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oliver: everyone. welcome to thetest-to-prep webinar, bringing pre-exposureprophylaxis into your hiv testing strategy. my name is oliver bacon. i'm with the sanfrancisco department of public health in ourcapacity building assistance for hiv prevention branch. i am also an hiv physician,and was a co-investigator

on the prep demonstrationproject here in san francisco. we also have sites inwashington, dc and miami. i'm going to let the otherco-presenters introduce themselves, startingwith thomas. thomas: good morning. good afternoon, everyone. my name is thomasknoble, and i work here at the department of publichealth in san francisco, in the community healthequity and promotion branch.

and my role primarily isworking with community-based organizations that we fund forhiv and hep-c rapid testing, with an element of qa andtraining, and the nuts and bolts, andall the logistics. and part of role isto make sure they are as successful as possiblein the work that they are doing. so, that is me. oliver: ok. melissa.

melissa: hi, good afternoon. this is melissa morrison. i'm the hiv prevention directorwith the tennessee department of health innashville, tennessee. so that's all i have to say. oliver: and megan? megan: hello, everyone. my name is megan canon, and iam the program coordinator here at the houston health, and iwork in the hiv std prevention

and viral-hepatitis bureau. and that's all. oliver: all right. great. thank you everyone. so before we get started,here's a poll question. we'd like to know what typeof organization you work for. so you should be able torespond on your screen. here we go.

the last few votesare coming in. so with 89% of the precinctswe have 48% health department and 25% community-basedorganization, 15% health care organization, and 13% other. ok. so hopefully, therewill be something for everyone in the next hour. so some quickhousekeeping rules. so if you have any questionsduring the webinar,

type them in the chat box. and we'll see how manyquestions we have, and we may takequestions along the way, and we may savethem for afterwards. and please, please, please, ifyou haven't already done so, please complete the hpat. we're required to providethe hpat because we are a cdc sponsored organization. if you haven't doneso already, please

do so via the linkthat's in the chat box. and if you've alreadydone so, great, and sit back and enjoy the webinar. and finally, please be sureto complete the evaluation at the end of the webinar. we value your feedbackvery, very highly. so a quick introduction aboutour san francisco department of public health cba program. so we are funded by thecdc-- thank you very much,

cdc-- to provide capacitybuilding assistance and high impact hiv prevention. that really breaks downinto three areas for us. one is hiv testing. and that includescommunity-based testing, home testing, noveltesting technologies, and partner services linkage. we also provide capacitybuilding assistance and prevention for atrisk negative persons,

really focusing on prepand test implementation, and also personalizedcognitive counseling for episodic substance users. and then our final area ofassistance is in policy. and that really includes data tosupport the hiv care continuum, harm reduction, jurisdictionalplanning, and working with cross-sector partners. we have a verycollaborative approach for delivering capacitybuilding assistance

with peer-to-peermentoring, site visits, providing resourcesand toolkits, fostering onlinelearning communities, webinars such as this one,and live chat office hours. and we really emphasizea cooperative approach. here's our contact information. so you can visit usat www.getsfcba.org. you can call us at 415-427-6226,and you can email us as well. so we're going to talkabout bringing prep

into your hiv testing strategy. and here's a brief roadmap. we're going to talkabout hiv testing in the prep care continuum,where hiv testing fits in. some characteristicsof commonly used hiv tests-- as you allprobably already know, there's a varietyof testing types, and they each have theirown characteristics, and are useful for detectinghiv infection at various stages.

how to incorporate prepevaluation and refferal into a preexistinghiv testing program. and particularly,melissa's going to talk about an example ofthat involving an hiv testing program for young black men whohave sex with men in tennessee. and megan canon is goingto talk about prep and hiv testing in houston, texas. so quick disclosure. so whatever we sayhere is not necessarily

the policy for sanfrancisco health department. and also, i may talk a littlebit about prep demonstration project, which gilead, the drugcompany donated medication. they had no role in datacollection or analysis. so starting withprep care continuum. so this is a kindof a generic cartoon of what prep looks like from animplementation point of view. as you'll see, most of theactivities involved with prep are very front-loaded.

there's-- quick question. all right. never mind. as you can see, prep startswith a pretty bare minimum of activity at the beginning. so there's an initialscreening visit. and that involves asexual risk assessment, basic medical history,and then you're looking for symptomsof acute hiv

infection, a lot of patienteducation about prep basics, how it works, the importanceof adherence, what side effects, what acute sideeffects they might expect, some baseline lab hivtesting, testing for sexually transmitted infections, andsafety labs, which really boils down to the renal functionand to the hepatitis-c viral status. and then often,navigation services provided, clinic referralsas needed, financial case

management. traditionally, that's beenfollowed by a prep initiation visit one to two weeks later,when the drug has actually started. increasingly, though,programs are recognizing that people don't want toand probably shouldn't wait, and are implementing same-dayprep initiation, where they do screening andinitiation at the same visit. that's typically followedby follow up visits,

starting at four weeks, and thenevery two months thereafter. and the follow-up visits areextremely straightforward. there's a symptom review,a sexual risk assessment, counseling, follow-up hivtesting, testing for sti, and testing for renal function. and it's really,really important to note that hivtesting is absolutely essential at the beginningof the prep process, because what youreally want to do

is rule out acute hiv infection. so what about thecharacteristics of commonly used hiv tests? so here's a case to helpfocus you on the issue. so this is a 23-year-oldhiv negative woman who just found outthat her boyfriend has been having sex with othermen from time to time. the boyfriend says he'sclean, whatever that means. she has no othersexual partners,

and she's conflictedabout how to proceed with the relationship. she's on birth control,implantable birth control. she did have intercourse,unprotected intercourse, with her boyfriend last night. she heard aboutthis new prep thing, and she wants hiv testing. so what are you going to do? so this is what cdcrecommends in terms

of hiv testing for prep. she is definitely anappropriate candidate for prep, and so needsbaseline hiv testing. so this is whatthe cdc recommends. at the very least,you should document a non-reactive antibodytest within one week prior to starting orrestarting prep, and then every three months on prep. and that can be as simple asa lab-based antibody test, hiv

antibody test, onplasma, or it could be a rapid fda-approvedfinger stick antibody test. it should not be theoral rapid antibody test. it should not be a self-reportedtest by the patient, and it should not bean anonymous test. you need to ordera test, and you need to document theresults yourself. obviously, if this initialscreening test is positive, the person needs confirmatorytesting and referral for care.

and if you suspectat their screening that someone could haveacute hiv infection, then the cdc recommends thatyou delay starting prep, and you send a rna test torule out acute infection. so just to reiterate,at the very least, an antibody test, ablood-based, whether it's whole blood, serum,or plasma, antibody test for hiv within oneweek before starting. this is a summary slide lookingat the most common features

of acute hiv infection, theclinical signs or the symptoms. so overall, the most commonsymptom of acute hiv infection is fever. the next most commonis fatigue, and then muscle aches and pains,and then skin rash. and again, toreiterate, if someone presents with thesesymptoms, you probably want to delay prepinitiation to really rule out acute hiv infection.

there's one importantcaveat, which is that many people whohave acute hiv infection don't manifest anyof these symptoms. so the absence of thesesymptoms is not assurance that the person does nothave acute hiv infection. but the presence ofany of these symptoms should clue you in thatit's a possibility. so these are the typical labmarkers of hiv infection, and when they appearafter infection.

so if you look all theway over at the left, day 0 is the time thatsomeone was infected. the first test that will startto turn positive after that is in red here. it's the hiv rnatest and plasma. and you can see that itstarts to turn positive 10 to 11 days after infection. the next most sensitivetest for early hiv infection is the hiv 1p24 antigen test.

that starts to turn positive15 to 16 days after infection. so a little bit laterthan the rna test, a little bit longerwindow period, but still prettysensitive early on. the hiv antibody testsstarts to turn positive three to four weeks after infection,and that's in blue here. and then, i just want topoint out in the green, about halfway down theslide, the eclips period refers to that period oftime between infection

and the earliest labtime of hiv infection. so what about these hivtesting methodologies? so the first testthat ever existed was the lab-based antibody test. it's an indirect testof hiv infection. it detects the antibody,your body's response to hiv, rather than particles ofthe virus or viral rna. typically, it was run as anenzyme immunoassay, followed by a confirmatory testif the eia was positive.

people often referto generations of antibody testing. the first generation were theearlier hiv antibody tests. second generation were alittle bit more sensitive. and the third generationantibody test, which is the most sensitivecurrent antibody-only test is what we're working with now. so traditionally, theenzyme immunoassays were followed by confirmatorytests, which for a long time

consisted of the westernblot, or sometimes a second differentenzyme amino acid. it usually took a day atleast between the time the blood was drawn and thetest was let out, because these are lab-based tests. they were notpoint-of-care tests. but the blood had to beprocessed in the lab, separate from the patient. so a major stepforward was the arrival

of the point of care rapidenzyme and immunoassay, in a self-contained testingkit that they run off of a finger stick blood sample,rather than venipuncture. and the timing typicallywas that someone would start there hiv counseling. they would get a fingerstick for their blood, for their hiv test. while the test was beingprocessed next door, which takes 15 to 20minutes, they would

finish the hiv counseling. if the test were negative, nofurther testing was required. and if positive then,additional blood would be drawn forconfirmatory testing, with a diagnosis of apreliminary positive hiv test. the patient would walkout of their testing visit with an answer, which froma public health perspective, was a great leapforward, because one of the problems withthe lab-based test

is not everyone would comeback for their test results. so with the rapid test, everyoneknows what their result is. shortly thereafter, anoral fluid test also became available, but it'sslightly less accurate than the finger stick test. and this is not pluggingany particular rapid test, but this is just like aself-contained rapid hiv test looks like. you can see, they tendto be self-contained

in little plastic apparatus. you can read the resultswithin 10 to 15 minutes, depending on the precise test. and looking at theinterpretation boxes at the bottom of slide, there'sa control line and a test line. the control line shouldalways read positive. the test line willbe only be positive if it's a positive result. so what about acute infections?

so we already said thatrapid hiv tests are not very good for detectingacute infection. really the two teststhat are much better at that are the rna test andthe lab-based fourth generation antigen antibody testusing the 224 antigen. so what's the deal withdetecting acute infection? well, patients are antibodynegative during acute hiv infection. and at the same time, they'rehighly infectious biologically.

they have very high viral loads. and they're highlyinfectious behaviorally, because they don't knowthey're hiv infected, and the same behaviors thatallowed them to acquire hiv also allow them to transmithiv to their sexual partners. and we think that a substantialproportion of all hiv infections, newhiv infections, are thought to be acquired from apartner who himself or herself has acute hiv infection.

and remember i saidearlier, acute infection is often asymptomatic. ok? so here's the rub. patients who have hiv infection,whether it's acute or chronic, need at least threedrugs to suppress the virus and the virus fromacquiring resistance mutation. prep consists of two drugs, sothe emtricitabine and tenofovir pill is actually two drugsco-formulated into one.

that seems to besufficient when it's present in the body athigh enough concentration to prevent an exposure fromturning into an infection. it is not sufficientfor controlling hiv once someone hasestablished infection, including acute infection. so if you give prep,just two drugs, to someone who has acute hivinfection and who doesn't know that, that canlead to virus being

able to select drugresistance mutations. and that will require morecomplicated drug therapy for that person'shiv down the line. so again, this isthe same information i presented before, but in aslightly different graphic, looking at the timeto positive test from acute infection requiredfor various different testing methodologies. so you can see looking overat the far left, the hiv rna

test starts to turn positivequicker, followed by the p24 antigen test, followed bythe hiv antibody alone test. and you can do theapproximate timing of symptoms coincides with the approximateacute infection detected by p24, or hiv rna. so what tests candetect acute infection? there's really two ofthem-- the hiv rna, or viral load,that was originally developed to monitor hivpositive patients on therapy.

it detects actual viral rna. it's not an indirect test. it's not looking for antibody. it's looking for virus. it's usually reported outin a quantitative fashion, as in copies permilliliter, or qualitatively either present or absent. it costs about $50 per test,plus the cost of the machine, plus the availabilityof trained technicians,

in a higher level lab. there's a cheaperversion of rna testing that involves coolingsamples, and we'll talk about that in a sec. it's complicated, but usefulin high incidence, high test volume settings. so the other type thatdetect acute infection is the p24 antigenantibody combination test commonly referred toas fourth generation test.

and it uses a thirdgeneration antibody test, which is the bestantibody test we have, coupled with a test forthe p24 antigen. ok. so this is a viral loadprocessing machine, just to illustrate the levelof technical complexity we're talking about, andthe trained technician there, standing up to the right. so this machine happens toprocess all the viral loads from southern malawi.

so this is cooling rnapooling technology. and not to belabor the point toomuch, but really pooling refers to taking a samplefrom all of hiv tests that are run in aparticular period of time-- let's say a week, and thentaking that sub-sample and combining all thesub-samples into one pool, and then testing thatone pool example for rna. and if it's positive,which will happen the minority of the time,because hiv infections are

relatively rare, most weeks, thepool sample will be negative. every so often, that poolsample will be positive, and then you go back, and yourun the individual samples. and that's an enormous savingin terms of cost and time. but again, the techniqueis somewhat complex, and it's only reallyworthwhile doing in places that testa lot of samples, and may detect a numberof acute hiv infections. so in san francisco, interms of a health lab,

we use a pooling, anrna pooling technique. blood banks arereally the place where rna pooling is used regularly. this is some more aboutthe p24 antigen test. if you look at the little alienvirus cartoon in the lower left, you can see p24is actually a capsular protein from the virus. so for a lab-based fourthgeneration hiv test, it's faster and cheaperto run than the rna data.

it can be run onindividual blood samples, or multiple blood samples. it takes about two hours to run. it's fully automated in themachine down on the right. and really, the test looksfor antibodies to hiv 1 to the gp 160, broken downinto 120 and 41 portions, hiv 2 antibodies, and antibodiesto the p24 protein antigen. ok. and it's a goodenough test, though, that it's really changed cdcrecommendations for hiv testing

nationwide. so instead of thefirst generation of hiv testing, which is anenzyme immunoassay, followed by a confirmatory western blot,the new cdc recommendations are starting with the fourthgeneration lab-based tests that i just showed you. if it's negative, it's negative. if it's positive, you followon with a separate antibody test that distinguisheshiv 1 from hiv 2.

if that is positive,then someone is confirmed hiv infected. if the differentiationassay is negative, then you have kind ofdiscordant test result, and you would break the tie withnucleic acid test, an rna test. and if that's negative,then the person that has a false positive hivtest, if that's positive, then they're adjudicated tobeing a true positive hiv test and a diagnosisof hiv infection.

so getting back to our patient. what hiv test wouldyou like to use? whether or not she needs pepor prep, she needs hiv testing. and you know that herlast potential exposure was within 72 hours-- actually,within 24 hours, 'cause she had intercourse last night. her source patient isthe unknown hiv status, but definitely at risk. and she may be in an ongoingrelationship with him.

so these are, again, theapproximate sensitives of the various tests. lab rna starts turningpositive in 11 days. the lab-based is p24antigen antibody test starts turning out to 16 days. the antibody onlytest, within 22 days. and that includes, actually,the rapid fourth generation test ultimately to determine. which although itlooks like an antigen,

it is less sensitivethan the lab based antigen antibodies test. so it's approximatelythe same sensitivity as the lab-based antibodytest within two days, and then the rapid testat three to four weeks. so using a rapid hiv antibodytest, it's the fastest one, it's the cheapest one. it's the quickest one. it will be availablein 20 minutes.

but it has thelongest window period. so you could missacute infection. if you were to use the lab-basedfourth generation antigen antibody test, there's amuch shorter window period, and the result isavailable later today. you could use pooledrna or individual rna. those have the shortestperiod that the results are in several days, andthen the most expensive. so here's what we do.

we started with a rapidfinger stick antibody test just to see. if that was positive, thatwould have changed the story right there. it was negative. and her blood was then sent fora lab-based fourth generation antigen antibody test. that turned out to be negative. she was prescribed 3 drugspost-exposure prophylaxis,

which will last her 28 days. she's working on getting herboyfriend tested for hiv, and the plan is to transitionher directly from pep to prep, if she's hivnegative on follow-up testing at the endof 28 days of pep. that's enough of me. and now, thomas knoble is goingto talk about integrating prep into hiv testing program. thomas: all righty.

that was helpful, oliver. so this is kind of a roadmapof how we roll things out here in sanfrancisco, with regards to getting prep movedinto the community, more specifically around ourhiv testing and other prevention efforts. so we started with communityforums, which were really quite fascinating towatch how the community-- we had a lot of interestaround the prevention strategy,

and a lot of energywith regard to whether or not we shouldgo forward with it. and i remember attending these. and at some point,the conversation kind of went from whether ornot we should use prep to, how do we access prep? so if any of you are outthere who are not actually started thisprocess, and started talking to thecommunity about prep,

look for that turning point. that will actually giveyou a strong indication that the community is kindof ready to move forward with regards to accessing it,versus having a conversation about whether or notit's actually for them. so then once thatkind of happened, we started trainingour outreach workers and our prep counselors. we created a product, an eighthour training that basically

look at the complexitiesof prep and how would you work with a client to helpthem assess whether or not prep was actually for them. and it would be somethingthat would actually benefit them or fit into their lives. and that was actually agreat process as well. and the traininginitially was eight hours. and now, it'sactually four hours. and kind of feel wetook out the role plays,

because people seemed to havea lot more understanding, at least within ourcommunity, about what prep is. and if people areinterested in that training, they're more than willingto send it out to folks if people wouldlike a copy of it. and they would like to takeit and make it their own, so we're more thanwilling to share that. and then we basically added prepto our evaluation web process. luther consulting was actuallyreally generous with the fact

that we were able to addfour assessments question- whether or not peoplehave heard of prep, and whether they were on init, and whether they'd been on it in the last 12 months. and then if they had been on it,where were they accessing it? so and that informationhas actually been a really goodkind of a benchmark to see how successful we'removing with regards to getting it out there.

about 70% of the folks had heardof prep that were accessing, and about 25% had takenit in the last 12 months. and then provider education,which kind of goes back over the other houses, is a lotof that training kind of talked to clients abouthow they interact with their medical provideraround the conversation of whether or not prepwould be good for them, because we were hearinga lot of pushback, that people wouldtalk to their doctor,

and their doctorbasically wasn't clear on how to handlethat conversation. so we want to makesure that the providers that these individualswe were referring to were able to have a culturallycompetent and appropriate interaction withthat client with regards to them gettingthemselves on prep. and then, we'rebasically integrated. so we worked our training nowinto our certification process

for hiv test counselors. so now everybody who goesthrough our certification process, which is afour-day training, also receives the trainingon prep within that. so it's now completely woven in. so next slide. so this is an overview--so basically, individuals do outreach. someone accessesprep for a test,

and then within that,the hiv test counselor has a conversation about andthe assessment of whether or not prep conversation isright for that individual. and then it is, informationis given to that person-- how to talk to providers,and everything i just mentioned a minute ago. if for some reason, there seemsto be additional barriers, or a client needsadditional information, we can actually refersomebody to a prep navigator,

and that navigatorcan help them work through even other barriersthat might be preventing them from accessing prep, or whereto go, and all other things. and the important thing hereis that you're actually doing high impact hiv prevention. starting at the top, thepeople that you're testing should actuallybe the same people that would be a goodcandidate for prep. so it kind of foldsnicely into, if you're

reaching who youneed to be reaching, you should also bereaching the same people who actually need to do prep. so that being said, so whenwe started this conversation, there was a lot ofconfusion around whether or not prep was kind ofhappening within the agency that we were talking about,or if somebody actually had to be referred outto medical provider. so this kind of just a visualwith regards to the fact

that it's kind ofall under one roof. so these are obviously ideal. and if a client feelscomfortable accessing an hiv test, that that particularagency is culturally competent, or has the savviness toactually provide them with prep, and have those conversationsaround whether or not prep s appropriate for somebody. so the next slide when somebodyis-- so if somebody actually had to be referred outto the medical provider.

so some of ourcommunity-based organizations don't have themedical infrastructure to actually offerprep within house. so this kind of reliesa little bit more on the test counselor tohave that conversation, and do what theycan to actually help navigate that individualthat's using prep with a medical provider that canactually write a prescription. so next.

so depending onwhat the setting is, it kind of impacts what kind oftests that individual can run. obviously, if it's amore medical setting, they have more accessto lab testing. and if it's acommunity-based organization, rapid testing is morelikely to be appropriate. so i thought these nextfour slides were actually really helpful. i attended the hiv diagnosticsconference in atlanta

this year, and dr. randalldid a really good assessment of what kind of hiv testingwas happening out in the field. and what she did isshe actually looked at a number-- 52 differenthealth jurisdictions-- and kind of asked themthe following question. so what kind of sample wherethey gathering for their hiv testing? and you can kindof see that there was a lot of rapidhiv testing with blood

happening in the field. so i thought thatwas a real help. this visual for me was like,ok, this is really helpful. and then the next slidekind of shows the fact that the rapidtesting is actually increasing as yearsgo by with regards-- it looks like standardlab-based testing is kind of steady for the most part. but rapid testing isdefinitely out there.

go for it. oliver's rushing me along. which is fine. so this is a quickvisual just look at sensitivity, specificity,what generation, and the runtime. each of these tests, theseare the seven different tests that are currentlyclia-waived on the us market. they all have theirstrengths and weaknesses

with regards to where theyfit, and how they fit. and the pricing is onthe bottom as well. that's the public health price. so there's a degreeof diversity out there with regards to these tests. and if anybody everhas any questions about why we usewhich tests and where, i'd be more than willing to havethat conversation with folks. so if you're actually lookingto change whatever particular

testing technologyyou're currently using, i can help withthat conversation. oliver: so i'm gonna chime in. this is oliver again. i'm going to chime inbriefly after thomas' awesome descriptionof integrating prep in the hiv testingto talk about what would be the ideal test forhiv in the context of prep. it should be easy to use.

it should have lowquality assurances needs. it should be cheap. it should crucially nipvery few true positives, and it should detectvery few false positive. in other words, it hasto be a reliable test. i think for prep, thechallenge is really going to be to develop arapid testing strategy that finds the key hiv as earlyas possible in settings where lab-based fourthgeneration and rna testing

are not readily available. because we don't want torestrict prep to places that can only do a fourth-gentest, or an rna test. that would reallyhamper, i think, the public health effectivenessof prep as an hiv prevention technology. so there's no rightanswer to this. if we only have rapid testingavailable, what should we do? i think one possibility isto repeat the rapid test soon

after prep initiation tocatch the people who actually had early hiv infection at thetime they were first tested. we don't know what theproper interval for that is. is it two weeks afterthey started prep? or is four weeksafter they start prep. we don't know if it actuallyprevents resistance. we need data on that. but i would say-- andagain, this is me talking. this is not the department ofpublic health in san francisco,

or the cdc talking. if i were somehowin a setting where all that was available tome was rapid hiv testing, i would probably repeatthe rapid hiv test pretty soon after theystart prep to make sure that we were catchingacute hiv infection as quickly as possible, meaningas quickly as possible after the antibodyactually turns positive. in other settings, however, ifyou have access to rna testing,

and or increasingly, the fourthgeneration antigen antibody test, the lab-basedtest that they wanted to use to reduce therisk of acute hiv infection at the start of prep. so i'm going to turn it overto melissa morrison, who's going to talk about integratingprep into a social network testing strategy in tennessee. melissa: thank you. good afternoon.

so i'm going tostart out and just tell you a little bit,for just a minute, about our demographics. because they don't letme do a presentation without showing this. next slide. just showing you how things looka little different in tennessee than they might in sanfrancisco or in houston, but may be similar tosome of your jurisdictions

where you are. and just these three arrowsare what i wanted to point out, that the majority ofour cases are in males. they're in non-hispanicafrican americans, in msm, and increasinglyin young folks between the ages of 15 and 34. and so when we thinkabout any changes we want to make intennessee, we always want to take thatinto consideration.

and so on the next slide,this also just shows you-- i'm going to talk a little bitabout social network strategy. and the two arrows are pointingtoward the county labeled number seven-- we're nashvilleand davidson county-- and the county labelednumber 12, which is shelby county, where memphis is. and that's where 2/3 of our newinfections are in our state. and then the other 93counties have about a third of our new infections.

so we really try to targetthings in those two areas whenever we rollsomething out as well. so on the nextpage, this is just a summary of what our currenttesting program looks like. so before we started thinkingabout how this prep fit into what we're doingin testing in our state, i think this is reallyhelpful to take a look at. for those of you that arepart of health departments, you'll be really familiar withcategory a versus category

b. and those of you thataren't, it's not that important. but anyway, it 'sthe way cdc kind of look at how we're doing ourtesting, and what's expanded, and what's not. so in our state, we're doingabout 120,000 hiv tests a year, which is quite a bitfor a state our size. and we found 462 new positivesthrough that testing. and that's about 63% last yearof all of our new positives, which was the highest amountwe've had in quite a while.

as you can see with ourlinks to care percentages, we're not quite where wewant to be, with 80% linkage within 90 days,and we're certainly having to kick it into high gearto try to get to 85% linkage in 30 days, whichare our new goals. but what we are findinga lot more folks in this are actually getting links. it's just perhaps notwithin the 90 days that this was measuring.

and sometimes, whenwe do reporting, we're outside of the loop. we still have time forpeople to get linked, and we didn't get to count them. but we're getting close to80% in most of our testing. the thing about this is--and i didn't split this out, because i didn't wantto bore you guys. but we are doing a varietyof test technology. about 70,000 of those tests,most of our health department

tests, are fourth generationbio-read tests run in the lab. and we did find somewherein the neighborhood of 13 acute cases per yearsince we've been doing that. we started in 2013. so the fourth generationtests are great. and it's great when we canget those tests happening. but not all of themwere able to do that. we're still doing somepoint-of-care oral testing with rapid tests.

part of the reasonwhy is in jails, we aren't allowedto bring sharps in, so we can't do even finger sticktesting in some of our jails that we're doinghigh volume testing. in other places,we have cbos that haven't gotten to thepoint where they're able to do-- especially notblood draws, but they're still having some difficultywith insurance issues and with being ableto do finger sticks.

so we are doing about, i'd say,about 40,000 of those tests are point-of-care oral. but there are few others thatpoint-of-care finger stick. and we have a variety ofpartners that are contributing to this 120,000 tests. we have health departments. we have std standalone clinicsin six of our counties. we have ers. we have corrections inboth jails and prisons.

we have cbos doingoutreach testing. and we have sqhcs who arecontributing to those numbers. so in taking alook at that, we've come up with two strategies inour state to incorporate prep into our testing program. and the first one i'mgoing to talk about is the social network strategy. and on the next slide,you'll see a little bit more about what that pieceof testing looked like.

and so now, the first blackcircle, the 1953 test, you'll see that it's not a hugenumber compared to the 120,000 we're doing in our state. however, it's been a reallysignificant program for us through capus because we havehad the highest positivity rate we've had out ofthis is 13.3% positivity. this testing in youngblack msm in memphis, which is our highest zeropositivity jurisdiction in the state.

so it's been extremelysuccessful for us. we've managed to, with verylittle money and investment, identify 71 new infectionsover this about-- it says four years. but because everythingwasn't a full year, it's about two and ahalf years of work. 71 new infections with anoverall positivity rate of 8.7% was pretty successful for us. we really struggledto hit 1% and 2%

positivity for cdc's threshold. so this was a prettybig deal for us. and so, we reallywanted to take a look at you know, we have targetedin on 1,953 young black msm in both memphis andnashville, that we think most of these guyswould be eligible for prep. and so, we've tried tothink about, how can we use this testingstrategy that was coming to an end, becausecapus was ending,

and incorporate prep into that. i will say, one thingthat i want to point out is that this was over threedifferent community-based organizations. and one of them did havethe ability to draw blood. and we worked out anagreement with them to be able to send bloodsamples to our health department in veryhigh risk folks, so that we could performfourth generation testing,

and try to find acute cases. and the other two agencieswere not able to do that. but we're still tryingto work with them and problem solve on waysthey can make that happen. so if you go overto the next slide, integrating prep referralsinto social networks strategy. what we've done and this isjust again actually last month, is that two agenciesthat were doing the majority of thetesting in memphis

are going back through alltheir previously tested hiv negative, young,black msm, and they're re-contacting them using thesame social network strategy model that cdc prescribes. and the idea is that youpay them-- not pay them. i'm sorry. i used the wrong word. you give them an incentive toreimburse them for their time for coming back in, andreceiving another hiv test,

and receiving some educationand counseling around prep. and so our social networkstrategy specialists are re-contacting eachof those 1,900 guys and asking-- not all at once. we're going to do it overthe period of a few months. but asking them to comeback in and get an hiv test. and they'll get thesame $20 incentive that they received whenthey first did this sometime in the last three years.

and then, they'llget some education. and we'll talk tothem about prep. and if they're interestedin, and still at risk, and still negative,then those clients will be referred to prepnavigator for next steps. and ideally, that's going tohappen within the same agency. we're working on gettingprep navigators placed in each of those agencies. and again, one ofthose agencies, they're

going to be able to draw bloodand get a fourth generation test. and the other agency, we'restill working on that. it's more than likely goingto be an oral fluid test. but if somebody is at veryhigh risk that perhaps had a recentexposure, we're going to try to get them intothe health department to get that fourthgeneration test. the other slide i wanted toshow you here round std clinics,

we are also looking at, withoutany additional money-- which i know a lot of you guys maybe in the same boat, thinking i don't have any fundingfor prep, and no one's handing us extra dollars tobe able to do these referrals. so how will this work? what we've done inour std clinics, we've just finished rollingout training for all of our dis across the state,and letting them in very-- i think very similarto what thomas was saying.

we started out witha longer training. we ended up going downto about four hours. and we went throughand trained all the dis on how to give prep referrals. and we've given them access toour provider directory, which is not probably as expensiveas san francisco's might be, but we do have about 25providers in our state who are willing to provide prep. and so, the dis haveaccessed all that.

we've actually pre-printedthem some referral cards, so that they can hand thoseto patients, put the name and number of theirprovider that they've chosen to make an appointment. and they can walk outof the health department with some information about prepand an appointment to get prep, even though we aren't at a placenow where we can provide that. and to keep it reasonable forour dis, because we don't have the funds to be able to providespecific dis devoted just

for prep, we asked them totarget five categories of folks who come into the std clinics. and this is any male ortransgender client that has a positive syphilis,but is hiv negative, a positive rectal swabfor gonorrhea or chlamydia that is hiv negative, anymale or transgender partner of a male, ortransgender std case, or any male ortransgender who answers anal sex equals yes ontheir interview record,

or idu equals yes. so for the most part, whenwe add all that up for all of our dis acrossthe state it's, no more than about 50to 70 people per year that we're asking them totarget for prep referrals. but we do have 60dis across the state. so that's going to add up toa pretty significant amount of counseling andreferral that will happen as a part of their regular job.

and so, i put in a couple extraslides about risk assessment here, because there's been alot of talk for us about that. and we're stillworking on how we're going to get our cbo staff toassess risk before they make the referral onto the provider. this is the tool from thecdc 2014 clinical provider supplement that was released. and this is a scorethat you add up, depending on how youanswer these six questions.

and if the scoreis 10 or greater, then they're evaluated for prep. and if not, they just getstandard hiv prevention risk reduction services. then the other thing iincluded here, the next slide, is something we werepretty excited about. so i want to say ihope that there's somebody from ohio on the call. we were not able--this is not our app.

we did not developthis in tennessee, but we're veryexcited about what arc ohio has done with this,because it's a great app. and we've been tryingto get ahold of them and get permission for usto talk to who developed it. and we haven't been successfulwith that up to now. but when you go to thatapp store for apple, this is one of the fewprep apps you can actually see and download.

and they have a reallygreat system set up. really simpletouch screen, where you can check all thestatements that apply to you, and then you can go on to thenext, and be able to show, you know, prep mightbe right for me. and then there's alist of what town you're in, and what providersmight be close to you. so we're looking todevelop something like that as well, which might the mostexpensive part of all this

that we've talked about. because up to this point, wehaven't spent very much money, or had very much money to spend. but with somethingalready put together, it's nice that you could takethis, and with permission, be able to replicate it. it's a lot easier than trying todesign something from scratch. so we were really impressedwith what ohio had done. and then just to moveonto data collection,

we are trying to put ourheads around-- again, without a lot ofmoney-- how are we going to collect this information? and we've had somedifficulty getting boxes added to prism,to be able to collect whether we've done prepcounseling in prism for std clinics. so until we can getthat done, we're actually just having folkssend us the prism id numbers

of those who get counseling. and we're going to keep trackof them the old-fashioned way. and we are working onsetting up a redcap database for collecting informationfrom our community-based organizations that arepart of 1506, which is our prep award in memphis. so for those of you thataren't familiar with it, and if you're thinking abouthow to keep track of this, i'd encourage you togo to project redcap.

it's actually beendeveloped by vanderbilt, but it's for use for free tocommunity-based organizations and any non-profits. and so we're going to besetting that up, actually, within the nextmonth or so, to keep track of how many folkswe're identifying for prep counseling, how many folksare actually getting referred, how many are gettingonto get a prescription, and then beingfollowed up from there

with some of our navigators. but it's very customizableand very secure, and it has mobile appavailability as well, which is pretty exciting. and then the next slideis just sharing with you what cdc has told us theyare looking for as far as reporting element go whenit comes to prep referrals. so in both of theseways that we are going to be identifying folksand referring them to prep

our testing programs, fromboth social network strategy and from our clinics, this isthe type of information, which is a nice start the cdc hasgiven us for what they're looking for, for what we'vedone as part of the grant, and we're also going toextend onto things we're doing that aren't part of the grant. but just looking atkeeping track of the number screened, the number eligible,the number referred, linked, prescribed, provided support,and provided navigation.

and now granted,everybody on this call may not have accessto full-time staff in order to go as far asproviding adherence, support, and navigation past theprescription period. but i think it'sreally important to try to collect as much ofthis information as possible, because we all want to know,where are people dropping off on this continuum? you know, what is it thatis going to cause someone

to not go onto a provider? or what's going to cause themto not get the prescription once they go to the provider,or more to stay on it and be adherent after that? and so, we want to tryto document reasons why people drop off, so thatwe can develop down the road different mechanisms to tryto intervene, and support folks, and get them as fardown the road as we can. so that's all i have.

in this last slide, just apicture of downtown nashville. oliver: thank youso much, melissa. that was a totallyinspiring example of how to integrateprep into what's a really, really interestinghiv testing program. the numbers you presentedabout new positive you've detected throughyour social network strategy made all of ourhair stand on end. thomas: i love theangle with no money.

oliver: yeah, and theangle with no money. exactly. thomas: where there'sa will, there's a way. oliver: yeah, but incorporatingsocial network strategy, just it's so right on. so now we are goingto turn it over to megan canon from thehouston health department. megan is going to talkabout integration of prep into hiv prevention contracts.

megan: thank you, oliver. and good morning orafternoon to everyone who's here on the webinar. thanks for stickingit out thus far. again, my name is megan canon. i'm the prep coordinator here atthe houston health department. and i'll be talking about aslightly different strategy of how we're integratingprep into our hiv testing, particularly with our hivprevention contractor.

and before i dive in, iwant to just kind of give some contextual backgroundabout the hiv and prep landscape inhouston/harris county, which is the countythat we sit in. and harris county in thethird most populous county in the united states, sowhat they say is true that. everything is indeedbigger in texas. and we have an estimated4 million residents who live in a very sprawledout 1,700 square miles.

so in terms of scope to explainhow big houston and harris county is, you could fitabout 36 san franciscos just inside of harris county. and in terms of what thehiv epidemic looks like here in houston, ourdemographics are very similar to tennessee in termsof who's getting impacted. so we have a high numberof gay and bisexual men, and other men who have sex withmen, who represent about 2/3 of our new diagnoses.

and then we also have ourafrican american youths are also highly impacted.lookingat the broader scale, houston has the distinctionof having the 11th highest hiv diagnosis rate in the country. every year, we have about1,200 to 1,300 individuals who are diagnosed with hiv. and if you look at themap on the left-hand side, it just kind ofgives a sneak peak of where that hivincidence is happening.

so clearly, a lot ofour outreach efforts are located mostly in thecentral and northern part of the city. i will mention we alsorank in the top 10 for syphilis, chlamydia,and gonorrhea. so we're also seeinga lot of co-morbidity, particularly with syphilis. and in terms ofhealth care access, i want to put in a plug onkind of the number of uninsured

we have in houston. one in four residents don'thave health insurance. and because we'renon-medicaid expansion state, health care accessis a big issue, which is a concern,as we're trying to get people on prep whomay want to access it. and then the last bullet point,from our latest msm cycle reported to the national hivbehavioral surveillance survey, only 3% of msms reportedusing prep in the past year.

so in terms of where thehouston community is in the prep conversation, we're verymuch in the beginning stages of just tryingto make sure people know that prep exists. so in terms of ourstrategy of how we are trying to integrateprep, we are funded by the cdc through 12-ps1201. and we use thefunding to subcontract with local, community-basedorganization

to implement either counseling,testing and referrals, or hiv testing, or health educationand risk reduction referral in non-health care settings. and of the seven contractorsthat we work with, six right now are fundedto do counseling, testing, and referral. and so with each agency,they have a target goal of the number of clientsthey're trying to reach within the contract year.

and our testingoutreach is permanently focused around msm, transgenderindividuals, and communities of color. and in terms of thetesting technology, the type of tests thatpeople are using also vary, depending on thesetting that they're doing the testing at. so we use determine and seeand then some other folks use oral quick.

in terms of our testingcapacity, in the last year our contractors testedover 6,000 clients, and found an overallpositivity rate 3.4%, which is pretty good. and then, of course, forclients who had tested positive, we link them into care,either with the agency that they tested, or route themthrough the health department. and because the people we'retrying to reach out to-- oh, go back.

sorry. i jumped. not there yet. but in terms of integrating stiscreenings and prep education, the people that we're trying toreach out for testing obviously are very goodcandidates for prep. so when integrating prep intoour hiv testing strategy, we amended ourcontracts this year to add the deliverableto all our contractors

who do dtr mustprovide prep and prep education to all clientswho come in for hiv testing, and then make referrals ifthe client is deemed eligible. and so, since we just startedthis strategy this year, here's a very,very small snapshot of how we're doing thus far. and to explain our datacollection process, because that's still kind ofin flux, what we do not yet have prep educationmeasures included

in our eclips database,which feeds into eval-web. so what we've beendoing is asking our cbos to fill out a separateprep data collection form, reporting on the number ofclients who received each prep education and prep referrals. and so then, wecompared those numbers to the number of hivtests that they actually reported doing forthat particular month. so obviously lookingat this chart,

we have some work to do interms of either documenting, reporting, or providing prepeducation to our clients who are receiving hivtests, because that what we contracted our cbos to do. and so we're lookingat kind of figuring out why that drop-off is happening. and it's something we'retrying to monitor and address at the moment. so, next slide.

and i will briefly mention--so the 12-1201 program hasn't had a lot of successes,despite the numbers that i just showed you. and because houston is fairlynew to the prep conversation, we feel like we've been reallysuccessful with offering capacity buildingassistance by providing prep training to the frontline staff of the cbos who we're contacting with,and we'll continue to do so. we also have dedicatedcommunity liaisons

to assign to each agency. so they help to help us withmonitor contract compliance, and addressing anyissues or concerns that come up with the numbersthat come out that are reported at the end of each month. and then in terms ofthe prep landscape, even though we are in thebeginning stages of just trying to get people to knowthat prep even exists, there are a numberof organizations

that have been doingthis prep work already. so we've been benefitingfrom that previous work. and then, on that sametoken, one of our challenges is that not all ofour organizations are as familiar with prep. and so we've been tryingto address this issue, by trying to make sure thateveryone has the prep literacy skill set to talk toclients by providing tailored prep training.

and then from a monitoringand evaluation perspective, this is where ithink in hindsight that this is somethingthat we are currently working on to try to address. it's something thatwe could've given more guidance onto our contractors on how to reportthese prep measures, since it's not currentlyalready included in our eclips database.

and then in talking with ourhiv prevention contractors, they've identified the need formore consumer materials, which we need to address bygiving them prep cards, and then also, a citywiderefferal network. because one of the challengesthat we're finding out, those are people who do youknow what prep is, and are interested in getting on it. we're having thechallenge in figuring out how to connect the dotsbetween prep referrals and prep

linkage. so if one of our hiv preventioncontractors refers someone to a prep provider. we are still trying tofigure out the process to ensure that thatperson actually does link with the providerthat they've identified. and that's something that someorganizations have navigators. some of them don't. so it's somethingthat we're trying

to troubleshoot on our endin providing assistance to their cbos. and i wanted to show oureclips modifications that are in the process of going out,hopefully by the end of summer, if not next month. and so, since we realize thatmonitoring and evaluation was something that we needed toaddress in documentation, in my head, it'sprobably something that might help with makingsure that our contractors are

reporting-- that prep educationand prep referrals are happening, eitherjust sample questions that we're in the process ofadding to our eclips database. and so when a staffperson is doing data entry on a client encounteron the risk assessment, we've added the questionson before today, had the client heard of prep,was the prep education provided to the client. and then because we'reinterested in documenting

the number of people who'vereceived prep education, because we are also responsiblesimilar to what melissa showed in the reporting table that thecdc is interested in seeing how many people learn about prep. we want to make sure tocapture that if the client's partner was present whenthe prep education was given as well. and then for anyone that answersno to any of the questions, there are drop-down menuoptions to help figure out why

the education wasn't given. and then, in terms of the resultsection-- so if someone's hiv test came back negative, thestaff person on the back-end would have to answerthese questions asking about prep screening,eligibility, and referral. and then, if thestaff person answers no to any of thesequestions, again, there'd be a drop-down menu, askingwhy the client either wasn't eligible, or whythey weren't screened

for prep in that encounter. and then just to quickly recap,i talked about all this before. but pretty much the things thatwe are working on at the moment is picking out thereasons for why we're seeing a drop-off inthe reported number of prep education encounters, and seeingif there's either a protocol issue, figuring out if themodifications that we're making to our datacollection will help out, figuring out if this isa staff capacity issue.

obviously, i just showedyou the modifications that we're making eclips. and then in terms of theother areas that we're working is continuing toprovide prep training. and then, exploring if we cancreate a referral network, and then sharingmaterials out once we create a socialmarketing campaign. so in closing, thank you forlistening to my presentation. hopefully, you learnedsome nuggets of what to do

or what not to do withintegrating prep education and referrals withyour hiv testing. and i'll hand the webinarreins back to oliver. oliver: thank you, megan. that was terrific. i think highlighting theneed for-- i mean, first of all, the fact that youguys are incorporating prep assessments into as manyof your hiv testing contracts as possible is fantastic.

and it also highlightsthe need for sort of a follow-on set whichis, how do we put together effective prepnavigation programs? and i will tell youfrom other activities that we're doing withother health departments around the country regardingprep, the need for figuring out the prep navigationprogram is really rising to the top of the list. so that is it for ourformal presentations.

but we have about 20 minutesto tackle some questions. and these can be directed atanyone on the webinar panel. some of you had already chimedin virtually with questions using the chat box. a couple of them, i'mjust going to start. someone asked, what do youmean by acute hiv infection? all my learning thus fardealing with acute infection is that it means thatthe infection will leave the body on its own, likehepatitis a. great question.

to clarify, acutehiv infection is not like hepatitis a. it'ssimply refers to the earliest stage of what isinevitably going to become a chronicestablished hiv infection. so once you have acute hivinfection, it's going to stay. it doesn't tend to go away. thomas: any hiv infectionprior to antibody response is how i would define it. oliver: so this next question,i think, is for thomas.

the speaker just mentioneda few minutes ago a training they used for theiroutreach workers to educate them onprep, who stated they would share the trainingcurriculum with the audience if requested. please let me knowhow i can request a copy of the trainingfor outreach workers. thomas: yeah, definitely. so if anybody'sinterested in that,

my e-mail is my full name. so thomas, and then there's adot between thomas and knoble, @sfdph.org. and yeah, no. i'm more than willing to sharewhatever training materials we have with regards tothat, or even help have a conversationabout what we've learned in some of the keycomponents to that training. so yeah.

no, whatever we've got, we'remore than willing to share. so just send me an email, andwe can easily make that happen. oliver: great. and so a question for melissa. in your algorithm foroffering prep, which trans sub-populations arespecifically referred to by tg? does this include bothtrans women and tans men, or only one? melissa: well, we areworking on doing a better

job in oursurveillance department and with our dis on identifyingtransgender clients, at the moment, ourentire prism database has about 40 transgenderclients in it. so we have been verybroad to say anybody that presents as transgender. we're also working on doingtraining with all the folks that interfaced with patientscoming through our health departments to emphasize whyit's so important to talk

about sex at birth, andthen current gender as well, and to answer thosequestions, and specifically ask every patient bothof those questions. and we had some difficultywith that up until now. so we have been verygeneral to say transgender, but we're onlyexpecting for right now that that might end uptranslating to five or 10 folks this year that people willsee and talk to about prep. so we didn't wantto exclude anybody

by being more specificin saying male to female. but anyway, if weget to the point where our numbers are big enoughthat we need to-- we're really trying to get thatgroup of people down to a reasonableamount of folks that are dis could work with. because some of them aredoing tb and immunization, and all these other thingson top of hiv and std as far dis goes.

so we wanted to get it down toa reasonable amount of people that they wouldn'thave riot on us. and when we have to add onemore thing to their bodies. so anyway, the shortanswer to your question is, we did say justtransgender folks in general. oliver: thank you, melissa. so a question about thelandscape in houston. so megan, tarrant countypublic health-- sorry, this is in fortworth, not in houston.

tarrant county public health infort worth, texas offers prep, but we face barriers fromprimary care physicians refusing to refer insuredpatients to our clinic. any strategies toovercome this issue? so megan, have you alsoseen that in houston? is this on anyone'sradar screen? megan; with providers notwanting to refer-- let me know if i'm gettingthe question correctly. so the question isproviders not wanting

to refer to otherprep providers? oliver: yes. that's what it sounds like. so it sounds like there'sreluctance among primary care physicians refusing torefer insured patients to the public health clinic. and it's not clearexactly from the question of whether it's a reluctance torefer patients to prep period, or whether it's abilling issue, that they

don't want to lose potentialrevenue by referring patients they would otherwise give prepto public health prep clinics. megan: got it. yeah, so as a disclaimer, we atthe houston health department, we actually don'tprescribe prep. i mean, similar to hivprevention contractors, we provide educationand referrals. in terms of ourprovider outreach, we haven't heardof pcps refusing

to refer to a prep provider. part of it could bea lot of referrals are coming from people whoalready are doing hiv testing that we have contact with. so we don't see a lotof barriers there. we just hired-- i'mreally excited-- we just hired a new outreach specialist,whose main job will be going out into the community to talkto peak primary care providers. so i think whenthat person starts

going out into the community,he might encounter those. but i think a strategyto potentially address, depending on the provider'sresistance referring out, it sounds like it'sjust a matter of giving technical assistance,of showing like, hey, if it's a matterof reimbursement, here are billing codes thatyou can use to potentially get reimbursed back fromwhatever the insurance plan is. if it's a matter ofprotocol and figuring out

what test you need, ithink that's a strategy that i would recommendwith kind of trying to address thatprovider's concern, if they didn't want to referout to another provider. oliver: got it. so that's very helpful. so there are billingcodes that can be used and can be provided to networkwith potential prep providers. so hm hm hm.

i'm going to navigatethis question to melissa. how does prep promotion navigatethe political environment in tennessee, asking for stateswhere the political environment may be hostile? you want to touchthat one, melissa? melissa: sure. yes. i would first ask youto identify yourself as a legislator or not.

[laughing] melissa: so yes, it isabsolutely a concern for us. to set the stage for thoseof you not in the south, i have had to field questionsfrom our legislators about whether it's appropriatefor health departments to hand out condoms or not. and they've questioned ourcondom contract in the past. we certainly try to keep a lowprofile when it comes to hiv. having said that,one of the ways--

we do have as partof our 1506 grant that we'll be workingwith-- in memphis, we have a large campaign we'llbe doing to increase awareness about prep for theoverall community, targeted to both msn andtransgender communities. and we're doing thatthrough subcontractors. so it will not be brandedwith the tennessee department of health logo. i love that san franciscohas their beautiful logo

with the golden gate bridgeon everything that they do. but we don't necessarilydo that where we are. that's one of the ways wetry to keep a lower profile, is by working throughsubcontractors. and so we have a leadagent, basically, that the money goes through. and then they hire thepeople who will do the work. but we did have to getlegislative approval to accept the funding towork with prep in memphis.

and luckily, thefiscal committee approved that funding. we were a little concerned, buteverything went through fine. certainly, if any you guyswatch late night television, and colbert or jon stewartand things, when they were on, they made fun ofus a lot for our-- we had "don't say gay" billsthat they were introducing to our state, and we had lotsof things that are not gay and transgender friendly.

and so, transgender bathroombills come up this session. and so, it is a concern. but we, of course,run everything and all of our projectsthrough everybody here at thedepartment of health, and can back up anything thatwe're doing, as far as data on how it can help save lives. but for the most part,we keep it low profile by being able to workwith contractors.

so i will say that a lot ofthe things i just talked about are what our plansare, and we're just now starting to roll out. it works a little differentlyin memphis and nashville than it does in some of themore rural parts of our state. and luckily, that's wherewe need to be targeting, is in our larger cities,which is a little more liberal than the rest of our states. so i'll leave it at that.

thanks, melissa. and i know thomas isitching to say something. and megan, if youwant to chime in too. thomas: yeah, we just rolled outa campaign, a social marketing campaign, for transwomen and men of color. and it had a lot ofenergy around it, and it wasn't even that sexy. oliver: when yousay a lot of energy around it, what do you mean?

thomas: i'm trying tobe kind, but people had some strong opinionsabout the imagery and just the concept ofthe campaign as the whole. they have strong opinions. if folks want to go to it,it's oursexualrevolution dot-- i want to say org. i'm not entirely sure. but it's fascinating howit brings out opinions, and i don't know whatelse to say about that.

i'm sure everyone on the phoneknows what i'm talking about. but even here in san francisco,something that you think would not create that muchcontroversy actually did. but the campaign has actuallybeen really well-received among the populations that wewere actually trying to reach. so that's the otherinteresting part of it. so it's culturallyappropriate for who we are trying to access. thank you, thomas.

and megan, youknow, any issues you want to speak to aboutsupporting prep in a medicaid non-expansion state like texas? megan: that is a good question. i was listening to melissawhen you were talking, and i was like, oh, yes,we also keep a low profile. if everyone remembers,back in the fall, the hero initiative washappening in houston. and part of the reason whywe've been somewhat delayed

in rolling outour program was we had to wait until theelection season was over, because we were given adviceto hold out until the dust had kind of cleared off, when thehero initiative was shut down, to bring up our project andgetting city council to approve our prep funding. so melissa, when youwere sharing your words, it very much resonated with me. in terms of workingaround the sub-commission

in a non-medicaid expansion,i think, especially for us, our priority is justhitting home prep education, and trying to do outreachas strategically as possible in the cases where weknow that we need to be, especially given the high numberof people who aren't insured. so a lot of theeducation initiative that we're rolling out will beincluding an enrollment piece, just because we knowthat we'll probably be interacting with people whoare under-insured, or don't

have insurance. so that's one ofthe main strategies that we're trying to addressthat particular issue. thank you. thank you, everyone. so i'm going to adda little follow-on. because a related question thatcame up in the chat box was, what about paying for prep? getting prep coveredfor non-insured people?

and i think that'srelevant everywhere. and it's particularly relevantin medicaid expansion states, because many, many, manymedicaid programs will cover prep, and they'llcover-- remember, prep is not just the pill. that's the most expensive part. but it's the pill, andthe visits, and lab costs. so what about if you areproviding prep to, or wanting to provide prep topeople who either are not

eligible for medicaid,or live in a medicaid non-expansion stage,or particularly, undocumented people. so there are somecrafty ways around this. and this is a little bitoff-topic for hiv testing prep, but it's such animportant question. it comes up all the time. so in terms of gettingthe cost of the drug paid, if you can document that someoneis not eligible for medicaid

and is not insured,but makes under 500% of the federalpoverty limit, you can apply that person to thegilead medication assistance program, which will payfor the cost of truvada and have it deliveredto them at home, or a pharmacy, or a clinic. what it won't pay for isthe cost of the visits and the cost of the labs. so if you can find another wayto cover visit costs and lab

costs, then the gileadmedication assistance program will cover the costof the drug itself. many, many, many, many questionsabout, will the webinar slides be available? yes, we will postthem just as soon as they've been given finalcdc clearance on the website. so yes, since we whippedthrough the slides, you will have a chance toread them at your leisure. and many questions aboutwhether, thomas, the training

slides that you mentionedwill be made available? thomas: definitely. and the social marketingcampaign i spoke of as well, if folks have questionsabout how that rolled out, and lessons learned. we're more than willingto share that as well. the condom message withinour marketing campaign was challenging to negotiatewith regards to the fact that syphilis is such anissue among populations

that we're trying to reach--i.e., gay and bisexual men. and i can easilyshare with folks how we navigatedthose waters, and how we ended up where we ended up. so it's just to help folksnot reinvent some wheels out. they're more thanwelcome to have ours. i'm scrolling throughthe questions. how to deal with drug resistancewith a false negative-- hiv negative prep client.

i'll tackle this one. so the issue hereis that if someone who has acute antibodynegative hiv infection starts taking truvada, weknow that those people are at risk for the developmentof hiv resistance mutations by their virus. so those viruses can becomeresistant to one or more of the two drugs in truvada. so how you deal with that?

so first of all, this isa very rare occurrence, which is a good thing. secondly, whenever anyoneis diagnosed with hiv before they go on therapy,one of the many blood tests they have is calleda genotypic resistance test to see if there anydrugs that their virus may not respond to. so using that informationto help construct an antiretroviral cocktail thatwe know will work for someone

is really important. and i want to reiterate thatit is almost always/always possible to find a drugcombination that will suppress someone's virus, even if theyhave a small amount of drug resistance due tohaving started prep while they had acute infection. i don't personally know of anycases in which that has not been possible. thankfully, the occasions forhaving to do that are very few,

and it reallyhighlights the need to rule out acute hiv infectionbefore starting prep whenever possible, and asquickly as possible after starting prep if thathas unfortunately occurred. let's see. going through questions. lots of questions aboutaccess to slides and training material. and the answer is yes.

and questions about assistancefor undocumented clients who are interestedin prep and pep. i think using the gilead patientassistance program is a way to get drugs, but again, doesnot provide for visits and lab tests. oh, here's one. so is anyone offeringprep to youth? this is a great question. so the studies that ledto the fda licensing prep

for prevention,truvada for prevention, were all performed in adults. so that means thatofficially, truvada for hiv prevention or prepis only package insert approved for use in thosewho are 18 and older. having said that, weall know that there are many youthyounger than 18 who are extremely high risk forhiv infection-- msm youth, particularly young msm of color.

and prep is definitely beingused in youth under 18, in adolescent medicine clinics. there are two studies of truvadafor prevention in adolescents run by the nih thathave recently wrapped up and are starting torelease their findings. and the bottom line that prepis safe and effective in youth under 18 years old. there are importantadherence issues with youth. youth tend to be less adherentthan adults to their prep.

and it looks like having morefrequent visits to the prep provider-- i.e., monthlyinstead of quarterly-- improves the adherence,is associated with higher levels ofadherence to prep among youth. there are importantissues about, can youth consentto truvada for prep without their parentsknowing about it? and that's very much astate by state question. i would say that in thestate of california,

there is a provision foryouth to get std prevention services, includingtreatment or prevention, without their parents knowing. but that's very much astate by state issue. but the answer-- melissa: oliver, cani chime about that as well when you have second? go ahead. melissa: sorry.

i didn't mean to interrupt you. believe it or not, actually,in tennessee as well, we from a state perspective,asked our general counsel, who reports to theattorney general, for an opinion about that. rather than tryingto remake any laws or establish any laws inour political environment-- especially consideringthat we have st. jude here in our state, who does a lotof clinical trials, and are,

in fact, about to doan injectable prep clinical trial for youthunder 23, between 13 and 23. so we were all very interestedin answer to that question. and we got our generalcounsel to give us an opinion. they reviewed our currentlaws, which sound like they're very similar to california's,as far as allowing minors to be able to betreated for an std without parental permission. and they gave us theopinion that they

felt like prep would fall underthat as a treatment for std, even though it's apre-exposure prophylaxis. and we have that opinionon file here in our office. and we have brought it out inquite a few situations, where we have partners whoare interested in being able to work with minors,but are a little worried about the legality of that. and so it's been very helpful. so i would suggestto any states,

if you're at the statelevel, and you're thinking about where to startand what to pursue, i would say instead of looking at tryingto establish a new law or to add something on legally,start with your attorney general's office,and see if you can get a legal opinion aboutwhat currently exists, and whether prepcould fall under that. thomas: that's great advice. oliver: melissa, that'sfantastic advice.

so on that note, we'regoing to wrap things up. and we'll let youknow that we're going to haveanother prep webinar in our series explicitly dealingwith adolescents and prep. and that will be in early 2017. so stay tuned for that. and finally, if you'reinterested in more information on hiv testing and prepfollowing on from this webinar, sign up for office hours.

they will be on august 11, from10:00 am to 1:00 pm pacific time. you can sign up atwww.getsfcba.org/events for a 30 minute slot to chatwith thomas or me about hiv testing strategies,incorporating prep referral into your testing program,for any questions about the different hiv tests, andanything else prep related. so with that, i'dlike to really, really thank our panelists,who were amazing,

and thank the audiencefor your great questions, and thank mehroz baigour communications maven for making this all possible. and that's it. so thanks, everyone, andenjoy the rest of your monday.