Chapters Transcript Video The Potential of Telehealth in Helping to Address Barriers to HIV Care Health Disparities and Telehealth - Alleviating or Accentuating the Problem?Originally Broadcast: October 15, 202012:30pm ET - 3:00pm ET Hello. I'd like to welcome everyone to our second blueprints for Success Training Institute. I am Dr Ayanna Elliott, a family nurse practitioner and senior medical scientist with Gilead Sciences, and I will be your moderator for today's program. Today's program will address the opportunities that telehealth presents an overcoming barriers to HIV prevention and care services for population groups who may not be reached well through traditional means. Briefly. Here is the agenda for today's program. We'll have to 20 minute presentations and 2 30 minute workshops. Our first presentation will be given by Dr Michelle and Drastic and it's called Is telehealth alleviating or accentuating health disparities that will be followed by a workshop telehealth implementation. Our second presentation will be given by Dr Rob Stevenson and is entitled The Role of telehealth in ending the HIV epidemic. That will be followed by another workshop on tele health and the status neutral continuum. Mapping the patient journey after our second workshop will all come back for a panel discussion in Q and a session on the content of today's program. You'll have an opportunity to ask our faculty questions. Please remember to click on the button below your screen to submit a question at any time throughout the program. Those questions will be saved for our Q and A discussion near the end of today's program. Now let me introduce the Training Institute, Siri's and provide a brief overview. This is the second in a four part Siris of our blueprints for success training institutes. You can see here the list of topics in the dates for the remaining programs. All of the programs follow the same format as today's program. With the combination of presentations and workshops in the discussion, we hope you'll take the opportunity to join us for each of the remaining programs. Now let me introduce our first presentation and presenter. Our first presentation today will be given by Dr Michelle and Drastic. She is the director of social and behavioral sciences and community engagement at the HIV Vaccine Trials network. Doctor and Drastic is also a senior staff scientist for the Vaccine and Infectious Disease Division at Fred Hutch and a clinical affiliate professor in the Department of Global Health at the University of Washington. Dr Andras IQ is an expert in community based participatory research and qualitative methods research she has led a robust social and behavioral sciences research agenda for the H V t n. For almost a decade, she has X offensive experience facilitating training on implicit bias, stigma, microaggressions and trauma to researchers, community based organization, staff and health departments. Please welcome Dr Michelle and Jurassic. Thank you, Dr Elliot. Really appreciate the introduction. And I want to thank everyone for having me here today. Um, I will start really with highlighting the disparities that we see in HIV and then go into telehealth. So HIV has always highlighted the factors that drive health inequities around the world. In the US alone, there are an estimated 1.2 million people living with HIV, and about 14% or one in seven of those people are unaware of their status and really in need of HIV testing. Although to 2018 data indicated and overall 7% decline in new HIV diagnoses, this decline was not experienced by all groups, and some groups and certain geographic areas actually experienced increases, particularly black and Latino X, m s m and the Southern U. S. We know that current health equity inequities, um, in the next slide. Please are driven by several factors and that individuals who have devalued identities are in specific regions of the country and are resource poor and much more likely to experience negative health outcomes. And here we have a list of the various factors that are implicated in the health inequities that we see. This list is not exhaustive, but these factors certainly drive the inequities that we see, um, in HIV access and care. So as we continue, what what do we mean by health equity? I'm gonna be talking about this quite a bit, and I think the Robert Wood Johnson Foundation offers a really good definition. And, um, here you can see that their definition outlines health equity as a state in which everyone has not only fair but just opportunities to be as healthy as possible. And as we move on, we see that the major factors impacting one's ability to be a suhel Theus possible our experiences of poverty and a rural existence. In 2018 we saw approximately 2.6 million Americans who are working full time jobs living at or below the poverty line, and this group of individuals is disproportionately comprised of black, African, American, Latino necks and native and indigenous peoples. Black and indigenous peoples have been hovering around 25% poverty for several decades now. And we also see that you know about 47 million adults live in rural areas, and these individuals who are living in poverty are faced with transportation issues, health care, access issues and insurance challenges. So I think that's really critical to think about the implications of rural residents. And then if we move on and we look at what is going on in the Southern states of the US and this is really outlined incredibly in several publications, um, that have been written by Gregorio Millette, who's with Amber? I am far on his colleagues, and they really refer to a sendem IQ that is occurring in the United States. And this endemic is the convergence of poverty, rural health care challenges and higher HIV prevalence. And you can see that at the end of 2017 Southern states represented 51% off new annual HIV cases while representing only 38% of the population. And then, if we look at the following illustration, this really, um shows how this endemic is playing out and this again is from Gregorio Millette. And you can see here that there are overlapping socioeconomic and health conditions that converge to create inequities and a disproportionate disease burden for black communities in the South. And we could do the same thing for Latinas, communities and native and indigenous communities and see pretty much the same maps. Um, so we are really faced with Sendem ICS, uh, that are overlapping, that really drive disease and are the foundation of the health inequities that we see. And if we move on, we look at we can see all of us who have been working in HIV for decades now have seen incredible advances in HIV treatment and prevention, the identification of new effective tools. So it's clear that these tools are effective. But what is also clear is that they are not benefitting everyone equally. We're not seeing equitable distribution and utilization of these tools. We continue to see disproportionate incidents rates among African Americans who comprised only 13% of the US population. Yet African Americans and black individuals represent 42% of new HIV diagnoses. And then, if you look at Latina chicks, populations who comprise 18% of the US population. They represent 27% off the HIV diagnoses that we see. And these disparities Wyden exponentially when you look at other devalued identities like sexual minority identity, where we see adult and adolescent men who have sex with men comprising 70% of new HIV diagnoses in the U. S. And the dependent areas. And these air even magnified MAWR when we look at gender minority individuals with the current reality of transgender people being an experience where HIV diagnosis rates are three times those of the national average. And as we continue to look at these intersecting the values devalued identities, we see that the stigma and discrimination faced by racial, ethnic, sexual and gender minorities served to create conditions and circumstances where each devalued identity and individual has is more likely to result in the experience of stigma, discrimination, violence and victimization, all of which increase one's risk of exposure to HIV and at continuing. We see that this is particularly true for young people with intersecting devalued identities among youth, we see lower rates of testing, resulting in fewer young people knowing they're HIV zero status. This results in delays of entry into care challenges with retention in care and lower rates of viral suppression. So it is really a domino effect where young individuals are not identifying their zero status, and then it sort of cascades into, um, advanced disease and challenges with viral suppression as we move on. And then if we look at the U. S. Communities with devalued identities, we all know carry a legacy of violence, victimization and trauma. And there's been a lot of research that has shown that this trauma is passed down over generations, often referred to as intergenerational or historical trauma. And researchers, many of them who are native and indigenous, have found that this trauma can be embodied or held personally and may result in something referred to as heightened stress vulnerability. And this heightened stress vulnerability might impair and individuals ability to cope effectively with stressors. And think about the implications of that. If you are a person with a devalued identity who, um, consistently faces challenges and stressors because of your identity, and then through this legacy of trauma may have challenges with effectively coping with that trauma. It results in quite a bit of stress and has implications not only for physiological health, but emotional and psychological well being as well. And there is no doubt that this legacy of trauma, which impacts not only the individual, the family and the community it's implicated in the health inequities that we see in communities of color and in sexual and gender minority communities as well. And then, if we look at HIV prevention and treatment, which is the next slide, we can see that those of us who are working in HIV often work to identify effective tools and strategies that can move individuals on the treatment side from being in situations of heightened risk to circumstances and situations where one is effectively engaging in HIV prevention and then on the HIV treatment side. We are always working to move someone through knowing their HIV status and being connected to care through viral suppression. And so this is sort of, uh, for those of us who are in HIV prevention and treatment, the continuum that we are always focusing on in terms of getting our communities to the health and well being. Um, that is, um, you know, at a level where we don't see the inequities that we currently see, And so if we continue, what we have seen is that trauma, violence, stigma, victimization, racism, transphobia and all of the beliefs, biases, actions that marginalized individuals and create a myriad of social and structural factors that individuals with devalued identities face on a daily basis. Create barriers all along this continuum. And so place individuals in situations and circumstances that exponentially increase their risk of exposure to HIV and then once exposed to HIV, decrease the likelihood of testing, uh, access to care and then maintenance and care an eventual viral suppression. So as we move on, I think it's important that we work to address these social and structural inequities, and one way we can do this is to close the implementation gap. As Tony Fauci stated, to end the HIV epidemic, we must close implementation gaps to ensure that all people with HIV are diagnosed and receive the treatment and care they need to achieve and maintain viral suppression. So how do we do this? The first step is really to start with you. So let's look at what starting with you means how do we do you, um So if we move to the next slide, we can see that there are really three key steps that I think in health care providers. Service providers really need to focus on to ensure that our biases are in check. I think one of the hardest things, uh, in terms of, you know human behavior is to recognize that we can be good people and still be biased. And all of us are biased in which our default setting as humans. But those biases don't make us bad people, but the more we ignore them, push them aside, pretend that they don't exist, the more of an impact they actually have on our behavior. So we really need tohave self reflection to recognize our biases and when they might impact our behavior. And we need to also not only recognize their own biases, but are there biases in the systems that we work in? And how might we address those biases? And and just as an answer to that question, that was sort of a rhetorical question. Yes, there are biases in our systems, and so how do we unpacked the processes and procedures that we have in place that could re traumatized individuals or are implicitly biased. And then how do we empower individuals? You know, and a lot of this work is in resilience, which I don't have time to get into. But you know, what are the factors that create resilience and individual self efficacy? Self esteem, social support, you know? And how do we partner with community based organizations to really promote education and, um, ethnic racial transgender? Um, L G B T Q. I, pride on bond really work Thio show and celebrate the value in identities that are generally devalued. And if we move on, another method which is really brings us toe telehealth is through identifying innovative methods to disrupt some of the existing in equities. And, you know, I think part of what we're going to explore today is, could telehealth be one of these methods? You know, as we discussed, we have effective tools for HIV prevention and treatment, but we suffer gaps in access in delivery of these tools, and telehealth is considered to be an intervention that may address some of the factors to create these gaps. Currently, I'm working on co vid 19 prevention, and I'm seeing the huge reach of telehealth in communities particularly communities of color here in Seattle. So I know that not only has it been something that's been in existence for a long time, so we have have, you know, the experience of implementing it. But now we're in a situation where it requires implementation. And so we are actively testing how effective it could be in addressing some of the barriers that have outlined before, particularly access toe help. So what is telehealth? Let's look at the next slide. So telehealth really, um, centers on live video conferencing. So you have your patient and your health care provider using two way conferencing for riel time consultations. You also have the ability to have access to patient data that can be transmitted to healthcare providers electronically. You know, obviously following HIPPA and other, um, guidelines, but easy sharing of data and information and then you also have the ability to do remote patient monitoring, you know, so the patient's health and medical data are sent in real time so that all parties are aware of progress and then you can use mobile communication, any mobile communication to really stay in touch and follow up and ensure that there are open channels of communication and what we've seen in, um the implementation of this as we move on, um is that telehealth has been shown to be effective in expanding access to healthcare in rural settings. If we can move to the next slide weaken, See this? It's been, uh, shown to be effective not only in rural settings but also among youth who are very social media and technologies savvy. So this sort of fits in with what they're normally doing. We've also seen this to be incredibly effective and stigmatized populations who may not want to come into health care facilities or may not find healthcare facilities welcoming. We've also found it, um uh, effective in populations that air hardly reached. And that says hard to reach. But I that really puts the onus on the population that should read hardly reach like individuals who are incarcerated, um, or individuals who live far from the local um, health center and so forth and individuals who experience transportation issues. So there have been, um, you know, indications that telehealth can be effective in these, um, specific circumstances. And as we move on, several benefits of telehealth have been identified you can see some of them here, and at the same time, I think it's incredibly important to show that there are potential challenges that one must consider in planning a telehealth intervention. So as with any methodology and intervention, you really have to weigh the pros and the cons for your situation and be proactive in really looking through how you might address these challenges. If you are implementing telehealth in your facility and as we move on as you consider the appropriateness of telehealth for your organization, there are clinical, administrative, technical personnel and reimbursement challenges that also need to be considered, and my colleague will go into more depth about these in the later session. But just to know that they're here in the slide set and you can refer back to them, um, as needed. So what is clear as we move on is that telehealth has the potential to significantly impact some of the most challenging problems in our current health care system. Specifically, those challenge related toe access issues with provider availability, particularly in rural settings, and there are also implications for reductions and cost utilizing a telehealth platform off course. All of these potential impacts could be sidetracked if policy barriers aren't taken into account. HIPPA privacy Security um, ensuring that patient information is confidential and so forth. So again, as with any intervention, knowing your population, preparing for challenges and being proactive about them is critical and then finally, telehealth. Maybe the next slide, please may be an effective method to bridge the gap between providers and patients. In a survey in Houston that, as you can see here, about 57% of the people surveyed who were living with HIV were more likely to use telehealth over one on one person care, and of those, 37% stated that they would use it frequently or always to replace clinic visits. So I think it's it's important to see that this is a viable option for individuals, and not only is it acceptable, but willingness to utilize telehealth is high. And then, in conclusion, I think it's really I mean, all of us on this call. No, as we moved to the next slide that devalued identities and the social and structural factors that differentially impact individuals with devalued identities have resulted in persistent health and equities, and in order to close these gaps. We really need innovative strategies that can reduce barriers to access and adherents. And telehealth could potentially be one of these strategies. It has been demonstrated that it's affordable and increases the ability to improve access to care in areas where providers air limited. And as with any intervention, there are limitations that must be explored and considered prior to implementation. So I really hope that this has provided some background with regard to what, um, Telehealth may effectively address and happy to take any questions later on. Thank you all for having me and appreciate the the time to speak with you. Thank you so much. Dr Andrew ASIC for your presentation. I want to remind all of our attendees that you can submit your questions to our faculty members through the button below your screen. Now we'll move into our first break out workshops of the program. You should have received worksheets in your email earlier today, but if you didn't no worries will provide a link to the workshops in each workshop room. Please click on the button on the lower part of your screen now to join a workshop break out and I'll see you back here shortly. Welcome back. I hope everyone enjoyed our first workshop again. I want to remind all of our E attendees that you can submit your questions to our faculty members through the button below your screen. Now our next presentation will be given by Dr Rob Stevenson. Dr. Stevenson is a professor and director for the Center for Sexuality and Health Disparities at the University of Michigan. Dr. Stevenson's work focuses on the development and testing of HIV prevention interventions and the intersection between violence and health. He is the lead investigator on several telehealth programs, including Project Nexus, Project Moxie, Icahn Plus and Project Caboodle. Now I'd like to welcome him and turn it over to Dr Stevenson. Thank you, Dr Elliot, for that introduction is a pleasure to be here today. So I'm Rob Stevenson and I'm going to talk to you today about telehealth. But what I'm gonna talk about today is specifically some of the ways that we might use telehealth for HIV prevention and HIV care. So let's start by putting this in context. We all know we can't escape. We know the Kobe pandemic that's going on around us. and it should be no surprise to anyone the data that shows just a huge impact that Cove in 19 has had on the delivery of health care in the US and other settings. The same health challenges that are experienced across the health care systems due to cope in 19 are being experienced, particularly for HIV care and prevention. Just think about this. There's decreased frequency of monitoring and clinical appointments, and by that I mean people just unable to go to their appointments in the same way that they were before the physical health appointments. There's less counseling and multi disciplinary support services. So if you think about our service providers, the mental health service referrals or the substance use referrals that we make on my counseling, those are usually happen organically during in person visits on. Because people are not going into in person visits anymore, there's just fewer opportunities for people to be linked to other services. There's also also discreet decreased virology laboratory capacity people just potentially anger in the viral load. Testing them and foundational as we know to the success of ending the epidemic is creating a healthy, virally suppressed population of people live with HIV on Cove. It 19 has really put, you know, a potential barrier to that. I mean, people just aren't able to go to appointments. Another huge structural change that has happened is that the rapid changes I mean Kobe, 19 happened so quickly. Healthcare systems have to like turn on a dime and change suddenly to new modalities of delivering care and what that is. Men is staff of being retrained staff of being repurposed. People have being moved to cov 19 car. All of that is taken away from the potential for HIV prevention and care in person. Also, social distancing means that they're just fewer opportunities are few fewer legal opportunities for in person gatherings. And so there's reduced opportunities for mobile outreach, community outreach, HIV educational programs. So all of this in the era this has happened rapidly in the last seven months on what we're seeing is this rapid limitation or restriction of access toa ph Oto excuse me to vital HIV prevention and care services, although we don't really have any national data on that is estimated that up to 70% of services I've seen reductions in HIV prevention and care on data from my own projects has shown recently that particularly vulnerable groups of youth people of color I see in massive destinations in their availability of local Chevy services. However, it's not all bad news. There is some good news. Thean Pact of Kobe, 19 is actually in a roundabout way. Created opportunities to think differently about how we provide HIV care. So most of you Head of the Cares Act, which is the Corona Virus Aid Relief and Economic Security Act. I have to read that. Eyes authorized an extra $90 million for the Ryan White HIV AIDS program, and there's been additional $65 million for the housing for people with eight program. This is the federal program that is dedicated to the housing needs of people Live with HIV water. Has done. Is this extra resource is is extra money the lived reality that people are socially distance has really forced us in a very rapid way to think differently about how it provides HIV prevention and care telehealth. I'm not saying it's the only answer, but it's definitely one of the biggest answers we have right now. Telehealth minimizes in person clinical visits that's obvious, but it also helps to prevent the spread of Kobe 19 because it's totally in lower social distance in. But what I'm really excited about is I presents a potentially innovative and effective way to provide HIV services in the future. You know, I think a short sighted way to think about this is that telehealth is good while while we're in this pandemic, I think I have the bigger than that. And I think we're realizing this really quickly in that Kobe, 19 has a lot of potential toe level. A quick can can create a level playing field for greater access to services. Lots of the things that Michelle, portraying hair talk, can in some way be addressed by telehealth. Reducing stigma, reducing physical access. Sorry, increasing physical access, increasing economic access to health services. So I want to talk more in depth now about some of the advantages of telehealth during Cove in 19. So there's some really interesting data from China on this is not really rocket science that shows that people who live in areas with a lack of health resource is have much greater rates of morbidity and mortality during cold in 19. It's not surprising if, at the population level you live in a geographic area that is characterized by a lack of services, you have fewer opportunities to get good quality care. However, I strongly believe that telehealth can surmount many of those economic, physical and cultural barriers to accessing care. So the CMS, which is the center of a Medicare and Medicaid services, I'm sure you all know that they issued sweeping array of new rules and waivers of Fred E. Can't Say that word federal requirements to make sure that hospitals and other providers can manage the surges in coping. 19. Let's step back and think about what this did. Essentially, the rules were relaxed. Knew there was. There was a shift in restrictions what hospital systems and health systems and service providers currently couldn't do via telehealth. Kobe, 19 has forced people to think critically about whether those rules and restrictions are realistic and has relaxed them. What it's done is mean that we now have more opportunities on a wider range of things that we could do with telehealth. So with regard to telehealth, the CMS will now pay for more than 80 additional services on these air cover a wide a range of services. Emerging department visits, discharge home visits and the CMS is essentially allowing telehealth to fulfill many face to face visit requirements for clinicians and for mental health services for rehabilitation services. The Hospice care. So what's really important to understand is that there's being a really this doesn't happen often that we see changing seven months. But in just the space of seven months as being this seismic 180 degree turn in how we view telehealth prior to CO V 19 virtual chickens with doctors and patients could only be done if the doctor had an established relationship with the patient. That rule has been relaxed and, you know, personally, I have experienced this. I've been able to get telehealth for this. We providers I haven't seen before. They've been good quality. I've got the answers I need on one of the, you know, looking at opportunity in crisis. One of the things that CoV 19 has really done is forced us to look critically about what's realistic and can legally be done. The telegraph. So let's take a closer look at some other data. Well, this'd just to prove what's been happening during the era of Kobe 19 and how we've seen this rapid expansion of telehealth. So Kaiser Permanente, which is one of the largest providers of health care in the U. S, is now reporting an average of 65,000 telehealth encounters every day. To put this in perspective, it was only 8500 day in April, So this is like a nine fold increase in 67 months. Um, it was a classic example of building, and they will come. You know, People's health care was taken away back over. It carries a permanent, did a really good job of jumping, you know, recognizing that change was required on was opening up the telehealth channels. If you look at the data on the right Tele health insurance claims of Ballooned, this is important. Telehealth is Justus billable as in person health, and that's foundational successes providers to be available to provide this much needed service. So tele health insurance claims ballooned between March over a year by more than 15,000%. This is huge. A 76% of hospitals are now connecting with patients remotely and tell my health isn't just you know what we're doing now? It isn't. Just assume it's using video audio chat email on other innovative technologies to connect patients with their providers, but it also connects providers with providers. So let's take a closer look at some of the trends now. Sure, so you'll see here. This data goes back to 2014 and if you look across, this is pretty flat lines. Up until 2016. Prior to CO V 19 healthcare providers were starting to see an increase in telehealth. But it was really specialized. People didn't see people didn't use telehealth for routine healthcare. It was usually and they definitely didn't use it for behavioral health. Um, it was used quite commonly in pediatrics, actually, but it hasn't really bean kind. It wasn't mean it wasn't in the mainstream of health care, telehealth over all and four specific types of telehealth have increased from 2014 to 2018. Interestingly, the type of telehealth with the greatest increase was physician to patient, which makes total sense. You know, all of us have experienced a reduction in our access to health care over the last seven months, and so it makes sense that the thing that increased the most was telehealth being used to connect patients with providers, and this increased by almost 400% eso prior to come over in 19. It made up 0% of health care visits, and it now makes up 00.2 point 002 is a tiny number. I understand if no one's impressed, but that's about 80,000 calls a day. You know, we are really starting to rely until a health we're no longer seen. Seen a specialized. What's most important is we're seeing it is something we can all do and not be frightened off. However, the lowest rate of growth in telehealth, as I kind of mentioned before, was provided to provider eso, where providers were using telehealth thio in their medical teams. That service provided teams to communicate, and interestingly, we're not seeing that grow as much as we are the patient provider types of care. Okay, so I've given you an overview of telehealth on the take away from the first part of this talk is telehealth is balloon. Covic, 19 created more money for telehealth. It created a relaxation of restrictions, but it really reframed telehealth is a necessity. I want to talk now more specifically around HIV on how we can use telehealth to expand access to HIV tha So the data is clear. No, I'm gonna give you a quick overview of some of the studies, but it's not really narrow debate. We know telehealth works. So in addition to potentially expanding access on when I talk about access, I don't just talk about physical access. I talked about cultural access because it can reduce stigma. I talk about economic access because it might be cheaper. Telehealth is being shown to have important impacts on HIV treatment and prevention. Telehealth has demonstrated the ability to increase access to quality healthcare, reduce patient traveled to medical providers on potentially reduce health care costs. I use a really good example. Eso I grew up in a remote rural area in the middle of nowhere. It was really boring. And if I think about like my childhood there or my adolescence there when I might want it to go for HIV testing, I would not have wanted to go to my local health care provider because they know everybody, and I don't trust that telehealth allows you to surmount that barrier. It allows you to not have to rely on some of the local. So for people in living in rural areas, what's interesting about Telehealth is that it potentially gives the same access to MAWR potentially more culturally competent, higher quality healthcare services that might be found in larger urban areas. We think about prep. I know that we're all really interested in Prep is a biomedical prevention option. The prep for telehealth programs have been shown to have sustained high rates of initiation of prep. It's really hard to make the decision to use prep on your own. Often a really important prep Tele Health Service might just be connecting with the provider or a peer counselor or a prep navigator through Zoom who can walk you through the pros and cons of prep. However, there's a lot more weaken Dio we prepped by telehealth weakened Dio. There's mail out specimen collection Kips that can actually see if you are a candidate for prep. You no longer have toe necessarily visit a doctor to be a candidate for prep. A really interesting study conducted by the Veterans Administration showed that the availability of telehealth programs let documented viral suppression among patients. They found that patients who visited or attended their ongoing clinical appointments via telehealth had higher rates of viral suppression. On is really interesting. I think it's because we telehealth. You feel MAWR in control of your own health. You can do your doctor's appointment, your physician's appointment from your own home. It's less stigmatized, and it's less about being a patient in a clinical unit. And it's more about having a chat with somebody from your own home. There's been a lot of radical work in Alabama on e health that stood at that demonstrated that telehealth enhanced patient engagement across the HIV care continuum. So they looked at 240 patients on 76.3% of them were retained in care, which is a very high amount over 12 12 month period. There's really interesting studies, not just from the U. S. Is well. The Welt Health Study in Kenya show that tele health interventions can help enhance a deal to enter it. Viral therapies, massive increases in a deer instead, ahrts among those who were able to access healthcare fire, telehealth and again, I think the reasons makes sense. You know you no longer in a clinical setting, you could do it in your pajamas from home. It's much easier to be relaxed. There's there's often less stigma involved. So I want to talk about now is some of the overall lessons that we've learned about telehealth. I feel like I'm on commission like I'm selling telehealth to you, but I really do believe it works. Um, telehealth can provide access to patients who live in rural areas outside of normal health care delivery. It broadens the range of options you have for accessing health care. You don't have to just rely on what is physically proximal to you. It can help simplify the process of health care delivery by triage in each case, and improving communication it can capture. Store a news patient data for better medical decision making. It's really important. As a health care provider, we tend to think off telehealth in a really simplistic way. Often we think of telehealth is just a zoom meeting, but it's more than that. You can use telehealth for chronic disease monitoring. You can use it for dentistry, for behavioral interventions for counseling, the physical occupational therapy. How many of us have seen you know, the number of you know you exercise ways of exercising their June's of clothes? I've gone online with people doing workouts from home by a zoom that you could do the same with physical therapy from home. It could be used for consumer and professional education. It can use a psycho education interventions as well. As I said, it's not just zoom. It could be used in a range of modalities that allow patients to engage with their health care providers in a way that they prefer. No, everyone wants to be seen on camera, and that's fine. You can do zoom with no camera added. You could do a video conference. Then you could do remote patient monitoring. You do phone calls, SMS. I mean, you know, for those of us who work with adolescents, there's a lot of options for using secure HIPAA compliant SMS text messaging systems to get Thio really provide quality services. I'm gonna walk you through four key lessons now from telehealth. Let's start with lesson number one. Uh, this is where I get stuck on myself for a little bit. I'm going to talk about two of the studies that I've done that really showed. How telehealth can they use in HIV prevention? So the two I'm gonna talk about called Project Nexus on Project Moxie So Project Nexus is a study for male couples. The two men in a relationship, however, they define relationship on Dwan. Of the things that has worried me for a while is we all know that home HIV testing is available. You can buy on Amazon. You can buy in CBS $40 test yourself at home, but there's no counseling involved to be test yourself at home. So I had the idea about 56 years ago like, Why don't we just mail? People are testing care on. Watch them do it by video chair, and that's telehealth. So I did a study with 564 male couples who were recruited from 47 states across the US It was really simple. Those in the control arm I just gave them to kids and get on with it on no human contact those in the intervention arm, they got to testing kits, and then they got a video chat where we watched the two guys, uh, test using the or a quick, rapid test. Some of them tested each other. It was kind of cute, and then they got a remotely provided telehealth session where we actually walk them through. In HIV prevention plan. The feedback was huge. People really loved this. They loved the idea of not having to go to a clinic to Thio actually getting HIV test. They could do it any time of day after 9 p.m. Was a really popular time for people to get the HIV tests. I think is really interesting. It's we talk a lot about putting the patient in control of their own care. That's what tell us how does. And that's what we did in Nexus. We allowed couples to pick a time when they felt comfortable to get an HIV test together. The other study I did was project Moxie, very similar study. But this time it was with transgender youth aged 15 to 19 on my idea here was I think transgender youth really struggle often when getting culturally competent care. So I wanted to give them a positive experience of testing in their own home and then to give them the skills to go on and test them in the future. So transgender youth recruited from across the U. S. And I recruited 202. They got eight every testing kits into the home. They scheduled a time with one of our peer counselors who walked them through the testing kit. Did the Standard Prevention Council in on linkage to care if necessary, But they also role modeled with them. Role played with them. How are you going to get another test in the future? How are you going to talk to your provider about gender identity would really trying to give them the skills so that they didn't have to rely on us, that they could go on, become successful testers themselves in the future. And I think that's a really important thing that telehealth on Dio is not just providing a service that's telemedicine. Telehealth is more than that is providing a clinical service, but it's often providing counseling and prevention skills as well. So, moving on, I was gonna skip the next slide and move on to lesson two. Um, so listen to is that you've got to simplify the process. Um, you know, we've all spent the last seven months wife and Zoom and listen to people who don't realize they're on mute. So not everybody is tech savvy. Um, but so the key to this is finding modalities of telehealth that above HIPPA compliant. Obviously, that's our number one on our easy for people to use. So, for example, let's take prep. We know that prep uptake is suboptimal, and it's particularly suboptimal in some underserved groups, such as young, Black, African, African American men Have Sex with Men. Some recent interventions of use telehealth and have aimed at helping improve prep service uptake. And these new telehealth interventions exist in both the private and the public sectors on the offer solutions to geographical and social barriers to prep services. What's really interesting is that some really well established programs conservers a model to scale up telemedicine or telehealth for prep the general schematic of telehealth programs from prep services is that they should be video compliant with the hipper act. One of the things that I discovered very, very early on in when I was deciding toe use telehealth myself as a provider was Skype doesn't work. Please do not your Skype Skype records everything that you say or type and stores it. Skype is not HIPPA compliant, but there's 100 services out there. Zoom Is HIPAA compliant. VCs HIPPA compliant. There's also really good HIPAA compliance scheduling tools as well that you can embed in your in your EMR or your patient management records that can really streamline the process for a potential patient to schedule their own telehealth appointment. Laboratory testing, as I mentioned, this could be done by a Tele holders. Well, um, either you could be done by in patient visits or our local facility or through a mailed out delivering self testing kit. And many states also allow mailer of prep medicines, or there could be mailed to local pharmacies where they can be picked up. E. P. T. Expanding patient therapy is something that can be done really beautifully through telehealth as well. So there's many ways for us to think very differently about the service we services we provide, and we can provide them ah, high quality and through HIPAA compliant services. Okay, so let's move on to the lesson Number three now lesson number three is it's more than talking to somebody by a zoom. We were gonna do telehealth correctly. I'm gonna provide high quality service. We need to offer a broad array of services. So telemedicine or telehealth, as it should be called, can be used to enhance Link is to our attention in care in rural settings. And I talked about this a lot on Alabama. The health program in Alabama is a really nice example of this. Eso, the medical advocacy and outreach group in a oh launched the Alabama Health Program in 2011 patients, seek care a clinic near their residents and access a remotely located HIV specialist via telemedicine. The telemedicine video equipment transmits riel time high definition of the clear virtual face to face communication. It's interesting when I talk about telehealth, I often get people pushing back like Well, bandwidth is an issue or not enough people are smart phones. That's just not true anymore. On. We have incredible bandwidth throughout the U. S. On the lot, enough people have access to high bandwidth Internet access on telemedicine. Telehealth really could be a reality. But what's important if you're going to do telehealth? Excuse me? I'm thirsty. I wasn't dramatic. Pause If you're gonna do telehealth, then you've got to provide all the wraparound services. Telehealth Think about this. So you're her service. You're a community based organization or an SL on you set up HIV testing by telehealth. You don't wanna do the HIV prevention and testing the CTR session by telehealth and saying, uh, you need a referral for substance use. You need to come into the clinic to see that. Like if you're gonna provide multiple services or multiple wraparound services that all got to be available on telehealth as well. You can't really. You can't really create a system where only half your services are available remotely. Otherwise, what? It kind of put your your patients at a disadvantage. Lesson number four before I wrap up because I'm sure I'm running over time is to provide a diverse range of interaction modalities so some patients can engage in a way they pervert prefer. So I mentioned Project Moxie area, which would, with transgender youth um, at least half of the transgender youth who attended our counting sessions did not want the camera on when we asked. It was a legit reason. Like we don't know who you are. We don't want you to see us, and that's fine. You know. Everyone know everyone wants to be on camera. It may take a few telehealth veterans before the comfortable with doing that, so these diverse array modalities allow patients to increase toe participating telehealth in a way that suits them. Some of the things you can do is called store and forward, which you will. You use electronic transmission of health care information, including images, documents and videos through secure email communications. So, for example, you may set up a secure email communication where you can send people there. Lab results. We've definitely done that with homemade STD testing remote patient monitoring, where you transmit health care and other patient information from the patient in location one to another location. So this is referrals where you take someone's land results and you can securely and in a hippo compliant way, send them somewhere else. Mobile health using mobile devices and APS for providing health care services on healthcare data, the really Common and Diabetes Management and Cancer care. And they're becoming more common in HIV, using APS where people can store their data. For example, their recent viral load s so that they can refer that where and they can show it to their health care provider or face to face. This is what we're doing now using video chat to provide face to face clinical or countenance services. So just to wrap up, I want to talk about, uh, the need to broadly adopt telehealth nature, every care. It's really important. As I said, it's gotta be HIPPA compliant. It's got to be quality. People have got to be trained how to do it. It's not a simple attendant zooming like I'm ready. We've all heard about zoom fatigue, you know, and that's a real thing. Zoom fatigue happens because it's harder to talk to someone on camera. You've got a trial about how you will smile. You know the visual cues that you get when you are in the same room and so on on the same. So it's actually a little bit harder to do, which means you require training to do it. But I still maintain that if we broadly adopt telehealth throughout the HIV care continuum that we can increase screening and timeliness of care, we can increase access to prep. We can reduce prep medicine delivery barriers, we can increase endurance. You know simple things. We can use health and health to support medication reminders. We can allow engagements when people are struggling with their medication. Most importantly to me that we can reduce stigma. People can choose providers that might not be proximal or close to them. They can be comfortable in their own home. They don't have to feel like a patient in a clinical environment. Overall, I think what the Kobe epidemic, because as forces to do is take a critical reflection of what telehealth is. B'more innovative in telehealth. And it's relax the rules. We could do more with telehealth now than we ever have been able to. So that's where I'll stop and hand back to Dr Hell, yeah. Thank you. Thank you for your presentation, Dr Stephenson. Now we will move into our second breakout workshop of the program again. You should receive your workshop worksheets in the email earlier today. If not, will provide the link. Once you get into the workshop, please click on the button on the lower part of your screen Now to join the workshop breakouts. And I will see you soon. Hello and Welcome back. I hope that you enjoyed our breakout workshops, and I'd like Thio reintroduce the faculty and Panelists for our Q and A discussion Doctors and Drastic and Stevenson. I want to remind our participants Thio, please submit your questions via the button on the bottom of your screen. Mhm. Now our first question, Uh, in your experience looking at the HIV continuum. Which types of services would you feel are better for telehealth? And, uh, Dr Stevenson, I'll start that question with you. Mhm. Thank you. It's a great question. I believe that you can provide services across the HIV continuum of care by telehealth. I'll be honest. The more complicated clinical ones do become a little bit more more difficult via telehealth, I think in terms of HIV prevention, telehealth is a natural fear. It's quite easy using video chat to provide HIV testing and counseling to provide referrals to wrap around services. It's quite easy to actually assess almost candidature for prep if you use home testing kits and home special specimen samples in the care continuum, I think it's also quite a natural fit for the telehealth, especially around endurance counseling. Although when you get into the more complicated clinical elements, then is going to require a bit more technological on wraparound care support. Yeah, I agree. A doctor and drastic. Do you have anything to add? Well, I think what I've seen in Cove it and, you know, full disclosure my telehealth experience is limited. But since Cove it is hit here in Seattle, we have seen a really, um uh, service being provided in terms of people who are unable to get into the clinic because of reductions in transportation, public transportation, eso the communities that are hardest hit are those that rely on public transportation and the rollout. The rapid rollout actually of telehealth has really allowed those individuals to stay connected on, but also to receive prescriptions that they might have to normally come in for. Um, uh, you know, all of that stuff has really, um, been beneficial. And we've also seen through our local, um, Odessa Brown Clinic, which is one of the original, um, Black Panther Party clinics are still here in our historically black neighborhood. Um, we've seen a really ability to involve individuals and families and continued mental health services, which has been critical in this incredibly stressful time for families, particularly those families who are losing income sources on and who are, you know, forced with the reality. Here in, um, Washington State of home schooling, Children on many also the of those who are in that income bracket area if they haven't lost their jobs, are in employment situations where they don't have the privilege to work from home. Eso You know, the assistance that this has provided in terms of even helping with schooling with Children has been incredible. I mean, that's not technically telehealth. But what has been happening with engaging um, students, uh, through technological means is really incredible. And it serves as an example of the challenges that we face when utilizing Tele Health isn't as one of the modalities. Let me ask you this question. It's It's a really interesting question. As we were talking about expanding telehealth, uh, as a response to our challenges with engaging folks in care, How do you forsee us addressing barriers with access to the technology that would support telehealth like smartphone access or just phones? In general, you know, service disruption can always being in an issue, especially as, uh, folks in particular in the midst of this pandemic have become underemployed or unemployed and the ability to keep a phone in the service on um, or even Internet access. We know that's dependent on how this this modality should work. So how do you think you know, addressing this barrier to the technology piece falls into play as it relates to everything that we have going on down and in the future? Well, I can ill will speak from my experience working in co vid on. And I think, um, what I've seen is where there's a will. There's a way. You know, I have found that all of a sudden we have lots of resource is Thio, you know, get people into care and some of the clinical trials that are going on. So the infrastructure requires building, and it requires resource is to do that. And, you know, I mean another. You know, a similar examples I gave before the Seattle school system, just really trying to address the disparities and kids who have computers and kids who don't and got a huge donation of computers so that all students and the public school system now have computers and have hotspots that they can hook up to, and their families are, um, given permission to utilize those hot spots for other services like telehealth. So I feel that if it's something that we as a society, consider important, then the resource is will be available to provide that infrastructure. And if we are ever going to really address the ongoing inequities that we see, we need to build that capacity. Yeah, I totally agree. I think it's one thing about telehealth that gets oversimplified is the assumption that everyone has a phone and everyone has access to the Internet. I think of people, people who are housing unstable. You know, there's a lot of people will often rely on local libraries for Internet access. Well, there's several problems there with cold feet. That's all much more closed on. Also, you can't really do. Telehealth in a library is not a private area, and so I agree with Michele. I think investing in the infrastructure is important, repositioning access to Internet as a health issue, but not just like yeah, I want to check with my friends. It's more than that, you know, invested in Internet hubs in disadvantaged communities, that people can go to and access the Internet in a safe, audio, visually private environment where they can get their health care if they can't actually access the clinic. All of these things already important on the good news is there's lots of for those who do have phones. There's lots of software that you can use. We use V C, which is what NASA uses to communicate with Mars on. You know, we've never had a drop call. It's really it's HIPPA compliant. You click the button your link to your provider. So there's lots of really cool technology that you can use if you have a phone that's going to result in a good quality connection. Yeah, I think that's awesome. And what a fabulous way to sort of kind of pulling in in this technology that we're seeing not just for what we would consider to be so you know, Ah ah, lower level use. But you know, this is technology that's being harnessed on, you know, quite a significant, um, platform with NASA using it. Um, I do know that I have heard of instances where providers have have shared about the experiences of their patients even having to go to the lengths of using public space that I know the library has not been one of those places where we've been able to access in Cove it times. Uh, you know now, libraries, particularly in the areas where I live in California, the Southern California area, have just been allowed toe open up for you toe go and just like pick up books, they leave alone your laptops, right? But the hot spot or WiFi connection piece is missing. But folks have, you know, shared experiences about going to businesses, pulling up to businesses that normally offer WiFi access. Andi people sitting in their cars to harness the Internet and and connect to the WiFi to do what they need to do. I think this, you know, we can learn from the resiliency and how people are going about, um, you know, getting, uh to the Internet and being able Thio do what they need to dio. Here's another question with cove it and the restrictions that are associated with it sort of taking over HIV. Resource is how do you see HIV public mobile testing moving forward? Either one of you can just jump pain. Well, I go ahead. Michelle. No, go ahead. I started last time. E do worry that the big mobile testing events that we have with pride events, you know, Prior was often people the opportunity to get tested. You know, I lived in amount for a decade before I moved to Michigan on we were to prides on. Did you know there was a line? There's always long lines at the testing. That was people's opportunity that came to Atlanta. Pride got tested. We're losing that because of social distance thing. But I think we're also missing an opportunity to create synergies between Kobe testing the nature interesting. Like we've worked out how to do mass Kilby testing in lots of places in very safe places, getting people out mass testing events. But when why don't we combining that? Why it was swapping you for Kobe? Why, You know, doing HIV testing and STD tests at the same time. It can easily be done. I got my flu shot the other day. I gotta drive by flu shot. I mean, I stopped and then just like, throw it, but like you just rolled up and put your hand out the window and got a job. This that would be like impossible. A year ago, people would have thought you were crazy. We're inventing new ways of doing things really quickly. And I think we can start combining services together. Yeah, I think that that the way we operationalize the definition of mobile, we're thinking van, right, um, and testing unit, as we have known it in times past. But Mobile could also meet this drive up model where folks can come. And in fact, I know there are people in the San Diego area who have set up this, uh, this in your car testing capacity. You can have the test. You drive up. Um, they come to your car, they test, you sit, and you wait for for the test results 15 minutes, and then someone comes back and gives you the results and shares the shares them with you. I think that's a part of the innovation of this all way Will learn a lot from this pandemic. We've learned a lot in the course of the HIV AIDS epidemic on various ways in which we can, um, implement interventions for prevention and care, and I think that that template, uh, has been duplicated, and we'll be duplicated. Maura's we as we Aziz, we journey into living our lives enduringly through cove. It, um here's a question for Rob with the increasing use of at home HIV testing how our providers addressing concerns about supporting people, receiving a, um, a confirmatory test result, um, at home or on their own. And that's, Ah, a reactive, positive confirmatory results. You Thank you for that question. That's one of the reasons that I got into telehealth. So, um, when the FDA approved home injury list in 2012 I support it. I think it's great, I think them or opportunities and way beyond way. Lola. The more opportunities you can get the older age we test, the better. But one of the things that always worried me was what happens if someone gets a a pretty Marie positive result at home? You know there's no counseling, there's no potentially no support system. The same is also true to get a negative result as well. There's no like opportunity to reflect on behavior change, which is the beauty of telegraph. So one of the things that's really important, particularly doing CTR with telehealth is to have a strong support system for linkage to care, and this is what we did. So we did. I think, about 900 telehealth sessions where we gave HIV testing. We had 6% positivity. Quite high positivity, Andi, because what you find is that the people who do it HIV testing by telehealth have not tested for a long time because they the living areas where there's no testing or they just they felt some kind of stigma. Barry to testing telehealth is their option to test. Um, so it's all about a preliminary result. We would link them to care within 24 hours with a follow up. Call it 72 hours, seven days, 10 days and 30 days. Um, we know people zip codes before we start the session and so we can use to onto dog. We can have a list of all the services. What's really good about telehealth? Use screen shares? I've done this myself. I've given preliminary positive results by telehealth, and one of things we're going to have to screen their function is to say, here's a list of services working out even to the granular detail. What bus route do you need to get there? Do you want me to get them on the phone and make an appointment for you? A really active linkage to care. And you can do all of that with telehealth. And that's how we've done it. Yeah, I think that's Ah. I think that's a very important part of of the linkage to care piece where you're not just saying here, um, this is where you can go, but really holding people's hand and, uh, and leading them to all of the avenues to access, um, the care and being able to have someone follow up or knowing that you can follow with with someone once you disconnect or disengage, How How can I go back and say to the person that was assisting me? Oh, you know, I don't remember what I heard. We understand from much of what we know about when people are engaged in and visits whether it's ah, counseling or it's a provider visit. They don't retain as much information as we would want them to were just pouring information. So how can I go back and recount them in? And that part of that navigation in that linkage to care, Peace, you know, says that we're going to do more. It's just not going to stop when I give you this. This result whether it's positive or a negative result. Let me ask you, Michelle, with patients who are engaged in care and may move across like state lines, Um, can they remain and care with their current providers, or do they have to transfer to another provider? Well, I would think it probably will depend on the care system, you know, And, uh, you know how much a provider has telehealth incorporated into their current, um, infrastructure. So it, you know, I think the question is, are the answer is maybe depending on the circumstances and the situation. And that is something that I would really encourage people to explore with their current medical provider to see if they have any linkages in the state or if they are able to offer telehealth over a distance. I mean, I think what is critical for individuals I mean, we talked a little bit about resilience before is that people have a sense of self efficacy that they have control over their own health. So the more options they have and the more information they have, the more people are able to make choices and feel in control of their health and their health care. So, you know, I think you know, information is critical and, you know, really encouraging people to find out what the options are before they move is really important. Yeah, I think that I think that is true. And also a part of that comes the benefit that we know that continuity of care adds to adherence and, um, positive outcomes for patients. And yes, it It probably is likely that ah, patient moving across state lines has some variable questions about it. It goes from the providers licensing to the telehealth piece, the health system as well as the coverage right and how they will then access medications. If medication is a part of that care plan, how will they then access that medication? Um, if needed. Let me ask Rob. It seems like one of the biggest various to telehealth whether it's prep for HIV treatment, is that most labs cannot administer the swap testing for extra genital testing. That's rectal or Fangio. Um, gonorrhea, chlamydia, testing. We know that this is important for most prepped users and many other people who are at risk for STDs and HIV. How does anyone know whether this may change in the future? Um, and whether this change in the future, whether we create drop in labs like class lab or or some other of these commercial community based lab doing swap testing or allowing swap testing. Good question on. We've just worked on that rather interestingly eso. We just did a sub study on that. Because although we've gotten really good at providing HIV testing and prevention services via telehealth, I do also worry about S T. I s. So we did another study with 50 male couples, and it was a two session telehealth intervention. So the first session was just a video chat. Took 10 minutes like this where we show them. Here's the kit that we're going to send to you. This is where you poke yourself, put it in this envelope and send it back. Yeah, 10 10 minutes. We send them the kit. They mailed it in. He went directly to the lab, the lab's and as the results and we had another telehealth session where we gave them their results and talking throughout the results. Man, we did differential rectal your resource swaps and a fingerprint for syphilis. Eso were able thio All of them 21% tested positive for an SD eye on what was really interesting is that almost all of them had tested with a provider recently because the provider no offensive providers had done a clean urine catch and all of ours that were for angel and rectal way identified. You ain't gonna find if you look for it eso it can be done through telehealth. You know, there's a lot of really good, you know, you see, probably see them on Facebook all the time. Home STD testing kits. You don't have to use those. You can use regular kits that you're using your office if you package them correctly and send them out to people. Yeah, I agree. I think that in some of the, uh, feedback that I've heard from around the country in programs pivoting with telehealth around prep en HIV services that the programs have adopted building what we would classifies their their own homegrown testing kits where theme the of clinic or office is sending the swaps necessary for the testing to the patient, along with instructions on how to perform the collection and then having the patient return the swaps to the actual lab with their requisitions. And I think that that goes, um, hand in hand what we know we was happening in various places where self swapping was taking place in the actual clinic. They would give you your swaps and you go in the bathroom and the clinic and, you know, do the collection and put them, you know, put them for the, for the staff to take care of the cinema. This is just sending them direct to the home, and I think it creates another opportunity to build on what has been done in times past. Um, so let me ask this question. I'm not sure how many more will be able to get in, but this conversation has been great. The dialogues from the audience, uh, coming in asking these questions has been fantastic. Eso often when, uh, someone is receiving a positive HIV result? It's the first time that that person has ever tastic. Um, what can we do to make testing easier and not so stigmatic in places throughout this country that goes back to what Dr Stevenson was saying. You know, we have to make it part of a regular, uh, suite of tests. Um, you know, when you go in and you get your blood pressure taken and your you know, your pulse, I think it needs to be, you know, one of the test that we just administer routinely. Um, you know, Thio address the stigma that is associated with it and other s t i s, for that matter, 11 of the things that I'm hoping comes out of co vid. Perhaps the silver lining is that we can stop silo going so many of, um, the health conditions that we see. I mean, one of the things that I'm seeing day in and day out is sort of this cross collaborative, um, reality that is unprecedented. In the 30 years that I've been working in public health, I've never seen so many organizations come together and pull their resource is and work collaboratively on a concerted effort. And, you know, my utopian dream is that at the end of all of this that people can see what silo ing has done to really, um, make our public health systems disjointed. And how can we work towards a more collaborative and less siloed way forward, where whole health includes things like HIV testing and and flu shots and and, you know, cardiovascular health and so forth. And, you know, we certainly who are on the HIV side who are involved in these collaborative efforts keep pointing that out all the time that this should be our new normal. Yeah, I agree. Um, in my clinical practice in HIV test is literally like the sixth vital sign. It's, you know, universal opt in testing for all patients. And, um, if, as we understand, the c. D. C s guidance on who and who should get tested and at what age, they should start getting tested. Um, if if we just put that in place enough, we would you know, we would run the gamut of doing due diligence, thio, timely diagnosis, all of the respective individuals in our in our populations. Rob, do you have anything to add to that? No, I mean I grew Michelle. I think, you know, starting young. You normalizing this, uh ah lot of America doesn't do great with comprehensive sex education. Andi, there's definitely not equal access to that. But, you know, just two things we don't talk about in sex education is one It's tried to have a relationship, Andi Also testing and just routinized a young age that people know that this is something that you know. You you, when you get toe having sex is or something, just something you're doing, we almost address it. Well, we do. We do address it way too late. Yeah, we do way all like, toe have sex, but we don't want to talk about and we don't want to talk about the paroles to supporting having healthy and in good sex. Uh, you know, this has been quite a rewarding conversation. Um, in program today with both of you. Aziz, we're nearing the conclusion off today's program. I want to thank our esteemed presenters and you our audience for participating in this robust learning opportunity to discuss the innovation of telehealth and forging forward the path on how we can look to better engage and care for our respective communities today and in the future. As participants in today's program, you, the attendees will receive a follow up survey about the program. We ask that you complete it, Um, and it provides any additional feedback as we look to build future programs that will help support the work that you do. In addition, you'll receive a certificate of attendance in a tool kit that includes key takeaways in some of the slides from the programs presentations, as well as additional information or where to look for more resource is as a reminder. Our next program on stigma and implicit bias is scheduled on October the 29th. I'm hopeful you will join us then. For now, I bid you a farewell. Stay safe and thank you again for joining us today. I know. Uh huh. Created by
