tuesdaytial leadership, at 7:00 p.m. eastern on c-span, and saturday at 2:30 p.m. eastern on c-span2. theuncer: next, a forum on trump administration new initiative to end hiv transmission in the u.s., originally announced during the state of the union. one hhs official looks at how it fits into the national hiv/aids strategy. later, health experts talk about the feasibility of the initiative at the local level, inspiration to help insurance policy, and programs promoting early intervention.

>> welcome, everyone. i'm with the kaiser family foundation. i am so pleased that so many of you could be with us today, including those of you watching on our webcast and c-span. this will be available archived after this event if anyone wants to watch it again, so thank you. like many of you in the room, i listened with great interest during the state of the union, where he talked about a new domestic hiv initiative and the bold goal of eliminating hiv in the u.s. within 10 years, then learned about the details. this of course has garnered a lot of attention, bringing a focus back to the epidemic in the u.s., and we mark what would be the first new funding for the epidemic in years and the promise of more to come. almost three months from that announcement, what more do we know? what questions are still remaining? especially how will it be and submitted which brings to today's event. our idea for this it was here about the latest on any of the

epidemic and have a panel with different perspectives plus questions and answers from, questions from you, and is open for most to for more of a panoramic view of this initiative and outfits into the large hiv response in the u.s. before i go on i want to thank my colleagues at kff for the hard work to make this happen thickly craig and lindsey and others on the team and also the key mitigation scheme at hhs that that the same on their end. on behalf of kff i'm very pleased to welcome admiral brett giroir, the assistant secretary health and human services. he serves a secretary pritzker public health and site advisor as well as the secretary cheap appeared policy advisor pick you receive the office the surgeon general and the u.s. public health service commissioned corps, and his office oversees many critical national issues including the new plant in the hiv epidemic in america to get served numerous leadership positions in the federal government and academic

institutions and very importantly is also a pediatric critical care physician. welcome and thank you. [applause] >> thank you very much. >> unsorted note admiral giroir needs to leave my 1040 comics or you i will have q&a, between ourselves and then open it up to you but will give him out so you can catch a plane to go pick he said he will watch the webcast later so you get to hear the panel discussion that will follow. thank you so much for being here. >> is my pleasure. thank you for inviting me. >> let me start with the general question to get us forget everybody here up to speed on what the initiative is about, the key elements, what you're hoping to try to do. i think a lot of us have a general sense but to make sure everyone is on same page i'll let you to listen. >> thank you for that. this initiative came about by the combination of people who

have spent their entire life 40 on hiv aids such as thought you and bob redfield. together with those of us have certainly taken care of patients with hiv but this has not been our application for our entire career including dr. george griscom myself, and when us preparing for my position i know personally i was really shocked to understand there still remain 38-40,000 new cases of hiv as you're in the united states. with all the tools and technologies to make that not so. i know i personally asked myself why are the still 40,000 new cases of hiv i you and the united states? the answer that i got was really the answer that because knowingly decided to not make it that way any longer. so over many months the principles got together and decided this really is the right time, that we are very outstanding antiretroviral therapy that is down to one pill per day, very low toxicity, the great majority of people can obtain an undetectable viral load. we also know as you will know

that undetectable means untranslatable. combined with that we have prepped, which is highly effective at preventing the acquisition of hiv, at least 95% 95% and may be much higher than that. we have proven models of care such as the ryan white program that is really been earthshaking in its impact on reaching perhaps the hardest groups of patients to reach, those with many social determinants of health that make an them insecure in the housing or food or transportation. and we also note we can go after clusters in a way we've never done before. the whole idea of this epidemic is to really reach this, ending the epidemic initiative is to reach of those have not been reached before. and we don't underestimate the difficulty of that. we know that one out of every two patients with hiv have been infected for at least three years before diagnosis, and one in four is up to seven years.

we know that's where most of the transmission occurs. this really is a community focused plan, focused on 48 jurisdictions, sam wanted d.c., that account for 50% of all new hiv cases. it's a very focused and targeted initiative to start that will expand further. we are also talking about seven states that have high a high moral burden because we understand what's important in miami or what's important in houston may not be true for rural states. and, of course, we focus on the demographics that bear the overwhelming burden of the disease, african americans, latinos and certainly very upfront in a proposal american indians and alaska natives. suggest as an overview, that's generally what this is about. we are absolutely certain that our goals can be achieved, 75% reduction in five years and 90% production within ten years pick

obviously that extra 50% gets harder. that's why takes a longer time. the last thing i will say because i don't want to forget this. remember, if we are successful, the diagnoses, the number of diagnoses in u.s. will go up in the next two years because we will be reaching people have been undiagnosed and not brought to care. just remember when -- i am going to be very happy if the diagnoses go from 40,000, the 60,000 or 80,000 because that means when reaching the people we need to reach and bring them into care. with that i will just respond to your questions. again thank you for the opportunity to be a to represent my colleagues and the secretary and, of course, the trump administration's policy. >> thank you. just for information for folks here, on the 48 and other jurisdictions, is the idea that over time they will be, it will be expanded beyond those or is that to be determined based on how things are going? >> we wanted to make the problem

trackable and have a plan. when you have 50% of the cases within 48 jurisdictions, send one in d.c., that's what i wanted to start there but there's going to be too real plans for dissemination. number one, as we learn lessons on implementing the plan it will be disseminated immediately to other jurisdictions. but secondly, yes, there will be formal transition depending on how the plan proceeds in reducing infections to expand it to greater and greater circles to the next levels for the cases occur. >> one of the questions that we had gotten is the gold sounds great, the idea makes total sense from a public health perspective. how do we implement this? going forward, what is the thinking of how to make this actually happen? >> i will give you a couple answers to that, and i was very impressed with one thing that tony fauci told me.

he said we all income and have worked on hiv and other outbreaks for now up going 40 years but this is the first time that all the agencies have really gotten together in a really coordinated synergistic program. i think that's a very important that were not just couldn't take new funds and run to her corners and go spend them. this is very important. we have to be able to find people who are at risk for stigmatize, bring them into care. that's primarily going to be a cdc and a local health function. all talk about and second but this has to be coordinated with the programs like the ryan white program of people actually treated and community health centers who can actually provide prep and fortune would you have about 50% of the ryan white programs that are associated with community health center so they can provide both. we have statutory limitations otherwise that we can go into. but the main first part of this program and the predominance of funding in the first year is to support local community health

workers. local community health departments that will create their hiv workforce as we talk about, these could be people living with hiv, it could be community health workers comp social workers, whatever, people in the community to reach the people of not been reached before. right now we have been -- we were going to award 12 or $13 million this year, not waiting for fiscal year 2020 money, but to support the development of community plans that will be in the community by the community for the community, and we both probably start pilot programs

this year in 19 as well with funds we have to my office in the minority aids initiative. it's really has to be a community focused because the problems be unique to the community. here you will see in the next panel that the problems in mississippi as we know are not the same problems as other parts of the country. they are very certain from those from the cherokee nation in oklahoma. >> i'm going to later at you go shows a couple slides make the point about the budget request. can you give an overview of what that -- >> so the budget request which turned out to be in the president budget was for $291 million this year. that is new money primarily to hrsa and the cdc. there will also be some redirection of funds to the nh center for aids research, not new money there but new money allocated within the nih to support implementation research as was meant to the indian health service. there are two programs that were zero previously in the president's budget. the minority aids initiative in my office for $54 million, and, and the sum initiative in samhsa. those are not counted in that too at a 91 million of those are part of the president budget moving forward. again, this is the first year of a multitier program and budgets come when you're at a time, but as you can imagine it is more, more people get into care, we need to invest more and more

particularly in the first few years. over ten-15 years this becomes an enormous money saver because every person with hiv will have additional healthcare costs over the lifetimes, but you need that investment up front because remember, if you have tens of thousands of people who have hiv but not been diagnosed, when you bring them into the system you are going to preventing new cases but you'll spend money up front in order to treat them, to provide prep or whatever necessary services. >> that was my next question. i know restrictions that are waiting for the funds are hoping that college will approve them in 2020, are also thinking it. if we put in new infrastructure or responded initiative, can we be sure what's going to come next? it's always a precarious balance of starting something new when you're not sure what would be there so et cetera intention to keep scaling up? >> we can't see much further than a few years but the principles and our really senior staff have outlined a five year

program very specific down to the jurisdiction, down to the coverage levels of people expect to be entering into the system. anakin nobody can can be sure of anything except i can say that the secretary has made this his number one priority adding to his other priorities, and he personally briefed the president was extremely enthusiastic about this program or else it wouldn't have made in the state of union. we have every intent certainly of us sing the program through for the time that we are able to steward it. >> so going and effort you talk about this, how you all thought about the ten year time frame and modeling that out. one of the things that heard you say and dr. fauci and others is the approach to figure out what would this take assume everything kind of stays the same which is how you do models, for those of us who do models that's what we do, we said everything remains the same and we look forward.

things are in flux and one of the things we've heard from stakeholders is excitement about the goals, about the direction and at the same time consumed other of the things happening in the healthcare environment such as pulling back on coverage which is other intention in the president's budget, repealing medicaid, how do you approach that i think about the initiative which has b-schools these go over here and public health approaches with larger environmental that a shifty microchip? >> so let me state up front what our assumptions were and i'll just talk about our approach. the assumptions were in our proposals, particularly in a a five-year proposal, was that there was no fundamental change in coverage. there would be no tsunami medicaid expansion. there would be no tsunami the more people with coverage, and we modeled down to the jurisdiction tour best

availability who would have medicaid, who would be privately insured, who would have no coverage or because and the gap in not expansion states and, of course, some of the states that were targeting were not expansion states and that has to be put in the budget. we assumed people who were are caught in between or with no coverage would get their prep through community health centers. it would also get the coverage through the ryan white program for our budgetary assumptions moving over the five years is to put all that money into the program. because of course what happens on the global level to who gets covered in where and how it will turn out in congress is not in our control. the second response to that question is that we have to be fluid and dynamic. the world will change.

we don't know what's going to happen tomorrow in the number of fronts. so we have set a structure that the six main agencies now including samhsa, a very important role, that the directors of those agencies sit on a policy team that will be meeting every month to review the situation with an integrated operations team that includes hrsa an office at hiv/aids. and, of course, we have -- [inaudible] that we announced and i think december 1 meeting in march. this was all to coincide with this initiative. it's nice when the plan worked out the way because we were not should initiative would go forward. we have a lot of smart people and we're going to listen a lot about what's needed community to community because were to assume this is a dynamic situation. we can do with assumptions but we just have to be fluid and dynamic and responsive. >> you just said something i made to ask you about earlier which is listening to the community. what is the plan for that part of this? >> we've started because i think all of us around the table, at least the principles, we are listeners first. i'm a physician, pediatric critical care physician, and if you listen to parents or the grandparents, 90% of your diagnosis they just by listening

and understanding. anything we really have to get smarter by listening. so we are committed to a listening tour. bob redfield and i have been in atlanta listening to the communities. we were just in baltimore where we had a community event where this into many, many different groups. of course we met with all the patient groups here but we will be going to a least one or two of the principles to all of the jurisdictions. we are planning that out over the next few months as we support them either finalizing their community plans. many communities have hiv plants already but they have the funding to make that happen so it's going to be relatively easy to supply funding to them. other communities are in various parts of the plan so we want to work with them. and we have a lot of interesting communities like those in louisiana who are really trying to do a number of things like different models on ending hcd which we know it's all sort of

part of the same equation but integrating their workforce to end hcd with the new netflix model for payment along with the hiv initiative to i think there's a lot of exciting ideas and models that what to put, that we want to learn from but also to make sure the jurisdictions can teach each other and learn from each other. >> and with that reminds me as well there's a national hiv strategy that is in the process. how is it working in concert or not with the initiative? >> there's several strategies that are being developed that really relate to each other. let me say first of all of this initiative relates to the national hiv strategy. this initiative is a subcomponent. the national hiv strategy being developed to get in my office is meant to be much more holistic, taking into account all aspects of hiv in need for research and other advancements, where this place is really a subcomponent of that. it is not equivalent to the strategy.

it's a subcomponent of the strategy, and by design we want to make sure that the president and congress know that no miracles need to happen. we don't need a new vaccine that we don't need a new therapy. not that we don't want that. if we had a vaccine that would be great but we don't need a miracle to happen for us to achieve our goals. there are many interrelated strategies as you understand. obviously i'm missing advisor for opioid policy, and is a part of this endemic, about 10% hiv associate with iv drug use so there's a component when you do bring us together. if you're in in in opioid click the program yet to be tested for hiv.

you ought to be revised about prep and that's not happening all the time. and also for the first time the same office that soon the hiv strategy doing the first federal strategy for sexual transmitted infection. i was shocked there really wasn't one, and this really falls into a busy week as well. there some estimates as much as 10% of hiv is associated with the increased risk by sexually-transmitted infection aside from that the impact on fertility on future cancer risk, et cetera all go up. these are all independent, they are independent but there coordinated. you will see common themes and pieces across all of these strategies but because of the importance of the diseases as will the national strategy, we believe they deserve their own strategy in coordination with the others. >> i want to turn to prep. i know that is a key part of this. the latest estimate, at the end

of 22 to almost 2000 or 200,000 people thousand people in the u.s. using prep. cdc estimates 1.1 million could benefit and a big goal of this is to drive up access. can you speak a little bit more about how that is going to be dealt with security action community health center? >> in our modeling, we need to get about, in our modeling proudest all works we need to have somewhere between 50-60% of all the people who have prep indicated on prep. i would love to have 100%, and our goal is going to be 100% but we really need to get the 50-60%, probably 60% of which is a significant increase over the 200,000 that we have. we really envision of course, i think as your recent survey shows, people have a better understanding about prep but they're still a huge knowledge gap about prep. there's a knowledge at implementation get for both hiv testing and provision of prep among the healthcare area. these are all things we need to

fix but we predominately think prep is going to be administered to this program through community health centers. because we feel many of the individuals who will be coming into the system will not have insurance coverage and community health centers leveraging the 340b program where we get highly competitive prices are really the way to go. but, of course, there are a lot of things happening in the prep world, right? there should be generic prep by 2021, generic truvada. there's a preventive services task force recommendation with a great aid liquidation which there are several steps to go through before this happens but conceivably within the next couple of years that recommendation would be prep is provided without out-of-pocket expenses. this does a lot of things channeling down but yes, we

absolutely and our models need prep at about 60% between vision community health centers as a primary delivery for that and, of course, if you don't know about human health centers, they take a 27 million people in the united states. they are going with the ability to do comprehensive care. they do about, think it'd to my hiv test last year. the mental health services, ma key services for opioids and take lessons were at the jurisdiction level, dr. sue guice and his team 150 community health centers in ryan white programs of the sort of the centers within the centers that we focus our efforts first and i think you had the opportunity to go to some of those specifics during the panel. >> one other thing on prep,, i know there's a lot of challenges to increasing access. what happened after that is price. in the media and other issues rising and debate about the price of prep, and issues around athens and ownership and how that is all going to play out. could you comment on that? >> i can't comment on that but,

because i don't know but i can tell you drug prices are a major issue for my secretary across the board and the ability to lower cost the patients without all the gains in the people winning and the patient in the system losing. we are very cognizant about the price of prep. the wac is about $1600 per month. there are number of programs now to make that accessible figure below-% of poverty level or co-pay, et cetera, et cetera. but let me just say number one we intend use 340b program which allows you to be obtained at a much lower cost for the government asks as substantial lower cost. we are in, i can say this because the sector said. we are in active negotiations with gilead to try to make prep much more available cannot just nibbling around the edges but in a major way.

the patent issue, i think, i'm not a lawyer, i don't pretend to be, but we can't come what the department could do would be sue for paying royalties. so it doesn't mean you can block thing to think things over -- takings over the royalties they would be owed to department would be in the years and we depend on the pricing. we are going to different avenues to make sure the pricing is much lower moving forward. again those negotiations are ongoing, and i'm very hopeful that we will have some very positive things to say in the near future. >> i have one more question before i'm going to let you all start asking your questions. one of the things i'll sort you talk about what it would be good to hear, recognition about playing the role as a very for people at risk and people living with hiv to getting the services

feel comfortable getting the services are doctors once i reach to them. how in an initiative that is a government initiative and it's hard to deal with that deep structural challenges, how can you or how do you envision tackling stigma? >> so stigma, bob redfield says this and it is true, statement is the india public health across the board from what you have an opioid use disorder and need to treatment or whether you at risk of hiv. if doing easy answer to this, i think we would be done with the problem right now but let me give you just a few thoughts on how we approach it. number one is we are talking a as a major national public health issue and i think when you people like the secretary and myself, and he gets to the state of the union address

talking about it, is a very important aspect to it. number two, treating it as a public health issue which it is. number three, at has to be community by community because the community is to differ. i have been educated a lot on the american indian issues with stigma, very similar although in a different way than the stigma particularly to msn, african-americans in the south. so it's got to be a committee based initiative. we already have spoken, we've had to make major phone calls with faith based organizations because think faith-based organizations actually need to be on the team. i've been very encouraged by what i have heard that people across the country really want to attack this issue. i think the people within the principles, i mean, we've always, particularly for clinicians, our only goal is to

help people. i went in a medicine to make a difference and help people in their lives. wherever they are, whatever they do. it's not a judgment or anything. it's just something you need to do. i think all of us are ready to open our arms, roll up our sleeves and work together on a community baselevel to make this happen. i think it can happen here at those been an idealist but also a very realistic implement to. i absolutely take it as my responsibility to implement this. >> thank you. now it's your turn. let me tell you how this going to work. ongoing to pick three people and when you ask your question lisa you are, where you are from. >> we will collect this question and we'll go from there. start. we have roving mics going around. we had some back there, matthew. >> it's good. the lights are good. i can actually see as opposed to normal. >> we will get you next and then overhear. >> matthew rose with health gap. one of the things that has been discussed about this for quite what is a discussion of what

model it ministry has been making assumptions they've made around around how this will work. are you going to release the data so other people can take a look and see what other assumptions might be missing, what might be document we can better improve? also when you're thinking about community engagement do you have parameters or framework for these communities building the plans so it's not necessary in a vacuum that have to create these of what you like to see in some of these plans that you know are data-driven responses? >> thank you. every good question and asking for a quick and specific. >> jill, what works association. my questions how do to plan to address the issue of criminalization of high risk behaviors. so particularly for latinas, latinas were undocumented, we are under constant threat, sex workers, transgender in a military. there's a long list. the we have the last of our first three overhear. >> national coalition of cdc directors. we're excited.

my question is actually around you mention the might be a couple pilot programs and her jamaican this before. do you know where those pilot areas for the plan will be located? >> okay. to the gentleman in the back first, there is no secret of data we have and we are absolutely happy to talk about our assumptions to get input, and we know it will be different from community to community. the core of the data are really where the new diagnoses occur, which are publicly available. the overlays of document health centers are there and at allied discharge but also the, there's a secret data file and strategy document under a top-secret thing we're talking about.

this is meant to be very transparent and we need to improve upon it. >> also the community to commend engagement, is there a way of -- >> so the cdc is writing and there's a funny opportunity now but we do, there's two things. number one is we want to make sure everyone is using evidence-based models, you know, you need to use prep, antiretrovirals therapy, to all the things where no evidence-based people are going to have see farce the working of our implementation research but yes, it will be parameters that evidence-based what we really want to bring the community to tell us what they need and how they're going to do it because communities is going to be very, very different but it sort of been in overwriting strategy for the administration, and it's the opioid response grant is to provide sort of a foundation of what's evidence-based, because it was want to be signed an evidence-based, but within that to allow communities to enact the programs to be sensitive to the particular communities needs.

in terms of where they're going to be, let me answer that. where they are going to be, i think, we are in the process of looking right now. some of the parameters we are talking about is we want communities who have at least a start of the plan or some momentum that you sort of pilot things because we were starting to to pilot we want to learn from them and to submit that information as well as of them learning are working from us to number two is we do want to have a couple hard areas. unit 52% new cases are in the south so we really want to have a commitment to a couple of southern jurisdictions because you got to do that earlier than later. we're also looking, i would love to have a community the primarily had american indian issues who i'm convinced has a related but sort of a separate, different problem set. and we would hope that we can get some of that funding out by june or july for some pilot programs.

again this is fiscal '19 funding for a way to get started. we also have an expiration date whether it's an 18 month or six years but we have an expiration date so we want to make sure we get as much done as possible. and number two, i think it's horrible to have everybody excited by the state of union and the nothing happen until when you get a budget potential because $291 $291 million is all make-believe until congress allocates that. and your question, i don't know how to attack this. i don't know because those laws are on jurisdictional bases, usually on state or jurisdictional bases. i can just say in general whether that criminalization of public health needs are never a good idea, whether you can't arrest my way out of the opioid use crisis and you can't legislate or arrest our way out

of things that are public health and behavioral issues. and again i don't, or behavioral component. so i don't know exactly how to approach this. i know there will be a tremendous barrier. i know that in community health centers or and ryan white programs we attend to take up everybody that we intend to take care of everybody. nsb an overriding goal and prepped at the can talk about that more but we certainly intend on taking care of anybody in need providing compressed and providing them services. >> and also some who can talk about atlanta and george's experience making potential in the right direction on this, eventually. -- overhear and over there. >> andrea with the hiv medicine association. i had a question about clinic

providing prep and is one if you are considering title x funded clinics which can be important source and more accessible for some populations for both screening and rep? >> so we have integrated a couple more things into our title x program. number one, screening which is not uniform and a thing as of last week 3000 centers, title x centers that provide prep was put on our website so that would be known. but absolutely we have to make use of every encounter to make sure that we take care of the patients holistically. vaccination is in the because i'm on the bandwagon for that. so yes, we have to make sure of that. as well as i'm working with doctor katz because of number oprah treatment program for example, that don't either screened for hiv or provide prep or referral. so yes, absolutely, ending at opportunity have to do that, we need to make it part of routine

medical care, and that's the goal. people need to be tested. people need to be screened. even indication for prep you need to be put on it. this is just routine public health medicine 101 that needs to be i think reeducated. i think you can tell me but i think if you look at the diagnostic data that seven out of ten people with hiv supposition within the 12 months before were not tested, i think with some complacency among the medical profession because we're so infected not treating hiv that is sort of the urgency has been lost pics i think we have to get rid of this complacency on the medical side and make sure that it's ubiquitous to we need to look at other models. i was at a a meeting with pharmacist whether some interesting models of pharmacy, pharmacists abiding prep in a

very non-stigmatizing way. i think we have to open our minds to all the giveaways we can reach people where they are. i'm sorry, i should had three questions. >> that's fine. we will go here. >> we will do to make more questions and i'll put those together. >> and you elaborate a bit on what you meant when you're talking leveraging 340 be more for prep purposes? in particular, since ryan white covered entities,, 340b eligibility because ryan white grant can't use 340b related to prep. >> so that's one. and i think there was somebody -- yes. >> nicholas from -- [inaudible] to follow up on the title x question, are the concerns, give concerns,, this administration have concerns about the title x gag rule as it's known, taking effect next week? and basically how that will impact some of the most utilized health centers within the title x program when screening as well as the opioid use disorder and behavioral health screenings, et cetera,, how that always an important role within the centers.

>> yes. so the ryan white funding, and i'm sure heather will talk about this more specifically, the ryan white funding can't be used to provide prep to prevent hiv. so community health centers can't. so they would use the 340b program to provide prep in use of 340 be pricing. about about half of ryan white also succeeded community health centers so it's a left pocket right pocket. use the ryan white funding to provide the hiv antiretroviral therapies but because they're in a a trance of the can also use the 340b program to provide prep.after having -- half or a

from the for me. boldly it would be a legislative change to allow ryan white to use the ryan white funds for something that could be brought together but this is what we can do right now. again we are not assume any changes to legislation or things in the future. and the title x regulations, so of course we are all concerned we wrote the regulations. it is the administrations regulation. let me just say i know there will be disagreement about things that i just want to make a clue what the quote gag rule is and what the gag rule is in. number one i don't think it affects hiv whatsoever. i think there's funded entities. they will provide services and the comp rights-of-way the way they've always been. title x prohibits the promotion of abortion as a mechanism of family planning. the gag rule does not stop an interaction between a provider and patient about abortion as an option. it is not prohibit that. what the proposed rule states is that there cannot be a direct

referral or direct of counseling, i.e., you really should have an abortion, or here as an abortion provider. although the clinics can provide names of servicers that you provide abortion. i just want to make it clear, there could be a lot of disagreement about that but there's not a gag rule that abortion cannot be discussed. i think if you read it and look at what it says, it allows that an anon directed way. personally i don't think physicians generally direct people what to do. i think you provide information and allow people to make their own choices but you don't direct them to do one thing or the other. i just wanted to clarify that of what the gag rule is and what it isn't. >> i think we have time for maybe one more, to more questions.

over here and in the back there. and make it quick, please. >> just a couple of questions. you mentioned about the principals at the table and it's noticeable that no one at the table, people of color or persons who are living with hiv and i was wondering why was that decision made? but also going to your community listening to her, i'm very interested in that because we worked a lot on the ground. how do you plan to set up community listening tours, how will they start and how to use and permitting them? because i think that input will be extremely important. >> the first question, we are very sensitive to having input from a diversity of groups. we are also allowing the cochairs to make sure we fill those positions with people who prevent -- with diverse backers. i can't help it, i'm a white

male who is -- you're stuck with me to organize this at that level because i have my position but i'm totally committed and we have done many different actions already to giving people of color, people living with hiv in two very important come into very important roles including -- the listening tours we we're working the local community health department as will also very specifically, we met with congresswoman barbara lee, congresswoman jackson lee, congresswoman wilson from miami who are all very supportive in initiative would also going to help us to make sure we get the right people at the table. it really depends.

i think there's a lot of congressional involvement to make sure we get the right people at the table so it's working collaboratively and in working with the communities. when actually when congresswoman lee asked me, every as i've a question, how did you know you have the right people at the table? i don't know because i don't who i am missing in miami or who i missing in oakland. you got to rely on a combination of the congressional leaders on the district as well as local leaders to make sure people are there. we are starting a listening tour now. again we've got a couple of jurisdictions but that's going to march on very soon. i'm sorry, i should've waited for the second question. i'm not very well trained in this. >> i promise we would teach out on time. wikipedia moment to say the last word. >> chelsea record, work with people in street economies. you mention a couple of time needing to get testing more regularized in many of the service. most of the clients we see are actively turning down testing

and actively turning down for those types of services because of the fear of stigma, because of the fear of treatment by their medical professionals. i want to mention we know there's a strong connection between hiv and intimate partner violence and particularly if you're going to be working in the native american communities, regular lysing this type of testing i like to talk more about voluntary testing and consent and the work you you are going to be doing to make sure those tests and referrals are safe for the clients. >> you know, i think what you just said are principles that we all believe in and i want to get input from you about where the problems are. we obviously, we have to increase the people who are bring bringing in detesting the rest have to overcome those barriers as you pointed out. again i don't know exactly how to answer your question in a very precise way, but i look forward to getting, seriously can email me. let's get input and understand where specific those issues are and what other services we need

to put on top of that. when things have been very impressed with in the ryan white program is their very holistic in their viewpoint if the person needs transportation, they provide transportation. if you need housing issues,, they get housing issues, and all those wraparound services. so maybe heather might have more correct answer to that that is not i do have to work with you on that. >> so i know you have to leave. i did notice wanted to take a moment and give us the last word from you before you head to the airport. >> so first of all, i appreciate the opportunity to be here. i really, i really do. i think this is a very important interaction and want to make myself as available as possible. i would only say that, that we are very serious about this effort, both from people have done this all their lives as well as people like me who are

really driven by public health. and i said before, when we had the opportunity to eliminate or effectively eliminate an infectious disease, whether it's wholly or measles for hiv, it's certainly something we should do but it's our moral obligation to do it and that's the way i approach this. i also know that there are going to be differences among commoners, this is going be differences with administration policies in one way, shape, or form and i understand that no matter who the administration is but this is something i think we can all get around. it's a critically important public health effort. i do really think it's a once in a generation opportunity that things are lining up, and that even in tight budgetary times we are able to get about $300 million of new funds, and we will get lot more in the upcoming years. so again, i'm willing to work with anybody at any time to roll up my sleeves to make it happen. i think i'm starting to know a lot of people here by their faces now, which is a good sign. and again i really appreciate

the opportunity to work on this and some of the public health issues that we can attack and help together. i think there's very little device on a partisan basis we we talk about these critically important public health issues, whether it's hpv or hiv or exercise, all the kinds the things we could do together to really improve the health and quality of life for everybody here. so again thank you. >> thank you. please join me in thanking -- [applause] >> great. as he's walking out we will do a quick set up. i will invite my panelist in a moment. and because it's the kaiser family foundation i will show you some data. i will start doing that while we wait. any moment you see our chairs, and then our panel so, and it will turn on their mics and we will be ready to go.

great, thank you so much. so just a little bit of us, just don't set the stage to make a little transition before we go to the panel, just have more discussion on this. setting the stage, one of the things that i think is important to recognize about the initiative being announced now is the united states is not performing as well as it could if you look relative to its peer countries. comparing the united states two other high income countries that we often are compared to ember looked at one measure of viral suppression can the u.s. is the lowest. all the way on the right bar, 84%. this is viral suppression of all people living with hiv. this is not what you want to be. i think the united states could aspire to be where the united kingdom is but it will take a lot to get there. also as we know from cdc and the

latest in the cdc has released him hiv incidence which have been going down is a longer going down. we have plateaued again and that's a concern. and, of course, in this country the epidemic is concentrated. we know the epidemic is affecting people in certain groups, in certain locations, much more than others. this is the current state of our epidemic. last on this, federal funding discretion of funny, this is a funny that congress appropriate every year, relatively flat for the last several years. it's not been increasing. while funny is not the only part of the croatian avenue from the new initiative, it can help jumpstart and get things to a new level. this new initiatives comes into that moment as admiral giroir talked about. it would mark new funny and this just shows you two of the key programs that would get new funding approved for 2020. that's the ryan white program on the left and cdc hiv prevention funding on the right pick what you see is taken out, forgetting

the orange bar for a second these programs have been flat funded for many, many years. they have not seen an increase. if the budget request is approved ryan white funny with go up 3% over fiscal year '19, maybe that's not about but it is deathly and relatively speaking change and particularly cdc. these graphs are not in scale with each other that's important to note that ryan white, over $2 billion program, cdc come hiv prevention prevention in use is funded at under 1 billion. this would bring it closer but these would mark significant increases. we just looked at the jurisdictions that have been selected for the initial focus, the 48 counties counties, d.c., san juan and then the seven states just to understand more about who they are, where they are and what we know about them. this is something we at kaiser will be tracking going forward. here are some basic

demographics. comment on the south can 23 of the counties, six states and d.c. in terms of the share that uninsured, greater than the national average, 31 counties and three of the states are in terms of the share that are great at the average of poverty, 30 counties and 60 in terms of targeting it's reaching far in terms of reaching communities that are in greater need. not that the others are not close to that average but this is an interesting and important metric to look at. in addition look at some policy and programmatic variables about 30 of the counties are in states that it expanded medicaid and two of the seven states and d.c. and san juan of course. almost all of them have part a programs. we might hear more about that from heather, and our community health centers in all these communities. that's one of the reasons community health centers were selected. they're fairly ubiquitous around the tree. also in terms of david on which

of these counties and states can which of the counties are in states of which of the states still prohibits syringe access and admiral giroir didn't talk about but has talked about putting a barrier to the success of this program, seven of thehea barrier to the success of the program. seven of the counties are in states that have prohibition and six states. it seems to be more of an issue for the states that have been targeted in the counties. recently released new polling data on u.s. attitudes towards hiv, something we've been tracking for many decades. people still see hiv is a serious issue in the u.s.. has the datarvey broken down by race and ethnicity. this came out right after the initiative had been announced.

most cannot hurt about it but we are optimistic. -- most had not heard about it but we are optimistic. there's an openness to this is something that should be pursued. we found as admiral gerard mentioned, there are still significant gaps in the public's knowledge of hiv treatment and prevention and this is the general public, not people not necessary with the targeted with information but it's an interesting metric to look at. most people are not as aware as we think of how effective anti-retrovirus are treating hiv and certainly in preventing the spread of hiv. on the bottom is prep it was interesting, we don't have the trend data. there's a been a tremendous increase in the share of people who know what prep is or something like prep. it's still not where probably we wanted to be so that's a sign of education has increased but there's more to go. these are just some things we thought we would share to get started. i will go to our panelists, who

i will call up. heather hauck, deputy associate administrator on hiv/aids bureau. kendra johnson was the aids director from mississippi, one of the seven states that will be targeted initially by the initiative. michael kharfen is the age -- aids director from jesse milan,.c., president of the aids database in d.c.. and finally dr. melanie thompson is a physician and researcher based in atlanta. thank you and welcome to everyone. ok. i'll let somebody else of deal with that. ok, thanks everyone. hope you can see and hear us. sorry about you over there. i want to start with heather, thank you. i made my font really big so actually do not meet -- do not

need my classes today. that is my trek. we referenced hrsa, ryan white, and you a lot in the opening. i'm going to turn to you first and let you talk about the role of ryan white and community health centers and some of the things we heard already. all, thank youof very much for the opportunity to 's role in the a hiv epidemic initiative. i thought it might be easiest for folks if i walked through the pillars of the initiative which we hope many of you have heard. the first is to make access to hiv testing much more available that it is now so we can address some of those statistics the

admiral mentioned this morning. in addition to the cdc working on expanding access, we also will be working in the community health center program to expand access to hiv testing as well. the program currently does around 2 million hiv tests a year but there is an opportunity to do more in reach in the community health center to reach the more than 27 million people they care for, as well is working in coordinating with cdc as they do outreach efforts to bring people into the doors of the community's health centers and get access to hiv testing. the second pillar of course is treat. we in the ryan white aids program player major role in terms of treatment, but also working in collaboration with our other partners, including cdc, who are often doing partner services and identifying people who need to receive hiv care. in the treat pillar we are trying to focus on the 40,000

individuals who are the newly diagnosed individuals each year. more importantly, we estimate that there are over 400,000 people diagnosed with hiv but not currently in care or not yet achieving viral suppression. we really want to engage the 400,000 of the newly diagnosed and not virally suppressed to make sure they received access to services either through the ryan white program or community health centers and achieve viral suppression for all of the public health reasons everybody is aware of as well as for the ir own individual health. we will really be focusing on that pillar of the treatment in our program. the third pillar is protect or prevent. that is the pillar that addresses prep, and there has already been a lot of discussion about the role of the community health center in the terms of prep. the community health center program will be largely providing prep services for the

uninsured, folks that do not have other resources to access inp, and we will be starting fully funded ryan white and community health centers because we know there is a cultural competency issue that needs to be addressed in a number of health center programs, so we want people to go to a center where there is some level of cultural competency because of the fact that they have a ryan white program. -- wel be starting their will be starting there but ultimately expanding access to prep for all of the duty health centers across the country as many of you may know there are over 12,000 health countryites across the so even opportunity to use that system to access to prep to the 50 or 60% that the admiral mention. and then last in terms of the last pillar, respond. that is were cdc is working actively with local communities to detect and respond to hiv clusters or hiv outbreaks. we see our role is really being

the access point for folks who identified through cluster detection efforts. so somebody is identified as living with hiv and not yet in care, we want our network or our services to be the door that they walked in. for folks who identified who are not hiv-positive but at risk and meet prep services, we really want to use the health service program to provide the access. so folks were in this transmission network in the services either because they are positive or need hiv care or because their risk and need prep services. so those are the four pillars and how hrsa is working all those pillars. obviously each of the federal agencies as a lead or a co-lead role in those pillars, but we are also working across all the agencies. we met a number of times with -- to talk about how they can use their science -- to reachmplement

those 400,000, as those in need of prep services. we met with them. we are meeting with ihs in a few weeks to talk about how we can work collaboratively flurry -- collaboratively with them around their pieces of the plan. we also work very closely with samsung -- with samhsa and have already met with the folks at samhsa to talk about how we can support their efforts. we have talked about how we can work with community engagement and the community plan effort that the admiral has alluded to a number of times. we know in the hiv community that community planning is integral to the ryan white program. it's a statutory requirement that there be local planning that involves a number of different community members from various walks of life as well as various agencies at the local level, so we in cdc have really been focusing this ending the epidemic community plan process to build on this foundation that

has already been established either through the ryan white program or the cdc hiv prevention program. all of those jurisdictions submitted a plan to both cdc and to be thee want this foundation for ending the epidemic plan. people have been engaged. many jurisdictions have done and ending the epidemic plan modeled after these plans. redo not want people to plans that have already done, but we know to do this different people want to come to the table and we need different partnerships. we see the community plan process for ending the epidemic as a commute the opportunity to bring different partners to the table and work with a local jurisdiction to figure out what it is that you need that we can roll into the hiv ending in epidemic plan. i will stop there.

hopefully that was a comprehensive but quick overview and i will be happy to answer questions. >> actually, one follow-up. to manage expectations people might have in 2020 but also because this is a question we have gotten. assuming the budget for ryan white is approved by congress, how will that funding be distributed and what is the timeline for that? do people have a sense of what that means? heather: a great question. as the admiral said, the money does not yet exist. our plan for how we will do this if the funding is appropriated -- in order for the ryan white program to direct the funds to the 48 cities in seven states, we need flexibility in our authority to be able to direct those funds. the purpose of that is there is an overlay in all of the

jurisdictions in the ryan white part a program. so each of those jurisdictions has a ryan white part a and each of the states is hundred -- is funded through the ryan white b.rt th so our intention is to distribute the funding to the existing comprehensive service delivery system in each of those jurisdictions established through the ryan white program but obviously we will need to see if congress authorizes and also what they appropriate for us. >> this happens every year, once the funding is appropriated, there's a lag before that gets granted out so that could be anywhere from. heather: these would be 2020 funds, so we would hope that if there is an on-time budget, but again to remind folks that has only happened once in 22 years, we would plan for a january 1 start date for the initiative funds. cdc is also aligning their start

date,or january 1 start it would start in the calendar year. that's entirely dependent on the timeline. as in the past, when we have a cr, that ships the timeline for all the planning we've been doing. that ships the goal. until we see with the timeline is from congress, we cannot definitively give a specific timeline. -- skipoing to stick around and go to jesse next. jesse, thank you for being here. jesse, as everyone knows is the -- what is your initial reaction to the initiative and what are the questions you still have, what are your members saying about it? jesse: doctor kate is one of the most brilliant people in this industry so thank you so much

for inviting me. i had two reactions, one is a personal reaction as a person living with hiv, to see the president of the united states even mention our existence in the state of the union address. i got to tell you, i had a similar reaction when president bush did that. with regard to the announcement, i thought, you just put all of us in front of the american population, so that reaction is one that i am still living with. of hope, actually. the community reaction is a bit more complicated. we know that this is a unique opportunity, almost a cataclysmic opportunity where the science has come together to make it truly clear that the epidemic can be ended, but the strategy is the question. that's what the community is grappling with. what is the strategy? it was very helpful to hear from dr. gerard that the national hiv-aids strategy still exists

and this is some component of it. that is a message that has not been articulated well but needs to get out. but our community, particularly the public policy council and the larger community has worked much of the last year and a half on a community roadmap we created and submitted to all five of those federal leads on world aids day. that community map looks largely at the larger epidemic nationally and what is needed to ensure getting to the end of the epidemic within five years. now we know the president has an initiative for 10. that includes addressing all of the endemic issues, sdis, viral hepatitis, and of course the opioid epidemic, had -- how all of those work together. we have heard that the sti and the hepatitis strategies are still to be defined, but are they still important.

on the other part are the structural issues, including criminalization and stigmas that are still very prevalent. the larger question about access to care has to be addressed. it is disturbing for many of us to hear and administration have this initiative but also working so hard to destroy the affordable care act , not only for people that are hiv-positive but those who are negative, they need the access to care. those are the things our

community is talking about. those are the concerns we have around the larger issues, the larger structural issues around criminalization, stigma, and access to care and how those will be rolled out to the initiative and how they can be supported. : we asked two different jurisdictions to be here because they are both in that initial wave and also different from each other. to help me and you get a sense on what someone with a jurisdictional half would be thinking, what do i need to do? i will turn to kendra johnson who is the ace director for the state of mississippi, one of the seven states chosen because it is largely rural but has hiv concentrated in different parts and has a lot of the challenges. we would love to hear from you about what those are, what your hopes are for this and what your questions are.

ra: thanks for having me here. when the announcement came out it was not a surprise mississippi was listed as one of the seven states. to me, it was something that i was happy to hear because we have known for a great deal of time that hiv is on the forefront in mississippi. i think this gives the opportunity to put it on a broader landscape and get people talking about it. know,cited, because, you there have been so many organizations and center for aids research centers who reached out with their support. one of the challenges that we face is public health manpower, and so this will give the opportunity to work with organizations who build our manpower to be able to work towards ending the hiv epidemic.

there are some challenges. mississippi is are largely rural state located at the bible belt. so there are challenges along all of the pillars that heather mentioned. the biggest challenge is stigma. no one wants to talk about anything that is related to hiv. however, i am hopeful that we will begin to have those conversations, but because of stigma, we have challenges to face such as getting people comfortable being tested for hiv when there are only county health departments in their areas where their family members work. we do not feel comfortable getting tested. also, mississippi has a large portion of individuals who have food insecurity and food desert.

i'm excited about the epidemic work, but in order to make it successful in a place like mississippi, we have to think outside of the box. looking at telemedicine, tele-press and looking at the person as a whole person. not necessarily focusing on getting people to get tested but seeing why they aren't getting tested. maybe it's because they're worried about food for their family members. so offering opportunities to provide other resources to encourage individuals to get tested. once we do identify individuals living with hiv, being able to link them to needed services. so you know, i think we have our work to do. i think that one of the things that will be a priority for us is to bring everybody to the table, those living with hiv, those from some of the rural

populations to determine what it is we can do to make this successful. we have worked on an integrated plan, however we're still working on her end of the epidemic plan, and i think that will be a starting point to create a roadmap to get us to some of those goals we want to achieve. jen: one quick follow up. in mississippi, if someone wanted prep, where would you go? prep is available. we will now focus on providing more information about prep expectations. there are still folks that do not know about prep and our great candidates that do not think they are eligible. i think it will start with mass education campaign about what prep is. we do have providers located in certain pockets of the state,

however we have begin to take -- begun to take a different approach to be able to provide prep through means such as tele-prep. as we continue to have a conversation with providers as well as working with those community health centers that will provide better opportunities to provide prep to folks in mississippi. jen: thanks. now we will shift gears to washington, d.c. i live in washington, d.c. and remember when we were in the news for hiv and your the bottom of the list for other urban . hasdictions and d.c turned around and is now look to as you can apply the public health tools and scientific evidence to make a difference. many of the things we heard about today.

one of the things i've been hearing from michael in washington, d.c. is if it is here, what does it need to get their? a place like washington, d.c. that is leading, how do you make a difference? thank you for including me in this distinguished panel. welcome to our nations capital for those who are visiting. we have come a long way. in 10 years we have made tremendous advances. a lot of that has been because of a collaboration with our community, with new partners such as our academic community. we have formed a unique center for aids research here that has multiple institutions. inis the only one like it the country and the health department is part of that. we have been able to leverage innovation as an approach with community by in and community participation and that has led

to a 75% reduction in new hiv manyosis, advancing among different urban jurisdictions. and yet we still have more work have seen likewe some of your maps, your graphs, a little bit of leveling in those reductions. and to get us to the next level, we have been concentrating and prioritizing what we need to do. we did an integrated care and prevention plan that had a portfolio, but then we also didn't ending epidemic plan to prioritize key strategies we needed to get here, and some of those are reflected in this initiative. that was reassuring to hear that we are all in the same track. some of the key pieces to me to distill that are about making sure that persons who are newly diagnosed are getting treatment right away and rapid irt is one of our highest priorities. we don't want want to leave any

gap between somebody being able to start the treatment and achieve viral suppression as quickly as possible. we've been piling that here and we have seen improvement. one of our partners went from 50% of newly diagnosed persons getting same day starts to 80%. so we want to make that a standard of care here as well as making -- to understand for reducing the stigma that has been barriers for many persons and then low barrier access to prep. it has been reassuring to hear about community health centers being partners with this, and we have a lot of overlap here with that in washington, ec -- washington, d.c. among our ryan white providers and our community health centers but we have more to do their. we do not see necessarily the same uptick that they've been

doing and to having a national directive of sorts. to say that they need to get on board with this. we need to find other access points, community access points. our clinical programs have been a great location for that. we are here in dc we call our health and wellness centers. is not about disease, it's about improving one's overall health. and then the next stage he is also dealing with the equity issues associated with it. and some of the audience members have talked about that as well. we cannot just deal with, as important as it is to offer testing and treatment and prep, but that is also to deal with all of the issues those persons are living with in their community and centering their lives in the community, where stigma is still an element. where if you are young person you may be reticent to go on prep because you cannot use your parents insurance or you are living in a street economy and that is the difference between where you will sleep that night and are you going to have food that evening as well.

we need to make this a priority. is making thatty hiv health force a part of the community. goingof the persons were to do that, along with our dis, important elements in linking people newly diagnosed and their partners, but the community itself as well are our true workforce. they are the persons living the day to day life experiences and they can be the tremendous asset to get us to the next stage. if new funds became available to d.c., what would be your next thing to use them for? it's a national directive, unity -- community health centers are helpful, but will be the next choice that could push things to the next level? of the mostme, one important choices is getting medication in people's hands right away so there is not a delay in order to do that. we know there are structural barriers to do that.

we are medicaid expansion jurisdiction and that has been a tremendous benefit. losing that could jeopardize all of the advances. still, there could be days before somebody can actually get those pills in hand. to me, one of the highest priorities and those resources would go to make sure people can start treatment right away and some of our community health centers that could work, but some others that does not. for those who want to get on prep. the other is building the community workforce in order to do that. we have done the model in d.c. of the health department itself hiring people from the community who are living the same lives as our focus population, and that to me is an important strategy to engage more people. one of the things we are experiencing, and this comes firsthand around persons who came in to our health and

wellness center. a young, gay, latino man who we talked about prep with him and he thought about it and he was not ready that day, for some reason. for some reason, came back two months later converted. that cannot happen again. we need to be able to say how can it be even easier for that person to be able to get on prep? melanie, i will turn to you and the reason i was excited you will be here as you can bring lots of perspective. you're a physician. you are one of the physicians who we all look to about how you do this and how to get other physicians to do it? i would love to hear about that and the workforce challenges. and you live in atlanta working atlanta and advocate in atlanta. i would love to hear your thoughts on atlanta as one of the areas targeted, just georgia in general.

melanie: that is a lot. say, thank you for having here. i'm excited about the initiative for one reason if not others. it has engendered more conversation that i've heard in years about this topic. i did not think many of us expected this to happen at this point in time with this administration. i think that is terrific. now the hard part is how we make it work. we have done the easy part. know,k the easy part, you we have not done it perfectly but the easy part is behind us. this is going to be harder. this is going to be more expensive. this is going to be more frustrating. when i look at this from sitting

in georgia, the state was among states the highest new hiv diagnosis. it can feel overwhelming, and yet, i think there is a real opportunity to have concrete plans. so what we did in full county, , metros largest county atlanta, several years ago, was to capitalize on a little bit of political will that came from the county commissioners when we said this is a terrible situation. we presented data and they said what should we do? we said take leadership and form a task force. yearsid that and over 2.5 we created the strategy to end aids in fulton county. that took about 120 people working hard. this was highly community driven. we went all over the county's,

had listening sessions where we actually listened. it was not a talking session. that is how we built this plan. yet, now we have the challenge of the fragmentation of our health systems in georgia because we have four counties in metro atlanta that have now been identified. these counties have not really work together in georgia. everyare 159 counties and one has its own health department, so that gets fragmented. having these four metro counties work together to take one county 's strategy and expanded to a metro strategy will be daunting. i feel people are intensely interested in doing the work. i would just have a sidebar, heather, the comment about the integrated plan. the integrated plan which

integrates ryan white and cdc funding is not an epidemic plan because it basically integrates two funding streams, but it does not deal with things like forrehensive sex ed schools. ofdoes not deal with some the vaccine problems we have about transportation and so on. i think we have to look at the broad epidemic strategies. georgia will have challenges in terms of coordination and the right people at the table, being sure it is community driven. when i think community, i mean more than people living with hiv. obviously, people who are at highest risk for hiv, but let's not forget about the health care workforce. it is the people who are working in the trenches who also really have the sense of what is not working in our communities. ,nd in my community, in atlanta

half of the people living with hiv are not in care. what does that mean? let's say through this initiative we could get those people back in care. who will take care of them? we do not have the workforce to take care of all the people living with hiv, so we are going to have to have policies that encourage loan forgiveness for people working in the health infectiousrce, disease, hiv medicine, substance abuse, mental health. but then also, the money could -- the money really has to ratchet up substantially for ryan white, and we are in a place where we do not have a we a medicare non-expansion state. ryan white is what we have. i told heather, i think ryan white was shortchanged in this

plan, don't tell anybody. people not being in care is driving our epidemic, we have to put more money into helping people stay in care. i want to say that this does not mean those people are at fault. it is time we took a systems view about helping people get in care and realize that at least in my neck of the woods, our health systems are broken and not providing what people need to be able to stay in care. tapestry of endemic issues and social determinants is going to have to be addressed if we are going to be successful. i do think we are at a time where if we see a safety net eroded by policies from this administration, we are sunk. there is no way we can end any epidemic.

i think it does give us a call to activism right now to be sure that does not happen. there is a time, this is the time i think we can make a difference. i think we can grasp on to what we are being given, but we have to get our leaders guidance about community engagement, having community at the table, having front-line health-care workers at the table who often are not at the table. these are things i think would be important to make this initiative work. jen: do you want to add something? i'm looking around. i have 10 minutes to get questions out all of you. three questions, same system. we will start over here. because of the recording, thanks. >> i am from the housing works in new york city.

melanie directly spoke to my direction but it came up with others as well, the social determinants of health. aside from the lack of medicaid expansion in several jurisdictions and the stigma, it is probably the biggest issue. food insecurity, lack of transportation support, and housing instability to name three, this administration proposed giant cuts in the hud budget, including vouchers. hear -- i know you're at half and i hate to land this with you -- but even thecongress to appropriate dollars you are talking about appropriating, is that enough to actually do this job if we are ultimately talking about addressing the social determinants of health? i work across the street at

advocates for youth and my question is to thank you all for bringing up you, young people. my question is how we don't -- andliving with hiv be the hiv initiative, and especially thinking about the 40% of youngh says people are currently impacted. >> last question for the round? >> thanks. csi health policy center. i work primarily in the global hiv space and a number of the social determinants mentioned are not unique to the united states. i'm wondering what lesson , positively and negatively, can our experience back to the u.s. strategy? >> who wants to start? >> i will be happy to start.

i really do appreciate the issues around structural interventions that need to occur and i think we've all been disturbed about the cut and i think it may have been a shocking mistake. it needs to be corrected. i think we expect the kind of leadership from the department of health and human services as with regard tod integration across all federal agencies, and i think that is important. some of the devil is in the details. i think that providing greater information and education for the health care workforce, so that we have state-of-the-art hiv care, particularly in the south. if the detail is that only funds will go through part a and b and and not to the program where the aids education and training centers are, you may have a significant problem and we do not -- we may not be able to address the opportunity before us.

we have to look at all these details about how the money will get out and what impact it could have been all of the different gaps we know exist in the system. >> just to respond to jesse's to stan'sd go back recognitionre is a that we need to provide a technical assistance to jurisdiction as well as workforce capacity development -- element. we are working to provide the workforce capacity, not only because we need for providers to do this work but but because we need providers to understand the impact of stigma and discrimination and to work through that. we will be providing technical assistance to the workforce as well as to the jurisdictions on how to coordinate all of this. i would say the admiral gave the administration's response in terms of when the modeling is done, there were certain

assumptions kept constant in terms of no changes in the system. obviously there are proposed changes in the system, but the way the modeling is done, those were not considered in terms of changes in any other funding. that is how we are moving forward. i've have also heard the admiral say publicly that this is just the first year of the five and 10 year plans. there is -- the modeling was done with an increase in resources over subsequent years in order to would dress the number of people we will be bringing into the system as well as the number of people we need to scale up to for prep. your point, we have worked closely around initiatives of using ryan white funds to look at housing strategies. expensive a very housing environment and the washington, d.c. area and we

have worked closely with our planning commission, which is our regional body and we've collaborated very much with virginia and maryland. d.c. is 62 square miles within a 6000 square mile metropolitan area, so being able to strategize across the region has been a key piece to us. one of the innovations we've aeen working with with hrs support is looking at lower level rental subsidies for temporary periods of time. we know there are limitations with funding and hopefully this reduction will not be in effect, but what we have looked at his other strategies to be able to meet the gaps people have, like providing that lower level of assistance, and yet be able to andrd to stay stably house we have also started an initiative around how to integrate workforce development with housing and living with hiv to know there are people who want to proceed with their

independence, so we've come up with that kind of strategy. also for our young people, we also worked with our regional planning commission and did an initiative around young people living with hiv. we looked at our statistics and across the board, young people have the lowest rates of viral suppression among our hiv population. so we started -- youth reach is the name of our project -- and we are working with community-based providers to better provide support for young people, knowing they are starting an hiv career. one day there could be a cure, that in the meantime, how to make themselves be able to self manage and be able to get the support they need to be successful, particularly in the transition from adolescent care to adult care, because we see a lot of young people drop off at

that point because adolescent -- adolescent providers have been terrific working with young people, and then adults do not do so well in the adult care system working with younger persons. that is an area we need to resource. >> i would add on to what michael said. when you look at the ryan white program at the national level we see many of the same trends. theg people do not have same viral suppression outcomes as the overall population. and youth are at 60% is more in the 70's. there has been great progress made but there is still a lot to do. in the initiative we are focusing on the population where we see the disparities continue to persist and we will work with jurisdictions using local data to identify those populations and work together to figure out how we can address persistent health disparities.

could --ng a key one youth being a key one. >> it is an opportunity for a limited funding, which $300 million is, even if it is up. there are a lot of services not directed specifically towards people living with hiv and i think this is an opportunity for us to get out of our silos and work with other groups in the community that are doing good work but not thinking about people living with hiv. this is where and ending the epidemic plan is important because it takes into account all of the social determinants. dan, thank you for bringing that up because this is an area that it is the toughest to get at and i think we have institutionalized racism, we have all the tough issues that have created this inequality and created the social determinants, what we call social determinants.

healthincome inequality, inequality, income inequality. we cannot shy back from addressing those. there are partners we've not connected with you. : we're pretty much at the end of time but i want to see one more question if anybody wants to stay for a minute. >> i'm on the advisory board along with you. i think this is an opportunity for us to build upon a model of building political will at the local level. the stateat department has worked closely with the executive branch and governments in many countries. that opportunity to work with governors and county executive's in these jurisdictions is right, so we create and end of the epidemic plan that is owned,

politically, but has jurisdiction. that is a great lesson and i think a great lesson we can apply here. unless i see someone who really needs to ask the last question, make it quick? >> good morning. i'm with nova health system. i am part of the ryan white planning commission, we called the commission on health and hiv and washington, d.c. we talk about ending the epidemic. we have to make sure we look at -- before anything happens, we have to look at the overall, how are we going to have early intervention services. you have to teach people how to make sure to not have an epidemic, not have anything happen before we get into the state of let's take care of that person now that they have hiv. no.

let's teach people how before that happens. what is the plan for that? i know you are right, $300 million, that is much -- that is not much at all. how are we going to do that? that is the burning question i have and i look forward to hearing what you have to say. >> i will last can shut and michael to answer that because they will have to do that -- i will ask kendra and michael to answer that. how do you have early intervention? mississippi it is going back to the basics and having conversations about s ci's and the risks associated and doing a better job in teaching medical providers to feel more comfortable with assessing sexual health risk histories and determining ways to better inform and educate the sci's as well as

hiv risk. it is going to take a lot of conversation at our level. we still do ways to go with bringing on additional testing providers,ll as hiv but i think this is a great opportunity. inis on everyone's radar educating and doing the best we force get an additional on board with providing those early intervention services. to stop with need the silos. somebody walks in the door, they get tested and find out there hiv negative and it is like -- find out they are hiv negative and it is like i cannot talk to you, i need to

send you to someone else, or your hiv positive, i cannot talk to you, i need to send you to someone else. we need to break down those systems and integrate the system . that is a way we are looking at how to create an hiv neutral status approach to care and the systems themselves. i also think we have to start moving upstream as well, to talk about sex itself. we have to be much more positive. -- without that, it has been part of the stigma and barriers to getting, to walking in the door because of one's sense of their identity and that sex itself is a natural and we have a lot of cultural and societal unpacking to do their. -- to do there. we as a health system and we has health providers have to start isveying that message, that

sex positive in a way that can help, particularly for young people to be able to say, i can control my help, i can manage my health because i have a greater confidence in my health. en: we went way beyond time because this is a really important conversation. at kaiser we are committed to helping convene this kind of conversation. we will be looking at the initiative and surrounding policy issues. maybe we will do this any year to see what we learned now and where we are then, but please join me in thanking our panelists. [applause] jen: thanks, everyone for being here and staying. i appreciate it. [captions copyright national cable satellite corp. 2019] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] >> c-span's "washington

journal," live every day with news and policy issues that impact you. , politicos zach coleman discussed campaign 2020 and where candidates stand on energy and environment issues. then heather connolly, former assistant secretary of state for european and eurasian affairs talks about the mueller report findings on russian interference in the 2016 u.s. elections. be sure to watch "washington journal," live at 7:00 this morning. join the discussion. >> today, maryland governor larry hogan participates in a politics breakfast in new hampshire. live coverage begins at 8:30 a.m. on c-span2, online, or listen on our radio at. also national economic director larry kudlow takes questions from reporters at the national