralizing antibodies, with completion of questionnaires about socio-demographics and behavior. Estimates of incidence and prevalence will be weighted by county, risk strata and sociodemographic characteristics of non-responders, and will take into account laboratory test performance.

Results

We enrolled 3842 adults from August to December 2020, and completed follow-up March 31, 2021. We reached target sample sizes within most strata.

Conclusions

Our stratified random sampling design will allow us to recruit a robust general population cohort of adults to determine the incidence of SARS-CoV-2 infection. Identifying risk strata was unique to the design and will help ensure precise estimates, and high-performance testing for presence of virus and antibodies will enable accurate ascertainment of infections.

Tuberculosis-Associated Hospitalizations and Deaths after COVID-19 Shelter-In-Place, San Francisco, California, USA

After an initial decline, tuberculosis cases involving severe illness increased.

A mandated shelter-in-place and other restrictions associated with the coronavirus disease pandemic precipitated a decline in tuberculosis diagnoses in San Francisco, California, USA. Several months into the pandemic, severe illness resulting in hospitalization or death increased compared with prepandemic levels, warranting heightened vigilance for tuberculosis in at-risk populations.

The Role of Community-Based Organizations in Improving Chronic Care for Safety-Net Populations

INTRODUCTION

Social determinants of health (SDoH) influence health outcomes and contribute to disparities in chronic disease in vulnerable populations. To inform health system strategies to address SDoH, we conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts.

METHODS

Varied qualitative inquiry methods - in-depth interviews, participant-led neighborhood tours, and clinic visit observations - involving a total of 23 participants (10 patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, 10 community leaders serving the same neighborhoods, and 3 providers from San Francisco's public health care delivery system). Qualitative analyses were guided by the Chronic Care Model (CCM).

RESULTS

Several key themes emerged from this study. First, we enumerated a large array, neighborhood resources such as food pantries, parks/green spaces, and financial assistance services that interact with patients' self-management. Health service providers leveraged these resources to address patients' social needs but suggested a clear need for expanding this work. Second, analyses uncovered multiple essential mechanisms by which community-based organizations (CBOs) provided and navigated among many neighborhood health resources, including social support and culturally aligned knowledge. Finally, many examples of how structural issues such as institutional racism, transportation, and housing inequities are intertwined with health and social service delivery were elucidated.

CONCLUSION

The results contribute new evidence toward the community domain of the CCM. Health care systems must intentionally partner with CBOs to address SDoH and improve community resources for chronic care management, and directly address structural issues to make progress.

Non-B variants of HIV-1 in San Francisco, California

The HIV-1 epidemic in the US has historically been dominated by subtype B. HIV subtype diversity has not been extensively examined in most US cities to determine whether non-B variants have become established, as has been observed in many other global regions. We describe the diversity of non-B variants and present evidence of local transmission of non-B HIV in San Francisco. Viral sequences collected from patients between 2000 and 2016 were matched to the San Francisco HIV/AIDS case registry. HIV subtype was determined using COMET. Phylogenies were reconstructed using the pol region of subtypes A, C, D, G, CRF01_AE, CRF02_AG, and CRF07_BC, with reference sequences from the LANL HIV database. Associations of non-B subtypes and circulating recombinant forms (CRFs) with patient characteristics were assessed using multivariable logistic regression. Out of 11,381 sequences, 10,669 were from 7235 registry cases, of which 141 (2%) had non-B subtypes and CRFs and 72 (1%) had unique recombinant forms. CRF01_AE (0.8%) and subtype C (0.5%) were the most prevalent non-B forms. The frequency of non-B subtypes and CRFs increased in San Francisco during years 2000-2016. Out of 146 transmission events involving non-B study sequences, 18% indicated local transmission within the study population and 74% appeared to be inward migration of the virus. Compared to 7016 cases with only subtype B, 141 cases with non-B sequences were more likely to be of non-US country of birth (aOR = 11.02; p < 0.001), of Asian/Pacific-Islander race/ethnicity (aOR = 3.17; p < 0.001), and diagnosed after 2009 (aOR = 4.81; p < 0.001). Results suggest that most non-B infections were likely acquired outside the US and that local transmission of non-B forms has occurred but so far has not produced extensive transmission networks. Thus, non-B variants were not widely established in San Francisco, an observation that differs from cities worldwide with more diverse epidemics.

NIMBYism as a barrier to housing and social mix in San Francisco

We explore the participation levels of NIMBY ('Not In My Backyard') proponents versus other voices at public hearings San Francisco, a city with an exceptionally dire housing crisis. Once very diverse, radical, and bohemian, San Francisco has become the most expensive city in the US, which caters to a wealthy minority-heavily connected to the tech industries of the neighboring Silicon Valley. Taking a qualitative approach, we review videos of planning commission meetings between 2018 and 2019 in San Francisco in which housing development proposals are considered. We find that NIMBYism continues to dominate the dialog at public hearings on development proposals. Planning meetings appear to be dominated by older, white, and financially stable residents, and this is a major (though not sole) barrier to the city's social mix.

Among Low-Income Women In San Francisco, Low Awareness Of Paid Parental Leave Benefits Inhibits Take-Up

Paid family leave policies have the potential to reduce health disparities, yet access to paid leave remains limited and unevenly distributed in the United States. Using California administrative claims data, we examined the impact of the San Francisco Paid Parental Leave Ordinance, the first in the US to provide parental leave with full pay. We found that the law increased parental leave uptake in San Francisco by 13 percent among fathers, but there was little change in leave among mothers. Data from a survey of mothers suggest that the limited impact may be partly a result of low understanding of benefits. Lower-income mothers reported even less knowledge of their maternity leave benefits than other mothers, and fewer than 2 percent of lower-income mothers had accurate information about the policy. The San Francisco policy also excludes small employers, which further limits its reach among low-income workers. A simpler universal policy may be more effective in expanding parental leave among vulnerable workers.

Dynamic Panel Data Modeling and Surveillance of COVID-19 in Metropolitan Areas in the United States: Longitudinal Trend Analysis

Background

The COVID-19 pandemic has had profound and differential impacts on metropolitan areas across the United States and around the world. Within the United States, metropolitan areas that were hit earliest with the pandemic and reacted with scientifically based health policy were able to contain the virus by late spring. For other areas that kept businesses open, the first wave in the United States hit in mid-summer. As the weather turns colder, universities resume classes, and people tire of lockdowns, a second wave is ascending in both metropolitan and rural areas. It becomes more obvious that additional SARS-CoV-2 surveillance is needed at the local level to track recent shifts in the pandemic, rates of increase, and persistence.

Objective

The goal of this study is to provide advanced surveillance metrics for COVID-19 transmission that account for speed, acceleration, jerk and persistence, and weekly shifts, to better understand and manage risk in metropolitan areas. Existing surveillance measures coupled with our dynamic metrics of transmission will inform health policy to control the COVID-19 pandemic until, and after, an effective vaccine is developed. Here, we provide values for novel indicators to measure COVID-19 transmission at the metropolitan area level.

Methods

Using a longitudinal trend analysis study design, we extracted 260 days of COVID-19 data from public health registries. We used an empirical difference equation to measure the daily number of cases in the 25 largest US metropolitan areas as a function of the prior number of cases and weekly shift variables based on a dynamic panel data model that was estimated using the generalized method of moments approach by implementing the Arellano-Bond estimator in R.

Results

Minneapolis and Chicago have the greatest average number of daily new positive results per standardized 100,000 population (which we refer to as speed). Extreme behavior in Minneapolis showed an increase in speed from 17 to 30 (67%) in 1 week. The jerk and acceleration calculated for these areas also showed extreme behavior. The dynamic panel data model shows that Minneapolis, Chicago, and Detroit have the largest persistence effects, meaning that new cases pertaining to a specific week are statistically attributable to new cases from the prior week.

Conclusions

Three of the metropolitan areas with historically early and harsh winters have the highest persistence effects out of the top 25 most populous metropolitan areas in the United States at the beginning of their cold weather season. With these persistence effects, and with indoor activities becoming more popular as the weather gets colder, stringent COVID-19 regulations will be more important than ever to flatten the second wave of the pandemic. As colder weather grips more of the nation, southern metropolitan areas may also see large spikes in the number of cases.

Awareness and uptake of pre-exposure prophylaxis for HIV among low-income, HIV-negative heterosexuals in San Francisco

We examined pre-exposure prophylaxis (PrEP) awareness and uptake among low-income heterosexual men and women in San Francisco in 2019. Of 294 HIV-negative survey participants, 42.5% were aware of PrEP. Few women (12.5%) and men (8.9%) had discussed PrEP with a healthcare provider; 3.8% of women and 0% of men had used PrEP in the last year. White participants (adjusted odds ratio (aOR) 5.39, 95% CI 1.02, 28.56), women (aOR 2.19, 95% CI 1.30, 3.70), and age 60 years or above (aOR 4.00, 95% CI 1.12, 14.34) had greater odds of being aware of PrEP. Testing for HIV or sexually transmitted infection in the past year was marginally associated with a greater PrEP awareness. Our findings reveal gaps in PrEP implementation associated with social disparities among low-income heterosexuals. Testing services and targeted promotional and educational materials are needed lest high-risk, low-income populations are left behind in San Francisco's aggressive "Getting to Zero" efforts.

Employer-Reported Access to Paid Parental Leave: A study of San Francisco's Paid Parental Leave Ordinance

A growing body of research finds that paid leave policies have significant population health benefits for workers and their families, but the lack of a national paid leave policy in the United States leaves most workers without access to any paid leave. In 2017 San Francisco implemented the nation's first fully paid leave policy, mandating that covered employers provide up to six weeks of leave to care for a new child. The objective of our study is to examine how the San Francisco Paid Parental Leave Ordinance (PPLO) affected paid leave access, including among workers in low-wage industries. Methods: We surveyed Bay Area employers in 2018, the year after PPLO took effect. We estimated difference-in-differences models of changes in access to paid leave before versus after implementation of the PPLO in San Francisco compared to surrounding counties. Results: Availability of paid leave in San Francisco firms increased from 45% in 2016 to 79% following implementation of the PPLO. This is significantly more (p < 0.05) than the increase from 32% to 47% in surrounding counties. Compliance was lowest (67%) among low-wage firms. We found minimal evidence of self-reported negative effects on employers. Overall, 82% of firms supported the PPLO. Conclusions: San Francisco's experience demonstrates the feasibility of using local policy to increase parental leave access.

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San Francisco recently enacted the first fully paid parental leave policy in the U.S.

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Access to paid leave increased in San Francisco relative to surrounding counties.

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Compliance was lowest among low-wage employers.

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Employers reported minimal negative impacts and high support for the policy.

Estimation of effects of contact tracing and mask adoption on COVID-19 transmission in San Francisco: a modeling study

The current COVID-19 pandemic has spurred concern about what interventions may be effective at reducing transmission. The city and county of San Francisco imposed a shelter-in-place order in March 2020, followed by use of a contact tracing program and a policy requiring use of cloth face masks. We used statistical estimation and simulation to estimate the effectiveness of these interventions in San Francisco. We estimated that self-isolation and other practices beginning at the time of San Francisco's shelter-in-place order reduced the effective reproduction number of COVID-19 by 35.4% (95% CI, -20.1%-81.4%). We estimated the effect of contact tracing on the effective reproduction number to be a reduction of approximately 44% times the fraction of cases that are detected, which may be modest if the detection rate is low. We estimated the impact of cloth mask adoption on reproduction number to be approximately 8.6%, and note that the benefit of mask adoption may be substantially greater for essential workers and other vulnerable populations, residents return to circulating outside the home more often. We estimated the effect of those interventions on incidence by simulating counterfactual scenarios in which contact tracing was not adopted, cloth masks were not adopted, and neither contact tracing nor cloth masks was adopted, and found increases in case counts that were modest, but relatively larger than the effects on reproduction numbers. These estimates and model results suggest that testing coverage and timing of testing and contact tracing may be important, and that modest effects on reproduction numbers can nonetheless cause substantial effects on case counts over time.

Using Standardized Checklists Increase the Completion Rate of Critical Actions in an Evacuation from the Operating Room: A Randomized Controlled Simulation Study

INTRODUCTION

Hospital evacuations of patients with special needs are extremely challenging, and it is difficult to train hospital workers for this rare event.Hypothesis/Problem:Researchers developed an in-situ simulation study investigating the effect of standardized checklists on the evacuation of a patient under general anesthesia from the operating room (OR) and hypothesized that checklists would improve the completion rate of critical actions and decrease evacuation time.

METHODS

A vertical evacuation of the high-fidelity manikin (SimMan3G; Laerdal Inc.; Norway) was performed and participants were asked to lead the team and evacuate the manikin to the ground floor after a mock fire alarm. Participants were randomized to two groups: one was given an evacuation checklist (checklist group [CG]) and the other was not (non-checklist group [NCG]). A total of 19 scenarios were run with 28 participants.

RESULTS

Mean scenario time, preparation phase of evacuation, and time to transport the manikin down the stairs did not differ significantly between groups (P = .369, .462, and .935, respectively). The CG group showed significantly better performance of critical actions, including securing the airway, taking additional drug supplies, and taking additional equipment supplies (P = .047, .001, and .001, respectively). In the post-evacuation surveys, 27 out of 28 participants agreed that checklists would improve the evacuation process in a real event.

CONCLUSION

Standardized checklists increase the completion rate of pre-defined critical actions in evacuations out of the OR, which likely improves patient safety. Checklist use did not have a significant effect on total evacuation time.

Will We Get to Zero HIV Stigma in San Francisco?

Cities worldwide are striving to get to zero HIV stigma as a condition to get to zero new infections. We tracked an indicator of perceived HIV stigma across surveys of men who have sex with men (MSM) in San Francisco from 2011 to 2017. Little improvement in perceived HIV stigma was observed, from 22.3% (95% CI 18.7-26.3) of MSM agreeing with the statement "Most people would discriminate against someone with HIV" in 2011 to 21.0% (95% CI 17.5-24.9) in 2017 (χ² test for trend 0.252, p = 0.616). Success in ending the epidemic may flag without addressing the causes of HIV stigma.

Food insecurity among formerly homeless youth in supportive housing: A social-ecological analysis of a structural intervention

A growing body of research indicates that structural interventions to provide permanent supportive housing (PSH) to homeless adults within a Housing First approach can improve their health. However, research is lacking regarding the impact of PSH on youth experiencing homelessness. This article seeks to understand how PSH for youth impacts a basic health need-food security- across multiple levels of the social-ecological environment. In January of 2014, San Francisco, California opened the city's first municipally-funded PSH building exclusively designated for transition-aged youth (ages 18-24). We conducted 20 months of participant observation and in-depth interviews with 39 youth from April 2014 to December 2015. Ethnographic fieldnotes and interview transcripts were analyzed using grounded theory. We present our social-ecological assessment regarding food insecurity for formerly homeless youth in supportive housing. We found that although housing removes some major sources of food insecurity from their lives, it adds others. Many of the participating youth were frequently hungry and went without food for entire days. Mechanisms across multiple levels of the social-ecological model contribute to food insecurity. Mechanisms on the structural level include stigma, neighborhood food resources, and monthly hunger cycles. Mechanisms on the institutional level include the transition into housing and housing policies regarding kitchen use and food storage. Interpersonal level mechanisms include food sharing within social networks. Individual level mechanisms include limited cooking skills, equipment, and coping strategies to manage hunger. Although supportive housing provides shelter to youth, effective implementation of the Housing First/PSH model for youth must ensure their access to an affordable nutritious diet.

Estimated Population Size of Men Who Have Sex with Men, San Francisco, 2017

Current population size estimates of communities at risk for HIV are needed to adequately plan interventions and care. We update the estimated number of men who have sex with men (MSM) living in San Francisco. Multiple data sources and approaches, including population growth, registered HIV cases, wisdom of the crowd, and a published estimate on the proportion of adults who are MSM were used for estimation. The several estimates were synthesized into a final figure with acceptable bounds using a Bayesian method. We project 69,974 (acceptable bounds 65,523-74,323) MSM are living in San Francisco as of the beginning of 2017. The population of MSM in San Francisco has increased by 19.4% since 2014.

Engaging Adults Experiencing Homelessness in Smoking Cessation Through Large-Scale Community Service Events

Cigarette smoking contributes substantially to the increased financial- and health-related burdens among adults experiencing homelessness. We describe findings from a case study of a model to increase access to cessation services among adults experiencing homelessness. In partnership with Project Homeless Connect (PHC), we piloted a unique service delivery model that involved providing brief cessation counseling and pharmacotherapy to smokers from this population attending large-scale service events in San Francisco, with the goal of connecting them to long-term smoking cessation care. We participated in three service events between October 2017 and March 2018. We offered brief smoking cessation counseling to 45 individuals, and smoking cessation counseling and pharmacotherapy to 7 individuals experiencing homelessness. This model could improve public health if expanded to other cities, particularly the 200 other cities in the United States offering PHC service events.

The transcortical equatorial approach for gliomas of the mesial temporal lobe: techniques and functional outcomes

OBJECTIVEMany surgical approaches have been described for lesions within the mesial temporal lobe (MTL), but there are limited reports on the transcortical approach for the resection of tumors within this region. Here, the authors describe the technical considerations and functional outcomes in patients undergoing transcortical resection of gliomas of the MTL.METHODSPatients with a glioma (WHO grades I-IV) located within the MTL who had undergone the transcortical approach in the period between 1998 and 2016 were identified through the University of California, San Francisco (UCSF) tumor registry and were classified according to tumor location: preuncus, uncus, hippocampus/parahippocampus, and various combinations of the former groups. Patient and tumor characteristics and outcomes were determined from operative, radiology, pathology, and other clinical reports that were available through the UCSF electronic medical record.RESULTSFifty patients with low- or high-grade glioma were identified. The mean patient age was 46.8 years, and the mean follow-up was 3 years. Seizures were the presenting symptom in 82% of cases. Schramm types A, C, and D represented 34%, 28%, and 38% of the tumors, and the majority of lesions were located at least in part within the hippocampus/parahippocampus. For preuncus and preuncus/uncus tumors, a transcortical approach through the temporal pole allowed for resection. For most tumors of the uncus and those extending into the hippocampus/parahippocampus, a corticectomy was performed within the middle and/or inferior temporal gyri to approach the lesion. To locate the safest corridor for the corticectomy, language mapping was performed in 96.9% of the left-sided tumor cases, and subcortical motor mapping was performed in 52% of all cases. The mean volumetric extent of resection of low- and high-grade tumors was 89.5% and 96.0%, respectively, and did not differ by tumor location or Schramm type. By 3 months' follow-up, 12 patients (24%) had residual deficits, most of which were visual field deficits. Three patients with left-sided tumors (9.4% of dominant-cortex lesions) experienced word-finding difficulty at 3 months after resection, but 2 of these patients demonstrated complete resolution of symptoms by 1 year.CONCLUSIONSMesial temporal lobe gliomas, including larger Schramm type C and D tumors, can be safely and aggressively resected via a transcortical equatorial approach when used in conjunction with cortical and subcortical mapping.

Laser ablative therapy of sessile hypothalamic hamartomas in children using interventional MRI: report of 5 cases

Hypothalamic hamartomas (HHs) are benign lesions that cause medically refractory seizures, behavioral disturbances, and endocrine dysfunction. Open resection of HHs does not guarantee seizure freedom and carries a relatively high risk of morbidity. Minimally invasive stereotactic laser ablation has recently been described as an effective and safe alternative for HH treatment. Prior studies have not, however, assessed HH lesion size and morphology, 2 factors that may influence treatment results and, ultimately, the generalizability of their findings. In this paper, the authors describe seizure outcomes for 5 pediatric patients who underwent laser ablation of sessile HHs. Lesions were treated using a frameless, interventional MRI-guided approach, which facilitated laser targeting to specific components of these complex lesions. The authors' experiences in these cases substantiate prior work demonstrating the effectiveness of laser therapy for HHs, while elucidating HH complexity as a potentially important factor in laser treatment planning, and in the interpretation of early studies describing this treatment method.

Continued Transmission of HIV Among Young Adults Who Inject Drugs in San Francisco: Still Room for Improvement

We measured HIV incidence rate, trend and risk factors in 564 HIV-negative young people (< 30 years) who inject drugs (PWID) in San Francisco between 2000 and 2014. HIV incidence was 0.93/100 person-years (PY; 95% CI 0.50, 1.73). Incidence varied between 0.62/100 PY in 2000-2002 and 1.06/100 PY in 2012-2014 (P for trend = 1.0). HIV incidence varied significantly (P < 0.01) by race/ethnicity: among Hispanics it was 8.19/100 PY (95% CI 3.41, 19.68), African-Americans 4.59/100 PY (95% CI 1.15, 18.37), and Whites 0.26/100 PY (95% CI 0.06, 1.03). Male participants who reported sex with men (MSM) had higher HIV incidence (2.63/100 PY; 95% CI 1.31, 5.25) compared to males who did not report MSM (0.50/100 PY; 95% CI 0.12, 1.99) (P = 0.01). Despite an overall stable HIV incidence trend, incidence was elevated among African-American and Hispanic PWID, and men who have sex with men. Addressing prevention needs in these key populations is critical for the goal of eliminating HIV transmission.

Nutrition from the Inside Out

Nearly 50 years ago, I set out to investigate the clinical problem of hypoglycemia in children with illnesses that limited their food intake. My goal was to gather accurate and precise measurable data. At the time, I wasn't interested in nutrition as a discipline defined in its more general or popular sense. To address the specific problem that interested me required development of entirely new methods based on stable, nonradioactive tracers that satisfied the conditions of accuracy and precision. At the time, I had no inclination of the various theoretical and practical problems that would have to be solved to achieve this goal. Some are briefly described here. Nor did I have the slightest idea that developing the field would result in a fundamental change in how human clinical investigation was conducted, with the eventual replacement of radiotracers with stable isotopically labeled ones, even for adult clinical investigation. Additionally, I had no inclination that the original questions would open avenues to much broader questions of practical nutritional relevance. Moreover, only much later as the editor of The American Journal of Clinical Nutrition did I appreciate the policy implications of how nutritional data are presented in the scientific literature. At least in part, less accurate and precise measurements and less than full transparency in reporting nutritional data have resulted in widespread debate about the public policy recommendations and guidelines that are the intended result of collecting the data in the first place. This article provides a personal recollection (with all the known faults of self-reporting and retrospective memory) of the journey that starts with measurement certainty and ends with policy uncertainty.

Safety and cost efficiency of a restrictive transfusion protocol in patients with traumatic brain injury

OBJECTIVE Blood loss and moderate anemia are common in patients with traumatic brain injury (TBI). However, despite evidence of the ill effects and expense of the transfusion of packed red blood cells, restrictive transfusion practices have not been universally adopted for patients with TBI. At a Level I trauma center, the authors compared patients with TBI who were managed with a restrictive (target hemoglobin level > 7 g/dl) versus a liberal (target hemoglobin level > 10 g/dl) transfusion protocol. This study evaluated the safety and cost-efficiency of a hospital-wide change to a restrictive transfusion protocol. METHODS A retrospective analysis of patients with TBI who were admitted to the intensive care unit (ICU) between January 2011 and September 2015 was performed. Patients < 16 years of age and those who died within 24 hours of admission were excluded. Demographic data and injury characteristics were compared between groups. Multivariable regression analyses were used to assess hospital outcome measures and mortality rates. Estimates from an activity-based cost analysis model were used to detect changes in cost with transfusion protocol. RESULTS A total of 1565 patients with TBI admitted to the ICU were included in the study. Multivariable analysis showed that a restrictive transfusion strategy was associated with fewer days of fever (p = 0.01) and that patients who received a transfusion had a larger fever burden. ICU length of stay, ventilator days, incidence of lung injury, thromboembolic events, and mortality rates were not significantly different between transfusion protocol groups. A restrictive transfusion protocol saved approximately $115,000 annually in hospital direct and indirect costs. CONCLUSIONS To the authors' knowledge, this is the largest study to date to compare transfusion protocols in patients with TBI. The results demonstrate that a hospital-wide change to a restrictive transfusion protocol is safe and cost-effective in patients with TBI.

Atypical pituitary adenoma: a clinicopathologic case series

OBJECTIVE In 2004, the WHO classified atypical pituitary adenoma as a distinct adenoma subtype. However, the clinical significance of this distinction remains undetermined. The authors sought to define patient characteristics, tumor features, and treatment outcomes associated with atypical pituitary adenoma. METHODS The authors reviewed records of patients who underwent resection of pituitary adenoma at the University of California, San Francisco, between 2007 and 2014. Per institutional protocol, adenomas exhibiting mitotic activity underwent evaluation for all 3 markers of atypicality (mitotic index, extensive p53 staining, and MIB-1 index ≥ 3%). Statistical analyses were performed using χ², Fisher's exact test, t-test, log-rank, and logistic regression. RESULTS Between 2007 and 2014, 701 patients underwent resection for pituitary adenoma. Among these patients, 122 adenomas exhibited mitotic activity and therefore were evaluated for all 3 markers of atypicality, with 36 tumors (5%) proving to be atypical. There were 21 female patients (58%) and 15 male patients (42%) in the atypical cohort, and 313 female patients (47%) and 352 male patients (53%) in the nonatypical cohort (p = 0.231). The mean age of patients in the atypical cohort was 37 years (range 10-65 years), which was significantly lower than the mean age of 49 years (range 10-93 years) for patients in the nonatypical cohort (p < 0.001). The most common presenting symptoms for patients with atypical adenomas were headaches (42%) and visual changes (33%). Atypical adenomas were more likely to be functional (78%) than nonatypical adenomas (42%; p < 0.001). Functional atypical adenomas were significantly larger than functional nonatypical adenomas (mean diameter 2.2 vs 1.4 cm; p = 0.009), as were nonfunctional atypical adenomas compared with nonfunctional nonatypical adenomas (mean diameter 3.3 vs 2.3 cm; p = 0.01). Among the entire adenoma cohort, larger presenting tumor size was associated with cavernous sinus invasion (p < 0.001), and subtotal resection was associated with cavernous sinus invasion (p < 0.001) and larger size (p < 0.001) on binomial multivariate regression. The median time until recurrence was 56 months for atypical adenomas, 129 months for functional nonatypical adenomas, and 204 months for nonfunctional nonatypical adenomas (p < 0.001). Functional atypical adenomas recurred more frequently and significantly earlier than functional nonatypical adenomas (p < 0.001). When accounting for extent of resection, cavernous sinus invasion, size, age, sex, and functional subtype, atypicality remained a significant predictor of earlier recurrence among functional adenomas (p = 0.002). CONCLUSIONS When compared with nonatypical pituitary adenomas, atypical adenomas are more likely to present in younger patients at a larger size, are more often hormonally hypersecretory, and are associated with earlier recurrence. These features lend credence to atypical pituitary adenomas being a distinct clinical entity in addition to a discrete pathological diagnosis.

The Docent Method: A Grounded Theory Approach for Researching Place and Health

To understand health, research needs to move outside of controlled research settings into the environments where health activities occur-homes, streets, and neighborhoods. I offer the docent method as a qualitative place-based approach for exploring health in a participant-driven, structured, and flexible way. The docent method is a participant-led, audiotaped, and photographed walking interview through broad "sites of interest" (SOIs). It is rooted in grounded theory and influenced by community-based participatory research and walking interviews. The three stages of the docent method involve: (a) a warm-up interview focusing on positionality, participant background, and mapping/planning SOIs; (b) a participant-led, photographed walking interview to and around the SOI; and (c) a wind-down interview in the community. I describe the methodological influences, development, and procedures of the docent method drawing from my own experiences conducting it with formerly homeless women living in permenant supportive housing in the Tenderloin neighborhood of San Francisco.

Health in the Tenderloin: A resident-guided study of substance use, treatment, and housing

Substance use researchers recognize that environments - our homes, streets, communities, and neighborhoods - set the stage for substance use and treatment experiences by framing interactions, health options, and decision-making. The role of environment is particularly salient in places deemed disadvantaged or risky, such as parts of the Tenderloin neighborhood of San Francisco. Since risk is historically, socially, and structurally situated, an individual's social position in a neighborhood shapes how risk environments are experienced. The purpose of this study was to explore how the environment shapes substance use and treatment experiences, described from the perspective of Tenderloin residents. I conducted docent method interviews with formerly homeless women living in supportive housing in San Francisco (N = 20). The docent method is a three-stage, participant-led, audiotaped, and photographed walking interview. As they guided me through target "sites of interest" (homes, streets, treatment programs, and safe spaces), participants discussed their experiences with substance use and treatment in the environment. First, they described that the risks of a broader drug market are concentrated in the Tenderloin, exposing residents to elevated and disproportionate risk. Second, for structural, economic, social, and physical reasons, participants described a sense of geographic or neighborhood stratification. Third, multiple levels of policing and surveillance were persistent, even in participants' homes. Fourth, despite all the challenges, participants found security and support in the Tenderloin, and considered it their home. In the discussion, I offer that the Tenderloin environment provided residents many advantages, but forms of structural and everyday violence largely defined their experiences in the neighborhood.

Global Health Diplomacy, "San Francisco Values," and HIV/AIDS: From the Local to the Global

BACKGROUND

San Francisco has a distinguished history as a cosmopolitan, progressive, and international city, including extensive associations with global health. These circumstances have contributed to new, interdisciplinary scholarship in the field of global health diplomacy (GHD). In the present review, we describe the evolution and history of GHD at the practical and theoretical levels within the San Francisco medical community, trace related associations between the local and the global, and propose a range of potential opportunities for further development of this dynamic field.

METHODS

We provide a historical overview of the development of the "San Francisco Model" of collaborative, community-owned HIV/AIDS treatment and care programs as pioneered under the "Ward 86" paradigm of the 1980s. We traced the expansion and evolution of this model to the national level under the Ryan White Care Act, and internationally via the President's Emergency Plan for AIDS Relief. In parallel, we describe the evolution of global health diplomacy practices, from the local to the global, including the integration of GHD principles into intervention design to ensure social, political, and cultural acceptability and sensitivity.

RESULTS

Global health programs, as informed by lessons learned from the San Francisco Model, are increasingly aligned with diplomatic principles and practices. This awareness has aided implementation, allowed policymakers to pursue related and progressive social and humanitarian issues in conjunction with medical responses, and elevated global health to the realm of "high politics."

CONCLUSIONS

In the 21st century, the integration between diplomatic, medical, and global health practices will continue under "smart global health" and GHD paradigms. These approaches will enhance intervention cost-effectiveness by addressing and optimizing, in tandem with each other, a wide range of (health and non-health) foreign policy, diplomatic, security, and economic priorities in a synergistic manner--without sacrificing health outcomes.

Trends in use of health care and HIV prevention services for persons who inject drugs in San Francisco: results from National HIV Behavioral Surveillance 2005-2012

BACKGROUND

Multiple developments addressing health of people who inject drugs (PWIDs) in San Francisco were initiated from 2003 to 2012, including expanded health care coverage, syringe access, HIV testing and universal HIV treatment.

METHODS

We evaluated 3 PWID cycles of the National HIV Behavioral Surveillance for several healthcare measures related to the expanded services. Using RDSAT estimators, we applied the Cochran-Armitage test for trend to evaluate signals of improvement during the time in which health system changes were made.

RESULTS

Participant demographics were similar (n=565, 535, and 570 in 2005, 2009, and 2012, respectively). There was a substantial increase in healthcare coverage (37.6 to 82.5%, P<0.0001). Obtaining syringes from pharmacies (17.8 to 32.1%, P<0.0001) increased substantially. Past year hepatitis C testing increased (16.5 to 33.1%, P<0.0001) with stable self-reported prevalence (45.7-54.2%, P=0.8). Among those with known HIV, antiretroviral treatment was reported among 46.6% in 2005 and 66.3% in 2012. Past year HIV testing declined from 74.2 to 42.1%, (P<0.0001) and the prevalence of unrecognized HIV among PWIDs was 42.2-42.7% in 2009 and 2012.

CONCLUSIONS

There is evidence of improvement in some health measures for PWIDs in San Francisco from 2005 to 2012. However, there are also some concerning findings, such as declining prevalence of HIV testing and high prevalence of undiagnosed HIV. There is a need for renewed attention and innovative ideas to track and address HIV and other medical sequelae among PWIDs.

High Transmissibility During Early HIV Infection Among Men Who Have Sex With Men-San Francisco, California

We estimate the relative transmission rate in early versus later infection among men who have sex with men (MSM) in San Francisco, California, by studying the characteristics of a sample of transmitters, recruited through newly diagnosed, recently infected MSM between 1996 and 2009. Of 36 transmitters identified, 9 were determined on the basis of testing history and serologic testing to have been recently infected. The unadjusted odds ratio of transmitting during early infection was 15.2 (95% confidence interval [CI], 6.3–33.4; P < .001); the odds ratio was 8.9 (95% CI, 4.1–19.4) after adjustment for self-reported antiretroviral treatment. This high transmissibility could be due to both high infectiousness and high rates of sex partner change or concurrent partnerships.

Driving under the influence of synthetic cannabinoid receptor agonist XLR-11

The case of a 22-year-old male Caucasian driver is presented. He was involved in a traffic collision. At the roadside, he displayed blank stare and mellow speech with a barely audible voice. A DRE found low body temperature, rigid muscle tone, normal pulse, lack of horizontal and vertical gaze nystagmus, nonconvergence of the eyes, dilated pupil size, and normal Pupillary reaction to light. A standard toxicology DUID protocol was performed on the driver's whole blood including ELISA and GC-MS drug screens with negative results. Additional drug screening was undertaken for bath salts and synthetic cannabinoid receptor agonists by LC-MS/MS by a commercial laboratory and identified the synthetic cannabinoid receptor agonist XLR-11 in the driver's blood. XLR-11 was subsequently quantified at 1.34 ng/mL. This is the first documented case involving a driver operating a motor vehicle under the influence of the synthetic cannabinoid receptor agonist XLR-11.

Activity spaces among injection drug users in San Francisco

BACKGROUND

Representations of activity spaces, defined as the local areas within which people move or travel in the course of their daily activities, are unexplored among injection drug users (IDUs). The purpose of this paper is to use an activity space framework to study place and drug user health.

METHODS

Data for this analysis is from an epidemiological study of street-recruited IDUs in San Francisco (N=1084). Study participants reported geographic intersections of where they most often slept at night, hung out during the day, and used drugs during a 6 month time period. We used GIS software to construct and map activity space routes of street-based network paths between these intersections. We further identified if syringe exchange program (SEP) locations intersected with, participant activity space routes. We used logistic regression to estimate associations between activity space variables and HIV serostatus, syringe sharing, and non-fatal overdose, after adjusting for individual and Census tract covariates.

RESULTS

Mean activity space distance for all participants was 1.5miles. 9.6% of participants had a SEP located along their activity space. An increase in activity space distance was associated with a decrease in odds of being HIV positive. An increase in residential transience, or the number of different locations slept in by participants in a 6 month time period, was associated with higher odds of syringe sharing. Activity space distance was not independently associated with overdose or syringe sharing.

DISCUSSION

Research that locates individuals in places of perceived importance is needed to inform placement and accessibility of HIV and overdose prevention programs. More attention needs to be given to the logistics of collecting sensitive geospatial data from vulnerable populations as well as how to maximize the use of GIS software for visualizing and understanding how IDUs interact with their environment.

Théoriser la violence en Améerique: Retour sur trente ans d'ethnographie

PHILIPPE BOURGOIS THEORIZING VIOLENCE IN THE AMERICAS A THIRTY-YEAR ETHNOGRAPHIC RETROSPECTIVE

This thirty year retrospective analysis of violence at my fieldwork sites in the Americas (Nicaragua, El Salvador, Costa Rica, Panama, USA) explores the importance and difficulty of recognizing the continuities of violence across historical eras as an ethnographer. Expanding on the continuum of violence concept, I propose the utility of identifying the mutually reinforcing interface of three overlapping categories of invisible violence: structural, symbolic and normalized. If theory is meant to help us see more, then theorizing violence through a continuum of categories of invisibility is useful because it contravenes the political effects of the contemporary hyper-visibility of interpersonal and petty criminal street violence. The increasing global reach of a punitive version of corporate neoliberalism over the past two decades has lumpenized large sectors of the urban and rural poor. Recognizing the links between categories of invisible violence in this globalized context of social inequality explains the demobilization of class-based demands for economic redistribution and populist support for physically repressive forms of governmentality that punish the poor deemed unworthy.