Not Getting to Zero HIV Among Men Who Have Sex with Men in San Francisco Despite High Care Continuum and Prevention Targets.

New HIV diagnoses among men who have sex with men (MSM) in San Francisco decreased by 77% from 2012 to 2021, presenting an encouraging trajectory toward zero infections by 2030. Unfortunately, the trajectory has slowed in recent years, with an uptick in new diagnoses from 2021 to 2022. We assessed the current HIV epidemic status and progress towards achieving the 95-95-95 HIV care continuum and prevention targets among MSM in San Francisco. Time-location sampling was used to sample MSM, recruiting at physical and online venues at randomly chosen venue-day-time periods from June to November 2023. HIV status was obtained by rapid testing; HIV care and prevention engagement were self-reported. Among 545 MSM, HIV prevalence was 24.4%. Prevalence was highest (48.8%) among Black/African American MSM. Of 132 living with HIV, 97.7% were aware of their status, of whom 97.7% were on antiretroviral therapy (ART), of whom 90.5% reported being virally suppressed. Among MSM not living with HIV, 80.0% had an HIV test, 56.5% used pre-exposure prophylaxis (PrEP), 27.9% consistently used condoms, and 9.2% used post-exposure prophylaxis (PEP) in the past 12 months. MSM in San Francisco in 2023 exceeded the first (status awareness) and second (ART use) pillars of the shared global 95-95-95 targets, and was greater than 90% for the third (viral suppression). Our current prevention tools are reaching diminishing returns. New medical interventions may also have a marginal impact unless we first address social and structural barriers that continue to result in HIV disparities and PrEP inequities.