Human/Animal Support Services: The Evolution of the San Francisco Model and Pet-Associated Zoonoses Education

, Aubrey H. Fine , Stephanie Venn-Watson , Laura Nelson , Andrea Brooks , John L. Lipp , C. Victor Spain § , Ilana Strubel , Belinda Wong , Dana O’Callaghan ∗∗ , Lori Popejoy ††

Pets Are Wonderful Support

California State Polytechnic University

National Marine Mammal Foundation

§Merck & Co., Inc.


University of California

∗∗National University and Palomar College

††University of Missouri

People come to visit, but they can only stay an hour and then they have to go; my cat, she’s always there.

Bob, pet owner with AIDS

Afraid of infection, I fear the birds (Tuberculosis), the cats (Toxoplasmosis), my dog, my horse (Mycobacterium avium), and people. For weeks, I was reluctant to leave the house. I didn’t ride my horse for several months. Walking in the park or at the beach was unpleasant because of the birds. My doctors gave contradictory advice—Dr. (A) said to get rid of all animals. Dr. (B) said it didn’t matter and enjoy what life I had left. My cousin asked if I couldn’t get a bubble like the bubble boy.

Stephen Yarnell, MD, When Doctors Get Sick, 1987

PAWS Keeps “Families” Together

Cecil, Charlie and Butter

Cecil Baker says he doesn’t know how he would take care of his “family”—his beloved feline companions, Charlie and Buttermilk Johnny—if he couldn’t rely on help from the volunteers and the vital services of San Francisco-based, non-profit, Pets are Wonderful Support (PAWS). PAWS was founded in 1986 by members of the San Francisco AIDS Foundation Food Bank—many living with AIDS themselves—who reached out to several food bank clients with HIV/AIDS who needed assistance caring for their companion animals.

Cecil, a diabetic who suffered a debilitating brain hemorrhage several years ago, has been a client of PAWS since 2005. His cats Charlie and Buttermilk Johnny (a.k.a. “Butter”) receive monthly home delivery of cat litter, food and other supplies from the PAWS food bank. As of 2009, PAWS was serving about 800 clients in the San Francisco Bay Area through its Companion Animal Support Services (CASS) program.

All PAWS clients, like Cecil, live on a fixed income. Many struggle with disabling illnesses, such as HIV/AIDS. Some are elderly and frail. And all need the extra support from PAWS to keep together the precious “family” they have made with their companion animals.

“Charlie and Butter are such good company—and they make me laugh. I really love them,” Cecil says with obvious pride. “But I don’t know what we would do without help from PAWS. The volunteers are so nice. They always make sure we are doing OK.”

Cecil adds that it puts his mind at ease knowing that if he needs to be hospitalized again, PAWS will be there to care for Charlie and “Butter.” When a PAWS client must stay in the hospital for an extended period, the organization works to find a temporary foster home for the client’s pet through the PAWS Foster Care Program. If no foster home is available, PAWS goes the distance to make other arrangements—even providing in-home care, if needed—until a foster home is found or until the pet can be reunited with its owner.

“It’s just so comforting to know there is an organization that understands how important pets are to people like me,” says Cecil. “Charlie and Butter are here to see me through both good times and tough times, and it’s important to me that I keep them happy and healthy, too.”

17.1 Introduction

People who suffer from chronic or terminal illness—and particularly those who also live at the poverty level—find their physical condition influences their quality of life and has a tremendous impact on their ability to accomplish everyday activities. For some, the physical and often psychological barriers manifested by their medical condition leads to a decrease, or even an end, to social opportunities and relationships previously enjoyed.

However, for many people facing these challenges, their relationships with their pets—their “companion animals”—offer a source of unconditional love and acceptance. These relationships also provide the opportunity for increased socialization, brought about by the need to take care of another living creature.

Human/animal support services (HASS) evolved during the AIDS pandemic to help keep people with disabling illness together with their animal companions for as long as possible in a mutually beneficial relationship (see Table 17.1). HASS provides


Figure 17.1 PAWS client Cecil Baker with Charlie and Butter.

Photo credit: Michael Tedesco

financial, emotional, practical and educational assistance to the disabled and vulnerable pet owner.

Table 17.1 Definitions of human/animal interactions (HAI) services

  1. Human/animal support services (HASS) are programs that help keep a person with a chronic/terminal illness or disability together for as long as possible with their current animal companions in a mutually beneficial relationship. HASS services include financial, emotional, educational and practical assistance to the disabled pet owner. These programs can be independent, volunteer-run, non-profit organizations. They also can be programs under the umbrella of other organizations such as humane associations or societies, veterinary hospitals, schools or associations, AIDS organizations or other similar human or animal community service organizations.

  2. Animal-assisted activities (AAA) are goal-directed activities designed to improve the patients’ quality of life through the utilization of the human/animal bond. Animals and their handlers must be screened and trained, but are not guided by a credentialed therapist.

  3. Animal-assisted therapy (AAT) utilizes the human/animal bond in goal-directed interventions as an integral part of the treatment process. Working animals and their handlers must be screened, trained, and meet specific criteria. A credentialed therapist working within the scope of practice of his/her profession sets therapeutic goals, guides the interaction between patient and animal, measures progress towards meeting therapy goals, and evaluates the process.

  4. Hospital personal pet visitation (HPPV) provides patients who are critically ill (and sometimes unlikely to leave the hospital) the opportunity to visit with their own pets in their hospital room. All patients, excluding those in bone marrow units, are eligible for visits facilitated by trained volunteers as long as the animal companion passes a special screening process.

  5. Companion Animal Support Services (CASS) are the services provided by HASS organizations. These include dog walking, pet care, food bank and delivery, veterinary care, in-home services, case management, behavioral assistance, pet-associated zoonoses education, client advocacy, emotional support and other services that help support the human/companion animal bond.

The previous chapter uses an ecosystem model to explain how support systems and animals may contribute to an increased quality of home life for those who struggle with chronic disease, but are able to live at home or in transitional housing (see Table 17.4 Bronfenbrenner’s definitions). (Note: Traditional animal-assisted therapy (AAT) programs and the benefits of animals in hospital-based programs are discussed elsewhere in this book.)

This chapter examines the history and intersection of the AIDS pandemic, the human/animal bond movement, public health education and veterinary medicine. There is a particular focus on the AIDS pandemic, as it helped to spawn the field known today as human/animal support services and pet-associated zoonoses education. Zoonoses (pronounced ZO-uh-NO-seez) are diseases that humans can catch from other animals. This background information will be followed by evidence of how animals can enhance the quality of life for people living with illness and disability.

The second part of this chapter will be practice oriented, focusing on the development of two successful San Francisco HASS organizations: Pets Are Wonderful Support (PAWS—, founded in 1986, and SFCCC VET SOS (, founded in 2001. Also discussed is how other communities may benefit from these types of services and how to develop and implement similar programs and services in their own community. The goal of both animal-assisted therapy and HASS is to work in parallel, encouraging positive emotional and physical health benefits from human/animal interaction (see Table 17.1).

The AIDS pandemic brought about a movement of volunteer-based social services for both people and animals. Many people living with AIDS are also pet guardians, who, as their disease may progress, eventually may require help caring for their animals. Traditionally, social services supported the financial, physical, and emotional assistance these populations required. Over time in the early AIDS pandemic, the social services field evolved to include human/animal support services (HASS) designed specifically to help keep the vulnerable person and his or her animal companion(s) together for as long as feasibly possible in a mutually beneficial relationship or “family.”

The San Francisco community, a leader in fighting the AIDS pandemic, also offers unique insights into the evolution and development of HASS organizations and programs such as PAWS and VET SOS. This has become known as the San Francisco model.

Additionally, the AIDS pandemic has provided opportunities for veterinarians, veterinary students and veterinary technicians to volunteer, participate, and make important strides in improving and enhancing benefits of animal companionship. In San Francisco, four veterinarians served as board presidents of PAWS, and many more have participated as board members, practitioners and volunteers. To date, 17 veterinary students have participated in the PAWS veterinary externship program. VET SOS also has a very active local volunteer veterinary program. By promoting pet-associated zoonoses education and the benefits of animal companionship, veterinarians continue to play a major role in public health and as members of the health care team. Current information and support is now easily available to the public and medical community on numerous websites (see Table 17.9). The medical and veterinary professions have recently started to collaborate together by forming the One Health Initiative (

Early in the pandemic, many physicians recommended that their patients with AIDS get rid of their pets to avoid the risks of zoonoses. Veterinarians, understanding the importance of animal companionship and how to minimize the risk of zoonotic disease, took the lead to dispel these myths through outreach and education. Today, the American Veterinary Medical Association, the Centers for Disease Control, the Delta Society, Pets Are Wonderful Support and many other associations and organizations all continue to play a role in promoting the understanding of the human/animal bond and pet-associated zoonoses education.

17.2 AIDS: an overview

Acquired immunodeficiency syndrome (AIDS) is one of the more serious and complex health problems humanity has faced in recent history. AIDS is caused by the human immunodeficiency virus (HIV), which attacks the immune system and can reduce an infected person’s ability to resist other infections and diseases. An estimated one million US citizens are infected with HIV, with as many as 56,000 new infections each year in the USA (Campsmith et al., 2008).

Although the epidemic has appeared to slow somewhat in the developed world, AIDS has reached pandemic levels in developing countries such as India and South Africa (United Nations AIDS/WHO, 2004). Worldwide, there were 2.5 million new infections in 2007 alone (see Table 17.2). Ninety-five percent of all HIV-infected people live in developing countries (UNAIDS/WHO, 1998). AIDS has killed at least 26 million people, orphaned more than 12 million children, and currently infects over 33 million people worldwide (UNAIDS/WHO, 2007).

Table 17.2 Global summary of AIDS pandemic

People living with HIV in 2007 33,000,000
North America 1,200,000
Sub-Saharan Africa 22,000,000
Western and Central Europe 700,000
People newly infected with HIV in 2007 2,500,000
AIDS deaths in 2007 2,100,000

From UNAIDS/WHO 2007 report on the global AIDS epidemic, United Nations Program on HIV/AIDS (

HIV is transmitted in various ways: sexually, through contact with infected body fluids; from mother to child during pregnancy or breast-feeding; through the sharing or medical use of infected needles; or through blood transfusions. The progression from HIV to AIDS is usually a slow process. It may be 10 years or longer from the time of initial infection with HIV until symptoms of AIDS appear. Before the availability of effective treatments, a person with an AIDS diagnosis had an 8–10-month life expectancy. Once immunosuppression has occurred, people with AIDS (PWAs) become susceptible to “opportunistic” infections, cancers and metabolic illness. These opportunistic infections typically cause minimal disease in healthy persons but can lead to death in PWAs.

As more effective and less toxic treatments become available, AIDS is becoming more of a chronic condition. Many individuals who start appropriate therapy early are now able to have productive and healthier lives. However, many of the therapies used to treat AIDS are still relatively new and have unknown toxicities when used over a person’s lifetime. Already, serious complications such as liver and kidney failure, heart disease and bone disease are on the increase in individuals using the AIDS treatments for long periods. In addition, these therapies are expensive and not generally available to populations in the developing world or to the uninsured or underinsured in the developed world. This obstacle has led to the evolution of two distinct epidemics, with 95% living in the developing world.

17.3 The psycho-social impact of illness: the AIDS virus

In 1986, when PAWS started providing its services in San Francisco, people living with AIDS/HIV were often isolated and typically suffered quick physical health declines. The psychological burden produced by AIDS and HIV infection exceeded that produced by any other medical condition at that time (Maj, 1991). PWAs are faced with the disease process as well as the psychological ramifications of this serious illness. Primary to these obstacles are HIV’s incurability and the associated public hysteria and misunderstanding (Cherry and Smith, 1993). There is a wealth of information that suggests PWAs have been targets of stigmatization (Bennett, 1990). Individuals with AIDS often describe feelings of isolation, alienation and estrangement and loneliness (Carmack, 1991).

Two specific categories of loneliness have been described: emotional isolation and social isolation (Weiss, 1973). Emotional isolation appears to develop as a direct result of absence of an attachment figure, such as a partner or close friend. Social isolation, on the other hand, occurs when an individual lacks (or perceives a lack of) an effective social network. Research reported by Christ et al. (1986) suggests PWAs may be especially susceptible to the experience of loneliness. They reported that 75% of patients with AIDS have diminished social support from friends, family and significant others.

17.4 The role of pets

Pets are a large and integral part of American culture. The US Humane Society indicates that more than half of US households have pets (HSUS, 2003). Pets are more common in households with children, yet there are more pets than children in US households (HSUS, 2005). An estimated 45% of Americans infected with HIV own pets (Spencer, 1992) and many other PWAs have contact with animals through traditional AAT programs while hospitalized or in a hospice. It is in these situations, such as living with AIDS or another chronic illness or disability, that the importance of finding meaning and joy in life through the positive interactions with pets may be particularly beneficial.

It is not uncommon for a child or an adult to perceive an animal as a peer or family member (Nebbe, 1991). Pets provide a valuable source of comfort and companionship for many individuals, including children (Wilson, 1991). According to Veevers (1985), animals may act as surrogates when they take the place of people. He suggests that “almost all interaction with companion animals involves some anthropomorphism and can in some way be construed as a surrogate for human relationships.” Serpell (1983) further suggests that animals can supply compassion in cases where humans are unable or unavailable to do so.

People with AIDS may perceive a companion animal to be a family member as well as a direct source of emotional support. (see Table 17.3). This is particularly important for someone who may feel isolated and perhaps neglected. In an article on companion animals for PWAs, Carmack (1991) notes that animal companions decrease feelings of isolation and provide a perceived reduction of stress. She also reports findings that suggest PWAs perceive that their companion animals help to reduce their stress levels. In turn, stress reduction can improve immune system function. Because animals require attention, affection and companionship, they can enhance feelings of being needed and valued—“I care for them, and that lets me forget about things.”

Table 17.3 Benefits animal companions can provide to people with chronic illnesses

Provide companionship
Decrease feelings of loneliness
Act as a surrogate for other relationships
Decrease stress
Provide a reason to exercise
Give the human caregiver a sense of purpose
Ease social interactions in public
Provide a sense of security to children and adults
Provide health benefits

Castelli et al. (2001) found that pet cats, but not dogs, offered comfort and companionship to people with AIDS, and enhanced their relationships with family and friends. They also found that people with advanced AIDS sometimes found the activity level of a companion dog to be stressful. In contrast, a calm cat was comforting as their lives became more isolated. Similarly, Siegel et al. (1999) found that men with AIDS who had close attachments with their pets were significantly less likely to suffer from depression than those men with AIDS who did not have pets as companions.

Chinner and Dalziel (1991) found that a resident poodle in a hospice setting facilitated interactions between people and improved both staff and patient morale. However, attachment to the pet does seem to make a difference as to how much of an effect the animal has on the person. Those who were isolated or lonely did not develop affection for the poodle. Early work by Rynearson (as cited in Cookman, 1996) supports the importance of attachment and notes that the reciprocal nature of the relationship between pet and owner is crucially important. It is wise to keep in mind, however, that not all people desire to develop an attachment to an animal.

Alternatively, Volth (1985) indicates that there may be a biological predisposition for humans to develop a strong attachment bond to animals. It is not uncommon to see many companion animals that may, for example, sleep in their owners’ rooms and accompany their owners on short trips and holidays. Many companion animals are recipients of special treats and gifts, just like other family members. Volth’s research points out that both dog and cat owners can become equally attached to their animals. Jorgenson (1997) observes that pets are a constantly available source of direction of attention and affection.

Cohen (2002), in a recent study about pets functioning as family members, found that pets do function within the family circle and give back as much as they receive from their owners. Within the animal/human relationship, there is an unambivalent exchange between pet and owner that may not exist in other relationships. Pets may allow people to express deep feelings and offer them a way to nurture another living being (Cohen, 2002).

According to Siegel (1993), companion animals within the home appear to acquire the ability to bring forth positive emotional responses from their owners. Positive responses are initially elicited from the good feelings derived from tactile and emotional contact with the animal. This continued pairing usually leads the owner to view the animal as a source of comfort.

Interestingly, a social worker in England pointed out that companion animals appear to demonstrate some of the same attributes seen as being favorable qualities in social workers (Hutton, 1982). Companion animals, for example, tend to help people use their own strengths to help themselves. Animals tend to have the ability to form and establish relationships quickly; they also are sensitive to people’s feelings and emotions, and thus are able to recognize those occasions when they are needed or wanted.

Cusak (1988) suggests that animals can function as human surrogates in a number of roles, including friends and confidants. Persons secluded within their homes may find the companionship of animals more meaningful. They can act as true friends, not only to pass time with, but also to engage in authentic relationships. Pets can bring laughter and tenderness into a home. They also can offer comfort at times of overbearing loneliness.

A good illustration of how pets support patients resulted from a study by Muschel (1985), who looked at the effects of animals on enhancing the quality of life of patients with cancer. Animals visited 15 hospitalized patients. Twelve of the 15 patients seemed very concerned about the “visiting” animals’ welfare and would go out of their way to reassure the pets. They also seemed more content and outgoing in the presence of the animals and were observed to sing and play with them. Interestingly, Muschel also alluded to how the animals seemed to be valuable as companions while the patients were struggling with facing death: “The animal’s quiet, accepting and nurturing presence strengthens, and frees the patient to resolve his or her final experience successfully.” Much in the same way, having a companion animal in a patient’s home would seem to elicit the same responses.

Companion animals in the home may also improve physical health by increasing the amount of exercise in which chronically ill people may engage (Meer, 1984). Pet ownership also has been shown to improve cardiovascular health by reducing anxiety, loneliness and depression (Friedman et al., 1983; Katcher, 1981; Wilson, 1984). Animals can be used to support and enhance healthier living patterns on many levels. However, PAWS clients were found to experience significant financial stress regarding veterinary care. Still, despite the financial stress, they found their lives more socially satisfying than people with AIDS who did not have PAWS assistance or those who did not have pets (ISAZ Poster, 2008).

In addition to benefits for chronically or terminally ill people, studies have shown that seniors with pets tend to be healthier than those without. They handle stress better, and are less lonely and more physically active. A relationship with a pet is especially important to seniors who live on their own and are responsible for the day-to-day tasks associated with pet ownership such as walking a dog, feeding a cat or simply brushing a pet. These activities give lonely and isolated seniors a sense of purpose and seem to contribute to significantly lower blood pressure and heart rates. Interaction with a beloved pet also helps to ease seniors’ feelings of depression and isolation. Pets become important family members and, in some cases, can even lead seniors towards more social interactions with other humans—for example, through daily dog walking.

While the important role that companion and therapy animals can play for people with chronic illnesses should be recognized, these people may need assistance in caring for their animals from within Bronfenbrenner’s exosystem (see Table 17.4). In most cases, research has been conducted addressing the importance of human contemporaries and their relationships to enhance quality of life. Shea and Bauer (1991) point out that relatives, neighbors, friends, and community organizations may provide tremendous support to the individual.

Table 17.4 Bronfenbrenner’s definitions (see Chapter 16 for more details)

  • The individual:

    • Type of illness, coping strategies

  • Microsystem:

    • Inner-family relations, parents, partner, children, animal companion, home environment

  • Exosystem:

    • Outside the home, neighborhood, friends, family, community agencies

  • Macrosystem:

    • Society’s view on illness

An effective community can provide much-needed assistance and opportunities for an individual. There can be people outside one’s immediate family who make life more meaningful and easier. Friends and relatives may make it possible for some people to continue living on their own by providing intermittent help with cooking, shopping, cleaning and pet care. Isolation may be prevented or decreased as a consequence of this external support system. Programs such as PAWS (Pets are Wonderful Support, described later in this chapter) or friends within the community can be viable resources for helping an individual keep a pet companion at home.

Close relationships outside the home may provide ongoing support as well as a sense of stability in the lives of PWAs (Jue, 1994). Supportive relationships, with friends or visiting animals, can contribute to an individual’s quality of life. These connecting experiences indirectly and directly contribute to offsetting the effects of isolation and enhancing a sense of self-worth. These findings support the role of companion animals and visiting animal programs in decreasing a person’s sense of social isolation.

In addition to the many benefits that animal companionship has to offer humans, it also should be understood that there are some risks, such as zoonotic disease and potential injury. The best interests of a pet should always be considered as well, as it is sometimes necessary to recommend and assist the person give up their animal companion. Following is a review of the historical significance of zoonotic disease and people with AIDS and the important role that veterinarians play as a member of the public health care team. The evolution of PAWS is also examined and the many companion animal support services (CASS) showcased. Finally, VET SOS, another San Francisco HASS program that helps the growing human homeless population and their animal companions is reviewed.

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