San Diego's hepatitis A outbreak has sickened at least 561 people since it began one year ago, according to figures released this week. Public health officials are continuing a targeted vaccination campaign, which they credit with slowing the spread of the disease.
Critics have accused officials of being slow to respond to the outbreak because it disproportionately affected illicit drug users and homeless people. The accusations recall another epidemic that continues to this day: HIV and AIDS.
Historians largely agree that the federal government was slow to respond to the HIV outbreak because it affected two marginalized groups: gay men and intravenous drug users.
"Unfortunately, there are significant parallels," said Terry Cunningham, retired chief of the HIV, STD and Hepatitis Branch of the county's Health and Human Services Department. Both diseases are easily spread by behaviors people are uncomfortable talking about, he said.
In the case of HIV, it is unprotected sex. In the case of hepatitis A, it is the spread of fecal matter.
Cunningham said that public health workers and nonprofits have had difficulty reaching the most at-risk populations for hepatitis A — people living on the streets — and have had trouble convincing them to get vaccinated.
"You have all of this fear, this misconception, these ideas that are unfounded, really exacerbating the issues at hand," he said. "It's amazing to me that we still have so many people who are uneducated about their health, about basic health care precautions. And it holds true still with HIV and with the hepatitis A outbreak."
Deputy Public Health Officer Sayone Thihalolipavan said public health officials have also learned a lot of lessons about disease prevention from the past mistakes of the HIV response, including building trust with at-risk populations and meeting them where they are, rather than expecting them to seek out help.
"Because of these stigmatized populations that we're dealing with, it's even more important to not pass judgment," he said. "They're so used to being judged that when you approach them and you don't judge them, often they're very appreciative … and they're more likely to work with you, partner with you and seek your services."
The number of hepatitis A diagnoses in the past year is fairly close to the number of yearly new HIV diagnoses in San Diego County. Officials say there were 499 new HIV diagnoses here in 2016. The number has been hovering around 500 for the past six years, meaning a new HIV infection occurs on average about every 18 hours.
The medical tools for preventing Hepatitis A are more advanced than those for HIV. The hepatitis A vaccine, introduced in the mid 1990s, is highly effective at preventing infection. There is still no vaccine for HIV, though HIV-positive individuals can become non-infectious if they are treated with antiretroviral drugs.
There is also a drug, Truvada, that is highly effective at preventing infection in HIV-negative individuals — but it has to be taken daily. The county's plan to eliminate new HIV infections within the next decade, called "Getting to Zero," relies heavily on expanding the prophylactic use of that drug in high-risk populations.
Cunningham said a major challenge in meeting the goal of zero new HIV infections is a lack of resources.
"Prevention funding was cut horribly back during the economic downturn," he said. "The County Board of Supervisors wisely passed the "Getting to Zero" policy … but it's an unfunded policy. So we don't have any more funding to do any more than we did before that policy was initiated."