Public Health Response

Mayor Breed confronted two major public health crises during her time in office — the COVID-19 pandemic and the rapid spread of fentanyl and the resulting spike in overdoses. The fentanyl epidemic that ripped through the country hit San Francisco particularly hard during COVID as critical lifelines and support went away and people were isolated. While overdoses increased in 2018 and 2019, they exploded in 2020.

The City’s public health response had to meet both the pandemic and the overdose crisis at the same time, which took an unprecedented focus. Many of the tools the City now relies on to meet the fentanyl crisis were already in place prior to 2020, resulting from early work in the Breed Administration to confront the use of methamphetamines. This includes the launch of the Street Crisis Response Team, a rapid expansion of mental health and treatment beds, and reforms to state conservatorship laws to better compel people into treatment.

San Francisco added over 400 new treatment beds under Mayor Breed’s direction, including investing in new abstinence-based and recovery programs. The City launched innovative programs like pharmacy on demand, bringing people prescriptions medication on the streets and in their homes. And Mayor Breed led one of the most significant changes to state mental health laws in decades by pushing year after year for conservatorship reform. Despite numerous setbacks, this work ultimately proved successful and under Mayor Breed San Francisco became the first county in the nation to implement these conservatorship laws which helped increase the number of people entering into conservatorship in San Francisco by 30% just in the first year.

These efforts began to yield progress after many hard years with more people accessing treatment and overdose rates declining in 2024 back below 2020 levels. But much work remains to be done to expand access to treatment, including adding more treatment beds with new state funding under SB 1. To ensure the City was ready, Mayor Breed directed Departments to coordinate and prepare applications when those funds became available, which the City has done.

San Francisco also navigated other public health challenges, including the rise of Mpox and the continued fight against HIV. Thanks to the lessons learned during the HIV crisis and COVID, the City rapidly responded to Mpox to ensure the community was informed, connected to vaccines, and aware of any spread of the disease, which limited its impacts. The City also continued to make progress fighting HIV through its Getting to Zero efforts, bringing new HIV infections down under 200 annually for the first time since the virus first emerged.

Under Mayor’s leadership, the City demonstrated what a diverse and aggressive response to public health looks like even in the face of some of the most daunting challenges San Francisco has ever seen. She also led major efforts to save Laguna Honda Hospital and to invest in public health infrastructure at the ballot through bonds. Hundreds of millions of dollars went into infrastructure, ensuring that the long-term health of the City, whether in hospitals or community clinics, was secure. San Francisco, despite the twin crises it faced, will be a healthier and stronger city in the long-term.

Fentanyl and Overdose Crisis Response

Mayor Breed led the significant expansions of treatment facilities and programs, as well as bold changes to local and state laws to give the city more tools to compel people into treatment. These were multi-year efforts that have been designed during a rising crisis to meet the severe challenge brought on by the rise of fentanyl.

San Francisco saw record overdoses in 2023. But with the launch and execution of the City’s strategy to combat fentanyl and bring down overdose deaths, 2024 saw a significant decline of over 20%. By the end of 2024, the City’s overdose rate was back below 2020 levels when the crisis first spiked. With new programs coming online in 2025, including Prop F and the deployment of new treatment bed funding from the state, San Francisco is poised to continue this progress in its fight against fentanyl.

Treatment Bed Expansion

Since 2020, San Francisco has added over 400 treatment beds to its existing capacity, an expansion of more than 20% to total about 2,600 overnight treatment spaces or beds. This impact has helped the City bring more people into treatment and care than ever before. In the fiscal year 2023–2024, 6,000 patients were cared for in behavioral health beds.

These beds cover a range of intervention levels, from immediate crisis care to long-term recovery beds. The list of bed needs were based on data-driven analysis, including the 2020 DPH Behavioral Bed Optimization Report called for by Mayor Breed to better understand the system’s needs. A full list of residential care and treatment beds is available on this page.

Office of Coordinated Care & Street Team Expansion

The SFDPH Office of Coordinated Care works to help priority populations, including people experiencing homelessness, people exiting hospital care, and justice-involved individuals, get in and stay in care. The department has street care teams in the community every day and night to invite people experiencing homelessness into mental health and substance use treatment.

• In fiscal year 2023–2024, approximately 25,000 people received behavioral health care in SFDPH primary health clinics and more than 4,600 people received substance use treatment and care through a specialty clinic. 15,500 patients, including 4,500 people experiencing homelessness, received specialized outpatient treatment.
• The City expanded evening and weekend hours at the Behavioral Health Access Center, the BHS Pharmacy and at clinics providing buprenorphine and methadone treatment to people addicted to fentanyl and other types of opioids. The BHS Pharmacy also delivers buprenorphine in permanent supportive housing facilities and helps people start and manage the medication.
• The City expanded the Street Medicine program to serve every neighborhood in San Francisco from 8 a.m. — 7 p.m. Monday through Friday.

A critical piece of Mayor Breed’s agenda was meeting people on the streets where they are with treatment and medical services. The overhaul and expansion of the City’s street outreach teams started in 2020 with the launch of the Street Crisis Response Team, and continued with the creation of new teams.

• The Street Crisis Response Team takes all behavioral health 911 calls. This team provides a more effective response to people in crisis and frees up police officers to focus on public safety and criminal issues. Data available on this page.
• The Street Overdose Team responds to people immediately after an overdose, and again within 72-hours, to connect people to care and treatment.
• The Post Overdose Engagement Team (POET) connects people who have experienced an overdose to substance use treatment.
• The Night Navigation Team provides people using fentanyl outdoors at night with immediate telehealth visits with a physician who can prescribe them with buprenorphine or refer them to a methadone program on the spot.
• From March through November 24th 2024 , the team encountered 2,269 people of which 912 or 40% started outpatient or residential medication.
• BEST (Bridge and Engagement Services Neighborhoods Team is a neighborhood-based group of behavioral health clinicians and peer specialists that focus on the most disruptive individuals living on our streets, with some of the toughest challenges.
• In just the first year, BEST has made more than 1,100 direct connections to services for their clients, helping hundreds access mental health services, substance use treatment, medical care, and shelter.

These teams helped deliver critical health results, including:

• In 2023, approximately 5,000 people received medication treatment for opioid addiction, either buprenorphine or methadone.
• Directly and through community partners, SFDPH distributes naloxone, medication that reverses an opioid overdose, and trains people on how to recognize an overdose and save a life. SFPDH distributed approximately 158,000 naloxone kits in fiscal year 2023–2024.

Recovery-based Treatment

Mayor Breed increased investment and support for people in recovery whose goal is to maintain abstinence from substance use. These services include transitional “step-down” housing services for people who have completed residential treatment and live in a supportive environment while attending outpatient treatment and transitional housing and wrap-around clinical support for people who are justice-involved with substance use and/or mental health diagnoses. The City also offers transitional housing and long-term housing through other departments, such as the Department of Homelessness and Supportive Housing (HSH) and Adult Probation, which are services that are not reflected in the SFDPH budget.

During Mayor Breed’s tenure, she added more than programs dedicated to recovery through abstinence, which total more than $22 million annually. These projects include:

• Minna Project (South of Market): The 75-bed facility provides wraparound services designed to aid the transition to independent living after involvement with the justice system.
• Salvation Army Harbor Lights (South of Market): The program provides care for people who are suffering from drug addiction and alcoholism. It is a six month — two-year long term residential treatment abstinence based program.
• Transitional “step-down” housing (Treasure Island): Transitional housing for individuals that have completed a minimum of 30 days residential substance use disorder treatment. Residential step-down programs are sub-acute, short-term residential facilities that provide coaching and support in a 24-hour staffed, open home-like environment. RSD provides a temporary drug and alcohol-free environment to residents that are actively engaged in outpatient services for medically necessary SUD treatment provided to the client off-site.
• Women’s Treatment Recovery Prevention Program (WTRP) (South of Market), is an expansion of the Healthy Evolving Radiant (H.E.R.) House, a women’s gender responsive alternative sentencing transitional housing program, and is designed as an expansion due to high demand and successful outcomes.
• TRP Academy (Tenderloin): The pilot program serves as an alternative sentencing strategy for justice-involved males seeking a highly structured environment that includes substance use counseling, career and leadership development, and transitional housing for 86 formerly incarcerated individuals.
• Billie Holiday Center (South of Market): This transitional housing site offers expanded opportunities for justice-involved adults through the launch of a 30-bed center.

Major Law Changes

One of Mayor Breed’s legacies is pushing for substantial change to mental health and treatment laws. She worked locally and with state legislators to make significant changes to laws with a goal of increasing access to treatment and removing barriers from compelling those most in need into care.

Conservatorship Reform and Implementation

When Mayor Breed took office, one of her top priorities was delivering changes to state mental health laws to strengthen conservatorship laws. She partnered with State Senator Scott Wiener and State Senator Susan Talamantes Eggman to push these laws, overcoming years of obstruction to successfully pass Senate Bill 43.

• SB 43 modernized the definition of “gravely disabled” and expanded the qualifying conditions for conservatorship from either a mental health disorder or chronic alcoholism, to add substance use disorder as a stand-alone basis.
• Immediately after SB 43 was signed into law by Governor Newsom in October 2023, Mayor Breed issued an Executive Directive to City Departments to ensure that San Francisco was ready to implement this new policy on day one.
• San Francisco became the first county in California to implement Senate Bill 43 on the day the bill took effect.

The most immediate impact felt by SB 43 was a 30% increase in temporary 30 day conservatorships granted in 2024, a major step in getting people connected to treatment while under involuntary holds. Mayor Breed continued to push for further strengthening mental health laws at the state level to further improve the ability to help people.

Proposition F: Treatment Pathway Initiative

Mayor Breed placed Prop F on the ballot in March 2024 to allow the City to require single adults with substance use disorder to participate in some form of treatment in order to continue receiving cash assistance. The law went into effect in January 2025, when it was launched by Mayor Breed and the Human Services Agency as the Treatment Pathway Initiative.

The Treatment Pathway Initiative requires people with a substance use disorder who want to access county-funded cash assistance to participate in some form of treatment to maintain their CAAP benefits. Individuals who refuse to engage in treatment will be discontinued from receiving county-funded cash assistance.

State Funding for Treatment Beds

Mayor Breed supported Proposition 1 on the March 2024 ballot, which is a $6.8 billion state-wide bond measure that will help fund the expansion and modernization of the State’s mental health system and provide housing for those on our streets. Most critically, during the legislative process for the measure, Mayor Breed pushed for locked facilities to be added in as an eligible use. Without that inclusion, the City and the State would have lost the opportunity to fund critical treatment for some of the sickest people in the state.

Upon the passage of Prop 1, Mayor Breed immediately issued an Executive Directive to City Departments to prepare for the implementation of SB 1 so the city was first in line when funding became available. The City met this goal by submitting funds by December 2024, including a proposal to double the city’s locked bed facilities.

CARE Court Implementation

On October 1st, 2023 San Francisco added CARE Court to its voluntary treatment options, which is a state-mandated court process designed to get people with mental health and substance abuse disorders the support and care they need. CARE Court is intended to support people who have been diagnosed with Schizophrenia and Other Psychotic Disorders. It is a voluntary process that is narrow in scope and is a less restrictive alternative to state hospitalization or LPS conservatorship. SFDPH has conducted more than 60 pre-filing consultations to government agencies and private individuals interested in making a filing.

SAN FRANCISCO AS A PUBLIC HEALTH LEADER

HIV Progress

Mayor Breed prioritized San Francisco’s continued leadership in our fight against HIV. This includes the implementation of initiatives as part of Getting to Zero, a consortium of over 300 individual community members, community-based organizations, educational institutions, industry partners, government agencies, and providers who work together to achieve the vision to make the City the first jurisdiction with zero new HIV infections, zero HIV stigma, and zero preventable deaths among people living with HIV.

Mayor Breed invested directly in HIV funding, including $3 million increased funding to support the City’s goal of achieving these goals by ensuring that all San Franciscans have equitable access to high-quality prevention, care, and treatment services.

The City continued its major progress in the fight against HIV:

• Since 2014, the number of new HIV diagnoses in San Francisco has declined by 59%, while nationally, new HIV diagnoses have only declined by 3% in the past decade.
• In 2023, there were 133 new HIV diagnoses, a 20% decrease from 2022 when 167 diagnoses were reported.
• In 2024, the City saw a steep 46% decline of HIV diagnoses among Latino individuals.

Mpox

In June 2022, SFDPH announced that the first probable case of Mpox had been identified in a San Francisco resident. In July 2022, the City became the first U.S. jurisdiction to announce a public health emergency for Mpox (formerly known as Monkeypox) in response to a global outbreak of the disease, which was disproportionately impacting men who have sex or close contact with men and other LGBTQ + individuals. San Francisco’s effective response drew from lessons learned from the COVID-19 pandemic and was a collective effort of teams from across SFDPH and community-based organizations. City leaders worked to ensure equitable distribution of the vaccines by working with organizations like the San Francisco AIDS Foundation and Rafiki Coalition. San Francisco has one of the highest rates of vaccination coverage in the United States. San Francisco City Clinic has been important to promote equity in vaccine access.

• Over 55,000 Mpox vaccines were administered between May 1, 2022 and June 30, 2023.
• 75% of all vaccines were administered in San Francisco.
• 38% of people vaccinated for Mpox at SFCC were Black or Latino, compared to 24% citywide.

Critical Public Health Infrastructure Investments

Mayor Breed authored and led two major successful bond efforts to strengthen the City’s public health infrastructure. These include funding to support major hospitals like SF General and Laguna Honda, as well as community clinics like the Chinatown Health Clinic and City Clinic.

• 2020: A $487.5 million bond to fund essential City infrastructure and support San Franciscan’s mental and physical health with new investments in parks, open spaces, behavioral health facilities, and housing and shelter for vulnerable individuals.
• 2024: $360 million bond to deliver key health infrastructure, expand family shelter, support street safety and road repaving, and improve public spaces in San Francisco.

Tenderloin Emergency Initiative

In December 2021, under Mayor Breed’s direction, the Department of Emergency Management (DEM) developed the Tenderloin Emergency Initiative (TEI), a multi-agency plan to improve crisis conditions in the area and tackle the drug overdose crisis. The mayor directed DEM to focus on the issues of drug dealing and violent crime, public substance abuse, safe passage and accessibility, neighborhood cleanliness, housing resources, emergency medical calls and illegal vending. As a result, the area saw:

• Increased law enforcement presence
• Expansion of community ambassadors programs to provide on-the-ground support throughout the neighborhood,
• The City conducted joint departmental operations to offer people services and move individuals living on the street into shelter
• Creation of the Tenderloin Community Action Plan, $4 million in funding for programs and services to improve public safety in public spaces, support youth and small businesses, and promote cultural events to benefit residents

Methamphetamine Task Force

Beginning in 2019, San Francisco experienced a significant rise in the number of individuals using methamphetamine, an increase that occurred alongside serious fentanyl concerns. Seeing the clear and urgent need for a focused effort to identify services, treatment, and prevention efforts to address the evolving trend, Mayor Breed and Supervisor Raphael Mandelman convened a Methamphetamine Task Force that included medical and public health professionals, researchers, substance use disorder treatment providers, emergency responders, criminal justice and law enforcement officials, drug policy experts, and current and/or former substance users.

The Task Force was charged with identifying harm reduction strategies to decrease and manage methamphetamine use, identify best practices for treatment and service options for current users, and develop policy recommendations to reduce the medical and social impacts of methamphetamine use on San Franciscans. Policies developed by the Task Force informed treatment and outreach models the City developed over the next five years.