asked for consideration. for what definitely seems to read as improvement in the both quantity and public quality of the care that's going to be provided to our seniors. so that's my comments. any further comments on the resolution? if.were prepared for the vote all those in favor please a aye. opposed? the resolution is passed unanimously. thank you >> thank you very much >> thank you very much for the work you've done >> item mate is [inaudible] in san francisco. zero hiv infections zero hiv gas zero hiv stigma >> thank you so much commissioners for allowing us to present what we think is a very exciting collective initiative. i do have slides and in your slide are both the -- all right. so, in your

package are both the sides as well as some slides on injection drug use and the program that the city has to address those because you asked that before. tracy packer is sitting here and available to answer any questions that you may have about this. i want to mention tracy is also a important member of the population health hiv working crew that you see listed on the slides and with two members of the gain to zero [inaudible] so i'm going to tell you a little bit about this collective impact initiatives. the question is, why this, why now, why us why we tried to get to zero new hiv infections zero associate hiv gas and zero associated stigma. so i would say that i think we have one of the best if not the best hiv

surveillance programs in the world and certainly nationally. we have this extensive care network that includes both clinical care, community care, and care for a number of other kinds of issues like needle exchange. we had from the beginning of the epidemic really strong community involvement and that's really propelled us forward to be at the forefront of the epidemic. and we've had political will to achieve our goals wonder the leadership of dr. garcia and under your leadership we have had a tremendous amount of support and we believe that we can get to zero. so we now have better than ever tools for prevention and treatment. we know that a daily pill can prevent new infections by over 90 percent. in hiv uninfected people and it's virally suppressed people who are

hiv-positive can actually reduce their risk of transmission of their on treatment and virally suppressed by overnight percent to mike by 96 percent. so we've got this great synergy right now between prevention and treatment. the affordable care act also gives us an opportunity to really provide care much more comrades of leak . so we believe that with court unaided effort we could be the first city in the country and globally to get to zero. but were going to need better coronation of a variety of different organizations although i working on hiv and [inaudible] was born getting to zero consortium. commissioner john is actually a member of member of the consortium. you can see here we got a number of the major partners. we have a number of representatives from different organizations and it's growing every day. we have the steering committee, as i mentioned, dana [inaudible] and jeff [inaudible] and diane [inaudible] from usc about a general hospital are also on

the steering committee and i'm presenting on their behalf. so, really where in service you can see the bottom of san francisco communities. so this is the mission statement of the organization. we want to convey a sense of urgency and possibility for getting to zero among san franciscans. we want to empower and engage abroad [inaudible] this is really collective impact effort. create communication and coronation amongst various stakeholders to implement the strategic plan and we had a very robust discussion at a community forum that we held last night in honor of world aids day in which we were talking about new mechanisms for better communication among the various people who serve our communities who are at risk for or are hiv-positive. to provide better services. we plan to mobilize all necessary resources to achieve division

and that means not just one group not just the health department but our variety of organizations that will be providing support for this effort. we want to have robust metrics so that we can be sure there were actually measuring how well we are doing and we made a commitment to report back on world aids day each year. in fact, this crew out of last years world aids day community forum in which the was discussion among the community members about is there a better way to coordinate. then we want to achieve decision by ensuring the health and wellness of individuals and raise living with hiv and arrest but we need weaning global hawk we don't mean just hiv health and sexual health mental health and physical health and a variety of other issues. so, just to give you a sense of where we are at this point we, the redline at the bottom is the number of new diagnoses in san francisco and you can see that we've had a decline in new hiv

infections by 30 percent over the last seven years. our guests have nearly halved in the last seven years. as a result obviously we have more people living with hiv, but living healthy with hiv which is the important component. as we compare ourselves to the numbers nationally, you can see that we only have six percent of hiv-infected people who are unaware of their infection. it's 80 percent nationally. we have more hiv-positive went to care rapidly and more hiv-positive virally suppressed and san francisco than elsewhere so we do feel we are poised to be dispersed city getting to zero. so, as an organization we would decide we promote free and initial initiative strip there's lots of other work being done but we want to focus on preexposure prophylactics because as i mentioned taking a daily pill can reduce hiv acquisition by more than 90 percent. rapid

antiretroviral therapy getting people link to care and on treatment right after they're diagnosed because again it will improve their health first and foremost but also reduce the risk of transmission to others. then, keeping people in care so they're getting all of the care that they need. so, i'm going to talk very briefly about each of the three initiatives. this was an article in the new yorker over a little over a year ago but why is nobody on this treatment if we've got this amazing way of preventing new hiv infections. and there was another article by my favorite new yorker, author, [unintelligible] wrote about the difference between anesthesia and antisepsis and the length of time it took to roll those two out. you can see that there were only 20 years apart and actually the anti-septic movement really started 20 years later. within six months of the introduction

of anesthesia most regions of the world had anesthesia and within seven years nearly every hospital in general anesthesia whereas anti-sepsis keeping operating rooms sterile, 20 years later after it was discovered that this was really a problem surgeons were still using the using sponges and still wearing old clothes with blood and other body fluids on it. it was really a generation before this became common practice. so the question is, what's the difference? why did anesthesia will out quickly and antisepsis not and i would argue there probably two reasons. one is that anesthesia is very visible whereas anti-sepsis is very invisible. you don't see the germs but you do see the patient writhing in pain as your doing surgery on him. also, you the time., qc the need for industry at the

time of the surgery where is the infections happen potentially weeks later so there wasn't the same connection. so, we unfortunate are in a position with hiv.infections are both invisible and separated. you don't often diagnose him for some period of time after the infection happens but we really can't let that be a slow idea. david evans and david bangerter wrote a nice piece that i recommend you look at called prep should be a fast idea not a slow one. there's a great law called my experience my prep experience a blog and it really was talking about how i think what people get concerned about is that prep why would you put someone on lifetime hiv med if just to prevent them from having to take lifetime into tragedy meds. there's a couple reasons why we don't believe that's a lifetime treatment. it really is during what we call seasons of risk in the same way

that women use contraception. seasons of risk. the other thing is that hiv even with treatment still can cause this chronic inflammatory disease and causes a mature aging. so we really do want to prevent new infections. one of our initiatives is this prep rollout. we've got a number of things you can see in your handout to launch for the users of prep to be sure we are reaching into communities most heavily affected by hiv, cupping them access prep and helping there be a larger capacity among providers to provide prep as well as help not navigating the cost of prep you will a number of initiatives for providers because not all providers are comfortable managing patients on prep so there's a lot of additional work that needs to be done in terms of training and then we committed to improving our measurement so that we can measure how quickly

is prep rolling out in the city. what are its positive impact by god we seen reductions and new hiv infections? what are potential harms, such as any natural viral resistance were seen in the community, it is been one case right out the we've heard of of a patient being denied wife insurance because they were on prep when in fact i say they should be more worthy of life insurance because they're taking care of their health. so we really need to track these kinds of things as well as cost and where plans to do that. the second initiative is what we call rapid. it's really about offering treatment immediately. san francisco is the first city in jurisdiction to promote offering antiretroviral treatment to all people infected [inaudible] this was in 2010 made a lot of headlines and it was absolutely the right thing to do and i think it came from we have a very talented

pool of clinicians here as well as investigators really understood that hiv is a chronic inflammatory disease and you don't want to wait until the damage happens. what to hit it early. three years later the us guidelines came out recommending the same thing. so we were ahead of our time again here. the challenge has been that when people are newly diagnosed they can go to multiple handoffs from the person who does the testing, to the initial intake treatment, and then on and on and they can get lost in that in all of those transitions and it can take an anonymous amount of time. so, we want to expand this linkage integration navigation conference of service program that we have called links,. we want to expand rapid which is a program a unique program of its kind that tempts cisco general were patients are offered treatment on the same day that

they get their diagnoses and get immediately linked into services they found that an enormous way helpful and reassuring. so we have, as i said, a number of plans to help with these coordinated efforts between the testing site and the rapid antiretroviral hub. finally, the toughest nut to crack israeli retention keeping people in care. both for their own health again as well as reducing the risk of transmission. there are number of different points that were going to need to address in order to get to zero and particularly we do have disparities here in san francisco. we've made tremendous headway and reducing numbers of new infections in women and people of color and injection drug users but we are not doing well by this communities in terms of print retention and care. so it's clear we need more communication and some novel approaches. i want to say that a lot of these things are at no cost to we've a lot of ways of improving all three

initiatives, but there is also going to be a business plan developed around this as well. as i said, we will be seeking multiple sources of support for this. i'm just ending with is really nice analysis by tim howlett in which she's looking at south south africa and the infection right and the [inaudible] what happens if you did not do anything and you get nearly 2 percent infected each and every year. if you could circumcise 90 percent of the men and countrymen know that reduces the risk of infection is only reduced in new infections by a third. if you do some behavioral intervention get people to sicily to reduce their number of partners by 30 percent increase their economies by 30 percent you could drive down infections by

two thirds but if you combine them you could this synergy and illuminate infections. so were looking for that kind of synergy between treatment and prevention we believe we can get to zero. i'm happy to answer any questions. >> is there any public comment? >> no public comment request should have any questions commissioners? >> thank you very much for a wonderful presentation. i'm so sad about this goal and so upset about the school and the multiple levels. one of we can reach getting to zero -- even getting to have -- it such a worthy effort. two, i guess the second thing, i really like the public-private collaboration that this is also the attempts. it's not a city attempt it in all city outcomes in public and private and i think it really leverages this environment of the aca affordable care act where people are insured and they get access to their care, that said, hoping we can learn

from this. i'm not only optimistic about this am optimistic it other possible collaborations perhaps looking at hospital ed utilization across the states with emergency. even public-private collaboration in our african-american initiatives that his approach to population of want to commend you as the [inaudible] project and dr. aragon for the vision for pulling these things together. with regards to how you doing this, there cost analysis, i be interested in hearing a little more about how you do that. [inaudible] more about the process of action pulling together these coalitions. as you can see, i actually feel very confident you get to zero together but more how are you pulling together really interest me because that's what were learning to move our system as we go from this project to getting to back to

diabetes care and [inaudible] care. this is something that it's very doable but there's many learnings here and that's what i i hope that we can take away. give any thoughts on that or meta-structure? >> i do. i completely agree up boxes in the general medical clinic in services.general hospital i think this can serve as a model for better communication and better care for prevention and care for all of our citizens within san francisco. so in the same way i think hiv has led the way in creating different kinds of reforms in healthcare system and certainly in research, but benefited other groups i think this can also. we have been an incredible city with incredible resources. i have to say that everyone who has approached to join our effort has been very excited about joining it. we have a small steering committee that keeps us moving forward and i want to credit diane havel or with cracking the whip and keeping us on a very very

tight timeline. we have really this initiative started in spring of last year and we are already at this point where the public comment from our community forum and were well on our way to developing the business plan. as i said were causally adding new people because for instance last night at community forum someone suggested why don't you get some face book people involved because social media is going to be one way we might even keep people in care because their phones turn on and off but they keep their facebook account. we are constantly reaching into not just the usual suspects. we start with the usual suspects, all the major organizations working on hiv. as other groups have heard about it they've asked to join and we are very welcoming group. then, we came up with this -- we did want to try to do everything at once because if you try to do everything it

gets a nebulous and you do nothing. we thought we would start with these three initiatives and we broken into much larger groups and make sure we have representation from major organizations, from private practitioners, from people living with hiv, people at risk for hiv. youth, people of color appear all of that within each of these three subcommittees to brainstorm and figure out what are the issues, what are the roadblocks to getting this done and how to use it collectively impact approach to actually address it. i hope that answers your question. what we did was it just took a core group of us coming together and saying, we are going to move this forward which is invite a bunch of people and see if they are game and they were. they been very committed and really working very hard on this.. dana van corder and jeff sheedy are here and there are bringing an honest amount of expertise in terms of how we structure things. so, i would say that i understand science more. they understand the structure and the

movement forward in engaging other partners. i know that jeff is going to talk with some google executives and dana has contacts with some of the companies that produce pharmaceutical companies. so we are just trying to use everybody's strengths and everybody's contacts to really bring this together. dana has got an honest amount of expansion project in form with helping people to provide information to people living with hiv and so were going to expand that two people were risk for injury >> dr. aragon is a slightly collective impact velocity and i see it in action here and again is very very excited. the final the final common goal as a metric, community-based discussion in this way with access the service in recognition that chronic disease i think there's a really great formula secret sauce and i think --

i have to say barbara is the secret sauce dip were doing this under her leadership and she provided us and continues to provide us with an enormous amount of guns despite a very busy day job. she manages the common speak in our worldly state form are community forms and as the leader of the health department weaving it's really important for this to really work underneath her umbrellas we are >> barbara i didn't mean to >> not at all. collective impact. also just be aware that concealed budget initiative from our division of our department. i'll be working because part of the issue the links program is a federally funded program. we do not want that to go away. and restarted again. part of our initiative will continue -- and this is one of the areas in the division of population health division is public cultivation has been that they bring in a lot of grants and [inaudible]

all the grants which ones a little ones we need to be sustainable because what happens with grants, and go. so, this is one of those grants were feel like it's very effective peewee don't have to retrain somebody we just continue the program. so just to note i've already started talking to our finance area that this is an initiative that i like to support coming this year but it's also we are only a part of this is going to be important to bring the public sector, the other providers, and ensure that we have collectively impact throughout the city. >> commissioner singer >> along with dr. [inaudible] i want to congratulate [inaudible]. just an incredible marriage on of compassion and ambition. i hope we are successful. if we are it will inspire a lot of other communities around the country to attack this.

>> my civic question sort of gets tries to get at the heart of a much more vivid heart of the matter which is intuitive to you but probably worth educating us about. which is transmission patterns today. verses in the past. what that means for where you deploy resources. >> so the san francisco epidemic has been a continuous largely epidemic in [inaudible] sex with men. that said, we do have others who are risk for hiv. i think one of things barbara said that's really critical is that we have programs that work, so now the outcomes among the homeless are equal to those who are housed in terms of mortality. that is really a remarkable statement and really has to do with the housing programs that we have that are so critical to what we do. so what we need to do is build on top of those. so, we see the claims in infections in

women and people who inject drugs. for the most part in men who have sex with men in san francisco. what we are seeing nationally is an increase in new infection particularly in young men and men of color. our efforts still need to focus predominantly on men with sex with men but we certainly need to reach into the transgender community who are very heavily impacted disproportionately probably the most heavily impacted population in the city. we need to continue to do our work with people who inject drugs and substance users in general. we heard a lot from members of the community last night at our forum about ways of continuing to engage key people in care. i don't know if that helps. we still have

racial ethnic disparities. our highest infection rate per 100,000 population are african-americans by far and away. latinos, carpet ahead of white men without sex men who have sex with men. we have say this ties into the african-american initiative as well. we have the same kinds of disparities that occur elsewhere is just there were doing better with them were still not there. >> for sure there are disparities. i guess, how do you think about as you attack the problem in a world that is resource constrained, how to bounce communities that have much higher infection rates in the community but overall are much smaller part of the overall infection rates for mike as you think about how to -- >> you're bringing up exactly >> so that if you try to solve any every problem you probably won't solve any them

>> right that so we start with these three initiatives. there is that age. there's a social justice issue that even small populations were totally small populations, their heavily impacted deserve the same services as other populations that are larger. we undercount very substantially the size of our transgender population and we do better job in san francisco than is done nationally. what we decided to do was to focus on three kinds of interventions and each intervention will be tailored to the issues we are facing in that group. so, the prep initiative, we will focus but donnelly on men who have sex with men. it will focus on transgender women about which we know very little about [inaudible] so we have some proposals about them supported to nih to fund to serve the

trans community. the issues, as i said, we are doing better in the infections in women people who inject drugs. african-americans but we are doing worse in terms of retention and viral suppression in this population. so that will be a different targeting mechanism in the retention piece. >> very helpful. thank you. >> commissioner john >> i just want to say it's been such a pleasure and inspiration to work with the consortium on this. and to really see all the ideas flowing a group of brilliant minds. i also want to just put this as a later contact in terms of how we are beating this globally and where we are in terms of benchmarks. so the unh just introduced this whole thing called 90-90-90. for those in public health we heard about that already. it is to look at, by the year 20 2090 percent of people living with

hiv status. 90 percent of them on treatment and 90 percent of them are achieving viral suppression. i think that without with our goals of zero hiv infections, zero hiv deaths and zero hiv stigma, we are in step, give not leading way i'd like in this campaign. the goal i think has not changed. by globally unh is still looking at 2030 as the year to end the epidemic. i think there are lots that we can actually do like susan mentioned earlier as a city. we are not the only ones coming up with getting to zero plan. new york state has a plan to but i think that in terms of friendly competition, make we probably will win this

by miles but don't put me on that. i think it's important also to really recognize were not just talking about the biomedical aspect of it because we talked about stigma. because how stigma translates into new policy, new laws, and even daily human interaction affects people's lives. it's because of hiv we get to really see how it plays out in people's lives. i think that to just name it call out the elephant in the room and not do something to address that really sends a message back to the community. with that, i really think the leadership in all the effort the steering committee and the

consortium has put into this. thank you for continuing to remind the research community, like it's great that we are advocating to scale up crap, but you can't lose any communities and beyond. currently, the transgender community is being left behind because they are so no practice in the at all. they have [inaudible] placebo group versus 11 groups on medication. so that is not helpful for us. the more concrete data we have i think the stronger this plan is going to be. so thank you >> that fermenter commissioners we did start getting a collection of data in terms of adding transgender to part of our collection of demographics and that's going to be for this. we do have two community members who are leaders in this and i just thought president shall if you allow them to say a couple words. i did want them to come to the meat without having to address that is dana van corder and jeff >> surely could we be very happy to receive that and thank