commission recognizes that we're on the homeland of the ramaytush ohlone, they have never seeded lost nor forgotten their responsibility as care takers of this place as well as for all people who reside in their traditional territory. as guests, we recognize that we benefit from living and working on their traditional homeland. we wish to pay our respects by acknowledging the relatives and ancestors of the ramaytush ohlone and the rights of their people. and we have announcement because of concerns and we'll explain why we're going to. >> it's possible that we may lose quorum during the

maoelting, so we're going to move the action items together so that the commission can ensure that they do their business. therefore items 9 and 10 will be moved directly after item 5, so all the action will take place. if they lose quorum, they will continue to have a information session, and continue to discuss, it will just be as information session not official meeting. we'll maintain the video and i'll take notes. i also like to acknowledge a clerical error on my part, there is usually a jcc update on the agenda and i erroneously deleted it it by accident. so the november 12, 2023, laguna honda meeting will take place and will be on the december 19th full commission meeting. and again i apologize for that. >> thank you very much. the next item on the agenda is

approval of the health commission of november 7, 2023, you have before you the minutes. are there any amendments, additions or corrections? >> if i may, commissioner chow asked me to make crepesings and there are several, it relates to the consent calendar which is on page 7, the finance and planning committee update. i added the sentences. she added that the committee requested that the body diagnostics be removed from the contract report since there was several issues with the contract document nation. the contract will be considered at the december 5th, 2023 meeting and then for the consent calendar which is on page 8, the next to, the november 2023, contracts report, i've included the claws excluding the party diagnostics

incorporated contract. >> thank you, so given the corrections, there a motion to approve the minutes. >> so moved. >> second. >> clerk: and i'll check for public comment, is there public comment in the room for the minutes? folks, if you're online, you can press star-3 to let us know that you would like to make comments. great, there is no public comment on this issue. >> all right, then, all in favor of approving the minutes please say aye. >> aye >> and commissioner chow, would you like to vote on this item. >> aye. >> clerk: thank you. >> wonderful. the next item on the agenda is general public comment, and i believe secretary has a statement regarding general public comment. >> yes, at this time, members of the public may address the commission on items of interest to the public that are within the subject matter but not on this meet ing agenda. each may address the commission for up to 2 minutes.

the brown act prevents any items not appearing on the posted agenda including those raised during public comment. please note that each individual is allowed a minute to speak on each agenda. written public comment may be sent, at the emailing address, the word health, the word commission, if you wish to spell for the minutes you may do so during robo comments without taking allotted time. will not be tolerated. we will first take public comment from individuals attending the meeting in-person in the room. sxl we will then take comment from these with a disability, i've given these individuals a code. i have not given any code so today we will have anybody requesting special accommodations.

there will be a time limit of 20 minutes on total amount that can be heard from each item for individuals who have not received any accommodation for disability. is there anyone in the room. all right, every one has three minutes. when the buzzard goes off, please wrap up the meeting. >> speaker: good afternoon, thank you for allowing me to a tebd the meeting. i'm going to talk about technology. the first thing is, first the person that was purchased by san francisco june 2020, at&t is the company behind it. they would not use any equipment obtained by the contractor. and is in vie laborsing of any applicable law.

yesterday i got my freedom of information request back and says i'm completely healthy and that's troubling, because the city and county of san francisco gave me multiple false diagnoses, and i'm not alone. this is happening because people are using first net and other technology to assimilate political greed and it needs to be addressed and it needs to stop immediately. i have the documentation and i forwarded it to you grant, and i'm not sure why it's taking so long to fix it. i have the documents, i have the evidence. thank you. >> okay, thank you. is there anyone else in the room that would like to make public comment. all right, folks on the line, as i mentioned before, there is no folks who received accommodation. great. so we have no hands for this item. we can go to the next. >> all right, thank you for your comments.

the next item is the recommendation to authorize the dph to accept and expend depths of 115,000, 37,000 and 10,027.96, and 15,400.24 from ethics systems corporation. >> mr. wong mr. l present. >> wonderful. >> wonderful. >> please speak up. >> we are seeking for your positive approval to accept a number of donations in the amount of 115,3500, from the ethics systems corporation. these gifts are from the safety net program and also to support

the community resource directory and behavioral health. they representative philanthropy giving and under sub community. the donation will hetch the improve ourselves to these communities and my colleagues and i will endeavor to answer any questions. >> thank you. is there any public comment on this item? >> is there any public comment in this item? folks only the line, if you would like to make public comment, please press star-3. no hands. >> all right, any commissioner questions or comments? all right, then we'll entertain a moment to approve the resolution. >> so moved. >> is there a second. >> second. >> all right. commissioner chow how do you vote on this item. >> yes. >> and every one else in the room. >> aye. >> aye. >> aye. >> thank you so much the resolution passes and we can move on to the next resolution. >> mr. wong, if you enlighten

us, it is the resolution to recommend to the board of supervisors to authorize the dph to accept and expend a gift, from the san francisco public health foundation. >> thank you very much, the public health foundation is donating 38 2000. through the department 6 public health. it's a contribution and improving the health and well being of mothers, children in our city. we're now seeking your approval for this donation which will be used for several services including prenatal care, planning of family options and adult health services. over arching goal of this funding is to ensure that our committees most vulnerable receive the care and support for this start in life, on

going well being. >> thank you, is there a motion to approve this resolution? >> so moved. >> second. >> and what about public comment on the item? >> any public comment in the room on this item. all right, don't see any. thank you. how about remotely, any public comment, press star-3, please. no one. >> any commissioner questions or comments. all right, hearing none, we'll start with commissioner chow, do you vote to approve? >> yes. >> all right, and the rest of us, aye. >> aye. >> aye. >> thank you very much, thank you for the presentation. now we're going to go to what has been item 9, right? yes. >> which is the "fast food nation" and planning committee update. >> yes. and commissioner chow chaired today. >> wonderful. >> thank you, madam president.

the finance committee heard the contract before which consisted of four different items. one was the barty contract which was discussed within our minutes. this was an issue of clarifying the amounts of money. a barty is a successor organization to welch from which the general hospital has been contracting for these am blah tory ecg monitoring devices. and so this is merely a continuation. it is a, a five-year contract at this point under a barty now, the amount of cost for each of the items remains the same. and there is an annual

difference of a negative 141,000 per year because this is now based on usage and so, we will be reviewing that for recommendations. the next item was for maximum, max minimum is another additional year of contract, is a travel, i think this is the one that is, let's see. yes. for these temps that are needed as personnel to fill-in for the hospitals and network facilities and particularly, including laguna hondas needs. and it's a 47 percent annual cost related to the actual usage. as you know, we have a nursing shortage overall and we have a ratio that have to be met within our hospitals.

so the maximum contract is being extended by one year with an annual difference of approximately 900,000. based upon needs. obviously, we don't need it, we will not be using that. the third contract reviewed for more renewal was the san francisco public health foundation. this was a renewal from three years to an 8 year contract and this is for the food security program. it's not listed on the report but over 14,000 are served by this program which is actually funded by a multitude of different projects. which is these are supplements to the programs that the state

has and is used very much by use as i said, about 14,000 people. so we would also be recommending that for you. and lastly, positive resource center contract which is being extended for three years, we have to full ten-year contract. the proposed amount is the 1,736,000 or increase of about $700,000 over the original contract was. approximately, 1035 people use the program for financial assistance grantsds wiz are helping people not be homeless. the problem that we had with

the positive resource center and discussion was of course their fiscal financial situation which over last several years had run a major deficit of reports from the business office monitoring most recently in october, in september. indicated that with the help that they've been receiving from the city and the department they have turned around their major assets and are now almost even in terms ever a balances budget. they still have some deliverables that were requested by the blcc office and we are recommending that the program be continued. it could be and the contract on extension of three years but as

you know, a contract are really yearly in terms of if we don't have adequate funds or if the organization is not performing well, the contract can be terminated. so the recommendation that we will be making is that, we would recommend approving this contract continuing their monitoring, and the finance committee would receive or report back regarding the deliverables that b o.c. c has recommended and they will also be wrapping up their audit for the past year. so we will continue maintaining a vigilance over their financial status. the reason for going ahead and approving this, is because their program their program evaluation has been excellent in terms of the work that they've been doing.

so we certainly want you to make a good time is important to be sure that they continue a good path for fiscal health. so about 6 new contracts that were before you. the first of those contracts are, regarding the, let me get the agenda and the program here. the first contract that we're proposing to you is from, data innovation llc. and this is to really connect about the laboratory data information systems to epic. it's a proposed contract amount of 762,616 dollars. over 2 million specimens are performed as general every year

and this will allow for this data to be transferred directly over to epic. it will be a five-year contract. the first two years that the contract to october 2025 will be putting into place. and then, our current contract with the current vendors will be ending in the company will then take over for the next three years in terms of having the maintenance for this information system transfer into, what they call the he pick which is i guess, you can look at the hrc or the labs that has been through this audit. so that's the first new contract.

with risk and consulting which will be public media campaign. thts for 540,000, 596 dollars for one year. this is to do public health education in regards to the ability of treatment for opioid, addiction and also the how to use the milloxzone and we'll be a one-year contract. they have done many media campaigns in different areas. the next four contracts are needed contract which will be

the supporting the phase 3 of the erh implementation. it is a total proposed contract for each of these forces. so you can take them as need vepders sort of like our nursing situation where as you need nurses and you pull them from various contractors. as you need to have expertise in the epic electronic health module, this then allows that they have the support different companies in order to have an expert help with something with the chart or any others that they list on your agenda an entire array of modules that they have. so this provides the back up force. they're proposing that u.s. t financial health to un, given a

contract a max of 3 million dollars, the second one will be a similar contract with 3, 14 corporation. these contracts are for five years so you have this bank of four companies for five years, able to then, service us. the fourth is impact advisor llc and the fourth contract is for telljens incorporated. so those four contracts are for the management of these module that's will allow our ehr people to select the expertise that are needed for a public problem. we then heard two presentations

from solicitations our rfps to give, we actually heard one because the second one had a technical problem. so we will hear solicitation at our next meet ing, which had to do with the black african-american maternal health program. so we did hear however, 77 a 1 and a-2, those are mental health that are school base and wellness initiative. as contractors were attached to each of these which are the contracts that will be coming before the finance committee and the commission. and those are the rfp solicitation that will give us the overall regions for example, one of the contracts has four different vendors,

well-known initiative has the, the has one vendor. and this way we will know how they fit into the picture of the behavioral child prescription. it was informational piece that we're lookering forward to hearing. again, as i said the solicitation for the black maternal screening. that ends my report and perhaps commissioner guillermo who was kind enough to join us to form quorum, may join us. >> thank you. >> that ends our report. >> well not only thank you, commissioner chow but i want to acknowledge. i think this report is emblematic on the work and detail that is involved in the part of the contracting

division as well as all the vendors that we work with. and as you see, they do great diligent work and ensure that we're being fiscally responsibility. i think that report was pretty characteristic and 5-minute report but there is a lot going on behind the scenes. i think we're all very grateful to every one for the efforts that are being made. so everything that commissioner chow reviewed is on the consent calendar. sol is there any public comment on this item? >> we're still on, folks are on item 9, if you would like to make public comment anybody in the room? what dr. chow just noted? online, anyone press star-3. no public comment. >> are there any commissioner comments? all right, we should go to the laguna hospital policy. >> we'll go to item 10 which is

the consent calendar, and commissioner chow just reviewed. >> okay, we'll do the finance separate. you have before you, all the contracts that reviewed by commissioner chow. >> i'm sorry, it's vote for everything on the consent calendar. >> should we present the laguna honda policy that is on the consent handle now as well. >> yes, please. >> so then, let's go ahead and have commissioner guillermo present the items that belong to laguna honda. >> thank you, commissioner green. we have been reviewing and asking for approval for laguna honda as needed for a number of reasons, not just limited to the recertification process. we did approve, recommend for approval to the full commission

the set of policies that are before you. there were some questions that the members of the jcc had of the policies and we ask that, that the ed its and corrections and additions in the questions that we had were answered prior to us us making a full recommendation to be placed on the consent calendar. we have received those and are, and per the members of the jcc, are approved, the inclusion of this set of policies on the consent calendar for today. >> so now should we move to approve the consent calendar. >> yes. >> all right, is there a motion. >> so moved. >> second. >> and i see public comment, is there anyone that would like to make public comment on consent calendar? anyone remotely. anyone online, press star-3.

no public comment, commissioners. >> okay, we'll go to vote. >> commissioner chow. >> yes. >> sxl other commissioners in the room. >> aye. >> aye. >> consent calendar is approved and i believe we go back to our regular scheduled programming? >> item 6. >> item 6. is proposed program revaou, city wide program to be relocated at 1263 mission street second floor san francisco california, 91413, welcome. >> and this is a discussion item there is no action on this. >> yes. thanks. can you hear me. i'm michelle rug lz i'm the director of dph units. the business units of contract d o.c. c and one of the things that b o.c. c does is make sure

that we're in compliance with the city's administrative code which is the, the citizens right to know act of 19 98 which we adopted as a dph good neighbor policy. you'll also hear it often referred to as prop i, because that wased or the nans letter. but, chapter 79. but anyway, so our chapter 79 and therefore our policy requires that for certain city funded projects to meet the criteria that citizens and neighbors are given their right to share their concerns about the city project. for dph, the project may be something that comes here or the action may be something that goes to another body to approve, like it's, the building is purchased for dph real estate takes it to the board and that satisfies the action. so one of the common places or

times that we bring, to you here, is a relocation of a city contracted vendor. so this can apply to city contracted vendors or dph that, so a project or a relocation if it's changing the use of relocation of wla the site was used before, funding, and that can trigger this. so it was triggered today and that's why we're here specific for city wide case management which is a set of program for under uc, that dph contracts with and they are relocating all of their contracts that are currently at 82 mission street to trial 63 mission street. so like, this is a hearing, there is no action today that is subject to health commission approval. i'm joined today by dr. who has

the director of the city case management program as well as jenna reyez who is director of the business office compliance. so nothing, this is been a not controversial items. and so, but they're here if you have any other questions besides me going over how we can comply with the process. the essentially the biggest piece of this requirement is that we post signage, 30 days before the hearing and this is the hearing. so and then also, our dph policy add at the second meeting has already happened at the community meeting. reposted our signage on november 3. and on your package there are copies of the signage and then attachment five is a photo crew proof that we posted the signage.

if you post signage on the building and the 30 days, you're not required to mail flyers to the neighboring, to the neighbors businesses. and so, we didn't do that mailing. if you, the site, there is not a ton right around there. but the city wide walked around the neighborhood and where there was four open businesses that they spoke toxer the flier. one of the flyers, we had the signage which has to be a certain size, 30 by 30 but then we also posted another attachment, how to contract the health commission. sol that was part of, that's a day they distributed. they did not get any comments or concerns raised. and then the community meeting was held on november 15th by the city light staff and the b o.c. c staff leading that and nobody showed up.

and nobody provided comments to city wide case management or to jenna reyez, the director of docc whose name is on the poster. i realize as i was preparing that you have attachment one which is a summary, i don't think i put down the updated spertion. so there is two empty boxes in there. the square footage of the new building is 28,571 rentable square feet. and then the hours of operation, 8:30 to 4:30 monday through friday. and discussing the move with the staff, it seems like they're actually going to improve the area with lighting and what not. but, you have questions about the program or if you want to wait if there is, public

comment, however you want to do it. so see if there is public comment. like i said, doctor. ms. sushi is here, if you want her to have her come up and talk about the program or any. >> thank you ,z there any public comment on this item? >> is there anyone here to make any public comment? i don't see anyone, how about we motelly. would you like to make public comment. there are no hands for public comment. >> and are there any commissioner comments or questions on this item? >> are the, just curious to hear from the doctor what the moves will accomplish for the organization? >> good afternoon, commissioners. the program necessitated to

move because we were losing our lease on existing building. so really it was an operation al necessity. so this is square footage is increased which is necessity, provides services are in high demands from the city. so we are, i think this is a great opportunity for to us have an expanded capacity. >> i had the privilege to work with city wide and the staff and what an amazing work city wide does. and i've been to the current or former building. and i'm glad to know that more square footage will be available for the amazing work that they do for the community and that the staff will be a little more comfortable than, they might have been before, you had a wonderful space. you created a wonderful space before. but i'm hopeful that it's going to be better. >> i look forward to seeing you at our new space. >> look forward to being there. >> thank you.

>> any other commissioners comments? well what a wonderful way to close out that item. i'm delighted that you have great experience. >> it's a great organization. >> thank you very much. wonderful. so the next item is dph update and i was thinking how incredible it is that you're presenting o close to the 25th anniversary of world aids day. it's hard to believe that 25 years have gone by. it's really a testament of how far we've come. so the presentations i'll just read your names, stephanie cohen, director of prevention and control. tran who is an pi modologist

and iesha, we've been looking forward to this presentation. so please again. >> before you begin, commissioners, the presentation i've worked with them to try to get it down to about 30 minutes and please note that it's longer because of questions. if every one is okay with that. >> thank you. thank you so much for the warm introduction. i'm stephanie cohen director of hiv prevention section and disease prevention branch. and i'll be presenting an updated h.i.v. update. next slide. a lon with my colleagues. we will share two data presentations today to show sdi trends and two program presentation to see describe

how we're addressing disparity during a patient centered approach. alongside of overdose and by those interactions, increase the adverse affects on the communities. response requires a multi sect tore al and holistic approach that we apply for our work in sdi and h.i.v. prevention and care. next slide. all the presenters work under the leader ship 6 our division director dr. suess an philip. next slide. and as a reminder this is our current structure. you'll be hearing from staff and the branches outline in the red boxes from arches, the

prevention and control and health equity. and i will also share briefly update to get into zero consortium. on that, i'll turn it over to sharon who is joining remotely and we'll start with our h.i.v. updates. >> good afternoon, commissioners and staff. is volume okay. >> you sound great. >> i'm sharon and epidemiologist. next slide. for h.i.v. we begin with trends. looking at the red line representing you new diagnosis, we see that the decline and new infections have stalled.

declined 28% and only 12%. in terms of prevalence at the end of 2022, represented by the last--we have an aging population in persons with h.i.v. also informs the mortality trends that we're observing shown by the yellow line. you see that, that's gradually increased since 2016. increase from 10 percent to 18 percent in 2018 to 2021. next slide. while we look at diagnosis

rates which take into account, biracial group, continue to be disparity for the new h.i.v. infections. 2022 for the first time, there were higher rates of new h.i.v. diagnosis in latino men shown by the solid green line than black men and race in both of these groups were substantial higher than in white and asian pacific islander men. although latino men, black women shown by the dashed purple line were higher than white and api men and also women of other racial groups. i would like to note that race are too small and may be unstable. population, denominaters are not available for trans women and trans men. next slide.

as i mentioned earlier, overall there is been a 12% decline in new diagnosis from 2019 to 2022. if i select populations at the same time period, new diagnosis for white, down by 22%, black 17%. all persons addicted to drugs, 9%. homelessness, 13%. persons homelessness were 17% of 2022 diagnosis. and latinx where new diagnoses increases by 10 percent with three quarters of latin diagnosis being latino. another population of interest towards the bottom, trans women annual diagnosis are stable through this time period.

next slide. for new diagnosis in the last five years, we further analyze outcomes to just linkage to care, and viral suppression indication. here each represents cases diagnosed that year. looking at the middle of group showing care, in 2022, 90% of persons were linked to care within one month of their diagnosis. and the percentage of viral suppressed persons within six months of diagnosis, has improved to 80% in 2022, just the highest of the year 2018. next slide. turn to go virus affected persons living with h.i.v., here we show viral suppression rates in the last three years, starting with the year 2020 shown in the blue bars and 2022 in the yellow bars. we focus primarily on

demographic that have lower viral suppression than the overall rate for 2022 which was 73%. now these groups were women, blacks, people age 25 to 49 years old. persons who injected drugs, who acquired h.i.v. through heterosexual contracts born outside of the u.s. and persons experiencing homelessness. although, these groups with lower suppressed, improvement to note among persons experiencing homelessness, viral suppression increased from 20% in 2020 to 52% in 2022. and this improvement maybe attributable in part to persons experiencing homelessness, getting reengaged to medical care after the covid-19

pandemic. engaging in care from 33% in 2020, to 70% in 2022. next slide. in summary, the rate of decline has evolved and protections are on going. high levels of linkage to care and viral suppression are occurring but despair its remain. and the concerning trend in h.i.v. that are highlighted include an increase on latinx people, and trans werjs the continued high proportion of new diagnosis in persons experiencing homelessness and the increase in accidental drug deaths. and the next section, you'll see what is reflected currently in trends and epidemiology.

>> commissioners my maim is tran and i lead the sti evaluation in arches. next slide please. overall, in san francisco, annual incidents rates for kla mid-ia morning, in gonorrhea in red and syphilis in green. the steep decline in 2020 is due to reduced testing. rates have decreased between 2020 and 2022 but still lower compared to 2019 while rates of syphilis have continue to decline. given the limited time, we will not be presenting data cross all sti but we do want to address president green's trend for race and ethnicity.

for chlamydia and early syphilis, by race and ethnicity and among males, the trends in rate by race ethnicity is similar to what is shown here. next slide please. compared to other jurisdictions, san francisco experiences relative high rates. the graph on the upper left shows san francisco in the orange doted line, with the higher gonorrhea rate in five years compared to california and u.s. as well as compared to los angeles and new york city. this trend is also true for chlamydia and syphilis. for primary and secondary syphilis rates in the left set of bars and early syphilis rates in the right set of bars, san francisco has the ryest rates compared to l.a., new york see and u.s. next slide. increased syphilis among females con general till remain an area of concern.

national increases among pregnant women and congenital syphilis since 2015 . the light on the right since 2013. next slide. we've seen increases in san francisco and reported female syphilis since 2014. given the goal of preventing congenital syphilis, we monitor persons who can become pregnant. gender who's were female or trans male. data for 2023 are through the third quarter. in 202 2, there were 186 syphilis cases 18 whom were pregnant. of the 18 pregnant cases six

experienced homelessness, one reported meth use and one reported heroin use. the left, represent syphilis cases. bit end of 2023 there were congenital cases, but we know there is a fourth case so far in the fourth quarter. and supplemental slides that we provided page 7 shows by rating and he is nisity. latinx were lower cases of all for all stages in 2022, at 211% than they have been in resent years. next slide please. while the response originated w9 graourntion we learned through investigations in 2022 the primary mode of transmission in u.s. and san francisco is close contract with sexual partners. therefore the m pox prevention control positions to the relevant groups with ash muches

and control branch and the community health and equity branch this. transition was completed in november of this year. next slide. after the first wave ended in late 202 2, there were support add i can. but in increase since july 11, result inside 50 cases reported through october 31 of this year. vas majority of male who report sex with other men. last mobsinger additional 12 reported cases. san francisco has the highest m pox in california. next slide. we have seen the des pater for race and ethnicity. the graph shows that san francisco population by race ethnicity the proportion of race and ethnicity in the blue bars. the red aeuro points to the two blue bars where the m pox is higher.

28% has been hispanic latino compared to 17% who are hispanic latino. and 45 are white compared to san francisco 39% residents who are white. vaccinated cases have experiences less severe systems and less likely to go to the emergency room or be hospitalized. next slide. by october of 31 of this year, san francisco residents received one dose of m pox vaccine. of those 59% also received their second dose which completes the volcano seen series. next slide. another population given their rates is adolescent in young adults, ages 15 through 24. next slide please.

while race have declined, disparity exist both by race ethnicity and gender. here we rate between 2018 and 2022. those identified as black a frick man american or hispanic experience higher rate compared to white, asian or multi racial youth. next slide please. disparity additional seen by age. we focus on chlamydia. we present the data by race ethnicity by age and the age group. you can see reflected in longer blue bars that the groups experience lower rates within each race ethnicity. and that a black african females, experience the higher rates, highest rates.

the same pattern is true for gonorrhea that is not shown here. next slide. finally we're always monitoring trends and rates and epi modology. next slide please. the known and perceived impacts on covid on health service sxz sexual behavior or network has muddled how to interrupt resent declines. hao*er you see on the aeuro in the left, in quarter of two of 2020. immediately following the first cases of covid in san francisco in march 2020. cases slow slaoe increases as screening services opened back up and people got in close contact again. next slide. the identified our first m pox in may of 2022, at the second arrow and then at the third arrow, we the san francisco

department of health, released guidelines for recommending post exposure referred as doxiy for sdi prevention in 2022. next slide please. after the introduction of m pox and dox' pab, we have outlined by the box, study totally decreases in chlamydia cases. next slide please. that same pattern is not seen among females p very few m pox cases. next slide. but among men who have sex with men both experiences the highest rate of m pox. the quarterly decline are seen and more notable in qeii and q3, the last two orange bars on the graph. next slide.

for gonorrhea there were decline soon after covid and m pox were introduced. but there was an up tick in quarter 3. this is seen on men who have sex with men among and among females not shown. next slide. for total syphilis, we highlight the data where there is men who have sex with men, quarter cases since m pox were introduced. next slide please. in some rate, elimination of congenital remains our objective. on going promotion and are warranted and continue to continue disparity needed to promote pok use.

and then finally sti the patterns will be evaluate. thank you. >> good afternoon, i'm nye eastbounder a under wood coacting director and i'll be discussing community efforts to address and ultimate use the curve on the disparity discussed during the presentation. so ending the epidemic, community informed to address the sin dem i can of h.i.v., sti and overdose, following the principles on the slide and there is a living document called the san francisco eta plan that will guide all of our prevention care work over the next ten years. before by grants through our

federal partners which is center for disease control, our california of public health and the city and county general fund as well as parsa, next slide please. sorry about that. so part of ending the epidemic effort is the health access model. so we have previously shared our hat vision. the hats provide low barrier and community services and welcome spaces free from stigma. the goal of the health access point is to ensure that all san franciscans have equitable access to all, sti prevention care and treatment services as well as harm reduction and overdose prevention services. next slide. so the community health equity and promotion grant from 7

health access points focusing on the following communities on the slide. all thoet health access points are population, focus nobody turned away from health services. also wanted to note that disparity were a factor in determining the amount of funding for each of the points. so the lat i can x received about half of the total funding for the health access point. we have launched in july of 2023, the planning phase before tha. we are currently collecting data from the hat of services delivery. the initial data submission happened this past friday and we'll have more outcome to share in the coming year. next slide, please. so some of our efforts, focus in latinx community to address disparity seen in the data.

we are advising community programs which for the latinx communities. check is also focusing on strengthening collaboration with our funded programs and other community partners such as the latino task force and collaboration to support the work needed in a number of new h.i.v. against latino and gay men. so we're work with health center as part of our health access point efforts. h.i.v. testing.

additionally we're supporting our ucsf pacific in their efforts to offer h.i.v. testing. in the heart of the mission district. next slide, please. like wise we have our efforts in the black community. because our ipoc in the black african-american youth. we have partnered with our street youth clinic where we fund a full-time health educators. we have created an access point for youth to order self sti tests and i'll talk about that a little bit in upcoming slide.

some of the other efforts in the black african-american community are the mobile contingency service. this is a street base out reach and brief intervention for people experiencing homelessness and focused on ipoc who smoke fentanyl. on going counseling and drug testing services. we are also funding three community advisory program focused on the african community, they provide expanded community engagement and continuous and meaningful dialogue to address h.i.v. in the black african-american community. and then lastly, we have a, a black african health access

point lead by rafiki coalition and they also have some partners in that. so our youth we support using young support through a variety of activities. our think no home testing program which i spoke about briefly in the previous slide provides low barrier access to free and confidential chlamydia and syphilis screening. providing sti h.i.v. screening and array of other services. and providing youth access at the clinics. where a black initiative sti committee pulls together

partners to think how to bring youth back to the clinics and promote and empowerment overall. lead a story project with focus on empowerment and youth development. they develop videos about sexual health and identity to share with other youth. the youth videos they live on the city clinic youth page. next slide please. we also have focus on people who use drugs. so we fund, which is lead by 186 in collaboration with dlied and alliance health project their population of focus, also excuse me, also includes people who engage in sex work.

check has a team, we call them wishes, it's the wellness initiative for social health and equity. so they support and capacity building and training for services for people who use drugs and experiencing homelessness across all of our access points. we also partner with behavioral health services. the next slide please. lastly i'll talk about our community base m pox prevention efforts. has been informed about m pox and how to access low barrier vaccination.

for the past year and a half, we created video and various languages to feature community members and prioritize lgbtq communities that provide health information on symptoms, and how m pox spread and does not spread. we contracted with a social media to increase message as cross social media plat forms. and then we've also developed a survey that offered the state inside on people's vaccine adherence during the street fair. and i'll turn it over to stephanie cohen. thank you. >> okay, next slide. hi again. i will start with updates from our getting zero consortium. getting to zero was a coalition

that was started in 2019. in getting severe include a press committee, retention, committee foc pused on people experiencing homelessness and one on h.i.v. and aging. over the past decade getting so zero has been responsive on issues and population. where we are seeing despair its. some key current areas of focus are overdose prevention as well as tacking new products such as the education and post purple access. our get to go zero meeting tomorrow in honor of world aids day, we'll focus on discussion and h.i.v. next slide. now i'll turn to the work section. i'll just describe our problematic efforts to describe a dress disparity in sexual health. this slide focuses on the work

of our linked team which is central to the work of get to go zero ending epidemic. navigaters who work to link individuals with h.i.v. and sti to prevention treatment and care. thed learning pair mid-on the left shows the vas of skills to do this complex work. in 2021, the team provided navigation services living with h.i.v., almost 60% of whom are xaoerntion homelessness and thoz. this work is helping contribute to those improvement among people experiencing homelessness. the team also works with many experiencing h.i.v. and as dr. win shared, they

have taken over m pox and served as of october 58, individual with m pox. a major focus of our program is prevention of congenital syphilis. this is an area of national concern and local concern and biden administration has created a task force. luckily, we have had task force for several years which includes partners from city clinics and maternal adolescent health and emergency department and urgent care and other key partners. in 2022 through this work, we averted 50% of potential syphilis cases. task force focused on many

programmatic initiative to see identify missed opportunities, developing work flow making optimization, maintaining a weekly pregnancy loss and increasing provider knowledge, around sexual health and syphilis screening. that now recommended syphilis screening three times in pregnancy including in delivery. many of our congenital syphilis and patients who are diagnosed with syphilis at delivery because they have not received any prenatal care. our training and technical assistance extend beyond congenital syphilis. we work with providers around the city who star

disproportionately, to increase to provide evidence base affirming case. we developed and did i sim nature guidelines and protocol and work with important clinical sites including m community sites like navigation center, our msx clinic and newly formed access points. we also provide clinical observation management and stis. next slide. san francisco city clinic is a nationally center of excellence and remains a integral part of our city wide get to go zero efforts. we, highlighting some of the work in 2022. several years ago, the clinic was awarded four-year competitive grants, one of 19 jurisdiction to receive the

award to optimize h.i.v. prevention in sexual health clinics. and with that funding, we have been able to implement a number of things to op miez prevention services. so it's at the clinic and throughout the san francisco network, we built a press registry to support retention and prep care. we scaled up our capacity improve patient experience and visit times. we have implemented long acting injectable prep and innovative new tool in h.i.v. prevention. we initiated medical and engagement through a prevention which resulted in the beautiful mural that was painted on the building last year. next slide. through our rta and training program we work to optimize the

delivery of prep throughout san francisco. next slide. and with these efforts, we have seen year after year increases with men who have sex with men who report that they are taking prep and we've seen these increases across ethnic groups, although some disparities do remain. these far surpass national data, only 11% of black african americans patient wise. next slide. by i am mrimgt new technology, injectable we're a dressing disparity. this slide shows the proportion of prep by gender on the left and race ethnicity on the right with the orange bars showing patients who are receiving all of our patients on prep and the blue bar represent those who

are receiving injectables. and you can see that through our l.a. program we're reaching populations including trans women and sis women as well as latin patients. the last intervention is psych lin propsighssis, this is a new sti prevent ition that reduces sti by nearly 70% and trans women. nons traited the ethicacy, and became the first jurisdiction in u.s. to release guidance. it's having an impact on city wide sti and through get to go zero new product initiative we're working to monitor up take to identify and address disparities and assess impact.

two important sites of delivery, president green you asked are both h.i.v. clinics. next slide. in summary, social determinants continue to drive the sti and h.i.v. ep deposit i can. we have promising new tools in both h.i.v. and sti prevention but intensive efforts are needed to ensure equitable access. you have heard about disproportionate on m pox. and this is an area of concern and focus for us. the reason are complex and i think we still have more to learn but we do think that stigma and lack of access prior to arrival in san francisco, lack of insurance, and fear of

immigration status all play a factor. lastly, our systems and our newly form task are critical to reaching latinx residents as well as other populations where we're seeing disparity. thanks for your attention, i think all four of us are happy to answer questions. >> thank you so much for that incredible presentation. what an amazing enterprise, we'll go to public comment. >> ye, eduardo, can you turn on the bottom light switch so we can get more light in here. thank you in advance. is there anyone in the room that would like to make public comment? and no one online either that would like to make public comment. >> all right, we'll go to commissioner comments and questions. >> thank you. >> i don't have any questions, i just want to comment on the

overall presentation. it just, one to congratulate you on being able to keep the issues of h.i.v. and sti prominent and very much in the public's you know, sort of mind set. because it's so easy with everything else that we're being confronted with for folks to think and there is not a lost visible you know, i think that it's really important for us to continue to, to keep the agenda that we have had particularly in san francisco with all the success. across all the demographic, i

think that's really key. it's very surprising, well maybe, not as surprising but very concerning relative to the latinx population. and then with the young, with the rates of sti in young women, i think that's something that we really need to be paying attention to. i want to thank you for being able to make this presentation. a lot of date and data, in order to keep our eyes on the prize. so thank you. i want to thank and thank you and congratulate to present the information on clear manner which is not always the case in any circumstances.

but really thank you for and very successful. and look forward to continuing to hear about your work. >> well, i can't say it better than my fellow commissioners. we're in awe of your work and the all that you a accomplished, the way you defined the problem and the way you're setting out to solve them. we're grateful for your work, you are really really among the many dwitionz of health that make us proud. so we're very grateful. i think colfax wants to say a few words about your amazing work. >> one more point, i think the other thing that i wanted to,

the partnership that you have created with the community base providers and others that supplement and augment, the leadership that the department has shown in this area. i think it's a model for the partnerships that we can do across many different health concerns, public health concerns that we have, not just in san francisco but across the nation and so again, i think that and it's been over decades. and that's how long it takes. this is an exemplar' way to show how important the departments can be. >> i graoe, the partnership that you make is also noteworthy and the leadership within the community that you're supporting and building through the partnership is also quite useful in and of itself. thank you so much.

>> if you can get one or two questions. and i'm really pleased that the integration of sti and h.i.v. have really worked out and we're all working together. and very massive reports that you have put together. i was just wondering why we have such a very proportion of these, this order compared to the entire united states. does everything that we have a different environment. wanted to clarify that syphilis

is so much higher than california and the u.s. do we do something different? >> thanks for the challenging question, one thing we know is once you have a high prevalence in the network it short of persist so i think part of it is that we have a stis in our community and that means anytime you're exposed to somebody you're most likely to be exposed to an sti, i think that we, have also, you know, as you know, we're one of the jurisdiction that's was hit hardest and earliest by h.i.v. and i think the conditions in san francisco, that put us in a situation where we had a, more of the tep dick and the things that put us at-risk for sti

rates. but the good news is that we have a strong collaboration throughout the health department and community. you've noted that you believe that the h.i.v. numbers are plateaus. but in previous presentations, we talked about i think both in the sti that we're still having, that we were having difficulty in trying to influence the younger generation. maybe i missed it the

presentation, of which, that we are trying to reach. i was surprised about the latino rates rising. we're finding that this is now under control? >> you can also make some broader comments. >> yes, while we did not include as much age related information, on new diagnosis today, did you reference the 2022, at the annual report in section 1. you'll see that by age, new

diagnoses are in the 30 to 39 followed by the 29 young adults. and young adults 18 to 24, it's ranged from 10 percent to 12-14 percent. and recently in the last year, it's 12 percent of new diagnosis. >> so is there a campaign on that? because you didn't really show. i think from the stand point of h.i.v. the use focus is that we're working with lyric for use. and i think we all, you know, strongly believe that we have to maintain a focus on youth because they're coming into their sexual debut without

having received prevention education. so it's always the population that is entering the network and that we need to have on going efforts to reach. i don't think it's why our new h.i.v. diagnosis are plateauing in rate of decline but it's a very important population focus for us. >> so, so i think on the basis of future presentation, we should be looking at this younger age also in terms of letting us how successful we are doing with the group. as i think you said, this is where much of the younger and much of the new infection is coming from. and i know that we had talked about trying to really reduce that and that might be, a focus that you would like to hear about.

but certainly i join my fellow commissioners on this report, i push forward because it's so rich and data, i want to thank everybody in this combination for the work that they've done. >> thank you. i just wonder, whether some of the reporting is due to the fact that you're so excellent at what you do, you probably track cases better than a lot of organization in this, in the country and also because you have done such a great job of destigmatizing, that maybe your numbers seem worse because you're doing better, i wonder if that's a component as well. so we'll go to director colfax. >> thank you, hi, everybody. i want to touch on partnerships, this is

recognized nationally and i often get text from colleagues that i used to work more closely with, who say, one of your team members is presenting and as usual, san francisco is doing a great job. i think the other part with the presentation, the team was, maybe a little too humble particularly around doxy pad trial that the city clinic was a major site for. and stephanie was coti, of this trial published in the journal of medicine. i think the other thing that was very that was very, ground breakinging for the department is for their recommendation, we

move aggressively. you're seeing some of the data that looks promising, we're not ready to say definitely do the dox' pad. from the month we initiate dox' pa*d from now, it's becoming commonized. and many of them have taking it, it's not considered an unusual thing for people. it's an example of ground break research going from academic journal to being applied in the community. >> thank you, and how weird that the study ends up operationalized.

thank you so much. would you all join me in applauding this group because they have done a great job and they continue to do so. [applause] >> all right, i guess we'll go. this is a hard act to follow, now director colfax, now you have to do the director's report. >> i'm not trying to follow. thank you again, everybody. so i did want to mention one thing, one thing is that at laguna hospital we're engaged in our second survey. we had surveyors come on monday and again this week. we're ensuring that we do all we can for a successful survey.

as always, we expect findings especially for a facility of our size. the goal is to ensure that findings are taken care of as quickly as they are found. and even after the survey that is complete, we anticipate the participation will take more time. so i really want to acknowledge that all laguna honda staff, surveys are stressful and they are, continue to go work very hard to make sure that we're doing everything that we can. so more news to come. but we are in a major, this is the second survey after the first survey that lead to successful medicaid certification. this is the second survey that is required for medicare recertification. just also, wanted to emphasize that you started, president greensinger i believe you start thed the presentation around acknowledging the world aids day. and we, we recognized world

aids day last friday, including making sure that people understand that san francisco is a leader in this work, both nationally and very pleased to see some of the activities going on. i was able to attend the aids memorial grove event which is a nice local event that has a national print. i encourage people to go there. in the written director's report i'm thrilled to announce that our new chief medical officers, medical director started last monday, december 4th.

dr. albert lamb, he has extensive experience examine expertise in skilled nursing, long term care facilities patient care. and you'll see his qualifications there. we're so happy to see him join the team. we're in the holiday season, and we would like everybody to stay as healthy as possible. so we have a lot of detailed guidelines. but i would point out the key areas, get back against covid-19 flu and rsv, if you're qualified for rsv, stay home, please if you're sick. get treatment if you do get sick. consider weaker a mask

particularly people over 65 and these recommendations were issued bye-bye other near by health officers. and then just another, i wanted to also celebrate the department's work, acknowledge the department's work during the apec conference during weeks ago. again under the population health department under the department. huge amount of work along with our other department division. and it was so ensure minimum disruption to see health and health service sxz to be ready to respond adverse events.

this would not have been possible speaking in may. leading up to a pack, between supporting a pack coordination and other resources, and exercises support and community messaging and facilitate planning for departmental and access healthcare facilities. to community partners and across the department, there were many other cxz including the environmental health branch was working very hard to ensure food safety.

we had the clinic open in late hours for people for people to access healthcare. and acknowledge the work at the hospital praum a center was coordinating with many entities. and working with adverse air he's with other governments to make sure that we're prepared for any catastrophic events which thankfully did not happen. i want to emphasize the work across the department and overall success of from thed public stand point of that conference. and i will stop there. i do have one more covid update. test positivity rate is 62%. we're not seeing a big increase after the thanksgiving, we may

see it in a week or two. and right now, there are 28 total hospitalizations in hospitals across the city. i think it's triple the national average. we have more room to go. we're doing better than national numbers by far. that all, i'll be happy to answer any questions. >> thank you for your question, we appreciate you calling out all the work that went into a pack. so it's a real testament, to

pull this off which is quite, quite an undertaking and then we're delighted that we have a medical director at laguna, that's such great news. so is there any public comment on the item? >> would anybody in the room like to make public comment? all right, we have one caller. can you unmute the caller and i'll put three minutes on the timer. caller let us know that you're there. >> caller: hi, i'm dr. palmer. i'm delighted that you recaoutd dr. laum to be the medical directer. so laguna honda does not run into trouble again. i know you've done extra goals. and you give us any estimates

of when, you know our range of when admissions might be reinstituted? we're going into flu season. and people are transferred out of county because they need the beds. i would like the assurance that you will continue to get, get to get those 120 beds back. thank you very much. >> thank you. that's the only public comment on this item. >> and then commissioner comments or questions? all right, i see none. so thank you so much for our report. and our next item is other business. is there any other business? >> let me check to see, would

anybody online like to make a comment online. so the meeting was officially adjourned at 5:35 for not having qualmer but you can just end. >> thank you, thank you for being here. >> yes. >> >> >> >> >> my name is bal. born and

raised in san francisco. cable car equipment, technically i'm a transit operator of 135 and work at the cable car (indiscernible) and been here for 22 years now. i grew up around here when i was a little can i. my mom used to hang in china town with her friends and i would get bored and they would shove me out of the door, go play and find something to do. i ended up wandering down here when i was a kid and found these things. ♪ [ music ] ♪ ♪ >> fascinated by them and i wanted to be a cable car equipment from the time i was a little kid. i started with the

emergency at the end of 1988 and drove a bus for a year and a half and i got lucky with my timing and got here at cable car and at that time, it really took about an average five to maybe seven years on a bus before you could build up your seniority to come over here. basically, this is the 1890s verse ever a bus. this is your basic public transportation and at the time at its height, 1893, there were 20 different routes ask this powerhouse, there -- and this powerhouse, there were 15 of them through out the entire city. >> i work at the cable car division and bunch with muni for 25 years and working with cable cars for 23 years. this is called the bar because these things are horses and work hard so they have to have a place to sleep at night. joking. this is called a barn because everything takes place here and the powerhouse is -- that's

downstairs so that's the heart and soul of the system and this is where the cable cars sleep or sleep at night so you can put a title there saying the barn. since 1873 and back in the day it was driven by a team and now it's electric but it has a good function as being called the barn. yeah. >> i am the superintendent of cable car vehicle maintenance. and we are on the first and a half floor of the cable car barn where you can see the cables are moving at nine and a half miles an hour and that's causing the little extra noise we're hearing now. we have 28 power cars and 12 california cars for a total of 40 revenue cars. then with have two in storage. there's four gear boxes. it's gears of the motor. they weigh close to

20 tons and they had to do a special system to get them out of here because when they put them in here, the barn was opened up. we did the whole barn that year so it's difficult for a first of time project, we changed it one at a time and now they are all brand-new. engineer's room have the four monitors that play the speed and she monitors them and in case of an emergency, she can shutdown all four cars if she needs to. that sound you heard there, that's a gentleman building, rebuilding a cable. the cable weighs four hundred pounds each and they lost three days before we have to rebuild them. the cable car grips, the bottom point is underground with the cable. it's a giant buy strip and closes around the kab and they pull it back. the cable car weighs 2,500 people without people so it's heavy, emergency pulling it offer the hill. if it

comes offer the hill, it could be one wire but if it unravels, it turns into a ball and they cannot let go of it because it opens that wide and it's a billion pushing the grip which is pushing the whole cable car and there's no way to let go so they have to have the code 900 to shutdown in emergencies and the wood brakes last two days and wear out. a lot of maintenance. ♪ [ music ] ♪ ♪

>> rail was considered to be the old thing. rubber tires, cars, buses, that's new. there were definitely faster and cheaper, there's no question about that. here at san francisco, we went through the same thing. the mayor decided we don't need cable cars (indiscernible), blah, blah. we can replace them with buses. they are faster and cheaper and more economical and he was right if you look at the dollars and cents part. he was right. >> back in 1947 when they voted that, i'm surprised base of the technology and the chronicle paper says cable cars out. that was the headline. that was the demise of the cable cars. >> (indiscernible) came along and said, stop. no. no, no, no. she was the first one to say we're going to fight city hall. she got her friends together and they started from a group called

the save the cable car community, 1947 and managed to get it on the ballot. are we going to keep the cable cars or not? head turned nationwide and worldwide and city hall was completely unprepared for the amount of backlash they got. this is just a bunch -- the city came out and said basically, 3-1, if i'm not mistaken, we want our cars and phil and her group managed to save what we have. and literately if it wasn't for them, there would be no cable cars. people saw something back then that we see today that you can't get rid of a beautiful and it wasn't a historical monument at the time and now it is, and it was part of san francisco. yeah, we had freight back then. we don't have that anymore. this is the number one tourist attraction in san francisco. it's historic and the only national moving monument in the world. >> the city of san francisco did

keep the cable car so it's a fascinating feel of having something that is so historic going up and down these hills of san francisco. and obviously, everyone knows san francisco is famous for their hills. [laughter] and who would know and who would guess that they were trying to get rid of it, which i guess was a crazy idea at the time because they felt automobiles were taking the place of the cable cars and getting rid of the cable car was the best thing for the city and county of san francisco, but thank god it didn't. >> how soon has the city changed? the diverse of cable cars -- when i first came to cable car, sandy barn was the first cable car. we have three or four being a grip person. fwriping cable cars is the most toughest and challenging job in the entire city. >> i want to thank our women who

operate our cable cars because they are a crucial space of the city to the world. we have wonderful women -- come on forward, yes. [cheers and applause] these ladies, these ladies, this is what it's about. continuing to empower women. >> my name is willa johnson is and i've been at cable car for 13 years. i came to san francisco when i was five years old. and that is the first time i rode a cable car and i went to see a christmas tree and we rode the cable car with the christmas worker and that was the first time i rode the cable car and didn't ride again until i worked here. i was in the medical field for a while and i wanted a change. some people don't do that but i started with the mta of september of 1999 and came

over to cable car in 2008. it was a general sign up and that's when you can go to different divisions and i signed up as a conductor and came over here and been here since. there were a few ladies that were over at woods that wanted to come over here and we had decided we wanted to leave woods and come to a different division and cable car was it. i do know there has been only four women that work the cable car in the 150 years and i am the second person to represent the cable car and i also know that during the 19, i think 60s and women were not even allowed to ride on the side of a cable car so it's exciting to know you can go from not riding on the side board of

a cable car to actually grip and driving the cable car and it opened the door for a lot of people to have the opportunity to do what they inspire to do. >> i have some people say i wouldn't make it as a conductor at woods and i came and made it as i conductor and the best thing i did was to come to this division. it's a good division. and i like ripping cable cars. i do. >> i think she just tapped into the general feeling that san francisco tend to have of, this is ours, it's special, it's unique. economically and you know, a rationale sense, does it make sense? not really. but from here, if you think from here, no, we don't need this but if you think from here, yeah.

and it turns out she was right. so.... and i'm grateful to her. very grateful. [laughter] >> three, two, one. [multiple voices] [cheers and applause] >> did i -- i did that on purpose so i wouldn't. ♪ [ music ] ♪

>> my name is nary shay assistant fire marshal. assigned at fire pro investigation. i was born in hong kong age 8 me and my family- (indiscernible) i grew up in sunset area and all employment jaibs are with the sitdy of san francisco. when i was growing up my parents were traditional chinese parents. they

emphasized school. they didt want us to join or play sports because they said school is the only thing that is important and want us to get a college education. i envisioned myself maybe being a doctor. after high school i went to uc berkeley and major in bio chem. after college what i did happen is-what happened was i landed a job at ucsf and was a research associate there. one day me and my co worker were talking and don't know how it came about, they talked about fire department and someone mentioned i would be good for the fire department. even though i didn't play much sports i was still athletic. fire department, what will i do in the fire department because i didn't know there were women on the engines and trucks and didn't know the difference between engine and

truck. the same night i was watching tv and there was a commercial of the fire department recruiting women firefighter and there was a woman all dressed and tolds to go to division of training and 27 and a half year later i'm erhoo. when there is more presence of asian person, asian community it educates the population and helps people understand our community rchl ism i think people hate because they don't understand. i will tell the young women that definitely consider you know, a career in the fire service. don't just think it is just for men, because the fire service is not just suppression. suppression is one portion of it it. there are different parts of it. there is ems portion, the medical portion, the fire prevention

portion, and there is also the fire investigative portion. all of the departments needs to work together to keep the city of safe, not just the citizens safe, also the first responders. i thinks the career in the fire department is great. i start #d as a firefighter, i had the opportunity to also become a paramedic and then i landed in fire prevention. i'm very happy at fire prevention because not only am i able to enforce the code and make changes to help the citizen of san francisco be safe in their homes or place of business, but i think my work also make sure that my fellow firefighters and first respond ers, when they respond to a fire, the building is also safe for them.