‘The virus will surge, if we let it.’
The tone was celebratory for the first half-hour of a late September UCSF forum, as Mayor London Breed and others applauded the city’s success combatting Covid-19, including the remarkably low death rate and a drop in cases.
These are all very good things. And when Dr. Diane Havlir, the slight and always impeccably dressed chief of UCSF’s Division of HIV/AIDS, Infectious Disease, and Global Medicine, spoke next, she credited the trifecta of public, political and community action for the city’s good fortune. But there the accolades ended.
“One of the reasons that we’ve been successful in HIV is, we don’t pat ourselves on the back too much and we keep on saying, ‘this is not good enough,’” said Havlir, in typically measured tones.
With covid, Havlir sees a fast-moving virus in which the city’s knowledge base changes daily and the virus retains its ability to spread and surprise. What has remained consistent, she pointed out, was the startling disparity in the coronavirus’s impact. The city’s Latinx residents – 15 percent of the city’s population – represent 50 percent of its Covid-19 cases.
Havlir watched that disparity emerge in mid-March, when Latinx patients began to fill the beds at Zuckerberg San Francisco General Hospital and Trauma Center, the provider for the city’s indigent and undocumented populations, where many of UCSF’s high-flying researchers, like Havlir, still see patients.
Up until then, Havlir had spent a lifetime researching and influencing the global trajectory of HIV/AIDS treatment – the mysterious new disease that, as a 23-year-old medical student, she first read about in a June 1981 CDC morbidity report. Now, at 62, she was seeing another medical disaster unfold, and one of the communities worst affected lived right outside the hospital’s doors. So, nearly four decades after HIV/AIDS grabbed her attention and became her life’s work, Havlir’s intelligence locked on the covid pandemic.
Over the months that followed, Havlir forged an unusually close bond with the Mission’s Latinx community leaders to test, study and track the virus whose spiky proteins attached themselves so relentlessly to the most vulnerable populations.
Each testing study produced new findings, new challenges and new ways that San Francisco’s political and public health officials might vanquish the virus. But only recently has the city translated Havlir’s results into action by heeding the findings of these studies to open more low-barrier testing in the city’s southeastern neighborhoods where covid has thrived. If, like the rest of the country, San Francisco experiences another surge, Havlir’s relentless research and alliance with community leaders could very well be the roadmap that prevents a winter calamity.
The goal is to address some of the toughest epidemiological challenges covid presents – why it thrives in certain places and how the city can best attend to and treat those communities. As in her AIDS research, Havlir looks at a pandemic to find the impacted populations not being treated. “It’s not their problem,” she said. “It’s our problem to figure out how to reach them.”
Such research is pursued not in the lab, but in the field, among those who are already sick or most likely to become infected.
For Havlir, “research isn’t just an academic pursuit about getting into the best journals,” said Dr. Bob Wachter, the chair of UCSF’s Department of Medicine. “Her goal is to make a difference in people’s lives.”
That you haven’t heard much about Havlir isn’t surprising. While she is well known in HIV/AIDS circles – she co-chaired the International AIDS conference in 2012, and has authored hundreds of research papers, including critical studies on the cocktail of medicines prescribed for those infected with HIV – she is most comfortable at work. Colleagues and community activists alike describe her as “warm” but “a very serious person,” one who seems to care little about developing a public persona.
Havlir did try Twitter in 2014 but, as her youngest daughter, Jackie, said with deadpan humor, “My mother is not funny.” After seven tweets on everything from HIV and TB reservoirs to the activity of PA 824+PZA, Havlir bid her 218 followers goodbye. Twitter may be Havlir’s only failure.
Back in late March, the only way to understand the jump in Latinx patients filling SFGH – they accounted for 80 percent of the new patients being admitted into the hospital – was to collect and study data. So, in early April, at a time when tests themselves were nearly impossible to come by, Havlir decided to test some 4,000 residents and workers in the Mission District’s densest census tract. Dr. Joe DeRisi, an epidemiologist and co-president of the Chan Zuckerberg Biohub, agreed to process more tests over a three-day period in April than the city had ever managed at one time.
Havlir had already learned from her HIV research in San Francisco and in field studies in Uganda and Kenya in which she reached more than 300,000 individuals that, in addition to meeting all of UCSF’s protocols of securing committee approvals for a research project, nothing happens – participants don’t show up – without true buy-in from the community and local political officials.
While District Supervisor Hillary Ronen quickly recognized the value of a study, Mission politics and advocacy circles can be a minefield even for the most adept outsiders. Havlir had the right guide: Diane Jones, a retired SFGH HIV nurse. Jones was not a Mission native, but over the last 40 years, she and her partner, LGBTQ activist Roma Guy, had earned plenty of street cred, partly as co-founders of the Women’s Building. Moreover, Jones’s daughter, Annie-Jupiter Jones, had grown up in the Mission, attended its schools, sent her children to local schools, and ran the youth arts non-profit, Loco Bloco, for years.
That’s the kind of history that it takes to make natives and activists like Tracy Gallardo Brown pay attention. Gallardo, now a legislative aide to District 10 Supervisor Shamann Walton, set up a meeting with the Latino Task Force, a tight group of local activists already responding to the economic collapse facing Mission residents – many without any safety net of unemployment checks or family help.
Those who attended Havlir’s first presentations – socially distant and masked meetings in early April at the Brava Theater Center on 24th Street – said that she spoke very directly and clearly about what she wanted to do and why. “Call me Diane,” she said. No. It would be Dr. Havlir, an elder explained, because in their community it was important to show respect for those with advanced degrees. The doctor listened. The leaders had plenty of questions. She answered them. The activists had suggestions – on where to test, the hours that immigrants were more likely to come, incentives to get them there. Havlir scribbled notes. (Her scribbles are well-known as the way in which she processes information.) They watched their ideas get incorporated.
“Sometimes when institutions come into our community to do something, they make us feel like we are the help,” said Jon Jacobo, the chair of the Latino Task Force health committee. It became clear early on, he said, that Havlir was different. She was interested in what they had to say.
Before long, the doctor and the community leaders began to plan. They became a team, with a name — Unidos en Salud, United in Health. And united they were: the doctor and the Latino Task Force wanted to find out why the virus was spreading so easily in the Latinx community and how they could stop it.
Havlir can make the dynamic sound easy, but her description also conveys how she sees little difference in the value of what she or a community leader can bring to the table: “We put things forward, we debate, we discuss, and then we do something. And then we say, ‘okay, what do we want to do now?’”
Havlir is “just, like, brilliant and really, really kind,” said Susana Rojas, a longtime activist who, with her daughter, Suzy, has been on the ground helping to figure out how best to respond to those who test positive. “She’s from the medical field, but she has a community heart.”
Even once the samples were collected and the testing tents put away, “She checked back in with us all the time,” said Valerie Tulier-Laiwa, who is on the executive committee of the Latino Task Force.
Perhaps most surprising to Tulier-Laiwa and others: When UCSF wrote up the research for an academic journal, the names of local leaders appeared as co-authors.
“She’s a model” of how to work with a community, Tulier-Laiwa said. A lot of leaders talk about equity, but Havlir “is busy doing something about it.”
And in a community that values family and volunteerism – and calls on their own niños, tíos and primos to step in – Havlir fit right in. Her daughter, 25-year-old Jackie, a computer whiz, helped build the dashboard to track results. Her son, Danny, an immigration lawyer, took the lead organizing one of the testing sites. (Havlir’s other two children simply weren’t in town at the time.) Her husband, Dr. Arturo Martinez, was on call to pick up extra testing equipment. And yes, they all speak Spanish.
When the results started to come back, Havlir and her husband delivered supplies to the first resident who turned up positive. That experience convinced her that the follow-up with patients had to be done with the help of a local wellness team model – something that she raised money for during the UCSF studies. The model was subsequently fine-tuned by the Rojas mother-and-daughter team and Tulier-Laiwa.
When the results of the study came back in May, they were appalling: 95 percent of the 83 people who tested positive were Latinx – none were white. Most worked frontline jobs, many lived in crowded conditions, 52 percent were asymptomatic at the time they were tested, and 29 percent remained asymptomatic during the course of the virus. Even those without symptoms showed high levels of the virus, an early indication that asymptomatic carriers were spreading the disease.
The results clearly indicated a need for more accessible testing in the Latinx community, as well as financial and other support to quarantine. Most of those who tested positive worked frontline jobs, earned less than $50,000 a year and lived in crowded households. Without the ability to quarantine, working to feed their families was a greater incentive than staying at home – especially for those without symptoms.
The importance of the April Mission study cannot be understated, said Dr. Monica Gandhi, a UCSF researcher and the medical director of the HIV Clinic, Ward 86, at SFGH.
Havlir “immediately figured out where the fault lines in vulnerability lie in our society, and in our own particular city, in terms of who would be more likely to get covid. And she just immediately figured out how to do large-scale testing campaigns, reminiscent of what she’s done in Africa for HIV testing. She just never stops,” Gandhi said.
The study spurred Breed to fund Ronen’s Right to Recover legislation. In July and August, the city distributed $2 million to covid-positive residents with no safety net in checks that equaled two weeks of minimum wage work. Instead of heading out of the house sick, 1,279 San Franciscans could isolate thanks to the $1,285 checks.
Havlir’s study ought to have been a call to action, but it wasn’t. The vast majority of the Department of Public Health’s testing remained outside of the affected populations. Moreover, DPH offered no support to the Latino Task Force to create wellness teams to follow up on covid-positive residents – despite urging by Havlir and other UCSF researchers in calls and meetings with the city.
It wasn’t until early July — two crucial months in which Latinx residents were nine and ten times more likely than everyone else to test positive — that the Department of Public Health allowed the Latino Task Force to open a testing site at its resource Hub on Alabama Street. And, for the first three weeks, there were battles on how many tests they would be allotted.
The city’s summer surge, in fact, was not so much a citywide phenomenon as one primarily afflicting the Latinx community.
Despite Havlir’s data showing the need to do more, relatively little testing was carried out in the Latinx and southeastern neighborhoods.
By mid-August, the city had tested nearly half a million people and only 9 percent were Latinx. In the month of September the city tested 128,145 residents and of the 93,629 who reported ethnicity, 13 percent were Latinx. In that month, Latinx residents had a positivity rate of 7 percent, compared to 1.09 percent for all others. Experts were baffled as to why the city wasn’t doing more testing among Latinos.
Nevertheless, Havlir continued to do what she could do – test and understand better how to reach those who needed testing.
Havlir’s earlier work in East Africa had taught her to meet people where they are. She tested African fishermen at night because they fished during the day. Dr. Carina Marquez, who has worked closely with Havlir at SFGH for years and has been on the ground in the studies in the Mission, where she also lives, had watched Havlir’s work in Uganda. “There were no guidelines” on how to bring in the community, Marquez said, but Havlir just carefully built bridges to locals – listening, hearing, and taking their counsel seriously. Her experience in Africa was a template that she’s followed closer to home.
Workers in the Mission, Havlir reasoned, might be reached more easily at BART stations. Tulier-Laiwa called the BART testing at 24th Street “brilliant” and credits Havlir with the idea.
Once again, the Latino Task Force called on its formidable cadre of volunteers. And again, Havlir enlisted her family. Jackie was on-site, and so was her eldest daughter, Becky, a doctor who had recently returned home to do a fellowship at UCSF.
Testing began in late July and ran on Wednesdays and Fridays for three weeks. Working-class Latinxs lined up. Tests ran out daily.
When the results came back, Havlir was not happy. At 11 percent, the positivity rates were higher than ever – higher than the collaboration had discovered four months earlier, in the April study.
“That’s just shocking,” Havlir said at the time, in a tone that was not angry but even-keeled, as someone with evidence that spoke for itself. “And that is completely unacceptable because we knew back in April which populations were being affected.”
But even in August, those were not the populations being tested aggressively. Instead, some 1,500 tests a day were being done at the Embarcadero, where the positivity rate was 1 percent. At most, 350 tests a week were being done in the Mission where the positivity rates were as high as 10 times that.
When I asked Havlir in early October why the city had been slow to respond to the disparities in testing resources she said evenly, “I think that’s a question for the city.”
“We have generated the data, worked with our community partners to show what the situation is,” she said. “And I guess it’s hard for me when people ask me about the city. I really want to help the city in any way I can, okay?”
Later she added some thoughts on how she works. “It’s really important to say, what do we know right now? What don’t we know –and be very open about both … that’s a research mind or just common sense.”
Early in life, the young Havlir showed a willingness to part from tradition. The suburban Chicago household in which she was raised included three siblings, a stay-at-home mother and a father who worked as a civil engineer. It was, she said, “very, very traditional” and quite unlike the one she would create.
At St. Olaf’s College in Northern Minnesota, Havlir flirted with a career in environmental law but then turned to medicine and landed at the Duke School of Medicine. It is there that she first read the CDC report on gay men dying from a little-known disease. What impressed her looking back, she told students on a return trip to St. Olaf 32 years later, was not simply the appearance of a new infectious disease, but the doctor who had looked at those patients differently and recognized a pattern. “The great discoveries in science, she told them, seem to start with someone looking closely and asking, “Why is this different?”
With that morbidity report in hand, Havlir called the CDC in Atlanta to ask for a summer internship and ended up spending the summer there taking calls from New York, San Francisco and elsewhere about outbreaks of the new infectious disease. Later, as a young resident at UCSF, she met a multitude of very sick young men.
She also met fellow resident and future partner Arturo Martinez, whose background could not be more unlike her own. Martinez, now a doctor at Kaiser where he set up its first kidney transplant department in San Francisco, grew up the youngest of 10 children in a household in east Los Angeles and one – a past Martinez and Havlir recognize in supporting scholarships for students from East Los Angeles and Africa. The couple have four children, all professionals in medicine, law, finance and computers. Nowadays three of her children live in the Bay Area and, Havlir said, to really relax, she spends time with her family.
For years, HIV/AIDS – its treatment and prevention – was Havlir’s consuming passion and when she has had the opportunity to allow research to shape policy, she hasn’t hesitated, colleagues said. Until a decade ago, San Francisco offered HIV patients treatment only when the virus appeared ready to explode into full-blown AIDS. But research by Havlir and others showed that, during the long-dormant period between the initial symptoms of HIV and AIDS, the disease that would kill them, the virus continued to damage patients’ organs and their viral load remained high enough to infect others.
As the chief of the HIV Division at SFGH, Havlir in 2010 decided to reverse years of making HIV treatment available only to patients with significantly compromised immune systems. Instead, she decided, the hospital should offer HIV medicine to anyone infected with the virus.
By 2012, the medical world recognized that patients who are successfully treated for HIV cannot transmit the infection to others. To Havlir, this meant that treatment should be offered on the same day patients learned they were infected.
“No one thought it was necessary, everyone was against it,” said Jones, who in 2014 was a veteran HIV nurse. “Even I was against it.”
At the time, it was customary to delay treatment, recalled Dr. Paul Volberding, the director of UCSF’s AIDS Research Institute and a prominent AIDS researcher. But, he recalls, Havlir said,“Let’s not just follow that dogma, let’s challenge that and show that [same-day treatment] does work.”
Today, immediate treatment is the global standard for HIV infections.
Despite months of data showing the high prevalence in the Latinx community, San Francisco public health officials had failed to make any dramatic course corrections on how to direct testing resources. Nevertheless, Havlir’s persistence appears to be paying off. Indeed, in the last month, the city has begun to revise its approach, taking many of its ideas from the UCSF/Latino Task Force studies.
For his part, Dr. Grant Colfax, the Director of Public Health, has no clear explanation of why the city did not move faster to redirect its testing resources. In an interview in early October, he pointed out that what DPH has done worked to reduce the city’s overall positivity rate and its case numbers. In that, he is right. And if San Francisco has no winter surge, the failure to reach the Latinx community faster will hardly blemish his record.
But Colfax has also started to reposition his testing resources to make sure the city is prepared for a surge. “We do need to ensure that we provide more permanent testing in communities where prevalence is higher,” he said. To that end, the city is closing the fixed SoMa testing site and moving 500 tests a day to the Alemany Market by mid-November, a site on the Excelsior/Bernal border that is closer to the impacted communities. It will operate five days a week. Colfax is also considering the efficacy of transit hub testing.
In late September, the mayor also announced $28.5 million more in spending for the Latinx community. DPH has asked for proposals from community-based groups, such as the Latino Task Force, to hire local contract tracers and create wellness teams in the affected communities — a model created by UCSF and the Latino Task Force. When that money will be meted out remains unclear. The groups are still waiting.
For their part, Havlir and the Latino Task Force aren’t taking it easy. They continue to collect data and mine it for more clues on how to improve treatment. Havlir recently announced the results of a September testing study at the 16th Street BART station where her goal was to reduce the time between a test result and isolation for positive cases. Much like offering treatment on the day of an HIV-positive diagnosis, Havlir wants to prevent Covid transmission by shortening the time between infection and quarantine.
As she did with HIV, Havlir homes in on the elements of an infectious disease that public policy can impact, always with the aim of reducing transmission. From the 24th Street study in late July and early August, she knew that the Right to Recover checks came too late – if they came at all – to give Covid-positive residents immediate confidence that they could afford to isolate. Although the Right to Recover money ran out in August, in September husband-and-wife philanthropists Michael Moritz and writer Harriet Heyman stepped in with another $2 million donation.
In the month before the 16th Street study, retired HIV nurse Jones and others on the Latino Task Force “were all in on” pressing the city to streamline the process for distributing the Right to Recover checks, according to Tulier-Laiwa. That worked. Covid-positive residents at 16th Street got their checks in 11 days, down from four to six weeks – a major victory, but not good enough. Ideally, checks would arrive the next day.
For the 16th Street testing, DeRisi at the Biohub shortened the turnaround time for getting results, which allowed researchers to increase the time of effective isolation. In the best of all worlds, quarantine would last seven-to-nine days, when a person’s viral load is highest. During the 24th Street study, researchers managed three days of effective isolation. At 16th Street, that increased to five days.
Still not good enough for Havlir. But she is encouraged by the accuracy of a rapid test she introduced at 16th Street — one that can be ready in 15 minutes.
“We need some more experience [with the fast test] because we don’t want to give people inaccurate results,” said Havlir. “But I think this is promising in terms of us even going further, which is finding people as soon as they’re infected and getting them into effective isolation.”
So is the city yet offering enough testing?
Not yet, she said, envisioning low-barrier testing seven days a week in the most severely affected communities.
True, San Francisco is enjoying a low case rate and re-opening continues. But Latinx positivity rates – at 3.1 percent so far this month – remain higher than the rest of the city’s population – now .55 percent.
“We still have an ongoing transmission in the Latinx community,” Havlir wrote in an Oct. 20 email, and as long as there are cases, the “embers are there for another surge” which we want to prevent.
She remains on guard. “The virus will surge if we let it.”
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