ple who have started this program there have been no new hiv infekdzs, again demonstrating the power of this help in preventing new inventions. >> if i can jump in. it's important -- the kaiser study. unfortunately the headlines out of that study in that cohort there was a reduction in condom use so some of the people trying to deligitimize prep latch on to that and the press unfortunately focused on that. the bigger news even if there was a reduction in condom use that not a person zero converted and that is extraordinary and that should have been the head line and i appreciate you including that in the presentation. >> absolutely. i think people don't recognize that condoms don't work all of the time. they break, slip and sometimes not used properly and people don't always use them properly,

so their effectiveness is probably 80% in preventing hiv transmission. and so the next slide is really about paying for prep because it could be expensive. the great news is the cdc made the recommendation that it's provided. medi-cal covers this in california and medicaid nationally. most employee sponsored programs pay for it and we have patient assistance programs outlined here but it's a complex situation and people seeking prep need a lot of assistance because each plan within a given program pays for a different amount and may cover one component but not visits or lab tests, and so we really need what we found is most successful in getting people prep is having the navigators that help them arrange the appropriate

insurance and find providers willing to provide it, so we have a three pronged approach for what is needed for prep. we need assistance from providers. there are providers not comfortable providing prep so support for the new prep clinics and training on line tools and assistance for the users and we still have the disparities and we need the information about availability into the communities most impacted by hiv. we would like to set up a user hot line so people can call and get information. there's a lot of questions that individuals have about prep and we need to address affordability and then we want to measure the impact of prep, both theup take of prep, the benefits of prep but also any negative consequences and in particular we know of one case life insurance denied to a person initiated prep and we want to make sure those discriminatory

practices for people caring for their health don't continue and i will turn this over to diane who will talk second two initiatives rapid and retention. >> so our second two initiatives are based on a strong scientific foundation which is there are benefits to treating individuals with hiv for the individual and the community. if i can get the next slide up. sorry. so i will keep talking while we're getting the slide going, so we know that early -- it's the same treatment for all hiv positive individuals, reduces infections, tuberculosis, and cancer. it also prevents liver and heart and brain damage and reduces

death. we are committed to the health of the person living with hiv in san francisco but there is a two for one benefit for offering treatment for hiv infeblghted individuals. hiv treatment is a very strong preventive agent for forward transmission. scientific studies have shown us that hiv treatment of an infected individual reduces hiv transmission by 96% by lowering hiv /rna or virus levels in the blood so effective treatment for those living with hiv is central to getting to zero san francisco, so one might ask with all of the benefits of treatment why aren't we treating everyone with hiv and hasn't been happening for a long time? there are two main reasons that the strategy of treating everyone hasn't taken traction until recently. the first is that we did not really understand that during the early phases of hiv when patients

appear to be a sim attic that the levels of virus in the blood are causing inflammation and affecting their organs. by treating people early we can prevent the damage to these organs. the second reason we weren't treating all individuals is because early on the drugs had side effects so what we thought would be the best strategy to wait until people progressed in their disease to a point where the benefits of treatment out weighed the risk. everything has changed now and now we know at all stages of hiv disease the virus is more toxic than medications. therefore we should start treatment immediately and for this reason in 2010 our clinic at san francisco general hospital served by the department of public health put forward a policy of treatment of all individuals for therapy of

living with hiv. we had a community forum. it was highly controversial. it was fevered in the -- featured in the "new york times" and other cities followed suit. the current u.s. guidelines now recommend treatment for all individuals living with hiv and global guidelines are going in the same direction. so what do we need to do right now? well there is a gap in successfully starting and maintaining treatment that you saw from the earlier slides. as well there continues to be new hiv infections in our city and we know that starting therapy right after a new hiv diagnosis is very advantageous. let me tell you two reasons why it's advantageous. first when someone starts therapy after the disease gins they can reduce the reservoir of hiv in the individual and hoping to have a cure in the future and that reservoir will be smaller.

second after infection with hiv virus levels are extraordinarily high posing this as a high risk time for transmission so by offering treatment immediately it's once again advantageous for the individual and for the community. so our first -- the program which is our second initiative in getting to zero is called rapid ar t and this program has been in effect in a small scale for the past year. what is new about the program? what happens as soon as a person is ditioned we offer treatment on the spot. instead of waiting for weeks for medication and there are delays and people don't start therapy we're compressing it into one step and supporting continued counseling for adherence. so this removes logistical

barriers to provide a client the opportunity to start therapy immediately so what we're asking in this initiative, our initiative number two in getting to zero is expand what is working. we have a system working. the rapid program is offered at clinics and san francisco general hospital. we want to offer this by city wide and by a small investment in navigators and some coordination of good standard practices we can offer this across the city and i can tell you there's already great interest around the united states about expanding this program and model to other cities. so initiative number 3 for the first year getting to zero is strengthening retention. it means we're happy we have more insurance options for people but i can't imagine there is anybody in the room who hasn't experienced a change in job, a disruption in the insurance and it becomes

complicated where you go, where you get your medicines. for many diseases having a short interruption isn't devastating. it's not the case for hiv. when they stop the therapy the virus levels immediately surge and it's very unhealthy for the patient and also puts the community at risk for transmission, so we need to work together, to close the gaps, connect the dots, and put in simple programs that are affordable such as a hot line that individuals can call when they lose the insurance so they can make sure that the medicine supply is not disrupted and stay in care and we need staffing at this time during the time for the patients and we need continued support of the current services, attention to housing and mental health in addition to these three new initiatives for us in order to get to zero.

the united states as featured in time magazine is looking to san francisco. the world is looking at san francisco to lead the way and end the aids epidemic. i am proud to be part of the consortium and express the gratitude for the support they have shown us and hope the strong support they're about to give us so thank you very much. >> supervisor campos. questions? >> thank you. i am wondering if we can ask about the consortium and the work of the consortium? i don't know who the person to speak about that. >> sure. so the consortium started -- it the world aids forum we had a year ago so that included supervisor wiener, the san

francisco aids foundation, department of public health, ucsf and project inform. we started talking about the possibility at that forum of getting to zero. >> >> and they said "why are you guys working together and talking to each other?" so we started a series of meetings and have been adding people to the group as we have gone and right now i think -- [inaudible] we have -- you know, we have engaged the folks from the hiv providers network so they have been participating. we have several folks from the department of public health, from ucsf, san francisco aids foundation. the fabulous folks from [inaudible] joining us. thanks ted and matt. ms. chung

is participating, the health commissioner. we also brought in kaiser. what is important is that 2/3 of the patients are seen in the private sector for hiv and most by kaiser in san francisco. having brad here the director of hiv services at kaiser has been critical. we have genie to bring in the private docks. we had their voices at the table but it's been bringing people in. we had adam taylor from scott's office, laura lane from your office has been participating and it's very open, and just everybody has been very enthusiastic about moving forward. we meet about every two months and focus on working collaboratively to come up with some ideas to actually make a difference in the course of the epidemic. we have the science that supports it. we have the community infrastructure to do it and it's imperative that we take some action. >> i think it's really important to have that

coordination and i appreciate the work and i think it's really critical that we do that. i will be honest one of the concerns that jumps out from looking at -- well, who is in the room and also looking at the roster including the steering committee it doesn't reflect the diversity of san francisco nor does it reflect the diversity of the communities actually having the hardest times so i am wondering how we can effectively reach out to those communities if the people crafting the policy and the strategy do not reflect the population that we're trying to target? i mean that's just from a latino gay man i can tell you that's a concern that i have as we're talking about this. >> well, we would welcome assistance from your office. the doors are not closed to

anybody, but we welcome assistance from your office in identifying people to participate in the consortium. i mean everybody is donating their time to do this. >> i mean if you're trying to eradicate infections in the african-american community and the latino community and the transgender communities and other communities it's important to have people from the table from those communities as well, so that's my suggestion. >> and i think with any effort you can always broaden the tent and proactive making sure that the diversity of a community is represented. i will note that api wellness is part of this coalition and just mentioned that cecelia chung is an active member, and the cbos that are doing this work are organizations that do work in a lot of different segments of our community. it's not just about

one segment but with that said we can always do more to make sure we're reaching everyone, but i don't think it's a fair criticism to suggest that this consortium is not reflective of the community. >> let me just disagree with that. i don't think it's just something that would be a good idea to do increase diversity. i actually think it's not just a good idea it's always critical to being successful. i appreciate the work that has been done but i think if we're really going to tackle this issue head on we have to make sure that from the moment that we start talking about the issue that the right people are in the room and at least based on this presentation, based on the roftster that i see i don't think the diversity of this community, especially the people disproportionately impacted is represented here and have an

obligation to point that out. that's not to take away from the important work that people are doing and points out that we need to address that issue and unless we do that we will find ourselves talking to communities that need the help without being connect in the way that is needed in a meaningful way and that requires that they themselves have a role in being a part of the solution. >> and i would be -- i think there maybe more diversity within the consortium than maybe evident from just presenting the pie chart. we are happy to get the roster to you if that would help. >> thank you. >> thank you. okay. so thank you to the consortium for that very helpful presentation. i have actually seen the presentation several times and have participated in giving it and every time i see it it gets better and deeper and extensive and it's terrific and i hope

you're sending it all over the country to teach other people what we're doing. now we will hear from the department of public health. greg wagner is here to present, and i hope you have really good news for us about the money. >> i will do my best. good morning supervisors. greg wagner chief financial officer with the department of public health. i don't have good news for you, but i don't have the bad news that we have had in some years past. unfortunately as you pointed out at the beginning of this hearing it has been an annual ritual for many years for us to have this

discussion in the board chambers about what the funding picture for our programs looks like and the change in the grants that we received from the state and federal governments for these programs. we are early in our budget cycle. we're still in our deliberations and awaiting information about what the funding picture will look like for this year, so we don't have as much information as we often do when we hold this discussion a little bit later, but i will just to highlight some of the concerns that supervisor wiener and supervisor campos made about the history how we got to where we are today, show a little bits of the past, and what the outlook looks like. i have a chart here that shows the percent of our programs for hiv prevention, health services, and

epidemiology and research that shows what portion of those programs are grant funded. as you can see hiv prevention is about 50% and health services 39% and reflective of the changes that we have seen over the years. >> >> if you go in the past those percentages are significantly higher and the fact that we have low ball general fund dollars in the program is really a testament to what this board of supervisors and the mayor of san francisco have done to step in and support these programs and it really has been critical to maintain the innovative response that we've had in the city in the face of the declining funds. a little bit more on the history, but this is going back over the most five recent years

of adopted budgets where 15, 16 as in year two of the adopted budget but you can see the redeclaration to the programs on the prevention side and the hiv prevention side and the ryan white grants. we had $14.6 million of reduced grants that the city stepped in to back fill and maintain these services. >> just to be clear and tell me if i am wrong this is cumulative, so when you have 1.5 followed by seven -- >> yeah. >> so it was 1.5 million in 2011-2012 and -- so we back filled that and part of the baseline and another 7.1 million at 2012-13 and cascading so i think really more than 20 million. >> you're right. the way that

this number is added up under state cumulative impact over time. you're correct. >> yeah. it would be good i suggest adding in the future as additional because showing the true impacts what we can do locally with the mayor and the board working together i think would be helpful. >> that is very fair. yes, we will do that and as you said it's been a very large change in the mixture of funding for those programs, and the city has stepped in. in terms of where we are looking forward for the budget again we're early in the process for both our internal planning and our information about what our grant funding allocations will look like. we do have preliminary notification that we will have a reduction of about $150,000 in hiv prevention for fiscal year 15-16, so we're

incorporating that into our thinking for the upcoming budget process. we do not have a notification or a preliminary award for ryan white, so that's still to be determined. we usually learn about that later in the spring. although you can see from the pattern over the last several years that i think it's fair to expect that we will see a reduction. i don't know if it will be at the size we have seen in previous years, but it's something that we are assuming that we will have to grapple with over the next four months as we go into the budget process. so again we expect -- we received our prevention award in december and we expect fairly high level certainty by may on the ryan white funding amount,

and obviously as we go through that process we will be in close communication with the board and the mayor's office to discuss how our response to that is going to look, and how we're going to make sure that we maintain all the great efforts that you heard about prior to -- prior to the financial discussion. >> supervisor campos. >> thank you mr. chair. thank you mr. wagner. i really appreciate the presentation, and again i want to thank the department of public health and director garcia for all the work on this issue. mr. wagner one thing that i think feel that i have to say is in looking at sort of where the issue of prep is, and i am very grateful to the department for working with my office, with supervisor wiener to get to a point where we started a program where

we're hiring navigators to facilitate access to prep and i also want to acknowledge that supervisor farrell who is not here as chair of the budget committee was really instrumental in making that allocation happen, but the concern that i have is that if you look at the presentation from the consortium and everyone who has spoken there is a huge reliance on making prep accessible throughout san francisco, and that's an integral part of the strategy and as important step that we took in sort of beginning the process of hiring nose navigators the. >> >> department of public department of public health in the city we're only talking about an investment of $300,000 for prep and when you think really about the significant role that prep is supposed to play in this strategy that is a

drop in the bucket if you will, so that's one concern that i have, you know, and so i am wondering if you can address that issue and sort of how you're looking at that as you're thinking ahead for your next budget? because if getting to zero relies so heavily on the accessibility of prep then have we really made the commitment to that that is needed? because $300,000 in a budget of hundreds of millions of dollars may not necessarily reflect the level of commitment that is needed, so i am wondering if you can address that issue? >> yeah thanks for that question. i would like to also offer the program -- the participants here a chance to respond to that. first of all i want to thank you for the work that you did and taking that

step to appropriate those funds, and that has really allowed us to start the process and advance that program forward and we are moving on that. we are in our current budget deliberations working with the coalition here to look at funding options and requests to enhance the programs. this is something that our director, barbara garcia, is very involved in and committed to. we have been having discussions with this with the mayor's office and continue to have with your offices on this committee and on the board, so we are definitely looking at the bigger picture as we go through our budget process and trying to think about what do we do to take the next step? how do we make sure we're leveraging our existing resources in the best way, but also is there a next step that we need to take through the

budget process? and we want to make sure that's a conversation that is not only internal at the department and at the health commission but it's something that we have collectively with all the policy makers here. >> well, i appreciate that, and i know i have spoken to director garcia. i know she's very committed to this issue so i know as we look forward to the next budget that's something that i really would like to see and sort of hear directly from the department of public health in terms of what the next steps are? and by the way it's not just about the city also doing what it needs to, but also if we can hear about what is happening in terms of communications with gillad. they have done some things and the fact is travatta is more expensive in the united states than in other parts of the world, and the point of

this is to make it accessible, not necessarily to line the company's pockets so i would like to hear more on that. >> thank you supervisor and i would like to offer -- >> thank you so much supervisor campos and thank you for your support in initiating that initial infusion of funds which i think is going to be critical to moving forward. we do have a comprehensive plan for all of these programs and we believe all three are required to get to zero and we believe it's needs to be a city, public private partnership so we are approaching both foundations as well as private industry including gill yad to support in this move forward and we have received positive responses. we're in the fairly early stages but we don't expect this is solely a public funded initiative. this is going to be a broad consortium.

>> great. thank you very much. >> thank you supervisor. >> thank you supervisor campos and this raises a point that i mentioned at the beginning and i will reiterate that we in addition to playing budget defense against the continuing federal cuts we really want to play offense this year and make sure that all the great things we're hearing about today in terms of getting to zero that we're translating that into budget support in addition to working to reduce the cost of the drug and all of the non budgetary things that we need to do and i know we will move forward a proposal during the budget process. great and next i want to invite up bill hirsch from happen, hiv provider network and you continue to do a great amount of great work in this area. >> good morning. thank you supervisors for the opportunity to talk. it's exciting after

years of budget badges to talk about expanding capacity so we can meet the need for services in san francisco. >> >> we were hearted when the mayor asked for no cuts in the budget instructions and we want to make sure in that vision of no cuts we're talk about no cuts and that includes a pretty broad array of things on the table and supervisor campos your concerns about kind of the broader impact on vulnerable populations is something that we share as well, so we want to make sure that the -- we know there is going to be about a million cuts in care and prevention from cdc. we know there will be cuts to housing and opportunities for people with aids. we know there are cuts to the community development block grants which fund a number of supportive services for associated with housing. we know there will be cuts to mental