 Good morning. My name is Elizabeth Lutz. I'm the executive director for the Health Collaborative and on behalf of all of the sponsors and Panel excuse me the the planning committee. We'd like to thank you very much for spending the day with us today I'd like to take the opportunity to say, thank you very special. Thank you to our sponsors in our planning committee and on your Information packets, you'll see a little piece of paper That's not enough to say thank you for all of the great work that everyone's doing and all of the the support That's been provided for being able to put this summit on today so on your screen you're also Seeing some of the agencies that were able to place faith in this and actually bring The opportunity to have a dr. Holly and dr. McCarthy Here with us today. So again, I'd like to just say thank you to you for participating and being a part of the summit and Thank you to our sponsors and our planning committee for helping coordinate this event here today I'd like to introduce miss audora Sanchez the executive director for Bear County Department of Community resources Back in about 2008 We got a mandate from a person you could never turn down judge wolf and he said, you know We've got a Ryan White HIV program that needs to be beefed up and fixed up and made best practices And so we take everything he says very seriously. So with Charlene Doria Ortiz's leadership. We did just that and this Meeting today and our sponsorship along with the health collaborative and others For these informative and training sessions as a direct result of the mandate we got from a man who is a politician But a very nice man on top of that Dr. Colleen I were talking outside and I said, you know, he really does have a heart You know, he's a politician, but he's a politician with a heart and since 1971 He's been serving the public first as a state representative and then he went on to be the mayor The city of San Antonio and he's been the county judge and he's been the moving force behind a lot of Backdoor improvements in this community that have improved the general health of the community But in particular, he's got a special place for For people who have chronic diseases and people whose health status isn't always the best So I'd like to introduce my boss judge wolf Or thanks Aurora and Thank all of you for the great work you're doing in our community As you know, Bear County is responsible for a great part of the health care of this community with our with our hospital system commissioners court voted in 2008 to put some almost a billion dollars with a B into Doubling the size of our hospital at at the UT health science at UT health UT a health science center area Some two million square feet will have there and then the building that that we built down downtown so We've really encouraged our hospital district to kind of spread its wings to look more at prevention than just treatment of poor cute illnesses And I think they're doing a good job of stepping up the pace And I know they do that in our emergency center in our clinics HIV testing, which certainly makes up a great deal of sense It's just still difficult Well, doctor, good to have you here this morning It's still difficult for me to believe that we're that we're still talking about HIV HIV and AIDS There's 1987 When I went on the city council and And it would you were just becoming Apparent that there was a great disease that was spreading across the United States and a lot of us didn't understand it We didn't understand how it would be transmitted There's a great dear fear during that period of time that this thing could really get out of control and Slowly, but surely programs were developed and and began to work on it. But here we are What 20 20 26 years later? And I think through history, you know when you have a major outbreak of a new disease or something usually has a lifespan of about 25 years And here we are today still in a desperate fight against AIDS and HIV And the testing and how do we go about treating it? So it's not been a Not been an easy task and it's one even today that we continue to kind of At least in the public's mind kind of pushed to the side so I think this initiative to Move forward and to try to get additional testing maybe not required but certainly in Physicians offices and doctor's office every time you go in for something with this dental or whatever If you can be tested for HIV, I think it's a very very positive step I had the opportunity to meet dr. Holly when he came in this morning You got up at three o'clock this morning in Beaumont to drive all the way over here That's a pretty good dedicated doctor. I would say and We had a chance just to visit a little while and about what he's doing and in his own Private practice in terms of HIV testing and the fact that it's not at an art at an amount of Expense to be able to do it five ten dollars or so So I think if we continued to move forward on this it's a step forward but more Just as important in that Though is that the health care collaborative and the work that's being done in terms of prevention? I think is extremely important. We started biometric testing just this year It's the first time that we ask employees to To to take a test to see if there's some problems they've got Obviously when you see it, you know, you may have one, but you see it again. I always know I have high Cholesterol, but when I got that biometric test again, I said, well, you know, I think I'll do something about it this year So I was starting taking a statin. So I think it's good that we're doing those sort of things that we're encouraging Recreation encouraging getting out taking care of your body This county is putting in some 85 million at 85 different sport at the 13 different sports complex to encourage that We're asking our district to continue to move on the prevention programs the the Work that's been started on terms of diet and what you can eat and what is good for you Oh, I just think that's extremely important. We were in the natural foods business for almost 30 years, I guess and And so here I am 73 and still in pretty good shape I tell everybody if they go to a natural foods place and eat, right, they'll die of nothing Well, it didn't quite work that way But you do have an opportunity to live a little longer and and to have a healthier life and a more productive life by taking care of your body by You know restricting your extra extracurricular activities to where you don't get in trouble by not drinking not smoking We all know those things, but I think the more we talk about them The better better opportunities we have to get people to ascribe to that sort that sort of life So I just want to thank you in general for what you're doing the private positions that are here today Dr. Shizkano. I don't know. I don't know where he gets all his energy from but He's involved in so many civic things in the community too and Uh So he's been a great great leader for our community and all of you that have participated in this and really appreciate the Physicians that are in private practice that are willing to take time and effort to help with some of these initiatives Aurora Sanchez has a great job for the county has worked very hard to try to Outreach and to make sure that we're funding and trying to help various organizations as they fight some of the very difficult diseases We have in our community. This is certainly one of them So thank you everything for what you're doing. Thank you Thank you, judge. Wolf. I'd like to Welcome Isabel Clark who is a our partner in this event here today And she's got some information to share with everyone and then we'll get started with some of our presentations So can I do any okay? Can you hear me? awesome Okay Well, I want to welcome everyone for coming today. We're really excited that you could actually take the time out We know that the focus today was to invite healthcare professionals people that provide the direct care Or you speak with those decision-makers that can help support routine testing in your institution So welcome today. We're going to have hopefully a good program It's it's mainly directed to people who are not so familiar. You don't know so much about routine HIV testing traditionally, we've had risk-based testing counseling and testing programs Mobile vans going out and taking rapid test kits out into the community targeting people routine testing is Basically trying to make everyone aware about HIV and the importance of knowing your status So that's what we're going to be talking today is about testing as a routine preventive screen a standard of care and It's an opt-out so we're not forcing it down anyone's throat But we're trying to impress you on the importance of knowing your status at that point You're going to be educated. You'll know more about the risk factors and hopefully prevent becoming infected down the road. I Wanted to just do a little bit of business inside your packets We did have the disclosure to learners. So really the activity it received no commercial support The speakers and planning committee had no financial interest The accredited status does not imply endorsement by DSHS the continuing education service Texas Medical Association or the American Nurse Quedentialing Center or any commercial products or services And so full disclosure information is included in your materials and that's just you know to make sure we're offering continuing education credits today So that's just part of the formal process of letting you know that no one has any interest or if they had we would have taken care of that So there'd be no conflict next if you are requiring Requesting continuing education you need to make sure that if you didn't register online that you have somehow done the formal registration to be here today That you signed in the participant sign-in sheets So we will need your email address and we need it needed to be eligible Allegable because the certificates will be emailed to you Of course participate be here and listen and then at the end before you leave you would need to complete the evaluation It is also in your packet and I think at the very back So that would need to be turned in and then we go back and tally them up and we'll send your certificates to you Once again, I want to thank our co-sponsors Department of State Health Services We have funding from CDC and created the test Texas HIV coalition So a lot of our meetings we have it sponsored mainly through our test Texas organization But we're trying to bring in stakeholders people who have an interest in providing routine testing or caring for people living with HIV our partners university health systems and Central Med they were our well actually there are partners here in San Antonio So I would hope of the people that are here from UHS and Central Med if you could stand up because we really want to acknowledge you as Being the leaders in San Antonio that you've been the early adopters. We've got and also One of the intentions is after we have this depending on where you work if you aren't doing routine testing We want you to go back to your facility speak with your leaders your decision makers And we're going to have a workshop provide technical assistance to help you set up a program at your site So that you can offer routine testing I'm going to talk a little bit about now the grade a rating So now you can bill for it and pretty much you'll get reimbursed So we do think now that things are moving in the direction that the barriers are becoming less and less It's much easier to do routine testing is just we need to get people more comfortable with it Our other partners as Liz said Bear County the Ryan White programs have been you know I've been working with Charlene I guess now for two and a half some I don't have pretty long time and been talking about doing something like this and The University of Texas Health Science Center the South Texas Family Aid Center They also were sponsors that contributed significantly and then the health card out collaborative They did so much of the organization for the community and Brought us all here today So our purpose today is to increase awareness about HIV and how it's affecting San Antonio and Bear County. Dr. Mangla from Metro Health will be here right after me to talk about the The data the surveillance what he's learned when he was working in Georgia at the state of Georgia and his work throughout the I think he said he may have been in South Africa too But so he's he's been very much in the HIV AIDS world and can share a lot in addition to the data from San Antonio Recognize the ethical issues related to routine HIV testing It is and everyone is in a health care profession They do have a code of ethics and I think HIV AIDS is very much of the heart of that It's even though there are some people can be uncomfortable going back into the late 70s early 80s people pretty much separated themselves there's so much stigma and We really need to bring it back into medicine as it is part of I mean HIV is a chronic disease and Medicine needs to take care of it. I mean it's not just specific to one practice We're gonna have lessons learned. Dr. Holly is here from SETMA He's gonna share what he's doing in primary care and then dr. Jamie McCarthy from Houston Memorial Hermann he'll be here after lunch to talk about implementing an emergency systems and Then we really want to encourage health care providers to implement integrated and sustainable routine testing So that's what we're here today to prevent you kind of the whole Overview of routine testing its importance the implementation different settings and then how you can actually get started So we did we got started after the late 80s in 2006 the CDC guidelines they released some revised recommendations They wanted to identify people earlier in the disease process We have people who are diagnosed late in the process so their their lives are shortened Targeted testing really isn't working. We still know that anywhere from 18 to 20 percent of the people in the US are living with HIV And they don't know it and this contributes to further transmission And in Texas one in three will receive a late diagnosis So either at the time they're tested they are diagnosed with AIDS or within the next year They receive an AIDS diagnosis, so they are very much advanced in their disease The guidelines are for routine opt-out Screening in health care settings, so it's not someone who knows what their behavior is and They they in the back of their mind. They know. Yes. I may have been infected I may have HIV and they go to a testing center These are for people who just don't know or they don't have access to health care And so there's no way for them to be tested. They're just not going to do it So the recommendation is to test all persons between the ages of 13 and 64 At least notify them they have the opportunity to opt out and say no I don't want to be tested if it's an at-risk population the recommendations were to test test annually and then The other purpose really was to remove the barriers to testing because so many practitioners would say well I have to deal with a separate consent that takes so much time and then in some states still have a pretest counseling so there's a pretty involved pretest counseling assessment that they would do before someone would get the test and When you're in a doctor's office if you have 15 minutes with a patient That's a lot of time if you're going to be required to do a prevention counseling work up before you even order a test That's out. That's just out of the question with medicine today. You you can't expect that in regular health care The rationale is that we do we know universal HIV screening programs work We have a very safe blood system today blood donor system and then the perinatal testing We have very very few mother-to-child Transmissions so that is mandated routine testing during pregnancy and have been able to identify Mothers that are with pregnant within they have HIV and they can be treated and most of the time those babies are born free of HIV The demographics have changed Basically, we have increased rates in the elderly I've spoken with a couple doctors that see patients in nursing homes and they say yes We've started testing and they've had some men in their 70s and 80s that They're just testing now for HIV and having to treat them Women ethnic minorities non-urban and the heterosexual population. So the ones that we they don't have the traditional risk behaviors They don't know what their past has been what other risks they may have been exposed to and then patients with HIV infection We know through Research that patients living with HIV they do go to health care because of other reasons But they're not offered HIV test and many times the complaints for their reason They're at the doctor's office could be related to their HIV disease Well, why do people not get tested and they're not coming knocking on the doors and setting up an appointment to you know Have their annual check and get their HIV test stigma and stigma has been with us since the beginning of HIV AIDS and persons Who've grown up in the time, you know, I think younger people are less aware of the stigma, but People in their 40s 50s 60s It's they remember the days when the fear of AIDS and so if they think that if someone says would you like an HIV test and They go well, yeah, they're worried that their provider will think oh well They have a risky behavior, you know, they're doing IV drugs or they have multiple sex partners Many don't believe they're at risk So there's been studies where you've interviewed people who had been diagnosed with HIV They give them a survey of the different risk behaviors. They may admit to participating in these behaviors But then at the same time they'll still respond No, I'm not at risk. So I don't know how I got HIV. So there's a lot of denial going on And as I said earlier Many people were dealing with folks who are in poverty. They don't have access to health care Or the doctor doesn't offer it or the facility And we know that they're seeking health care on average four times before they're tested The big one to is providers don't think their patients are at risk and many have never been trained or just you know, maybe had one hour Lecture on HIV AIDS and so it's not familiar with them And if you're not familiar with something it is uncomfortable talking to people So the role of awareness on HIV status is it's huge As I said about 18% of the people are unaware of their status Once people become aware that they're HIV positive They change their behaviors and so they're less likely to transmit and then if they're in care and on antiretroviral treatment their viral load decreases hopefully to undetectable and Anywhere from 90 to 96% Decreased chances for transmission. So it is huge So that also contributes to your community viral load if you can get all your people who are living with HIV in Care on treatment to undetectable viral loads. You can pretty much prevent More HIV and definitely we can prevent AIDS the benefits of routine testing basically want to identify HIV early in the Disease process when you just detect someone early. They have a greater response to antiretroviral therapy Reduce viral load lower transmission lower health care cost and improve quality of life Those people are going to live longer and contribute to your community So it's just a win-win, you know, you're not spending as much money on their care because they're not going to be sick And they continue to work and contribute So we're going to shift to our project in Texas after the CDC Rupertized the guidelines. Of course, we all had to sit down and think about how are we going to react to this? So this is our response We have Things going for us in Texas. Texas law supported the revised recommendations. We had to change nothing I mean, we already had everything in place HIV consent can be included in your general consent. You don't require a separate document The pre-test and prevention counseling is not required and then One of the things to our laws say that if someone is positive you have to arrange access to care prevention and support services For those people living with HIV, so we already had everything established it. We didn't have to do anything different The 81st legislature like that's four years ago They they mandated that DSHS spend $4.4 million to support routine testing and health care settings to according to the CDC guidelines We applied for a grant. We got funding and in September of 2008 We had our first partnerships with Harris County Sheriff's Department and continued to partner with them And then we started with two hospitals in Dallas and Fort Worth Parkland Hospital and Dom Peter Smith And we do choose our partners that tend to serve Their their public hospitals or community health centers because we're trying to reach the the people who don't have access I mean as much access so that that is where our dollars are going Once again, I want to thank University Health Systems and Central Med because they are really leading the way here in San Antonio Shared just a little bit about them, but in July of 2010 we brought on University Health System And then in July of 2011 a year later we had Central Med University Health they started testing in their express med clinics They have an emergency center which is staffed and run by the medical medical school They have a lot of physicians, you know going in they've got their interns So there's a lot of change so for them it was much easier to start in the express med It was a smaller setting. They had a little more control, but in October of 2011 they've been Doing routine testing in the emergency center have a lot of changes. We nothing can be the same There's always a new challenge around every corner you turn, but their testing numbers have increased significantly I'd say in the last Six to eight months and they're doing a lot more testing in the emergency center. They're general consent It's included in the general consent. I mean the HIV Test and then they have signage set up so that according to the 2006 CD side guidelines All our patients are offered the HIV test ask your provider if you have questions And so that's the opportunity for them to provide the education and the importance of the routine testing They do the conventional blood draw and submit it to their lab internal lab and To date they've identified 46 positive persons 22 new People who did not know that they had HIV before this test and then 24 previous Their positivity rate is a point nine overall and to be cost effective the CDC They've done all their you know crunch their numbers to be zero point one Have a positivity rate is cost effective So there are nine times that and when you look at the new positives the previous it's like point five So they really this is a very cost effective program and when you talk about oh well you found some previous positives What does that mean? Well, it's Another chance to get someone back into care and 88% of their patients that they've identified with HIV that they've tested are Into care so many times people may have been tested and never followed up with an appointment They didn't they said I was feeling fine. I'm healthy. I don't need to go to the doctor Or someone had a bad experience or they've moved and it's just an opportunity to get someone back into care At Central Mad we partnered with them beginning in July of 2011 and they offer routine Testing at the standard as a standard of care in 12 of their clinics So they're out in all of Bear County. I believe also. There's some a couple of sites in New Braunfels area, so they're kind of going a little bit beyond this community Once again, they're test HIV test is in the general consent They also do the credit conventional blood draw But they send their tests out to lab core where they're processed. They have an established patient base So if you're in primary care, you're not in the hospital setting, you know You have established patients Basically you would have them come back for an appointment if they're positive and then discuss the importance of what the diagnosis means and get Them into care They have from the get-go. They've been billing and then reimbursed. They have a lot of their Patient base either they're in the title programs or Medicaid And so half of all of the tests that they do are billed so they're reimbursed And we only pay for the half that don't have a payer and then their outcomes. They have identified 44 positive 12 new and 25 previous there were seven that they didn't really know the history and That happens a lot and so it might be some that came from another state and our their Data hasn't made it to ours. So we aren't able to get a clear picture Their positive rate is 0.3 Which is very good I mean you would expect 0.1 or 0.2 for the little primary care settings in the small communities because you just have a much smaller Population and it's not as random And their confirmed rate is 73% and sometimes that the number is actually lower Because somebody you confirm to care may not have been reflected in the latest data that they submit to us We have done this is what we've done since the beginning of our project and we include the numbers from the city of Houston We partner with them quite a bit and we're supporting the memorial Herman system But we also work with bentob LBJ and we share our data so in the state of Texas with the CDC funding between city of Houston and the DSHS program We've done almost a million tests 981,000 and we've identified over 10,000 positive persons living with HIV and of that almost 5,000 are new positives our overall positivity rate is 1.1 So that's 11 times over what would be recommended as cost-effective and the new positivity rate is 0.5 So we definitely know that our Funding is going into the right places. We are testing in the right Centers and we're getting people identified and into care So just what has happened since the CDC guidelines we've made a lot of progress next slide and 2010 we have never had a national strategy. We had these guidelines the revised guidelines We've been funding projects all in all the different countries in return We demanded that they had a national strategy. We're going to send you funding you have to have a strategy so we now in 2010 have our own strategy and The purpose really is to identify the undiagnosed cases. I'm reducing number of people who become infected To increase access to care and improve health outcomes for people living with HIV and that is huge I mean at the beginning, you know, it's like we want to do as many tests as possible But if we're not getting those people into care You know the transmission of HIV continues and then we want to reduce the HIV related health disparities because we do know that There are populations that really have less access. They don't go in and Have regular medical care and so we're trying to reach those people and help them in 2010 the CDC and the American Public Health Laboratory they proposed a new testing algorithm and Why did they do that because we've been using the algorithm that was established in 1989 and what it said then is that the Public Health Service recommends that no positive test results be given to clients or patients Until a screening test has been repeatedly reactive on the same specimen And then a supplemental more specific test such as the Western blot, which would the confirmatory You want to that validate so you want to make sure the person is positive next slide. However, there are limitations The Western blot today. We now know that we have a lot of tests that are much more sensitive So the Western blot if you have a preliminary positive the Western blot can't even identify Confirm that positivity rate until weeks out for some of these tests We now have fourth generation Technology where we can identify the p-24 antigen. That's the protein that is the first thing that will show up in the blood Before the antibody so it will actually pick up that antigen and it'll pick up also HIV one and two and Also, we have a lot of cross-reactivity more than 60% of persons with HIV to infection They will be misclassified with HIV one through the Western blot So clearly we need a new algorithm and Jenny McFarlane. She's our team lead with at the state She's gonna share a little bit more about that in just a minute So in December 2012 Although we had this proposed algorithm and some people had purchased the four-generation testing I think they were available at the end of 2010 and 2011 Bio Rad and Abbott have the the platforms They were able to identify either the antigen or antibody However the multi-spot you need to differentiate and The packaging did not approve it to use as a confirmatory or a reflex Differentiation test but that happened in December 12 And so that was sort of the green light and then we have the nucleic acid testing to either detect the RNA or the DNA of the Very early virus and so we can confirm acute cases It's early as 11 days. I mean you're not going to see it in the early first 10 days But after that so and in the Western blot it may take three months before it could even confirm So we are really making a lot of great strides And the other piece that has been so exciting on April 30th the US Preventive Services Task Force They released their new recommendation for HIV screening as a grade a that is like the top grade It's grade a b but a is the best And what the recommendation states is that clinicians should screen for HIV and Adolescents and adults between the ages of 15 and 65 if the young if you have younger adolescents or older adults You know, they're increased risk test them And then as the CDC guidelines all pregnant women including those who are who presented labor who are untested or they You don't know their status. So this Pretty much I think we've had so much resistance of who's going to pay for it now We can code for it. What this means next slide basically is that? But we know that the you Let me back up the grade a that it's going to stay that way There's high certainty the evidence is so strong that it's very unlikely that any of the new research that comes after Would change this so they're going to continue to You had keep this as a great a Screening intervals this is always kind of everyone wants to know how how often should I screen? Well, they've made an attempt they the little caveat that there's insufficient evidence to determine optimal time intervals However, they recommend at least a one-time screen for everyone Repeat screening for those known to be at risk for HIV infection. You have someone who's had multiple partners The men having sex with men or IV drug users and then rescreen annually groups that are at very high risk and then Depending upon it's professional judgment clinical judgment, you know what your your population needs, but I think the Least I'm concerned like three to five years What are the implications we know that? With this it is going to take a lot more resources if you're identifying people with HIV Of course you can get them into care so it's going to cost more money But ultimately we're going to save because if we're going to be able to get them treated and decreased transmission The federal rules require that private insurance and Medicare plans will pay for this So there's coding and there will be no copay so that you don't have to worry about I don't want to do a test that my patient didn't request and they can't pay for it So we think this is a new day and we're hoping that the people who hear this our message over and over again We'll finally go. Oh, yeah, I think I can do that Just ending with the American Medical Association ethics policy They said stated and this was back when the 2006 guidelines came out It's the physician's duty to promote patient welfare and to improve the public's health And these are fostered by routinely testing their adult patients for HIV So they recognize back in 2006 that yes, it is your duty to identify any patient of yours that is living with HIV and Then the national strategy the vision is we want the United States to become a place where new HIV infections are rare And when they do occur every person regardless of age gender race ethnicity sexual orientation Gender identity or social economic circumstance will have unfettered access to high quality life extending care free from stigma and discrimination so we are hoping by just constantly talking about routine HIV testing that will become more normal HIV is not this word that you whisper. It's it's a chronic disease that can be treated and So I'm going to turn it over to Jenny McFarland. She has been with the Department of State Health Services for a long time working in the field for about 20 years and She has a lot of knowledge and she's going to continue Can you all hear me? Thank you. Good morning Is there a pointer by chance? Okay, I'll use my finger or I I'm I'm a roamer when I talk But thank you all very much for including me in your agenda today. I'm Jenny McFarland I'm with the Texas Department of State Health Services and I have been working with HIV and AIDS for quite a while It's been over 26 years now and I started in the day where we would work with patients and pretty much say to them You know, okay You're concerned about getting an HIV test. Let's get you tested. But you know what? We still don't know whether or not you were infected back in 1987 when I started doing this, you know, maybe six to nine months ago But now as Isabel said we have the ability due to the newest test technology in order to determine whether or not someone is infected actually about 11 days after their infection and What does all this mean and why is it this Western blot is you know our hardcore Workhorse test that we've used why are we looking at it differently now? Well, if we look at days before the Western blot turns positive, we pretend we start at day zero That's when the Western blot turns positive. But now let's look at other test technologies that have occurred Well, the vernostica test some of you may remember this this was the oral fluid test that's used with the Orsher test Well, the folks that used to make vernostica, which was actually the processing fluid used and stopped using it and it would detect infection actually after the Western blot Now these are the rapid test kits that are available Now many of you are familiar with these rapid test kits because if you've worked with the HIV Counseling and testing program or a services organization, you know about the targeted testing which we do which is very important And is a partner in routine testing So when we look at the rapid test kits that are out there We see that they will identify infection a little bit earlier before the Western blot So if I use a oral fluid Or a quick test it actually if you use oral fluid, it's right around here with the vernostica. Now if I use blood It's going to be right before the Western blot. So you say, okay Jenny, we'll fine. We're using these tests It's identifying infection and then we use the Western blot Well the more sensitive test like the insti which will get you results in 60 seconds It's the newest rapid test kit that's available If it comes back reactive and then you run a Western blot It is possible the Western blot will come back non-reactive or indeterminate and then you have an acute infection And this is where identifying remember the national strategy and remember the goals is to identify every HIV infection We look at these other rapid test kits. We see that they're close and they are good tests These are not we're not trying to disparage these tests at all But we want to let make sure clinicians know the options Now multi-spot and reveal multi-spot is the differentiation test you're thinking what does that mean? It will determine whether or not you're looking at HIV one or HIV two. It is an important Product that is now in the new algorithm And then aviac is actually the oral fluid test that is now used with the Western blot And so when someone sends in their or sure Test it or excuse me. It is one of the options that is used But again, we've got these concerns with using oral fluid testing where you don't have as much antibodies in your oral fluid Again, if I've an established infection, it's going to show Now these are your third-generation tests advia vitro's GS one that is the The third-generation These tests are used in most of your laboratories in your large-scale testing centers They are very effective tests and and they have been used now again I'm running in a third-generation test. It's reactive I send it for Western blot and I'm also talking about the immunofluorescent assay test as well the IFA Which is the other confirmatory test you run it again. You could have a non-reactive or indeterminate and Then these are our new Superstars these are the fourth generations test. These are large-scale platforms. You can batch them and run these tests The architect will get you results in about 35 minutes or so So these are at four settings that have a large volume of testing And as you can see here great sensitivity to early infection Okay, and now we have our aftima test. This is our nucleic acid test again Identifying infection quite early. Now. Why am I going through all of this with you all? I'm going through all of this with you all to start thinking about what does identifying early infection mean It means identifying a cute infection and that is so important because when I have a cute infection I am at my most infectious and I will contribute more to Transmitting virus to those who are exposed than any other time And this is why it is so important when we get infected. Let's say zero over here Today I get infected Now after about 10 days 11 day my RNA is spiking so much that I will the aftima test will pick up HIV infection The p24 this is the combo test about 16 days after infection Go ahead and click the next Yes. Oh Sorry Okay, I'll try not to move around too much. I'll hold it. Thank you Not move around Okay, so Between the window of 11 days and 22 days look how look at my HIV RNA Look at my viral load spiking. I'm very infectious right here And we can identify infection during this time period If we are running either an aftima test of Nucleic acid test or an RNA test if we're running a fourth generation test or even right at the end around the third generation test at 22 days Now remember those other rapid test kits again They are very good test kits. They are very important and the other test technology is out there But where do I really want to identify my infection when I have people who are in their cute stat in the cute face? and then Unfortunately at this moment and I do believe that we will be at a time But that we will get to a time that we can identify infection within the first 10 days I mean, I never thought when I started doing this in 1987 and had to sit down with patients and say You're gonna have to get tested again in the next three months in the next three months in the next three months the fact now we can say 11 days ago 14 days ago 16 days ago in all your past You were not infected with HIV. Let's talk about what that means for you down So why is this again so important well 49% of people who have a cute HIV infection They do develop symptoms and they do go to health care settings But they are not tested for HIV and that's again why Isabel was laying the framework for why routine HIV testing has been encouraged by the CDC since 2006 This has been since 2006 and we still do not have it established as a standard of care and we want to support medical settings to establish Go ahead So again, let's go back to What happens when I'm acutely infected? this is the risk of transmission and how how what happens and The importance of identifying infection And then if you get an excite and if I don't identify infection what happens next? Well, I continue to have behaviors such as I'm protected sex where I can acquire sexually transmitted infections and when that happens my viral load spikes Again the missed opportunities your patient is coming into you has pelvic inflammatory disease Okay, yeah, we're gonna give you a big old shot of reception. We're gonna treat your infection But are you testing for HIV? Go ahead So what does the algorithm say I'm getting to it? Well, this is the schematic of the Recommendation for the algorithm and as you see it's now recommended to do fourth-generation testing as a screen and think it Oh my goodness, you know Jenny this test is very expensive. What are you thinking? How do you know? How are we gonna afford this? actually The test manufacturers and if you are you know, you can negotiate this you can negotiate this with the test manufacturers You can talk to them about I'm gonna do both testing now People are doing the fourth-generation testing as much as it costs them to do the third-generation testing Let's say you work with an outside reference lab Talking with them about your new contract and negotiating with them I'm gonna start adding this to my panel for my annual visits for my patients. I'm gonna get one test per lifetime I'm in my emergency center. I'm my urgent care center. We're gonna, you know, look at our instrumentation And see whether or not we want to lease a new instrument. You know, you have choices here You have choices and we want to encourage you to start exploring your choices So with your fourth-generation if it is negative, hey again, that's that great situation now Remember the fourth gen is 16 days after infection So again, you can pretty much tell your patient about two weeks ago 16 days ago and all your history You were not infected with HIV But let's talk about how that will impact your life and whether or not something has happened since then Now if it is reactive, we need to differentiate whether or not we're looking at HIV one or two And we run the multi-spot and it is FDA approved to be your confirmation test You run the multi-spot and Here we have it will to show you whether or not we're looking at HIV one or two antibodies The first one is HIV one you found HIV and one antibodies your patient has HIV one You run the multi-spot HIV two shows up You've got a patient with HIV two and in this country HIV two is still very rare Now there is also a possibility you've got HIV one and two and again You need to run additional testing and there's an entire algorithm the CDC and APHL just did a Wonderful webinar about this a week or two ago, and they talked about how to tighter out The testing to determine what you have Now the quandary of those, you know frustrating Non-reactive Western blots or the indeterminate Western blots Have you get has anybody in here ever seen those before among your patient practice? Remember you'd say come back and get tested in three months We're not gonna have to do that anymore Because we since all of this is blood Your serum can your testing schedule can reflex to a nucleic acid test And you'll be able to see whether or not you've got an acute infection So if you've got HIV one negative or indeterminate on your differentiation assay The reflex is to do the RNA test or in nucleic acid test If it is hRNA positive, you've got a cute HIV infection. It's already negative You don't have HIV infection Next now, how do you interpret this this is gonna cause some changes and some Great deal of education of how to interpret this Not only what you're looking at when you're looking at the lab paperwork But also how you talk to the client about this And this is some guidance and many of these slides We have been working together now working nationally with other jurisdictions such as Massachusetts California New York and we are all working together to help interpret, you know what these tests How to talk to your staff about this how to educate staff, but also how to educate your patients about this So this is some guidance right now That is in draft form The State Health Department our lab at the Department of State Health Services is running fourth-generation tests. They are using the Bayer rat instrument and We are still running a Western blight for confirmation Because we that we are doing our validation study right now with the multi-spot So by September 1 of this year, we will be running the full algorithm And if there is a non-reactive or indeterminate on the Western blot, we are sending our samples to Dallas for NAT testing Okay, next one. So this is what the antibody the antibody differentiation assay looks like Now again back to why this is important because again we saw between 2011 and 2012 a validation study was run and we saw the significant number of Acute infections that were missed and New York San Francisco in North Carolina and You see here of the 27 Western blots that were run Seven of them were positive. Well, great. We've found some established infections there But look at the number of indeterminates and negatives And again with the immunofluorescent assay test. So like I said earlier The great thing about the NAT test is that it will resolve discordant results And if you are sending your samples to our state health department, we will send in doubt them to Dallas for NAT testing and Houston Health Department, they are running their own NAT testing as well. Go ahead So like I said HIV-2 is rare But it is a concern because we do have a larger immigrant population Especially in Houston and Dallas and we want to resolve whether or not we've got HIV-2 infection because it does impact the treatment of the disease for that individual Go ahead now many of you some of our partners Throughout the state have been sending their specimens to Dallas when they get a non-reactive or indeterminate Western blot and Dallas has been great about sharing their data So what you see here is in 2011 this is the number of NAT tests that were submitted and Then you see a hi is a Q HIV infection So in 2011 49 specimens were submitted and these are all from hospitals emergency centers a Q HIV infection is walking through emergency center stores and Fortunately, they're not being missed because for these programs for these hospitals When they have that indeterminate or non-reactive they're shipping it off to Dallas and the Dallas is testing it and letting them know whether or not We've got a new infection. This is fairly significant. Don't you think? Would you expect to have seen this? No Yeah, yeah So this is the other thing that we're trying to help providers understand is the missed opportunities and This is a way for us to assist you in providing a providing more support to your community and helping build a healthier community So what do we do again? We're building partnerships We're coming together. We're working together because in the past like Isabel said for those of us Who've been in HIV field for ages now we used to say oh, this is ours or the HIV you know testing sites STD testing sites, you know, we do it all we refer you to the infection disease doc It is a chronic condition now, but we recognize we need to pull together and work together as a team Because public and private partnerships are crucial So that we identify those who have not been identified What we see in Texas now is we've got almost 70,000 persons living with HIV in our state and we normally identify about 42 to 4500 new HIV infections each year now look at the so the Red line is little persons living with HIV look how it's climbing This is great success. This is a success of The treatment that has occurred and then the 4000 you know, it's staying steady It's not dropping and again. This is a success of prevention and the deaths have been staying steady and or declining Because people are not dying due to AIDS related conditions as much as they used and then what has happened in the last few years We have been working nationally with partners and it is establishing how we can have the continuum of care and the stages of engagement So first we have to identify infections and then we've got a Successfully linked people into care and we help them need to help them stay in care Get them onto antiretroviral therapy and then Assist them in maintaining an undetectable viral load back to the idea of the more virus I have in my community The more likelihood if I get exposed to HIV I can become infected Now if I reduce the viral load, but I still have lots of people who are HIV infected in my community There's less risk of acquisition So our Texas treatment continuum when we look at the cascade what we call the Gardner Cascade We believe that of the hundred people see a hundred percent of people who know their HIV status Only about there are about 20 to 18 to 20 percent who do not know their status Okay, so those folks like Isabelle said earlier are contributing to about between 57 and 70 percent of all new infections. So in the state of Texas, let's look to see what this looks like We estimate there's 80 over 84,000 people living with HIV in the state of Texas but we know We know 69,000 of them have HIV. We've identified them good for us in this state of Texas for each year And this is for a year in 2011 64% were linked to care in three months. That's a great success Okay, no, it's not ideal, but it is a success 60% had a met need meaning they were able to Make it to their medical care provider. They were able to make it to their appointment. They had live drawn. They had a met need Now this next slot this next column retained in care between 2007 and 2011 29% were in and out of care, but they did get care and then 34% were stating care and For our state 39% have a viral load that is suppressed to where it's undetectable This is the treatment continuum and this is where the partnership between public and private falls in. I'm gonna have to go quickly So of the people that were linked to care How long does it usually take? Well, we see that in 78% were linked to care in three months That is very good But there are people who do get linked to care long that does take longer Then three months greater than four months and then unfortunately We do have the proportion the 70% who were not linked into care And that's again were the public and private work together because we have public health follow-up to help this with this So the proportion of people linked to care retained in care when we look at public versus private again We have a Ryan white care system throughout our state and their job is to identify assist people who've been identified and staying care the The yellow bar here is all persons living with HIV and when we look through the people that are not Ryan white clinics Or excuse me all people and Then we just look at the Ryan white clinic patients We see the great success of our patients who are engaged in Ryan white care services Does this make sense? so Where do we go from now? You know, where do we go now? Where do we go from here? We recognize that we have excellent test technology available to us How can we use it? How can we adjust our practices in using it? Because we have come so far Over 650,000 persons Have died due to HIV or AIDS related condition Over 1.1 million people are living with HIV right now. We've got almost 70,000 in our state alone We are in a situation right now that we can come together and start moving forward and using what is in front of us And again, we want to support you all we want to support your communities We want to support you as providers to work together And so, you know the stigma has decreased greatly Most of your patients think they've been tested all along whenever they do all you do all that blood from them So keep that in mind and we are here as a resource for you We have a great deal of commitment from our commissioner and our deputy commissioner when it comes to this project and Assisting it's not just a project. It's assisting and changing the standard of care Thank you very much Sorry, I was too far in the back. So I apologize for that Our next speaker is our very dear friend. Dr. Anil Mangla. It's Chief Epidemiologist for San Antonio Metro Health Department And Dr. Mangla, thank you so much for being here today and providing us some more information on the health status of our local community Okay, we're ready to go My name is Dr. Mangla. I'm the Chief Epidemiologist here for San Antonio Prior to this I was the director for infectious disease and immunizations For the state of Georgia and also the acting state epidemiologists and prior to that I actually spent some time with the United Nations Association and worked with the international infectious disease task force and so Judge who brought up a few things about history and the past in HIV and Jenny also brought up, you know, 30 years ago how HIV worked and where it was So what I want to show you initially is a little history and and and what we saw in Africa in Maybe a decade ago and how things have changed there and then come back home and kind of look at our data locally and and and see how things have changed and What are our barriers and where can we go from here? so prior to Going any further. I do want to thank few people on to thank Elizabeth for inviting me It's an honor to be here and to share this with our community all my STD HIV staff at Metro Health For actually providing this data and doing this analysis so we can actually share this with the community members and Of course someone who's done a phenomenal job in Presenting data data analysis and looking at some of these graphs is John Belanger and Kira Hessler and thanks to them and of course DHS With some of the slides we actually have utilized from their section So just a quick history and origin of HIV The origins go to as far back as the 1930s And the first case kind of was isolated in 1958 In in 1982 it was actually known as the gay related immunodeficiency disease and then a French scientist physician identified this in 1983 as AIDS From there we started getting the serological test in 1985 and of course the most famous AZT trial started in 1986 and then from 87 we actually had some type of treatment for these patients now while my days in Africa white feeling all actually developed a Web of causation and you can see how complicated this is But but the key things they actually look at already 15 years ago is Testing and counseling and the other thing that was key that they had already identified is treating STD's Identifying STD's before actually they get to HIV transmission So you can see this goes back years and years and this is something we are trying to identify and still fight today So we need to kind of look at history and see what was identified While we get to move forward This is also then by whitefield how they identified how the progression of AIDS was Especially during the African day. So if you look at this in a social environment Where one person has a new sexual partner without taking any precautions after six years You're gonna have of course six bad partners And when you enter when someone new enters this environment The individual would be exposed to the sexual history of almost 15,000 individuals So you can see from this statistical Model how HIV propagated in these countries especially in the African countries where there was actually no precaution or no condom use or The more important thing no treatment So again a while being with the United Nation I spent some of my time at the epicenter of where HIV was and you can see how The disease progressed and the sub Sahara Africa was really very very Affected with some of the prevalence rates going up to 50 percent and in countries like Botswana Swaziland had that high number of Individuals that actually were infected This this is an interest in graph and you can see the the amount of Projected deaths in South Africa as the years went by so this is would be a normal Trend for death and because of HIV you could see that number But this was not just projected because when I was there in 2004 These were things that were coming in the newspapers Graves to be recycled because there was no place for people for burials You can see how the governments in those countries were fighting HIV and thought it's just in hypothesis You can see ministers they actually fought and resisted against therapy And this was if you look at the date on the 12th They were still fighting if they want to kind of ban the drug or not and then 13 next day They asked and they banned never open now. We know today never open is a key medication for the transmission from mother to child and we have successfully Eliminated newborn HIV cases to more than 95 and higher percent But again you can see 10 15 years ago. This was not the case because the governments were still fighting these drugs The only thing they could do and this was a sign that I had Kind of took a picture while I was in Swaziland and you can see what they were promoting at that time and you can see you USAID Is the use of condom so again the prevention was key But prevention was the only method they had they had no treatment because if you remember at this time There was a big thing about patents and due to patents There was no generics at that time, especially in these developing countries so treatment was minimum and so the only other alternative for prevention was condom use and You can see the famous HIV sign and what they really kind of had in the newspaper of AIDS reality So I bring this up to show how scary it was at that time And and AIDS was a scare when you heard of HIV it was almost a death sentence So there's some sensitive slides and then I'll go to kind of our data But you can we had a while we were there we had kids draw pictures of what they think their village is all about and and and look at these pictures 13 year old girl living alone and And the key thing they have here is these coffins and this was a norm You could see this in any village that you went in the sub Sahara, Africa regions There's another one and you can see you get the picture of of A trend even of what kids were actually looking at dark colors coffins death. There's another one Alone girls so this these things gave you a picture that this was a major major concern Then we come to the next step So there was a lot of research done in with the pharmaceuticals in seeing what can we identify? So there was a variety of drugs that were identified starting from proteas inhibitors integrase in inhibitors entry inhibitors and what they did is They looked at the life cycle of the HIV drug and at every point where there was Replication there was entry they tried to find an inhibitor From there. We have had tremendous success if you look at if you look at the slide from 85 to write down to 2013 there's numerous medications that have come up. So treatment is now Possible and so with all this there's been numerous generic medications and with the generic medications There's been a large Access of this in many of the African countries and This was very interesting because again as Jenny had brought up and and and Judge Hulf has brought up the key year is testing You need to identify Individuals that have HIV so the World Health Organization actually had it. Oh, sorry so So the World Health Organization actually had a press release that clearly showed that Antiretroviral therapy to be 96% effective in reducing HIV transmission So if you provided access to care Linkage to care provided the medication antiretrovirals viral load goes down transmit transmission decreases many of these African countries for after 2001 2004 started providing almost seventy five percent of their population with these antiretrovirals Guess what happened if you look at some of these statistics there's been a Exponential decrease in the amount of HIV in these countries. I'll just kind of give you Proper percentages the country Malawi decrease the HIV Incidents by seventy three percent Botswana that had almost a fifty percent prevalence rate decreased the amount by sixty eight percent nabibia fifty eight percent Zambia fifty six percent Zimbabwe and South Africa around forty to forty one percent look where we are in the United States Right, we still stable. We haven't done much change in all these years Now let's come to San Antonio. We're not just stable our numbers have increased So, so where do we stand? What are we doing? So let's look at where we are in San Antonio So I'm kind of give you a big picture first of Texas and you can see the taxes rate in 2001 was thirteen point five four hundred thousand population when we come to Bear County Just in the state of Texas or the state of Texas is seventeen point two Bear County. We at twenty point six per hundred thousand population Living with HIV again our numbers are not the highest in Texas But again with third the highest when it comes to cities So you can see kind of a distribution of people living with HIV But use our local statistics and you can see there's been a two percent increase from 2001 to 2002 but if you look at when we look at this Five-year trends a moving trend we have from 2000 to 2012 we have a forty seven percent increase in our cases in HIV So again, if you looked at some of these African countries, they've gone down. We've gone up in the past decade So let's break it up and and and look at kind of just rates if you look at rates We are actually one point two times higher and then the state of Texas And we are one point six times higher than the national average So again, we're not doing very good both compared to the state as well as nationally When we break this down further into who is affected where is this coming from and so When you look at that you can very clearly see the males are much more almost seven times twice as Well, if you look at females and males, it's it's five times more At risk than the females. So we have in our population here the males are much more at higher risk What about ethnicity again ethnicity the black population? has a rate of fifty point five four hundred thousand population compared to the Hispanics and The white population We broke it break it down by age and as you can see age groups The key age group here is 20 to 24 the age group of 25 to 29 is going up But what is also concerning is this line here? See this is the population 15 to 19 and if you notice we actually have in and and and I bring this up because when you look at Syphilis we have sometimes in our clinic at Metro health people under the age of 21 Coming into the office with STDs. So you can see that this is a population that's on the rise Which Transmission category are we looking at here in San Antonio that's key to us and if you look at it most of the cases we have here is MSM men having sex with men so After identifying this type of information our STD clinic and and our DIS Staff are actually really focused in our efforts in these areas And we also looking at many of the bath houses that are here because that's looks like a key area that is to be targeted and That would be more discussed in detail in one of the breakout groups when my Metro health STD section is actually going to be presenting that Again transmission category if you look at different cities Comparative to San Antonio We in San Antonio you're also pretty much Majority is MSM, but you can see many of the other major cities also is actually Indicative of a transmission, which is due to MSM We also have a little of the heterosexual IDU use and both the MSM and IDU use the other important thing here that expositions you got to look out for is The issue of co-mobility and when you look at co-mobility you can see almost 15 percent of this population of Infected with other STDs and then TB and if you look at if you remember when we talk of co-mobility is in the in the late 90s the TB rate in in in the sub Sahara region was actually going down and when we looked at HIV AIDS coming back as one of the Major diseases in those areas. We had a spike in the TB cases there And so this was really a clear indication of you know, we're more co-mobility is and and and it affects many of this population so kind of Putting that aside you can see our HIV rates have Gone up in this city and and and not to forget now STD So I'll really go real fast in the STDs because I want to make sure that we have time for some questions And if you look at the STD rates, you can see the STD rates in the US is about 4.5 per 100,000 population But you can see where we stand in bear county compare and taxes is much low just very similar to the national average this is giving you a kind of just an idea of when you look at counties and this was On on the CDC website and county-wide if you look at some of our counties here very high when it comes to STD This is giving you primary and secondary syphilis again our numbers here in bear county both 2011-2012 pretty high we gone much higher within just that one year So this is this is so this is kind of the key if you look at the US rate and the Texas rate very similar, but We lead the state in bear county when it comes to STDs with our rate been 50 10.5 per 100,000 population This is broken up into the type of STDs and you can see that we have an increasing in actually Most of the STDs but when you look at Syphilis our numbers are going much much much higher This is an idea of where we are with syphilis and I'm looking at all stages and it would syphilis We are two times two Times higher than the state of Texas and 3.6 times Higher than the US rate US rate Texas. You can see where we are and just over the past year. We have actually even showed up This gives you an idea of our numbers So we have gradually increased over the past years and there has been no decrease in the STD rates but just over the past year 11 to 12 we have gone up much much higher with STD and there's few things that may be also important year is We initiated in the health department a much more vigorous STD program And when you look at an STD program what we had is we increased the capacity of DIS and the DIS Folks which is disease intervention specialists have done a phenomenal job and and and in that sense What they've done is increase the amount of tracking and and and partner contacts So this increase maybe twofold. There is a real increase in Bear county no doubt, but we also Identifying many more syphilis cases and in that is also kind of showing right there So that may also look at you know Are there more numbers that are going up more people getting infected and Are we identifying more people or many people were not tested? So those are kind of key Factors that we need to kind of affects we need to look as we see that graph This also is now looking at The primary and secondary cases of syphilis rates 2000 2012 and you can see our rates are much much high When you break it up into gender Again males are much much much higher with 30.5 per 100,000 population Compared to females, which is just 6.3. So again about almost five six times higher ethnicity The African-American population again much much higher comes the Hispanic and then the Wide and other almost the same when it comes to rates Women and men so you can see when it comes to ages a Lot of the ages are all already increasing with when you look at the age group 30 to 34 being pretty high One of the highest and then comes the age 35 to 39 In men a little different Highest again year is the 25 to 29 where There's a decrease but as you can see there's a decrease in syphilis here when it comes to ages 15 to 19 The other issue we have in here as you know if the con if syphilis rates are increasing especially our primary and secondary Let's look at what happens with congenital syphilis congenital syphilis if we're looking at the US average 8.5 You're looking at bear county 31.4 for 100,000 population Syphilis rates has just Shut up in the past one year where we actually if you look at the rates here our rates Are almost nine times higher than the US average and congenital syphilis last year We had almost the highest amount of congenital syphilis cases at 18 cases during the year 2012, so that's That's really a concern if you look at the syphilis cases in infancy as I was saying 18 And then you look at primary and secondary cases in women 56 so again what we are doing at the Metro health clinic is we are now trying to monitor any pregnant women that come in and trying to follow Trying to get follow-ups within every almost every month till they Give birth so we can make sure that if they do get infected during their pregnancy They get treated because as we know congenital syphilis is 100% preventable if we can get treatment in time This is just a kind of broad picture of some of the statistics that we have in and you can see here that The age of mother age under 20 With our cases for 2012 29% were under 20 24% were between 20 and 25 and graded in 25 47% the average age of a congenital case women was 25 years old. This is a very important kind of Analysis that was performed which clearly kind of shows you The 29% had absolutely no prenatal care, right? But what is disturbing to me is is This number where you look at 29% had more than 10 prenatal care visits. Have you look at it more than 10 prenatal care visits? normally The individual is going to get a screening when they get their first prenatal care They're going to get screened when they give birth so you have two screenings But there was never that in between screen and that was key in identifying And if we could have do the screen or perform the screens we could identify these mothers and prevent these cases So these are very important analysis where we can actually put forward some type of policies and some type of Methods where we can actually you know decrease these numbers other important information we identified was Mothers of congenital and syphilis cases also had other risk factors and behaviors which were drug use incarceration and of course sex workers so the recommendation recommendation year and our Health director has sent a letter out to all hospitals and all providers emphasizing the importance of Screening and and what we do in is we have identified that They need to add a early third trimester Screening for syphilis For all high-risk women and and when you're looking at high-risk Bear County is considered high-risk and as a matter of fact the state of Texas is high-risk So we are encouraging physicians locally to Perform these screens During early third trimester in this women because most of these women have been infected as you can see during their pregnancy other things that our Section is doing here in that metro health and I'm not going to go into detail with this But this will be presented later by our DIS Section is you can see in in trying to prevent syphilis. There's a variety of new Programs that have been initiated both within the clinic as well as in the community We have also Increased our outreach Regarding congenital syphilis and again, this will be more discussed later today And of course with HIV there's been a variety of initiatives that have been taken to make sure that we Making providers aware we have in CBOs aware and of course just a community. So there's there's many press releases that have been Conducted and we are also Going to be doing many many more during this year just to make awareness and To show the community that this is an important issue and how do we face it? so on that note, I'll kind of stop and I'll take any questions and and and You know, I hope this has been helpful and if anybody needs this type of information Please contact us and we will be glad to share that with you Thank you Yes The HIV one a it's a different. It's a type of strain So what you have is when you look at worldwide? We have more HIV locally as HIV 1 HIV 2 you'd normally see a larger percent of that from Africa Now there is what happens is some of the individuals and it was few years ago where individuals were actually Infected with both HIV 1 HIV 2 and that was actually called the superbug Very concerning because it's very resistant to some of these antiretrovirals There's the right So so that's a very good question when you a few years ago there was a article in the MMWR where CDC looked at it was a city of Philadelphia where they had an increase a spike in the number of syphilis cases and it was attributed very clearly to the Sex workers here. There is when we're looking at syphilis here We're looking at a variety of risk factors now We don't say sex workers is the key But that is one of the risk factors. We also look in when we looked at incarceration We started doing a variety of testing and I think we do syphilis testing there and a large number of Cases are from folks that are in the jails as a matter of fact in it in 2012 was it Three three or four of our cases were actually from the jail So, you know, that's again a area. We should actually Keep in mind that it's a key you know Contributed to the cases that we are getting here in Bear County So we have our DIS individuals here, which are going to talk about that So we actually are looking very closely to social networking and they're actually looking at a variety of these websites And trying to link this because when when our patients are coming into the clinic we actually Asking them questionnaires and and and then I mean the DIS would talk about that later But yes, we are looking at social networking as well Right But that's I think that's the same thing we have seen when I spent some time in the clinic Last year we had actually Individuals coming, you know, they were given education. They were given condoms make sure, you know You look at prevention and and guess what three four months go by and they're back in the clinic with the same thing So you're absolutely right. I think that's not just you know in one clinic. I bet we must be seen that all around Right When we looked at data and I and and I don't have that slide here, but I think If you looked at our cases for congenital syphilis for 2012 Greater than 50% of the women were married And so again, it's it Bisexuality, you know, it's it's it's a other man going out coming back home And having intercourse with the woman who doesn't know that That that that is something, you know, we are looking at our analysis and seen if that is also that one perspective Remember In San Antonio, especially with Transmitted And remember also when it comes to HIV the statistics that we stated earlier, which was you know among the Populations that do not know their status Of HIV infection they contribute to and it is estimated up to 72% of all new infections If I have a right Screaming And also the fact that public health follow-up now is becoming more and more educated and knowledgeable about applications such as writer, you know But even in their proximity, who else is interested in hooking up and it is cultural as well Well, thank you again