Chapters Transcript Video Evolving HIV Testing as the Entry Point to HIV Prevention Evolving HIV Testing as the Entry Point to HIV Prevention Originally Broadcast: Tuesday, March 30, 20215:00 - 6:00 PM EDT Mm, Hello. My name is Christopher Chance Watson, associate director of HIV marketing at Gilead Sciences. And on behalf of our employees worldwide, I would like to welcome you to today's plenary at the Impact Biomedical Summit. Our plenary is entitled Evolving HIV Testing as the entry point to HIV prevention. We at Gilead Sciences are truly honored and humbled to sponsor this program at the summit this year. In the next hour, you hear from an expert panel that we'll talk about ways to sustain the urgency of HIV testing in spite of the challenges posed by not only covid 19 pandemic, but all of the other systemic issues we know that challenges our delivery system. As we know, this is the first decision many make in the quest to get into HIV prevention, regardless of status. Also, as a reminder, we are happy to offer this program live in Spanish by clicking the link below. You can join that session right now. We thank you for joining us today, and as you look forward to all of the work that you're doing, we thank you for your continued dedication, commitment and tireless efforts. As we all work together, to end the HIV epidemic. And now it is my steam pleasure to introduce you to our moderator for today's program, the magnificent Marlene Magnus, who is the assistant director of the Division of disease prevention and control for the Houston, Texas, Health Department. Marlene, please join and please continue to take this conversation. Thank you so much, Chauncey. And thank you, Gilead, for sponsoring this very important plenary conversation is Chauncey said. I serve as the assistant director here at the Houston Health Department for Disease Prevention and Control, and later in this conversation, I'm going to be joined by two esteemed colleagues. Clover Barnes, bureau chief with the Integrated HIV Services division at the D. C. Health Department. And I'll also be joined by Dr Leandro Mina, the chair of population health science professor of population, health and medicine and director of the Center of HIV AIDS Research, Education and Policy at the University of Mississippi Medical Center. But first I'd like to just get us started talking through a discussion about HIV testing and where we are now and looking at where we are now. We're working to end the epidemic part of the work in ending the epidemic around the health disparities and barriers to HIV testing and my life. The importance of ongoing initiatives to reduce new HIV infections. The 10 year ending the epidemic, or E T. Plan, aims to reduce new HIV infections to less than 3000 by the year 2030. Reducing new HIV infections to this level would essentially mean that HIV transmissions would be rare and meet the definition of ending the epidemic. Four key strategies of the U. S. Department of Health and Human Services, or HHS, are as follows. Diagnose all people with HIV as early as possible, increasing the number of new and existing patients tested for HIV and highly impacted areas. By expanding outreach within those communities and increasing routine and risk based HIV testing of health center. Patients treat people with HIV rapidly and effectively to reach sustained viral suppression. People with HIV who take HIV medication as prescribed and stay virally suppressed will not transmit HIV to their sexual partner. Increasing the proportion of people with HIV who are virally suppressed is a key strategy to prevent new HIV transmissions preventing new HIV transmissions by using proven interventions like pre exposure prophylaxis or prep syringe services programs, finally being able to respond rapidly and quickly to potential HIV outbreaks. New methods allow us to show where HIV is spreading most rapidly and allows us to invest in geographic hotspots, using data to guide our decision making and supporting the establishment of locally tailored plans. There's also funding to drive this strategy. In December 2020 Congress passed and the president signed the fiscal year 2021 federal budget and includes funds to implement the ET Initiative 175 million for the Centers for Disease Control and Prevention to reduce new HIV infections. 207 million to the Health Resources and Services Administration rehearsal. Allocating 100 and five to deliver HIV care through the Ryan White AIDS program. And 100 and two million to provide HIV testing, linkage to care and prep and other associated medical costs to the health center's program. Five million to the Indian Health Services, or I H. S for an initiative to treat and reduce transmission of HIV and HCV in 16 million for the National Institutes of Health, or NIH, for evaluation activities to identify effective interventions to treat and prevent HIV. Lastly, the HHS National Strategic Plan was updated in January 2021. This plan complements the E T E initiative and it covers the entire country and has a broader focus across federal departments and agencies that affect all sectors of society. Next, I want to talk a little bit about how much progress has been made and achieved toward the 90 90 90 goals. But advances aren't even and much more needs to be done. I want to highlight the latest data from 2018 from the C. D. C. Strong progress has been made towards achieving the 1990 90 goals. 86% of people living with HIV in the United States know their status. Among people who knew their status, 65% were receiving HIV care. And among people accessing treatment, 56% were virally suppressed. However, more must be done to reach these goals in order to end the HIV epidemic. New York City is the only U. S municipality participating in the Fast Track Cities Initiative to have met the 1990 goals. Based on data, its numbers are 93% 90% and 92 as a 2019. As a comparison, San Francisco's numbers are 94 80 and 94%. As of 2019 in Washington, D. C s numbers are 87 78 85% respectively, as of 2019. In comparison, seven European cities, Berlin and six cities in the United Kingdom all have surpassed the 90 90 90 goals. As we come back with a focus on the United States again, we see that as of 2018, the rates of undiagnosed HIV are high, especially in southern states. For example, the rate in Louisiana is 17 to 20.3% compared to 7 to 12.4% in New York between 2010 and 2016. Southern states accounted for an estimated 51% of new HIV cases annually, even though just 38% of the US population lives in that region. In addition, the South has a higher proportion of new HIV diagnosis in suburban and rural areas, compared with other U. S. Regions closing unique prevention challenges moving on health inequities continue and are growing in the United States. A decrease in new HIV diagnosis overall has been observed, but trans vary for different groups of people from 2014 to 2018. New HIV diagnoses in the United States declined 7% overall, but trends vary for different groups of people. If trends of HIV infections from 2014 to 2015 continue. Approximately 41% of black men who have sex with men or M S M and approximately 22% of Latin X M S M in the United States will be diagnosed with HIV in their lifetime data from 2000 and 9 to 2000 and 13. The lifetime risk of HIV diagnosis is approximately seven times higher in black women and more than three times higher in Latin next women than in white women. As we look toward varying rates of undiagnosed HIV, we still see that this varies by population. The rate of undiagnosed HIV in 2018 was 14% for Americans. Overall, I was 17% for Hispanic and Latin nexus and 45% for you. The first is 5% for people aged 55 years and older. Again, these inequities continue to prevail, and this is what we've got to address next. I'd like to have a little bit of a discussion about the impacts of the covid 19 Pandemic 19 is exacerbating these racial disparities in communities most affected by HIV. This slide shows the disparities and the impact of covid 19 by race and ethnicity. The focus on the impact of Covid 19 among African Americans as we see racial and ethnic minorities continue to be disproportionately impacted by covid 19. The next slide really shows how the Covid 19 is also threatening the goals of the national ending. The epidemic plan we see. In a recent study of a large urban HIV clinic in San Francisco, they evaluated viral suppression and retention and care before and after telemedicine was instituted in response to shelter. In place mandates the odds of viral non suppression for 31% higher during shelter in place than before covid, despite stable retention and care and visit volume. Another study found that there was a 58% reduction in acute HIV screenings in Chicago emergency departments from January to May of 2020. However, efforts were made there to intensify connections to the emergency departments to enhance acute HIV infection screening and patients who were suspected of having covid 19, and ultimately between January and August of 2020 they were able to boost the number of acute HIV tests to approximately 20,000. The rate of HIV diagnosis was significantly higher in 2020 compared to the previous four years. Equal the number of cases identified in 2019 and more than doubled those identified in 2018, so again in 2020 good, effective work was done to diagnose new HIV infections. Despite the challenges of Covid 19, a commitment like that was done in Chicago is crucial in combating the threat to ending the HIV epidemic posed by the Covid 19 pandemic. Now what about the South? Changing our perspective in looking at a recent study, 2019 study in the South looked at barriers to HIV testing in the deep south of the United States, and the top five patient barriers were related to the cost of testing access to specialty care. Not feeling at risk for HIV infection, Concerned that HIV testing will reflect badly on them as a people concern of being judged by their clinical provider. When providers were asked to rank patient barriers to HIV testing their responses where patients were afraid of the results of the test outcome, reflecting badly on the patient as a person and being judged by the health care provider or HCP, or concerned that others would find out and not feeling at risk were ranked amongst the highest. This article really just highlights some of the barriers to HIV testing that patients face. And many of these barriers can be addressed through appropriate education, about risk identifying available resources and, of course, ensuring access and awareness of cost and coverage options Continuing on to talk about our current HIV testing, uh, initiatives and where we are, we look first toward our federal agencies, and many of them have initiated programs to reduce undiagnosed HIV efforts. And some of that work includes campaigns to educate the public and health care providers about the importance of HIV testing. For example, the CDC developed the Let's Stop HIV Together initiative. We also see that the get yourself tested campaign for youth was initiated and even the U. S Department of Veterans Affairs, the V a developed to get checked campaign for veterans and those health care providers. We've seen federal programs support state and local health departments with community based organizations to improve the availability of HIV testing and communities with the greatest burden of undiagnosed HIV infection, and also supports around research to improve the availability of testing, to improve linkage to care and to develop and deploy new and more efficient testing technologies. There are many examples of each of these agencies initiatives, and I'll only highlight a few C D. C developed and recommendations around testing algorithms. And that was very important for clinical providers and others not directly engaged in HIV To understand what's required in their settings about screening centers for Medicare and Medicaid services, or CMS, in coverage and quality of care for beneficiaries. As a matter of fact, CMS, it is the largest payer of healthcare coverage of low income people living with HIV in the United States. This is all encouraging news. All these efforts underway at the federal level. But what's happening at state and local jurisdictions? Let's talk about that at least 48 states. As I demonstrate on the next slide, 48 states have plans in place or in development around e T. E. 25. U. S cities have joined the fast track cities initiative as of December 2019, and those initiatives commit to meeting the UNH targets. These are the same as the 90 90 90 goals, and these also include 10 cities in the South. Atlanta, Austin, Baton Rouge, Birmingham, Charleston, Columbia, Dallas Durham, New Orleans and San Antonio. Even in December of 2019, immediately following this summit in Houston, Houston signed onto the Fast Track Cities Initiative as well. And while each city and region will offer different approaches, each has the same goal. Ending the epidemic. Mhm. And what about community based organizations? This next slide I'll talk about what we've seen through the CDCs National Prevention Information Network. More than 10,000 organizations in the United States currently provide HIV testing services, and among these, 86% offer conventional blood HIV testing, 40% rapid blood HIV testing and 400.4 mobile testing 0.3 rapid oral HIV testing. The statistics show that there is an opportunity here for community based organizations to evolve testing technologies to reach people where they are. And, for example, home HIV testing has been found to increase the number of people who take an HIV test, as well as testing by people who are most vulnerable to HIV. In response to Covid 1956% of providers reported having provided clients with home HIV test kits, with an additional 21% planning to offer home HIV test kits in the future. In the private sector, pharmaceutical and diagnostic companies are also committed to ending the epidemic through its own initiatives and partnerships around increasing access for HIV testing. And I really want to close this slide by highlighting a great quote from one of our local partners him here, Uh, Jen whaddaya And when she reminded us that we're at a moment here in the United States where we have to consider a revolution in the way we bring HIV prevention and care services out to people spring. And with that, I really now want to help us move and focus on, uh, initiatives in the South and in Washington, D. C. Uh, it is my pleasure in my excitement, to begin with the spotlight on Washington D. C s testing initiatives. Allow me to introduce you to clover. Barnes Clover, as I said, is the chief for integrated HIV services and the D. C. Washington, D. C. Department of Health. Excuse me. She has a very distinguished career as a nurse, leader, healthcare administrator and beginning in Connecticut as a pediatric nurse. Through her subsequent roles as chief operating officers at Milwaukee Health Services and a senior principal consultant for community health connections. Over has received numerous accolades and awards that recognized her achievements and, most importantly, her commitment. Health care for all. Welcome Clover. Thank you so much, Marlene and really Clover. There's so much to talk about in terms of what you all have going on in Washington, D. C. I'm so familiar with many of your programs, but today I hope you can highlight and share a little bit for us about your sexual being dot org campaign. It seems to have had an incredible impact on people living with HIV. So can you share a little bit more with us about it? Sort of its purpose, its its its background. And what are some of the lessons learned you've had from that program? Absolutely. So our sexual being campaign really wanted to normalize talking about sex, you know, people are going to have sex, sex. It's good. It's not a bad thing. We don't want people to hide the way they talk about it. The way you have sex is perfectly good and well, and we wanted to reflect that in our campaign. So our campaign used people from the local D. C area, some staff, some friends of the Department of Health to really, um, kind of have people see themselves in the campaign. And so we had every different type of partnership or relationship you can think of highlighted in our campaign, and then we really wanted to make it more normal. It was really about normalizing the way we talk about sex. So we had happy hours and, um, speakeasies and really kind of relaxed kind of conversations where you could play trivia you could hear from a go go band. But the whole time you were getting some type of education or some type of normalization and talking about sex and the things that you do and making it really normal to know your HIV status and to be comfortable talking to healthcare providers and others about the way that you choose to have sex, we really wanted to highlight or reach out to African American women and men um, gay and bisexual men who have sex with men, our Latino population, transgender persons and really just let everyone feel really comfortable in who they are and being who they are and having sex in the way that they choose to. Yeah, that's really one of the things that I think I love so much about the campaign. Is it sex positiveness? I mean, it really is about not being afraid or ashamed to have the conversation. I mean, we're all grown, uh, and it's something we all do. And so the way that you've sort of been able to infuse for work around prevention as well into that campaign is extraordinary. What would you want to share with other programs about how they might be able to replicate, uh, some of what you were able to do and accomplish to that program in their own jurisdictions? So we really want to make sure that people know that it's okay, And I think for that you have to kind of know your audience, right? So if you're in the deep South, you know, having a billboard with two men on it might not be as comfortable, you know, to start. Maybe you'd get there eventually, but you start someplace that's an area of disruptive innovation, but something that will allow you to continue to grow your campaign. We also wanted to make sure that we were kind of hitting all different targets and parts of the city and parts of the area so that we wanted to normalize people asking for the test or knowing their HIV status. Just like you know, your blood pressure. You know your height and weight. When you go to the doctor, you should know what your HIV status is and make it normal for you to talk to your provider about that or to seek out those services, regardless of if you think you're at risk or whatever. It's just normal for everybody to know their HIV status. And I'm glad you brought that up because that's another campaign that I think has been quite successful for you all. And we tried to emulate many components from that campaign and some of the work we're doing right here in Houston and in Texas, the ask for the test campaign as well, where you know people may assume, as we all know in this industry that you know when I go to the doctor, I'm getting my routine or annual checks. I'm getting screened. And the idea that No, no, no, that may not be the case, depending on your provider, depending on the state. Depending on the laws where you live, it's better to ask for the test. And so can you share a little bit with us about that campaign as well? Because I think that's just a powerful initiative. And you all have had that going for many years now. Yeah, and it's something that we we wanted to normalize, that we had it included, Um, as part of your ER visit or whatever you do that you would get an HIV test as part of your normal panel or work up whatever that you were going to the doctor for or seeing your provider for, and that it shouldn't be taboo. It shouldn't be something that makes you afraid or nervous. Or, you know you're feeling like you're out of the ordinary because you're getting HIV test. It's just like getting a complete blood panel or a CBC. Whatever you're getting, it's the same. It's the same aspect that you need to know that about your health is part of being a healthy, healthy and well person. That's right. And so I've also heard, um, that you all have some plans around the future of HIV testing or or some of the initiatives you have going on there. Can you share a little bit with us in the audience about what's up next for D. C. What do you have? Exciting in the future? Sure. So this past summer, we launched home testing initiative called Get Checked D. C. And it was in response partially to, um, the covid 19 pandemic. But also just because, as you spoke about in the earlier slide, it's a great way to get people who are afraid to go to the doctor or going to a provider to get tested. Um, as I spend to the, uh, the whole testing you can get S t I or HIV testing or both, but you also can get an order sent to like a lab corps office or a lab provider and walk into the lab and get your test done. And then we would call and notify the folks about their status and make sure they follow up with the provider. So just ways that you can think outside the box and get your testing done without necessarily having to walk in face to face with a provider. Especially when the pandemic started because a lot of folks weren't doing testing. A lot of tests had just stopped at that. So thank you. Clover. Uh, so hold tight. We're not done what you get. I appreciate you giving us a little bit of insight about your programs there in Washington, D c will come right back to you. Uh, let's move on. Next to have Dr Leandro Mina share a little bit of what's going on in Mississippi. And so let me introduce Dr Leandro. And he is, as I shared earlier, the Chair of population Health Science, the professor of population, health and medicine and director of the Center for HIV AIDS Research, Education and Policy at the University of Mississippi Medical Center. He also serves as the STV medical director for the state of Mississippi and co founded Open Arms Healthcare Center, the first LGBT clinic in Mississippi. And so thank you for joining us today. Leandro. Thank you for having a great pleasure. And, you know, I know that you did a lot of work in helping to co found both open arms as well as my brother's keeper. And I really wanted to offer the opportunity for you to share a little bit with us in the audience about your work and the work of those organizations and why they're so critical and why you chose that is your mission to help get those organizations off the ground, right? You know, I think you know, it's it's kind of some of what you said in the introduction. You know how we need, You know, space is that really, you know, are places that people want, you know, to visit. And, uh, I think you know, open arms. In many ways, it is, really You know what happens when you have, you know, ingenuity, you know, combines with determination, you know, to address the needs of the population. And in many ways, the Marois keep, you know, as a community based organization, really, you know, has shown the way of community. Basically, what community based organization can do to, really, you know, contribute to the care. Continue. You know, open arms came up as a testing side. They consulted, you know, with the community about what kind of clear they wanted, What kind of services that were interesting, How that should look like one of the key things that we are learning the processes that people didn't want. Just an HIV test, you know, people wanted, you know, health, You know, an assessment. You know, primary, primary prevention, health and assessment and what they come up with, You know, it's something, you know, come called becoming a healthy you, which was, I think, photos idea that combines, you know, an assessment that was free. That included, you know, uh, blood pressure, you know, a BMI glucose, cholesterol, gonorrhea, chlamydia, syphilis, HIV later on the r B hep C screening, you know, And that was a package when people came in in many ways, you can call it. It was an HIV test wrap around, so people didn't feel stigmatized. But also the deliver, you know, much more than an HIV test. So I think, you know, that was a great concept and very unique around and around that, you know, a clinic that really was the reflection of a whole community was really big, and I think that that's a success in the same way later on. We have learned from that process, and we continue to consult with the community about what's missing, what do you need? And we were learning that people were interested again in a fast confidential services. People in the South are very concerned about their privacy and the confidentiality. People you know don't have time to spend a half day in a clinic, especially when you don't have, you know, paid medical leave, you know, to get tested for STDs or, you know so in many ways, you know, press personal health, which is the second test inside that we have in the city of Jackson. What's the result of a partnership of corporate? You know, academic and public partnership to really offer exactly that. It's a nurse driven testing, only cleaning where people can go in and out, and we think 30 minutes get tested for HIV, gonorrhea, chlamydia, syphilis, happy and Pepsi. In addition, people get the opportunity to register for future participation in clinical research, and I would say about 75% of the people who come in, you know, want to participate in clinical research and very often get called, you know, for that opportunity. So again, it's about overall, you know, asking people learning, you know, listening, you know, to our community, you know, how should we do this better? You know what makes sense to you and really, you know, using that information to to redesign, you know, and to modify the services, you know, that we provide. And you shared so many golden nuggets there about what other programs can do sort of replicate some of those successes in their own jurisdictions. So I oppose that question of clover and now to you. But you shared so much services are free. Uh, really asking community. What should those services and what should the clinic and its atmosphere and all of it, What should it look like to them And really getting that guidance and feedback directly from the people you're trying to serve, I think is absolutely critical and important. So thank you for highlighting the work that you did there. And then, of course, you know the confidential nature and how we go about service implementation. That's really, really important, particularly in communities who already feel exploited and are already, uh, marginalized in many ways and being able to be supportive in your care delivery in that way. So thank you for highlighting that, and, you know, I really want to ask, but it sounds like there's so much that might be going on there that you've been able to accomplish in Mississippi. But what would you say would be the one testing initiative that's had the most impact on the community in Mississippi, particularly in rural areas? You know, it's gonna be very simple. You know, rural areas are particularly challenging because it's not about having access, you know, but having access that people are as comfortable, right? You know, accessing. You know, sometimes there's the issue of there's a neighbor. There's an out there is someone who knows me, You know who may work there, and that will be enough for people not to come. You know, the health department, You know, um, in Mississippi since the early since the late 19 nineties, you know, instituted routine, opt out HIV testing in all the health department clinics, and for me, that is the most effective, you know, a strategy that Mississippi has had. Unfortunately, you know, because of reduced, You know, um, funding to public health funding. Many of these clinics have had to close and from having over 105 you know, county clinics where people could walk in and get I mean, and the moment you walk in, you will get a free HIV test, right? As part of routine care. You know, many of these claims have closed. Now there's limited, you know, service because of Kobe. It, uh, the fewer claims are open have now limited, You know, the hours of operation. And I know that in certain, you know, areas there's a weight of about six weeks to get tested, you know, in the health department clinic. So So So in principle, I think routine HIV testing, you know, opt out Testing is the best strategy that we have ever had. In addition to that, I think, you know, to several populations we are exploring, you know, a number of alternatives. Many of the community organizations open arms, for example, is about to launch a statewide campaign to promote, um, especially prophylaxis with home testing. But have in mind that as we think about vulnerable populations and we're sending a test home. You know, who are the people who actually can receive a package, you know, at home so they can get test and no one will open it up and say, What is this? I mean, so it's important to test different strategies. I mean, other organizations like open arms micro Skipper also care for me with Jackson Medical Foundation have been testing mobile clinics, you know, to go into different communities and partnering with some of the colleges and universities are located rural areas to try to attract youth to this is but again in rural areas. Uh, the stigma. And I think that in the gender and sexual minorities who live in rural areas are so vulnerable, right to losing the little support that they have from their families and the communities that they really can't afford. Right? You know, being out in a way that things will be a lot easier in, uh, in some of the urban you know, centers right where you can Carola go from one place to the other and that maybe people would not know what you're doing. That's right. That's right. And I'm glad you share that about Some of the uniqueness is of how we go about the work of how we should go about the work in rural communities. And so you may have spoken to it already just now. But looking forward to the future about what are some of your future focus areas or priorities around testing and and population groups? Who are you looking to really hone in on in Mississippi and offering quality services to death? Uh, well, centrally, you know, many men you know are important. Important population always continue to be a per will continue to be a priority. But there is a, you know, some new recognition, right, that black women are in particular risk, you know, of HIV and, uh, and and and Jackson. You know, not everyone knows that Jackson has the highest rates of HIV infection black women among all metropolitan statistical areas. So we really are, you know, trying to go working with health care providers to again routinized HIV testing, make sure that everyone has access to HIV test everyone that makes sure that everyone is offered an HIV test. Um, the other thing is that we don't have a large Latino population in Mississippi. Behold. But we have a fast growing Latino population in Mississippi and that includes, you know, made us with men. You know, many individuals who are undocumented that because of, uh, policies, you know, that we have, you know, have tremendous, you know, mistrust not only for health care settings. There is tremendous governments trust, you know, that. Really Florida kind of a pushing further away from the opportunity to be, you know, engaged in care, uh, tested and engaging in care. Yeah, and thank you for that. And you're right about, you know, the ever evolving nature of our communities and our populations. And it's important that we, you know, stay abreast and stay aware of the trends. You know what may have worked around testing initiatives and strategies. You know, a decade ago, we may need to change and really pay attention to the needs of what's happening in our communities today. So thanks for alluding to that as well. So, uh, Dr Meena, the same instruction to you don't go far. We're gonna transition now. Uh, and have you come back in a few minutes? I am going to go back and share a little bit more about some of our work in the state of Texas. So we've heard from D. C. We've now heard Dr Mina talk about Mississippi so I'll share a little bit about some of the work that's been underway here in Texas. Uh, thinking firstly of the work around the Texas HIV syndicate that actually serves as our statewide H I V S. T. I, a community planning group and again drawing from broad recommendations in the Texas HIV plan and other related documents are members of the syndicate make policy and system and practice recommendations create tools to regional stakeholders to address HIV and other S. T. I. S. It acts as an advisory body to the Texas Department of State Health Services, or DSHS. But what I think most important in terms of highlighting the work that they have done or the resources that have been created by that group The Texas Routine HIV Screening tool kit, which helps support the adoption of routine HIV screening, as Dr Mina mentioned, is underway in Mississippi, has been underway for many years in Texas as well. It provides information on how to address barriers to testing consenting billing, uh, delivering results. Linkage to care. Another important resource, I think that's come out of that group is conversation starters, which are basically one page documents similar to flyers that helps support linkage systems that our client centered and responsive to circumstances and needs. Essentially based on recommendations coming from the field staff in our community that really harness the power of leaving and getting out of the office and into communities with resources and information, using lure technologies on how to communicate with clients and so on, Making linkage to care a bit easier The Texas Black Women's Initiative is another important, uh, group and strategy I'd like to highlight. I was one of the founding members of this initiative in the state of Texas, and what has been incredible about the work of that group is the way in which they have been able to mobilize various communities. You know, Texas is a very unique state. We are big cities, and we have very rural areas. And so, trying to meet the needs of each and every individual community be a challenge if your approach is one, uh, from a state level. And so the Texas Black Women's Initiative really seeks to work with community based community level groups in their own geographic regions on strategies that make sense, uh, for them. And it has been exciting to watch the work of that group, Blossom and Globe. And then finally, I'll talk about the test Texas HIV Coalition again. Our department was one of the founding members of that coalition in creating a statewide network of experts who promote and adopt routine HIV screening in health care settings. And so I think part of what Leandro said has been one of the most important successful strategies. I would definitely say the workaround routine screening in Texas we don't necessarily have a law or a statute that promotes and requires the mandate around routine screening or the offering of routine screening even. And so, unlike some of your cities and states. So what we've been challenged to do is make sure that health care clinics and providers are aware of CDCs recommendations around screening in healthcare settings and really getting them practical peer to peer for how to get that done, and one just to highlight a recent success, because I could not pass up the opportunity, but locally here just in January 2021 working with our Harris Health System here in Houston, they conducted their one million health department funded routine screen. So between August of 2000 and eight and January 2021 they conducted 1,002,357 tests, and they've identified 2304 new infections. Important important work, a new positivity rate of 23040.23%. This rate is more than twice the 0.10% recommended, uh, for minimum implementation of routine HIV screening. So I just I have to say congratulations to the Harris helped team past and present All of the work that's been done over there, uh, and again has been one of the most successful strategies that we've seen, uh, in Texas. And so with that said, we've learned a lot now from what's going on in successful strategies with, uh, d c. Mississippi and Texas. So really, I want to open it up for a conversation on these opportunities and where we might be going in HIV testing. We've covered where we are. But how about some discussion about the future of the work? So both clover and Dr Meena shared a little bit with us about their their plans around moving forward. But I really wanted to move it up and and really offer opportunity for a discussion about other successful programs that we may be aware of that maybe out and doing great work. So I'll just put it out there to both Clover and Dr Mina tell us about any other success stories, particularly rural programs. I don't want to pick on you per se, Dr Mina, but, uh, what are some other programs in places around the US that you know have been able to be really, really successful? Uh, either in rural south or just real parts of America. So I think, you know, again, you know the number of problems that really, um um are understanding, right? You know that individuals who are living with HIV nowadays were not fully engaging care, you know, perhaps, you know, that's not happening. Not because they don't want to, but because, you know something is keeping them from that. I mean, ideally, we all want to have really good health and that there are a number of programs you know, that are in the country. I mean example, I think probably the region won the Max Clinic in Seattle. You know, they have low, very access clinic. Bander bill, you know, has a clinic, You know that that really gives this, you know, strength based, you know, approach to identify those people who are not fully adhering to medication. Uh, that has taken a more really patient center approach to address the social determinants and similar to that we have, you know, again, through partnership that includes, in a corporate, you know, academic and public. We have a program in Jackson called All in. There is, um uh, in many ways, uh, embraces, you know, those individuals who are out of care who are not adhering to medication, who should not show up and tries to mitigate the impact of the social demands of health, you know. So what we do is that we recognize that many people when they have to make the choice between coming to the clinic because they have to their labs, you know, or missing income because they don't have, you know, paid medical leave, you know, they're gonna go to work. So what we say is that you know, Let us, you know, help you with that. We give people about $50 you know, for coming and doing their labs. Either Barlow is suppressed to give an additional, you know, compensation. Because again, you know, for low income individuals, you know, participating in the care is expensive. It's much more expensive, you know, time for many of us, right? Who have health insurance, who have, you know, vehicles who have, you know, a support system. So we do, from transportation to childcare, to addressing food insecurity in many different ways, uh, to providing, actually, you know, a financial incentive not to be able to support people. And that is also combined with intense case management. We have a team of a amazing, you know, case managers who basically, you know, develop a close relationship with patients and are there in the corner all the time, you know? So that's an example. I think that that against some of the recognition that in order for us to end the HIV epidemic for all, if you think about the 90 90 90 you talk about right, once you do, 90% of 90% of 90% you're left with 27% of people who are not quite there. Right? So it's not fair, right? That we, uh Except, you know, that they may not be able to reach the same kind of a degree of, uh, you know, wellness, right? That everyone else So So that's kind of one of the things that I've seen emerging in the country that I really I'm really excited about because it's a recognition that for some people we just really have to do more. And we have to just accept that. That's right. That's right. Thank you so much for highlighting that, by the way, because I think you know people that have an expectation. We're having conversations around HIV testing and testing as a as a clinical service. But really, the success of these programs and what we're talking about that really has impact on individual the health outcomes are the other sort of soft services that are required and necessary. I even dare not to call them soft. They're necessary in order to ensure that we've moved everyone along the way toward these better health outcomes. So I appreciate you describing some of the work around partnerships and incentive, ations and all of that that that's required to be successful in these programs. And so I guess I'll go to you next. Clover. We've spent a lot of time, I think, in our individual conversations about the work that we're doing on best practices and some of the things that that work and I think early successes. And, you know, Dr Mina alluded to it also that, you know, we're testing different models, if you will, around home based testing, integrated testing, what are things that we can we can bundle together to be able to offer a more comprehensive service people. And so can you share a little bit about your home based, uh, testing strategy and really, the house so many places around the country are, you know, they heard about it. They, you know, heard some success. They don't know how to get started. Maybe you can share a little bit about, you know, practical steps that programs and people might be able to take to help get that kind of a program off the ground, You know, regardless of model. I know we're testing new things, and it's relatively few for some of us But I just thought you might want to share some practical tips around home based HIV test. Sure, absolutely. So we partner really closely with our regional partners in Maryland and Virginia because we know that people play and work across those jurisdictional lines. And so just doing something in D. C. Won't have the effect that we needed to. We really have to be strategic and work together as a region to try to get those things done. And so our partners in Maryland or Virginia, uh, started some home based testing earlier, and we were able to learn from some of their, um, information. There's also information on the Web from other folks have been doing it. So we kind of knew some mistakes not to make you know some things to think of another kids to have a great testing coordinator. So shout out to my testing coordinator back at D. C. Help and um, to have somebody who really is focused and can get it done. And then we really have worked to hire people who look like the people that we want to target. And so some of the people who work with the testing coordinator to make sure these things go out and to answer Some of the calls are people from the community, people who may not have had the training and all those things that we necessarily want them to have, but can do some really good peer to peer access and introduction to information and can really learn and build their own skill set and become a very useful asset to your ending the epidemic campaign because they're able to infiltrate the community in a different way than many other people can. And so we have some of our we call them health impacts specialists working with our testing coordinator to work on these testing initiatives to make sure they're appropriate and that they're going out in the correct manner, the correct language. You know, when you're talking to somebody, sometimes you can turn people off, depending on how you speak or how they speak. But really meeting people where they are as best we can. And so I think you know, if you can look at your resources right now, we offer it for free. We don't charge anybody for our testing for home testing or for the lab based testing. But we will, uh, you know, for sustainability we will have to build if people have insurance, but we don't turn anybody away. Um, And so I think if you can, you know, isolate some resources in order to kind of see it and get it started then, um, it pays dividends as you go. We have sent out more than 1000 tests in the sixth, almost nine months. Now that we have been working through this initiative knowing that we started during the pandemic, you know, we weren't sure how quick the uptake would be, but it's growing rapidly, and it's it's showing dividends right away. It was encouraging to hear more programs, uh, think about how they may be able to offer home based services. You know, given where we are with the pandemic and what's happening in many communities, it just really has ignited, uh, some innovation around. How do we do this work differently? How do we sustain, uh, some of the gains that we have made? And then, as Dr Nina described, how do we bring everyone else along? And that takes creativity. And I'm glad you talked about resources as well, and being able to identify some supports to get things going. Uh, and that may not happen with availability of funding you have now, but maybe partnering and thinking through partnerships and other creative ways that we link with the private sector and others to be able to to do some of that work. Um, And then I guess before we transition to open it up for everyone else maybe, uh, one of you, Uh, and I'll let you pick, can talk about how can we, um, truly describe for our communities the value of adopting or adapting status Neutral approaches when we're creating HIV testing programs. You know, there's always a next step, if you will around someone who may test positive and learn that they are living with HIV. But what happens to the same, uh, marginalized folks who are, uh, still at risk? They just happen to test negative on this test. So just wanting to have one of you address that idea around a status neutral approach in HIV testing, you can start, I think I think it said right. You know, the most important thing is that we're taking care individuals, you know? I mean, people and the same person who test positive for HIV is the same person you know who was before HIV negative. And the status to approach right to HIV prevention is one that is, by nature, less stigmatizing. And if you recognize, you know the tremendous power the stigma has. You know, HIV stigma has in preventing people, you know, accessing, you know, testing services, accessing treatment. You know, we really have to think about and going back to some of the world that we have done and many everyone has the right. It's about building services, you know, Uh, that has less, you know, there are less stigmatizing, right? You know, creating, you know, training, you know, staff. You know that uses communicates with patients in a way that they are less stigmatizing, you know? So So I think that that's the benefit of a status neutral approach, you to HIV prevention and the delivery of the services in general. If I could answer that as well, we do some status neutral programming in D. C. We started with the regional early intervention services program, where we really set up continuum that runs from prevention to viral suppression and really looking at. There's no wrong door to enter into the system. But we also know that if we watch negative people who are at risk for HIV or get tested regularly after a certain number of negative test, they're going to Syria convert And so how can we stop that? How can we stop that process from happening? How can we ensure that the engagement that they have, that they're comfortable enough to keep coming to the clinic and get those tests and get that education can continue despite the fact that they are, you know, having these practices and what not right. So if they cereal convert, they shouldn't have to go to a different part of the clinic and deal with completely different people and build new relationships. You know, that seems to be not the best model going forward, right, the best use of our resources. And if we can partner with organizations that have the capacity to do both, why not train them to do both and braid the funding in a way that they can be both your prevention and your care person, regardless of if the person zero converts? So we've really worked to implement some intensive case management for people who are high risk negatives and really to lead them to prep or lead them to things to health and education and things that can reduce their risk but also not turn them away. If they do serial converter and they can deal with those same peoples and those relationships that they built to continue to, uh, get care and be their best and and safe itself, that's right. That's right. And so I definitely wanted to make sure that we got to the audience. And I know there are questions coming in, and so I want to take one from S. Jones. And the question reads, Should we vote or mandate that HIV and other illnesses be automatically checked at first and annual visits to healthcare providers, clinics and hospitals? You know, I think we can mandate a lot of things right. So we have lots of mandates and and usually, you know, sometimes it takes some time to ramp them up and get them started. You know, I think there are ways to get it out. Mandates are often hard to enforce, you know. So you know we can make all the mandates we want about certain things, but really, the enforcement of it is what may become the biggest issue. But I think it it lies in education and building relationships with the providers and your your community and really helping them understand and be educated and what it is and why it's important to have that testing upfront and just to include it as part of your regular normal panel and work that you do to ensure that you're normalizing it for everybody, not just these people, not just those people, but for anybody who comes through your door. I think it's the best approach we can take right now. Absolutely thanks for that clover, because that's one of the things that we've been working on in Texas is really ensuring the routine offer that at least everyone who comes to the door is offered an opportunity. I'll take one more question from the audience before we have to wrap up today. I think I have time to squeeze in the question from S. Culbertson. How do you balance the wants of your communities and constituents when they asked when what they ask for is in direct conflict with States or local statutes. So how to be responsive to communities, even though the laws of the land won't allow for that to happen? Mm. I mean, I think that's an interesting thought to you. Look like you were going to go ahead, doctor me and I'll let you go. You're probably a very qualified and I am. But, I mean, I will say that that that that's the power of the community, right? You know, the community can do the advocacy for changing and all the laws. You know, uh, in a way that very often, you know, as healthcare providers, you know, we can do right. You know, we very often go to the community and work with them and given that and given information, right so they can lobby, you know, for those you know, necessary changes that need to take place in order to improve the care of the community, the quality of life and services for the community. Right and good policies should be driven by good data. And one of the things that we try to do, at least in my seat here at the Health Department, is provide good data to communities and constituents about. You know what are, uh, what's working? What's effective in programming and what we see is happening with disease transmission and so on. So that information that data can be provided to communities and constituents lay people who can do what they will with that information, with sharing and lobbying to our policymakers and people that have the final say so on those laws. And so I would absolutely echo what Dr Meena shared and let me just go ahead and wrap it up. I just have to thank you clover. Thank you, Dr Mina, for being here with us today and sharing these outstanding, uh, practical tips around successful HIV testing initiatives in your states. And it was inspiring and informative, informative to learn. And so I hope community organizations and community members have learned something through this. Talk about how they can duplicate some of the success of these programs and especially want to commend, uh, Dr Meena and doctor and Clover. I'm almost gave you a title, Doctor clover, uh, that we especially commend you for your ongoing leadership and dedication. Also want to thank Gilead Sciences again for sponsoring this program, Their passion and commitment for this work and supporting ending the HIV epidemic, uh, is phenomenal. And thank everyone of you for attending the session today and keep providing the same passion, commitment, dedication that you are in your communities. I love this conference. I love the members to this conference. And so don't forget to complete your post program survey. It is important for us. It will be arriving via your email. Your feedback helps us to strengthen future programs. And in closing, I'd just like to say thank you for your awareness and together. Let's continue working towards ending the epidemic. Yeah, yeah. Created by