Chapters Transcript Video Blueprints for Success Training institute - Ending the HIV Epidemic Blueprints for Success Training Institute Ending the HIV Epidemic Originally Broadcast: November 19, 2020 | 12:45 pm – 3:00 pm ET Good morning. Good afternoon. I'd like to welcome everyone to our fourth blueprints for Success Training Institute. Today's program will look at efforts towards ending the HIV epidemic. The program will reflect on the progress that has been made and the challenges that still remain in terms of sustaining urgency towards ending the epidemic and addressing the health disparities that continue to impact communities impacted by HIV briefly. Here's the agenda for today's program. We'll have 20 minutes presentations and 2 30 minute workshops are first. Presentation will be given by the dynamic doctor, only black socks. And I'm so excited that we have heard this today. Her presentation is called It's Not, if not now, when sustaining urgency and ending the epidemic that will be followed by a workshop on creating partnerships in the community are second presentation will be given by none other than Mr Greg Millet and his presentation is titled Addressing Health Inequities to help end the epidemic. That will be followed by a second networking workshop on overcoming barriers to ending the epidemic. After our second workshop will all come back for a panel discussion, an audience question and answer sessions, or you actually have a chance to ask questions to our faculty. Please check the button below your screen to submit a question at any time throughout the program. This is the last in a full court Siris of our Blueprints for Success Training Institute. We hope you've been able to join us for some or maybe even all of the previous workshops. So it is with special excitement that I am pleased to welcome my first speaker today, Doctor. Only Black stop. Dr. Blackstock is the founder and executive director of Health Justice in New York. AH consulting firm. Providing content, expertise in HIV sexual health, L. G B T Q Health and racial equity. She's recognized as a key opinion leader in the areas of HIV prevention and treatment, as well as health, equity and racial justice for racial justice to public health and health care organizations. Dr. Black Spot is a primary care and HIV position and is also a researcher who recently served as the assistant commissioner for the New York City Health Department Bureau of HIV, where she led the city's response to ending the HIV epidemic. Now I'll turn it over to Dr Blackstock for her presentation. Thanks so much, Dr Rightly for that intro. It's such a pleasure to be here with all of you today, um, to discuss what we need to do to sustain the urgency, Um, in terms of ending the HIV epidemic. So if not now, when okay, moving along. So the global HIV community, you know, has really come together behind this common goal of ending the HIV epidemic. Since the beginning of the epidemic, there has been a great deal of progress toward reducing the impact of HIV and communities throughout the world. Um, in December 2013, 3 U N AIDS program decided to put forth treatment goals to achieve by 2020 this treatment target of 90 90 90 which means 90% of people living with HIV are diagnosed and know their status. 90% of those individuals are on treatment, and then 90% of those who are in treatment are virally suppressed. On globally, we've seen governments, non profits, private sector companies all coming together to really focus energy and resources on achieving this goal of ending theme epidemic. So moving along. Um, so when we look at what progress has been like there has been strong progress towards achieving this goal. But it dances are uneven and we know that a great deal of work still needs to be done. As of 2019, the 1990 target were 81% of those diagnosed of people living with HIV were diagnosed. Of those, 82% were on treatment and then 88% of those were virally suppressed. So we know that really ending the epidemic is really a foundation for really a more healthy and equitable future as we move forward, so looking so domestically in the United States again, we have also seen progress to reduce HIV diagnoses, although we have not seen the same degree of declines across all populations as well as geographic regions. Overall, from 2014 to 2018, new diagnoses in the U. S declined 7% but again we saw that trends varied for different groups. So for black people, the black people comprise 13% of the US population. Black people account for 42% of new diagnoses. During the same time period, we saw new diagnoses decline among white men who have sex with men or M S M we so diagnoses remained stable among black M s m and increase among lat Latin x m s, m age 25 older. We also saw declines in new HIV diagnoses among CIS gender women about a 23% decline over that time. Um, today the South is really the epicenter of the HIV epidemic and we see that Southern states account for about 51% of new HIV diagnosis each year. Although Onley 38% of the US population lives in the south next. Okay, moving along on DSO really to really help propel continue the momentum behind ending the epidemic We saw the federal government announced last year Ah, plan for America. Really a 10 year initiative that aims to reduce new HIV infections toe less than 3000 year by the year 2030. Um influenced by ending the epidemic plans here in New York City, in New York state and throughout the country. This plan also puts forward four key strategies the first being to diagnose all people with HIV as early as possible to treat people with HIV rapidly and effectively to reach sustained viral suppression So immediate treatment, same day treatment, preventing new HIV transmissions by using proven interventions such as prep and syringe exchange programs and then responding quickly to potential HIV outbreaks using the technology of molecular of HIV surveillance. And so in recent years we've seen that national initiatives have shifted their target from fighting the epidemic to this, um, ambitious but achievable goal of ending the epidemic. So as we move forward, um, and so making progress again has occurred there really a dedicated focus on this ambitious but achievable goal. We've seen at least 48 state and local jurisdictions have ending the epidemic plans Aziz identified by the red. The red circles identify those jurisdictions that have plans available on Ben is including the number of states, the blue states or those that have state jurisdictional plans. And the great states are those that have stance plans in development. 25 US cities have also joined the Fast Track Cities Initiative, which commits to meeting the U. N. AIDS 90 90 90 targets. And again, while we've seen different cities and regions differ in their approach to ending the epidemic, the goal remains the same, and that is to end the epidemic so as we move forward. Um and so the course of the HIV epidemic has has really changed over time and been shaped by advances and innovations and treatment and prevention and other approaches to care. We know at the beginning of the epidemic, HIV was very much considered a death sentence. Ondas time moved on. We saw new developments that really changed as we saw the first drug approved to treat HIV in 1987 followed by approval for the first oral HIV test, Um in the mid nineties was really the introduction of highly active antiretroviral on treatment. We saw the first rapid test then being approved by the FDA and then the introduction of single tablet regiments which we know have really helped with the feasibility of adhering thio daily HIV treatment, um then the innovation of treatment as prevention as a scientific breakthrough and then, more recently, in 2014, we saw the CDC proposed guidance around the use of prep for prevention as well as you know, immediate or treatment for all individuals diagnosed with HIV regardless of CD four account. And so HIV has really evolved into a chronic and manageable disease for most individuals granted that. You know, there's still a great deal of HIV stigma that exists that that needs to also be addressed and really underlying much of these efforts have been community organizing. Activism have played such an important role, insuring these advances have happened moving along. Um, and so we've also seen, you know, for treatment. HIV regimens really evolved over the last two decades or so. So starting off, they provided moderate viral load suppression. Many were very toxic, causing a number of side effects and also required a multi tablet regimens multiple times a day. Then we saw this evolved to improve viral load suppression improvements in cholera bility, but still a predominance of multi tablet regimens. And then over the last few years, really potent regimens that achieve high viral load suppression, Um, that are much more tolerable and predominantly single tablet regimens moving along. Um, and so again, we've seen these advances, you know, evolve across the prevention and treatment continuum. So, you know, in terms of prevention, we've seen, you know, pre exposure prophylaxis. The idea of taking a medication every day before you're exposed to HIV to help reduce your risk of getting HIV. We've seen the U S. Preventive Services Task Force also provide recommendations for this that all individuals at high risk for HIV should be offered prep. We've also seen, you know, post exposure prophylaxis, which has been around for some time but sort of increasing attention to its use. The idea of taking medication immediately after being exposed to HIV for 28 days and then in the treatment side, we've seen immediate initiation of treatment and really being driven by the fighting of treatment as prevention, which is starting on dstets eying on HIV treatment every day because of its, um, sort of individual health benefits, but also the favorable side effect of preventing HIV to thio sexual partners if someone is ableto maintain an undetectable viral load and continue adhering to their treatment. So as we move forward So yes, we know over the last several years, undetectable equals on transmittal has has gained ah, lot of steam, um, really sort of put forth by the prevention access campaign, who believes that this message of undetectable equals un transmittable, so achieving an undetectable viral load and continuing to adhere to maintain an undetectable viral load results in really effectively no risk of passing HIV to sex partners on. But this message can improve the lives of people living with HIV by reducing fear about potential sexual transmission, decreasing stigma associated with HIV and providing a motivation to start treatment and to stay in care on DA on treatment. Moving along eso again in terms of prevention medication again, according to the CDC. Prep eyes highly effective for preventing HIV when taken as prescribed. We have existing, you know, guidance from the C. D. C as well as multiple state jurisdictions on. But we also see the U. S. Preventive Services Task Force giving a great a recommendation for offering prep toe all persons who may be at placed at high risk for HIV. Um, acquisition. And we've seen, you know, substantial increases over time the number of individuals who are who are using prep, although we still see significant inequities with much lower numbers of black and Latino M S M um, black women taking prep sing along again. So in terms of the need for for early treatment initiation, we know that the Department of Health and Human Services recommends initiating HIV treatment immediately or as soon as possible after reactive tasks or diagnosis on, because this approach has really been associated with an increase in the uptake of HIV treatment and linkage to care. Also a decrease in the time to which someone becomes virally suppressed and then improvements in the rates of urologic suppression. So it's really recommended that we we educate patients. We speak to them about the benefits of HIV treatment and discuss strategies to optimize their engagement and care and adherence to treatment moving along and again. The favorable side effect of treatment is that is treatment as prevention, which is has been proven to be highly effective in terms of HIV prevention strategy when viral loads remain undetectable. Eso recommendations related to the treatment as prevention strategy include, you know, if swarming all persons with HIV about the benefits and limitations off immediate treatment, offering treatment regardless of CD four cell count, and ensuring that patients understand the importance of adherents adherence and how the strategy reduces the risk of transmitting HIV through sex thesis. CDC says talking to patients with HIV about treatment as prevention as well as the benefits of viral suppression is one of the best things that we have health care providers can do for our patients overall health and to stop HIV transmission. So as we look forward on DSO when we think about, you know, HIV treatment and prevention, you know you think about, you know, how can we provide this in a way that is really seamless and streamlined? And so really, the goal of of status neutral is to bring people, regardless of their HIV status, into care for either HIV treatment or prevention as needed. And so for both pathways, both parallel pathways involved linkage, um, to provider, you know, assessment, including a sexual health, sexual history, drug use, history, engagement in care, whether it be prevention or treatment, risk reduction services, prescription of HIV treatment, prescription of prevention strategies or recommendation of prevention strategies, including prep aan den, continued engagement in care moving along okay. And the HIV status neutral model, because it really results in, you know, parallel pathways, regardless of one's HIV status, is really something that we think is really sex positive can help to significantly reduce a stigma is a really into integrated a holistic approach to addressing HIV prevention and treatment on Beacon. Really help us as we move forward towards ending the HIV epidemic moving along. Um, part of this approach also includes, you know, three key interlocking components eso multilevel intervention. So structural interventions which influence policy on gun laws around, for instance, syringe exchange, you know, enabling community based HIV testing. We need structural level interventions as well as behavioral interventions. So messaging about how individuals may be able to help reduce the risk of HIV promoting HIV testing in various settings, enabling counseling services to be widely available. And then also biomedical interventions a zai mentioned such as prep been packed and HIV treatment. All of these interventions will work, you know, in concert to help us to achieve our goal of ending the HIV epidemic moving along. Eso several cities have have used this status neutral approach to engage individuals and HIV prevention and treatment and have been quite successful. So in New York City, where I previously led the Bureau of HIV at the New York City Health Department, we, uh, set a comprehensive HIV services at our Department of Health uh, sexual health clinics that offered rapid HIV treatment for people who were really diagnosed that offered same day prep services and count counseling, as well as patient navigation to continuity care either or prep or for HIV treatment. Seattle has also seen tremendous success with promoting HIV testing in non clinical settings, having a prep drug assistance program available to individuals who may not have insurance or access to programs to cover Prep Bond also funding culturally relevant medical services. And that our colleagues in San Francisco have been very successful with their U. N aid getting to zero program where they've expanded prep services as well. It's been very successful with same day HIV treatment for new diagnoses. Andi have also done quite well with engaging in retaining patients and care being along in terms of current treatment strategies. They're really helping Thio make progress. So again in Seattle and King County in Washington, um, that jurisdiction reached the 1990 milestone in 2017, and about 90% of newly diagnosed individuals in 2018 were linked to care within a month of diagnosis, and an estimated almost 50% of men who have sex with men who may be at high risk for HIV are using prep. Similarly, in New York city. We were really excited last year to become the first US fast track city to reach the U. N. Aid 1990 milestone, with 93% of people living with HIV having received a diagnosis, 90% of people diagnosed with HIV on treatment and 92 per cent of those achieving viral suppression moving along. So so what have we learned? We know that there has been strong progress in many jurisdictions towards achieving three U. N s 1990 90 goals, but we know that advances have been uneven and more must be done. We know that geographically, we see differences and by race, ethnicity a swell we see, Significant difference says in achieving these goals. Um, the course of the HIV epidemic again has been shaped by innovation and advances and prevention, a zealous treatment, a swell as, um, models of care and that the status neutral approach really emphasizes three importance of sustained engagement in care for people living with HIV or those who are at risk on the steps along. These parallel pathways are similar regardless of one's HIV status, which helps to reduce HIV stigma on that current treatment and prevention strategies arch are really helping us to make progress towards ending three epidemic. Thank you so much, Dr Blackstock. Thank you so much for that very informative presentation. I just want to remind the audience to please submit your questions via the button on the bottom of your screen. Now we will move to into our first workshop of the program. You should have received worksheets in your email earlier today. If not, will provide a link to the worksheets in the workshop role. Please click on the button on the lower part of your screen to join the workshop break out. I hope everyone enjoyed our first workshop. I want to remind all of you that you can submit questions to our faculty members through the button below your screen. Now it is with great pleasure for me to introduce our next presenter, Mr Greg Mellott, who is vice president and director of public policy at amfAR. Mr. Millet is a nationally recognized epidemiologist and researcher with significant experience working at the highest level of federal HIV policy and development, and he continues to publish new research on the intersections of HIV covert 19 and racial and ethnic health disparities now I'd like to turn it over to Mr Millet. Great. Thank you, Dr Riling and welcome everybody. It's really a pleasure to be here today and to be a co presenter with my colleague Dr only Blackstock. And I hope that everyone had a great breakout session. Um, for this part of our meeting, I wanted to talk to you about addressing health inequities to end the HIV epidemic. So when you take a look at the HIV epidemic in us, it's really not a homogenous national epidemic, but rather a collection of diverse local micro epidemics concentrated mostly in the Southern U. S. As well as so called hotspots, um in large and urban centers as well as specific counties. Now there are fundamental differences in health system, infrastructure funding and HIV related laws and policies between the regions. And during 2016 In 2017, off the 3007 counties in United States, half of the new HIV diagnoses were concentrated in 48 hotspot counties watch and including Washington, D. C. And Puerto Rico. Now we don't only just see some of these differences in terms of the epidemic by geography and counties We also sleep differences in the epidemic, but who is affected by HIV moving along now? The HIV epidemic in the United States, unfortunately, continues to disproportionately affect marginalized communities. And despite major advances in HIV treatment and prevention, ethnic, racial and sexual minorities continue to face higher rates of infection than the general population. In 2017 of new infections reported among men in the United States, 56% were among black and Latin X m S M men who have sex with men, which is a group that makes up less than 1% of the population in the United States. Now, if current trends of HIV infection continues, approximately 41% of black MSF and 22% of Latin nets and the some of the United States will be diagnosed with HIV during their lifetime. The lifetime risk among black men generally is greater than six times the risk among white men, and the risk among Latin X men is nearly three times the rate of white men. Now, these disparities are persistent among women, a swell and based upon data from 2009 to 2013, the lifetime risk of HIV diagnosis is approximately 17 times higher in black women and three times higher among Latin next movement than in white women. Based on data from 2006 to 2017, the HIV prevalence in transgender women is 14% compared to less than 0.5% among US adults, and one in 10 new infections occur in people who inject drugs. So you might ask whether we have a plan to end HIV. And Dr Blackstock covered a lot of this earlier today, but I want to go a little bit more in depth in terms of what that plan means moving along. So on February 5th 2019, President Donald Trump, in his State of the Union address, announced the intention toe end the US HIV epidemic by reducing new infections by 75% within five years and by 90% within 10 years now. This initiative began at the grassroots level in several cities across the US and was ultimately picked up by the federal government. It's a departure from 2015 National HIV AIDS strategy, which called for the 1990 goals to be reached by 2020. The initiative is focused in 48 counties. Washington, D. C. San Juan, Puerto Rico were greater than 50% of HIV diagnoses occurred in 2016. In 2017, natural an additional seven states, also with a substantial number of HIV diagnoses in rural areas. In February 2020 the Department of Health and Human Services awarded 117 million toward the goal of ending the HIV epidemic, also known as E, in the United States, which includes almost 54 million to 195 health centers with service, delivery sites and geographic locations identified by the ET Initiative, as well a 63 million to 60 Ryan White HIV AIDS program recipients. The strategy itself focuses on communities at risk for HIV, including black, Latin X and Native American communities as well is gay and bisexual men, and it also includes scaling of interventions that prevent and keep prevent HIV infection and keep people living with HIV and care. But given this really ambitious plan, there are challenges that remain moving along, so the challenges that lie ahead there are quite a few as you could see here on the slide, although there is new funding to achieve the goals, their simultaneous cuts to existing social safety net programs, including those that give access to affordable health insurance and low cost medications. In addition, five of the seven states that are part of the national program have not expanded Medicaid. This is a problem, given that Medicaid expansion is associated with greater HIV testing, greater access to opioid treatment, greater viral suppression and greater access to prep services they should be epidemic is already reflective of health disparities, which poses another challenge because these disparities are long standing and not easily reversed. Kobe, 19, is also having a negative impact on E. T E efforts by exacerbating existing disparities. Entertaining the goals will require a concerted and genuine effort to overcome the economic, cultural and social barriers that prevent disenfranchised and vulnerable people from obtaining the services they need. So for E. T. E. To be successful, it needs to address infection rates among those groups at highest risk for HIV because we can't end HIV without actually addressing those communities where we have markedly high rates where rates are actually increasing in some areas. Okay, moving along please and part of the reason that we need to take a look at some of these communities is because of the persistently high rates that we see despite comparable rates and risk behavior. Now, while I was at CDC, my colleagues in the i post of meta analysis and the meta analysis is basically taking a look at all the research studies possible. Andi seeing if there's a trend in the analysis that you're seeing and we published a meta analysis looking at some of the drivers for the high rates of HIV for black and sm on what we found is that black and sm across studies engage in fewer rates of HIV risk behaviors and another M S M. That includes less unprotected sex with main male partners. Fewer male sex partners, more condom use during anal sex with other men who have sex with men, and they're also less likely to engage in substance use. Now, despite reporting more preventive behaviors, black MSN across our meta analysis had a threefold greater odds of testing positive for HIV and a six fold greater odds of having undiagnosed HIV infection compared to other M S, M and black, and some now currently face the poorest helped outcomes due to the intersection of discrimination, stigma, poverty and other social political disadvantages. Diagnoses of sexually transmitted infections were greater in black amisom than in other MSF. We also see this replicated in other studies. So, for instance, there were the results for prospective observational cohort study off 803 black and white M S M in Atlanta. And they found significantly higher rates of HIV diagnosis among black M S M compared with white AMISOM, which was not attributable to individual level risk behaviors. The research showed that the many HIV related disparities for black and SM were those related to HB clinical care, access and use, as well as structural issues such as low income unemployment, low education and incarceration as well a sex partner characteristics rather than disparities and sexual and substance use risk behave years. Elimination of disparities in HIV infection in black and SM cannot be accomplished without addressing structural barriers or differences in HIV, clinical care access and outcomes moving along. So what is the definition of a health disparity? Healthy people 2020 defines a health disparity as a particular type of health difference that is closely linked with social or economic disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on certain characteristics, including racial and ethnic group, religion, socioeconomic status, gender, age, mental health, cognitive, sensory or physical disability, sexual orientation or gender identity, geographic location and other characteristics that are historically linked to discrimination or exclusion. And as we're seeing now with covert 19 concentrated in communities of color, these disparities are due toa underlying social as well as economic inequities moving along. Now, this slide shows that health disparities are symptoms of broader underlying social and economic inequities. Andi. It includes that disease disparities, especially for covert 19 as well as HIV, are really symptoms of these underlying social and economic inequities that reflects structural and systemic barriers and biases across sectors. Now research has shown that social determinants of health these are the conditions in which people are born in grow, live work as well as agent are primary drivers of health. They include factors like socioeconomic status, education, neighborhood and physical and environment, employment and social support networks, as well as access to health care. These systematic inequities overlap with high rates of HIV, and by that I could just demonstrate moving along, please. There are actually studies in HIV, um, that have looked at these systematically systemic inequities across different areas of the country. For instance, there was a research study that was conducted in 80 large cities in the United States from 1993 2000 that showed that major correlating factors for HIV included income inequality, poverty, educational attainment and residential segregation. The above factors, coupled with social inequality in the form of institutionalized racism and anti homosexual stigma, have developed over time into synergistic drivers of disease transmission in the United States. Take, for instance, access to prep data from a 2017 study by the CBC showed that black and Hispanic M S M were significantly less likely than white. M S M. To be aware of prep medicines, toe have discussed prep medicines with the health care provider or to have used prep medicines within the past year. Now, use of prep medicines among those without health insurance was relatively low across racial and ethnic subgroups. However, according to the DHS of the estimated one million Americans at substantial risk for HIV, and who could benefit from prep medicines. Less than 10% are actually using these medications. Currently, these air there are also geographic patterns to these disparities, especially among black Americans moving along. Now, this slide shows overlapping socioeconomic and health conditions and counties with disproportionate black populations, and of the 677 disproportionately black counties. Now, these air counties that have greater than 13% black Americans 91% of these counties air concentrated in the southern United States. As you can see here, the South has relatively higher numbers of poor uninsured adults than in other regions, has higher uninsurance rates and more limited Medicaid eligibility than other regions, and accounts for the majority nine out of 14 of states that opted not to expand Medicaid. As a result, more than nine and 10 people in the coverage gap reside in the southern United States, and not only our rates of unemployment and lack of insurance high in those 677 counties. But there are also high rates of diabetes, heart disease and HIV as well, and these pre existing conditions plane of important role in the poor. Clinical outcomes from Kobe, 19, also in these counties that elevated rates of Kobe 19 in these counties. Other factors include transportation, social and health services that are inadequate in rural areas. There are also cultural factors that fuel stigma discrimination, which are also prevalent in many of these areas. And there's also a slow adoption of the latest leading treatment and prevention services Moving along now, this slide shows the disparities and impact of covert 19 by race and ethnicity, with a focus on the impacts of covert 19 among African Americans. Now, African Americans account for 12 point 1st, 12.4% of the total population. But our 22% of debts from Cove in 19 and my colleagues and I found in a paper that we published earlier this year that nearly 20% of U. S. Counties that are disproportionately black, meaning that they have a population greater than 13% in those counties that those counties accounted for 52% of Kobe, 19 diagnoses and 58% of Kobe, 19 deaths nationally. County level comparisons can both inform Cove in 19 responses and identify epidemic hotspots, and county level data are also important because of the fact that much of the cove in 19 data by race still is not disaggregated, so we still don't have 100% disaggregated data by race and ethnicity for Cove in 19. To really track this pandemic, social conditions, structural, racism and other factors elevate the risk of cove in 19 diagnoses and deaths in black communities. Now, although I am discussing African Americans, this slide also makes clear that covered my cloak over 19. Mortality is likewise high among Latin next populations as well as indigenous populations. So this is something that is broadly affecting communities of color in the U. S. Just like HIV. When we think about ending the HIV epidemic, we have to be careful that we're actually ending the epidemic and not simply displacing the epidemic moving along. Now, What I mean by this is that you know, there is quite a bit of movement of individuals who are at risk for HIV or are HIV positive out of cities. And this is really the potential impact of gentrification, which unfortunately is probably being magnified by the cove in 19 recession that we're experiencing right now in the U. S. And to give an example there is research in San Francisco from 2006 to 2014, which showed significant out migration of people living with HIV with black M s m far outnumbering white M. S M. Who were leaving San Francisco. HIV status may influence out migration because of the need to live in a place with the lower cost of living and desire to move closer to family or caregivers. The most vulnerable people living with HIV are being displaced from San Francisco due to a rising cost of living, and are relocating to areas where funding and infrastructure for managing HIV care are lacking or non existent. Gentrification may also lead to a movement away from cities by communities at highest risk for HIV. And some suggests that a part of the reason why cities like San Francisco are making big gains in HIV is because the communities most affected by HIV have moved out. This trend is replicated in other large cities. We're seeing it here where I live in Washington, D. C. We're seeing it in New York. We're seeing it in Chicago. There is also a historical context that is associated with disparities that I think we need to discuss moving along. In many ways, we see that history is actually repeating itself with these unequal legacies, that there's a persistence, uh, to these disparities. And there's reasons for this. One of them is that conservative policies have aggregate aggravated disparities in the Southern United States, where there is a the legacy of slavery. Um, and there are actually data and studies showing that for those places in the U. S, where you had a high proportion of slaves that you Seymour conservative ideologies, um, that are really problematic for some of the work that we need to get done in terms of HIV. There's also many marginalized communities that have historically experienced disparities in access to health care. And this inequality of access unfortunately continues today. And just as antiretroviral therapy was less available to people of color in previous decades, uptake a prep medicines is far lower among people of color. Today, the legacy of mistrust of health care for providers among people of color continues today, and there's also a legacy of patient distress among people of color that contributes to less adherence to treatment and less viral suppression. But we can still make an impact to reduce disparities. Despite this legacy, and despite some of the systemic issues that I discussed earlier moving along, there really is a way forward, and there are some elements of some hopeful signs that we're seeing. So, for instance, more than half of Americans diagnosed with HIV receive services through the Ryan White HIV AIDS program, which has substantially increased the rate of viral suppression among key populations. A stated goal of Ryan White program is to reduce HIV related health disparities to help E. T. And part of this is done by services that address the social determinants of health, where we actually have bridging services that provide access to care by giving people transportation, where there's access to child care and other services that can really help reduce some of the social determinants that I discussed beforehand the largest. We also see some of the importance of health equity, um, in terms of addressing some of these social determinants as well as disparities. And what I mean by that is that the largest study in the world to examine racial and ethnic disparities regarding Cove in 19 testing and mortality found that while black and Latin X veterans were worse affected by Cove in 19, mortality rates were the same across the race and ethnic groups, Reacher said. Researchers said that the health disparities tend to be reduced in the VA. Could have been a bearing on the findings. So, in other words, because there's greater health equity in the Veterans Administration, we're not seeing higher rates of mortality for blacks and Latinos once they're in care as compared to whites. And this is something that's very different than what we see in the rest of the United States. Also, recent Supreme Court rulings have upheld protections for gay and transgender people as well as immigrants and social movements and marches in support of black lives, matter and black transgender lives. Matter have garnered widespread support across society and point to progress in reducing stigma and marginalization. Last, innovative, community centered responses thio, pet or making inroads and an example of these responses is start talking from Alabama, moving along now start talking. Alabama is a social media campaign created to reach young gay men of color. In Alabama, black and SME age 15 to 29 years are 11 times more likely to acquire HIV than other Alabama residents and start talking. Alabama aims to achieve an increase in HIV awareness, coupled with decreased HIV stigma, by sharing prevention, testing and treatment information, as well as offering support for individuals living with or at risk for HIV. The campaign not only discusses the impact of stigma discrimination, but also strides to one talk about techniques to resolve issues related to stigma and discrimination to provide information about testing, prevention and treatment services. Three supply tools that could be utilized to promote equality and four discussed techniques to help members of the community feel comfortable with their HIV status. Now. Similar efforts are also underway in Florida. Moving along the know your HIV status, Campaign and website offers Resource is to Florida residents to help build awareness of HIV AIDS and educate the community on prevention, testing and treatment options. To help support individuals at risk for HIV people living with HIV and their families, The website offers tools such as an interactive reduction tool to help evaluate and reduce risk factors. Free home testing kits, a search engine to find testing locations based upon ZIP codes, support training videos and information of resource is for HIV prevention. The know Your HIV status campaign also provides of list of HIV test sites and offer couples HIV testing and counseling, as well as information for women who are pregnant in the Miami Dade area. In 2018, Hispanic Latin next individuals represented the highest proportion, nearly 60% of people within HIV diagnosis. And this was followed by African Americans as well as white individuals. When analyzing HIV diagnosis by mode of HIV exposure, men who have sex with men comprised the largest percentage nearly 70% and that percentage was reduced drastically for female heterosexual contact as well as male heterosexual contact. Individuals between the ages of 20 and 39 years of age were revealed to make up the highest proportion off those who received an HIV diagnosis in 2018 in the Miami Dade area. Moving along so in summary. Despite advances in HIV treatment and prevention, challenges remain in hotspot counties and among ethnic, racial and sexual minorities. However, there is a lot that can be done to address some of these issues. First, we have a plan and ET plan for America that focus on individuals at risk for HIV two. There's a recognition that there are systemic inequities that overlap with high HIV rates and risk. Three. We know that people of color are disproportionately impacted by Cove in 19, and it's just the latest installment and chapter. And many of these inequities that we see for other diseases, including HIV, that disproportionately impact people of color for history is repeating itself. A Z unequal legacies persist, and we showed data that a little bit earlier. And despite these challenges, there are hopeful signs of progress, and we know that innovative community oriented responses are leading the way. Thank you for the opportunity to speak today, and I look forward to any questions you might have. Thank you, Greg, for that very informative presentation. Now we will move into our second workshop for the program again. You should have received worksheets in your email earlier today. If not, no worries will provide the link to the weight worksheets in each of the work workshop room. Please click on the bottom of the lower part of your screen to join the workshop breakouts. Welcome back, everyone. I hope that last workshop was informative and fun. So now we're going to transition into our interactive panel discussion. And I just want to remind you guys Thio, submit your questions by the button on the bottom of the screen. So I'm excited. Let's go with the questions. Okay, Sorry. First question is for Dr Blackstock. Yeah, How can we better combat stigma against prep and U equals you within the field, for example, Discussions of risk company, he says. Risk compensation or people referring to convalesce sex with biomedical prevention as unsafe or risky? No, I think that's an excellent question. I think there are a number of different strategies to use to combat HIV stigma. Crap stigma just from some of my own experience here in the city, for instance, um, we launched last year very large social marketing campaign around undetectable. It was un transmittable and really getting the message out to both HIV positive as well as HIV negative New Yorkers toe let them know about this sort of new piece of information that many people, and actually many people live with HIV were not aware of. Um, I also think that having folks share their experiences about, you know, being on treatment or being on prep can be really powerful. So you know, we know, for instance, like prep use is low among the number of groups that are highly impacted. But thinking about, for instance, this gender women. There aren't a lot of women out there speaking about like their experiences with crap. And so I think when people don't see people who look like them or may have similar experience to them, it's very hard to sort of imagine how this might be a good fit for them. And so I think, just hearing in the ways that we can do community based organizations, through marketing campaigns, people to sort of share the personal stories that people have of why they decided Thio go on treatment or why. Let's say someone who is HIV negative decided that it was safe for them to have an HIV positive partner because they were using the people's use strategy and prep. Just hearing those sort of personal narratives, I think, can also make a huge difference. Thank you for that, Greg, Would you like to share anything? Thio? Add on to Dr Blackstock question. I mean statement. You muted Greg thing. Only thing that I'd like to have thank you. Is that you know, Sigma something that's that's pervasive. We've had HIV signal from the very beginning of the HIV pandemic. Um, it was a stumbling block then. And unfortunately, 40 years into the epidemic, it remains a stumbling block. So even though we've had all these major, um, advances in terms of prevention as well as treatment for HIV, one of the remaining barriers that we still have is really addressing HIV stigma in a concrete fashion. And I'm hoping that that's something that that all of us can can continue to work. Thio really break down and move forward because we need to make sure that stigma is reduced for E h E and E t to be successful. Great. I totally agree. And I'll just So my little two cents in, Um, since he says, How can we better come back? Stigma. I think, just being able for all of us, no matter where we are in terms of our walk in life for professional that we just talk about HIV, that we just talk about sex thio everybody. And by doing that, that can also help with just, um, being able to also a road, hopefully in some aspect of stigma. So I move on to the next question on to either one of you. Can you talk about how upstream interventions like housing can make a difference? That's a great question, So I'll let you go first, Greg. Sure, there. So it's. It's very clear from the literature that housing makes a difference for people living with HIV. So there's one study in San Francisco that found that compared to people who are housed, people who are either living in a single room occupancy or who are actually homeless had higher viral loads. Onda were less likely to be undetectable. Um, there's another study from San Francisco that was just published, I think, earlier this year in AIDS that found that those people who are homeless, who were tested and diagnosed with HIV had a 26 times greater mortality rate as compared to individuals who, once they're diagnosed, are diagnosed and actually have ah, home or housing. So housing is key, uh, to prevention. It's key for HIV care. It's something that we know has to be a component of E. It's something that's been a component of the national HIV AIDS strategy, and we need to make sure that we address that and other social determinants of health as we move forward. Thank you for that. Dr. Black said, Would you like to share? You know, just, you know, emphasize. Yeah, Greg's point. I always think of, you know, housing as prep and housing, Um, as treatment. I think the challenge is that so much of the funding is very siloed. And so I think I would love to see a new national HIV AIDS strategy put out by the federal government that really on. But I think of all the Obama initial plan also did this, but really coordinating the various federal agencies, including HUD, to figure out how we can really push this ambitious goal of ending the epidemic while coordinating various agencies that address social determinants of health. Thank you for that and also bricks and you mentioned the ET around housing. I know that some of health departments I covered the South, for example Mississippi, Alabama, Oklahoma, Louisiana, Arkansas as well. Being able to work with the Health Department, I feel like community based organizations should be able to say, Listen, we know that our community needs housing. And here are some ideas that we have for the community. And so being able Thio, engage the health care system, particularly those health departments that are getting those e. T. A. Funding around housing is so important. And so for those of you that are on the call, I'm gonna ask for you to be empowered to have those conversations with those entities that actually got those federal dollars and to be able to give them recommendations on how you feel housing can be addressed, particularly in your community in a particular state thing. Um too, because, you know, we know that when it comes to contact tracing, as great as our community based organizations are, um, in making sure that marginalized populations feel safe and are able to contact race, we know that if people don't have stable housing or have outdated addresses, we're not able to end the epidemic because we're missing people who might have been exposed or trying or missing people who are HIV positive for no longer engaged in care because they don't have access to stable housing, and we have incorrect addresses for them. So it's very clear, exactly, is only had mentioned and as you had mentioned that housing is really one of the primary ways that we need to continue to end H HIV in the U. S. Thank you for that. We have a lot of questions. Okay, so can you talk about Okay? Okay. Here we go. One of my biggest barriers to advancing prep exist among health care providers themselves. They're often prescribers that failed to follow through with patients. Wishes to access prep due to their own. This conference with the medication. There are also plenty of prescribers who claim to be okay with it, but their tone with their patients and lack of confidence surrounding it, this weighs the patients. Oh, my God. That's that is so true. I know this because I have the unique experience of getting to be the fly on the wall as the medical linguist. Interpreter. What is your advice about working with these clinicians? Such a great point and excellent question. So I'll let you go for a soccer black that? Yeah. No, this is like a continued issue. I think since we've seen approval of prep, we've been really contending with, like, health care providers, not always sort of being sort as excited as some of us are about this prevention technology. And I think the challenges prep in particular. We need healthcare providers because it requires a prescription so very different from, you know, condoms, for instance, so providers can be a barrier. I've personally been part of initiatives to educate providers all around the country about prep and just to show how really easy it is to prescribe. But I would have to stay in that one and one encounter that, you know, pick the patient is having with a provider, Um, that is not being open or doesn't seem open to providing prep to, like, walk with it to make a complaint and then walk with their feet. I mean, there are lots of I think prep locator their websites where people confined providers that are willing to prescribe prep and to support folks achieve their sexual health goals. But that that is definitely a challenge. And I want people to know that it's okay to get a second opinion, see another provider really at and you know, and or even advocate for yourself and explain to the provider you know why you think this is a good fit for you. Um, but this is really continued work that I think many of us are trying to do to get many health care providers on board. Yeah, and it really points Thio. You know, this continuing discomfort that we see among physicians on around sexuality as well as taking sexual histories This is something that's been, you know, an issue for decades now. Um, well, I was young. I used to teach medical students about sexuality at Duke University, and I mean, this was back in nineties and people would be snickering and feeling so uncomfortable these air, these air medical students, these air people in their mid twenties or older, um, and really couldn't deal with these types of questions. So you transfer that to a setting where they are actually dealing with their patients. And you could imagine the degree to which, um, it might not only make patients feel uncomfortable, but patients say they'll perhaps this is something of medication that I might not even go for s. So I think that we have to do a better job of some how incentivizing or trying to figure out ways that this is a part of the evaluation process for medical doctors on DTA. Also exactly is only invention that if your doctor is not doing what's right for you, then to definitely find another position, who can Yeah, it's unfortunate, I think, about I practice in the VA and I remember when men would come in and they want that little blue pill providers would just write it with no questions asked. Did not make the person feel uncomfortable or anything like that. Now this other group, Hill with prep completely, totally different story. And so I think that person for asking that question and I would say, continue to be empowered to be that linguist interpreter and to make that patient feel or the individual feel like, even though the provider may not be open, that you're there to be an advocate and to educate that individual and like what Dr Blackstock mentioned is that there's so many other places that that individual hopefully can go, that that's not the only one stop shop place. And if it is that to allow that person to be empowered to demand what they feel is appropriate for them around their sexual health, I definitely wanna say that. Our next question is to Dr Blackstock. Who did you need? Okay, So who did you need to engage to ensure that HIV awareness program reached the public in New York. Okay, so e think one of the really exciting parts of being part of ah, public health department is that we have, like, we have tons of community partners on DSO. You know, one of the initiatives that we have at the health department is called the New York Knows, which is the largest HIV testing jurisdictional initiative. I think in the in the country and so have developed relationships with clinics and community based organizations and hospitals. Andi also like non health related organizations over the years. So, you know, a lot of times we do have these large sexual health and social marketing campaigns that air seeing throughout the city. But often times, you know, sometimes those messages also need to be tailored. And so we really rely on or relied on our community partners to sort of do that. Tailoring to the specific communities that they served, I think was unfortunate for New York is that you guys have funding. You have the support from those individuals who are in key decision making positions. I think it's more challenging when you have when you're located in a In a state that has less resource is as well as in states where the leaders are not as progressive as in other places such as California and New York. So again, the community has to be those individuals to take the lead and to have that big stick toe walk with a big stick and to demand those entities and those individuals in those leadership roles to be able to come to the table and provide some type of support. And then I just add also like we just have to be, you know, just in terms of being more creative when things air, please are so limited. So you know, the reach, for instance, of like social media can be a lot whiter than, for instance, like us, a marketing campaign that's on brick and mortar stores. And so we've been able to support community based organizations and them creating their own campaigns to get the world word out about HIV testing about prep. So I understand in New York City, where definitely unique case, but I think there's some creative approaches that might be able to, like bypass some of these challenges. I'm refunding. I told you guys think being creative as well, innovative all of that in today to where I feel like in some cases we weaponize sex. And so being able to have that conversation around risk in such a negative manner that we now have to be more positive in terms of being able to empower individuals in terms of how can I have wonderful sex? How can I have wonderful sex in a way that I'm going to stay healthy as best as I can? And being able to frame it in that manner to me will allow more people to be engaged to have that conversation? Greg, would you like to say anything? No. I think that you both covered it. A bleak. Okay, great. I don't want lead you out. Next question. Given the current pandemic, what are the panels? Thought on the use of tele health and benefits to those in underserved communities. So let you go first grade. You know, we talk a awful lot about where the Kobe 19 pandemic, um, is a problem, Andi Degrees to which we see a lot of the same problems unfortunately, that we've seen with HIV that, you know, 30 40 years apart. We're making a lot of the same mistakes, unfortunately, but there are some places where we see some positive things, and one of them is telehealth. You know that telehealth has been instrumental in getting different patients, different profiles of patients, um, involved in prep care involved in even their regular HIV care than perhaps the standard model has. And there's certain aspects of it that has been helpful for some community based organizations as well as clinic. So much so that they're actually thinking about adopting a telehealth component once the covert pandemic is over. And it's not just telehealth. We're seeing the same thing as well. In terms of the opioid epidemic. Before the Cove in 19 Pandemic, you needed to go to a methadone clinic to get your meds, your methadone for opioid substitution therapy. Now, because the cove in 19, they're actually allowing people to bring their methadone home, which is something that should have been done decades ago and why that's important in particular for people living with HIV who are using opioids is that if you bring your methadone home, if you bring your buprenorphine home, you're more likely to be adherent to your medication. For HIV, you're more likely to be virally suppressed. So these air innovations that we're looking at now because of the Cove in 19 Pandemic that might be useful for us to consider once the pandemic is over to really implement and use this part of our E t E efforts. Thank you. That black stuff. You have anything to add to that? Yeah, I did it with Greg said. And, you know, as a provider, it's actually been like, super exciting to be able to still, um, communicate and speak with and be available to my patients, even though I'm not physically in the clinic. And you know we have patients. Sometimes you may have mobility issues, you know, other challenges with getting the clinic. Maybe they're they're working caregiving responsibilities, and this can allow folks to like to really remain engaged in care while they're able to address, you know, other priorities issues, um, that they're involved. And so it's been really exciting to see this, like pivot t telehealth this sort of acceleration to a technology that is, Greg said, we should have been using before something that was primarily used were thinking about rural health, um, and challenges with transportation. And now you know I'm in the city and we're using it. So it's exciting to see this move forward. Yeah, I would just say that I had an example where one of my providers in New Orleans was actually with early on in the pandemic, trying to keep up with their patients, their prep patients and using Tele Prep. And what was interesting is that the first session, trying to tell the person to use it to hit the tap button and locate certain keys on the on the person's um it was actually was their grandsons, um, laptops slash ipads that they were using, and my provider said I did realize how many people, even though they're on social media they don't necessarily are tech savvy. So being able to spend that time as a as a prep navigator as the nurse to kind of walk through with the patient or with the individual doing that teller visit is important because if not, you end up not having that time. So even though we're talking about telehealth, which is very important, I think also we have to kind of be mindful that everyone may not be tech savvy and so building that that time, or that essence of the actual visit, to be able to make sure that your patient of the person you're dealing with is comfortable, it allows you to be more effective and efficient. You know, I think that's a great point. And part of the reason why you know, your friend found the need to do that is because as people living with HIV weren't aging population in the U. S. You know, there's so many of us who are over the age of 50 myself included, who may not know how to use some of these technologies. So there's certainly going to be that that on ramp that we're going to have to deal with and in really bring some some groups of the speed. But it's it's something that could still be helpful for some of our patients. Exactly for some of the reasons that Dr Blackstock consent Wow, There was a comment insist that technology is a disparity and that, Greg, you don't look over 25. E was thinking, I need to figure out what Greg Secret is, but just to add also that, you know, with a lot of my patients, especially older patients, we just use the telephone like we're not doing, like, video visit. And for many people, that has been sufficient and inadequate. So and thank you for that doctor, blacks, because I get a lot of questions about what is using the telephone. Is that HIPPA compliance? And my statement is, Hey, it's a We're in a pandemic. So by any means necessary, take care of your patients, take care of yourself and let's get through this safely. You know, honestly, I Let's see if there's any more questions. Let's see what we got. Okay, so here's one in terms of covert 19 we talked about initially in terms of the pandemic. So, Greg, where we are now, the CDC is making recommendations as nobody to travel right now as it relates for Thanksgiving holidays. What do you think is the best strategy for those who are on the call? We're going out and talking to people about HIV prevention and at the same time they're hearing questions about Oh, Cove. It is still man made, you know, still having to combat those so called Miss. How do you What are some strategies you think that we can use in terms of being able tohave that conversation with HIV concerned about HIV but also covert 19 and being able to appreciate the parallels between the two? No, Absolutely. I mean, I think you know a lot of this. This this mistrust runs deep, um, in our community and actually for very good reasons, you know, where the community is not just being paranoid. Um, there were data that were published way back in 2005 that found that over 50% of African Americans said that HIV was man made disease. They went ahead and they did another large survey with the African American community 15 years later and found exactly the same proportion who said the same. So it just hasn't budged. And we're seeing the same thing right now when it comes to Cove in 19. In terms of vaccines where you're seeing much fewer African Americans. In a survey with Kaiser Family Foundation, only about 13% of us Um said that we would take the cove in 19 vaccine even if it were free and available. Eso there's there's a legacy of distress that we definitely have to contend with. People, um, we need to meet people exactly where they are. We have to realize, too, that the messenger matters for this. Um, there was another poll that was done just a month ago, where they found that those individuals who asked if they would take a vaccine of President Trump um uh, extended it and said that and endorsed it. And it was only two in 10 Americans where a six in 10 Americans said that they would take a vaccine if their provider said that they should take it. And I honestly think that, you know, within our community, if it's somebody who's influential, if it's a preacher, if it's someone who's involved in a sports arena or some sort of public health figure or instagram figure someone else who's taking a vaccine, um, that that provides a lot more weight, and particularly in our community, Um, there's a lot more weight given to people who previously might have been against vaccine, so we know the presidents of HBCU said that they would not take a vaccine for many different reasons that really make sense on a lot of mistrust in a way that has been politicized. Um, but if those same HBCU presidents, um, in the future turnaround after seeing the way that vaccine efforts are progressing and say, Okay, I have enough trust now that this is something that I would endorse that actually probably carries a lot more weight within our community because it's somebody who previously said no, who is now changing their minds and saying, You know, after more consideration, I think that this is something that's safe to go forward with. Thank you for that. Please submit questions. We wanna have more questions. Come in. And I just wanna go ahead. Dr. Blackstock, when I was in the mix, just wanted to also just add onto a Greg was saying about Miss just okay. I totally agree with everything, he said, Um, and and also with this idea of really with this idea of holding space for, you know, when I talk to my patients and you know patients express, you know, concerns around safety and all of that like those we have to validate, you know their concerns and recognize with the way that historic and present day, you know, racism, discrimination, you know, have affected their trust in the health care system. Um and so I think at some point to be like Okay, yeah, no, Totally. And totally get that. Like I have patients who get HIV is man made. But what we see in the literature sometimes that people can actually have these beliefs and still sometimes engage in care. And I think particularly azi Greg was saying, If they have trust in, like, their individual provider, that could make a big deal. So I think actually, what's actually really important? I haven't started doing this, but I've been thinking a lot about it. It's really starting to talk to my patients about the cove in 19 vaccine like, what do they know about it? What are their thoughts? Because, you know, it's not gonna be out for a number of months, but like in that time, can we provide, you know, information? Um, that might be able to sway or convince, you know, patients that this might be something for them and also just to say that mistrust also is a survival mechanism and also can really empower folks. So I think we just need to, you know, harness the positive aspects of it. And then also is Greg was saying, using influencers key opinion leaders from the community toe also provide additional information that may be able to shift opinion on the vaccine. I totally agree. I want to just tell you guys last night, um, I had my talking to my family members and we were actually talking about Kovar 19, and they know what I do. The work that I do with HIV and they asked me So key. Sure, you get in the cove in 19 test. I mean vaccine. And I said, Yeah, the second way, not the first. And then they say, because I was like, you know, the health care was, you know, people who are 1st 1st responders, they will be in the first way. I'll get it the second way. And my family members actually said, Oh my God, you're so brainwashed. And I had thio like pull up and then, like, really be able to appreciate what they were saying, and it ended up being such a really good conversation because, like you said, Dr Blacks are being able to appreciate their mindset and their points that they were actually making. And then for me to actually be ableto have the knowledge and the breakdown, the science, along with the historical perspective toe have the conversation, and so out of that, they were like, Well, we'll do. We'll do the fifth way to take the vaccine. But it does matter with the messenger because again, social media is so powerful, positive or negative, the information that's there is so impactful. And so just again being able to understand that we all have a position in this fight as it relates to HIV as well as covert 19. So the next question is for Dr Blackstock. Can you expand on how, as a provider, you meet the needs of the patient as it relates to telehealth? When did you decide to use the phone versus telehealth? Right, So you know they're having many different factors. Some of it also has to do about you know how, for how sick the patient is or if they're dealing with any acute or urgent issues. Um, you know whether to use, You know whether to be able to see them, to be able to lay eyes on my patient versus you know, it, being sufficient to use the phone. You know, if there's a patient who may be having challenges with adhering to their medication, you know it can be more personal to be ableto look, you know at someone and sort of have a sort of different sense of like accountability when you're able to, like, look in someone's eyes, um, and then also asking patients also what they prefer, what their preferences. A swell makes a difference. So I see patients. So I took them by phone, do video visit, and I also go toe physically to clinic. So when I, you know, ask patients to come in, you know it's really about weighing the risks and benefits of them coming in. Given the Cove in 19 Pandemic, you know, if a patient has a very low T cell account, you know what I mean. A compromise in some way or as opportunistic infection. I might be trying to figure out how we can do most of our work, you know, remotely, as opposed to in person But a lot of this is it's kind of like each situation is a bit different, but really communicate with the patient to see what makes the most sense. Yeah, being able to offer them individualized treatment or in terms of their visit. I love that So two for both of you guys. Both presenters mentioned examples of mentioned examples of some examples of projects or programs that have achieved significant success in making progress towards the end the epidemic. Can you speak to either one or any of those examples or models specifically? So just being able thio kinda in terms of the conference presentations that you gotta get you present, you gave be able to speak on some of those models in a little more detail, so we'll go with Go to you first. Um, Greg, you know, I I think that when it comes to some of the models, there's different types of models that we can start considering for ending the epidemic. So there is a community level models that I discussed is part of my presentation. There are also federal and state models, like some of the ones that Dr Blackstock of discussed during her presentation and what's taking place in New York aan den. There also models that are that we have in terms of the federal government itself and what the federal government could be doing toe and the epidemic. It's very clear that we all have to be working in concert with one another, and we even have models as well, from the private sector and models from from non profits and in order to end the epidemic. You know, I think that, you know, part of what I hear in the question, and it's the thing that I resist a little bit, um, is part of this, you know, that there's a silver bullet out there somehow, um, that can help us move everything along. There really isn't a silver bullet. One thing that we learned with HIV is that it has to be everything pulled together to make us end the epidemic and for us to make progress. It's exactly the same problem that we're seeing right now with the American public when it comes to Kobe 19 and some of the announcement of the vaccines. Everybody is, you know, so focused on the vaccines. Um, not realizing that that's not gonna be a silver bullet. Even once we take the vaccines were still gonna have to social distance, we're still gonna have to wear mass andan and and And we have to realize that that's going to be a part of our life for some time to come. Same thing with HIV is you know, there's not a one thing that's gonna get us to the end. It's multiple things that we have to do in concert with one another to help move us along. Yeah, I totally agree with Greg and but it also makes me think about some of the programs that we have that in New York City that have been successful have also been sort of like multi modality, multiple strategies in once of this holistic approach of thinking about a care coordination program that we have for people living with HIV that involves, like, you know, working hand in hand with a care coordinator, essentially doing directly observed therapy, doing self management skills development, you know, it's like all like multipronged because people need, you know, a great deal of support, to be able to really overcome all of these sort of structural and social barriers and obviously not all will be overcome. Obviously, there's much more work that needs to be done in a policy level. But, um, yeah, those programs that use lots of different approaches and provide a lot of support for patients, I think, are the ones that have really been the most successful that have used, like patient, you know, navigation, for instance. And community health workers, those that have been trauma informed, like all of those do. Really. Well, thank you. Okay. And this is the last question. What gives you hope about our opportunities to end the HIV epidemic as we look towards the future, So I'll let you go for a sector Blackstock. All right, Um, so, you know, I think the reality is like we have all the tools. We have the tools, like, you know, the biomedical tools and, like, the know how thio end this. But the really reality is that there are, you know, you know, Greg's presentation highlighted there. These really large social and structural factors, um, that need to be really addressed, and some need to be dismantled. So I think, you know, having a holistic view, that sort of brings in the biomedical but also recognizes, like the structural factors and structural factors that then influence behavior. I think an approach that that does that that also prioritizes racial equity. L g B T Q equity. Um, in the sort of in programming, along with the biomedical interventions that have worked well, I think will be incredibly important. And again, this sort of unsmiling of the the way that funding happened so that we can really provide prevention and treatment services in a way that is as comprehensive and holistic. Yeah. You know, I think there are two things that that that gives me hope. And the first is, you know, for those of us who are old enough and have the benefit of, you know, being alive from the very beginning of the pandemic through now. And I grew up in New York City. My dad worked at ST Vincent's Hospital, so, you know, we were literally in the center off the epidemic from the very beginning to see where we were, where so many people were dying from HIV, where I had friends every time that I came home from college break who were no longer there in New York or who are in hospital beds toe where we are now, where people are living with HIV, having Children with HIV, getting married, growing old with HIV. It gives me so much hope because we've done that in a very short period of time. When you really take a look at the expanse of everything that's taken place, Andi, I think the other thing that gives me hope is, well is the fact that we actually can end HIV. There are a couple of jurisdictions in the US where in the next 5 to 10 years it really it's possible for us to get to very few HIV infections within those jurisdictions. And what gives me hope about that is that the American public has become so jaded about HIV and information about HIV. It's no longer front page news, But once we have proof of concept, once we actually end HIV somewhere first in the U. S, that's going to be huge news. You're going to get the American public reengaged in HIV again. We're going to get the federal government reengaged in HIV again. You're gonna have more resource is going to HIV saying, Well, if they were able to end it in this one place. Well, why can't we end it where I live on, But it gives me a lot of hope for us as we move forward that this is something that can absolutely be done. Oh, I love that I love that. So I just want to say thank you to both of you. You are Guys are or excellent as always. And it's always, um, exciting for me because every time I hear both of you, I learned so much more. I love it. So now I would like to close and just wanna first remind our participants that you're gonna receive a short follow up survey. I ask that you complete the survey. Your feedback is so important to us, and it allows us to continue to plan more programs. In addition, you will. You will receive a certificate of attendance as well as a tool kit that includes key takeaways from the program. Where to look for additional information. I want to thank each of you for taking time out of your day to attend this program. As I mentioned early on, this is our last virtual training Institute. These programs were designed to provide education and workshops with the goal of understanding the end the epidemic strategies as well as being able to address the challenges that we know we must in order to overcome and to sustain urgency and to further the progress around or tours and in the ending the HIV epidemic. So I asked that you be inspired by the presentations by Dr Black Spot as well as Mr Millet. And I hope that the workshops that you participated in that were informative. You are vital to the goal of ending the HIV epidemic. So I ask that you enjoy the rest of today as well as the upcoming holidays and be blessed. Thank you. Created by
