seen this slide previously and you will be getting another presentation later this summer. it's important to know that san francisco is seeing great signs of success in the fight against hiv. in red you see new hiv diagnosis declining as well as deaths on the pink line while people living with hiv is increasing in the green bars. the predominant reason for this has been the advocacy and efforts of people at risk living with hiv primarily gay men to advocate for and embrace strategies as they have learned about them and originated within gay men's communities. in san francisco, we now have this opportunity as one of the first city worldwide to get to zero with hiv. this is a consortium which is

a collective impact model utilizing different organizations and we are joining in with many others in the goal of reaching this point of zero hiv infection, zero hiv deaths and zero as hiv stigma in the city. we have this great goal that is within our reach of getting to zero for hiv, std's are increasing at the same time. we have the same numbers available for 2014. they are finalized. you see gonorrhea in blue, chlamydia in black and syphilis in red primarily because people are choosing are prevention strategies that are only for hiv. people are choosing safer sex

practices based on knowledge of zero status but not using condoms for every sexual act. people who are hiv infected and being on treatment have viral load the chances of transmitting hiv to a partner. all of these are being utilized throughout the city and we have the data to support that and i will show you somg -- some of those data. as we look historically we have some examples in the past that std rates are secondary to behaviors designed to prevent hiv infection. if we look at the gonorrhea rates for $100,000 population we look at how the peak occurred in 1979 and 1980

the decline of hiv aids and the decline in gonorrhea. the changes in gonorrhea were not the initial event that occurred. it was really changes related to the devastation that occurred with hiv aids. as you can see now currently from 2009-2014 we have some increases but on a historical scale they are no where near the highest rates we used to have. however we are still concerned and would like to make sure the rates are slowed down or ideally reversed to see declines. the population affected by std has not changed since the last time i presented to the commission. it continues to be gay men and adolescence and those under 25 years old and transgender individuals. one thing about the data is we need to do

a better job about who is the transgender individuals and receiving better care citywide. we'll continue to work on that and improve within our own network and population in house. here is some of the data that really support how this affected men who have sex with men in san francisco. you see both gonorrhea and chlamydia rates per hundred thousand population for men and females. and then for adolescence, for -- gonorrhea rates as well and african american against other ethnicities. we have a little understanding for why std rates are increasing because of participation in the national hiv surveillance program which is

cdc funded and involves 26 states in the united states. san francisco is one of them and there is a survey of gay men and they have their blood taken for hiv testing. these are the waves that have occurred since 2004. the blue line are people reporting always using condoms for anal sex. the red line reports sex without condoms with five partners and the purple line is asking people are you using prep or preexposure profile axis. there was very little prep in 2004 and condom use was going down and specifically treatment of prevention

and also again knowing one's status and the status of ones partner. it's very helpful to see this data as a survey and as a scientifically selected sample of men in order to validate what we are hearing at city clinic and providers. i wanted to convene focus group and what we learned from gay men themselves why we are seeing increase in std. four groups consisted of hiv infected men who have std previously, hiv negative men who had an std previously and hiv positive and negative men who had and had not been with an std previously. it's a

concern and i know how it's going to be treated and move on from there. it was helpful for us to hear these voices and to really then try to go back and think how we might have a more holistic point of view and from people telling us what their interest and priorities are to try to support sexual health the best we can in san francisco. so what we are doing now to address std's can be broken down into primary and secondary prevention and our upstream efforts. in secondary prevention where a person that's already had an std and we are trying to prevent on going bad outcomes in that individual who has that had std or transmission to other partners. we do partner notification particularly for syphilis and that's the way we try to impact the spread of std from that person to their partners and we recommend support repeat

testing as the cdc recommendation and then clinician training and consultation support is really important and based at city clinic. primary prevention is one of our ideals to really have people not get an std in the first place. we have prevention efforts that are located at std clinic as well as san francisco aids foundation and magnet as partners and bayview is another partner. promoting condom use is something we are continuing to do throughout the department and training in std management so they are agents throughout the city. so what we are increasingly want to do is look at upstream factors that weigh in to sexual health and really thinking about this in a larger sexual health framework. understanding what community priorities are so that's been a real boone to having our focus

groups to doing that and thinking about policy works that impact our ability to improve sexual health. one example that have was the work that many of this department did along with the district attorney's office and public defenders office and police to say that condoms would not be used as evidence in san francisco and that is a policy that hasim applications -- has -- implications and that is in the city overall for supporting health. this map shows in 2013 for males in top and females in the bottom where rates were highest for chlamydia, it has more rates per hundred thousand. this is an example to show that you the three sites we have shown you in magnet and third street for std dollars which are quite limited. they are

geographically located to serve the populations at highest risks and neighborhoods at highest risk. what we would like to do is to be able to overlay all the clinics that serve any people within the city particularly in these areas of highest morbidity and density to work with them and support them and have them be active partners doing primary prevention and secondary prevention as well. that will be a big goal and specifically my branch to support that go work and optimizing clinicians in supporting std's and hiv throughout the city. i will be back talking to you about increasing rates. the goal is that in a five or 10-year plan we are able to put a lot of these plans into action and really work again

closely with clinicians, work with communities and try to address the increases. so in a short-term we will be doing additional focus in the population including your -- young african american males and females. we also want to look at some of the barriers are and challenges to doing sexual health which are very busy in a physical encounter which can be 15 minutes and how we can help with that as a department as that's what we really want to focus on. then the third part is very much related connecting to those clinical networks including our own health network to maximize the existing clinical resources and how can we add value where it's possible. that can be consultation in whatever way is most effective and efficient

for people and giving them data feedback and identifying what data might be and ideas like expedited partner therapy like giving a patient a prescription to a partner directly or perhaps even home based screening or retesting at 3 months so a person doesn't have to come back and wait in a clinic for something like that. >> we had sort of going along with those ideas we had a group discussion with matter experts within the department of public health in march and the ideas came out which are implemented are that we should ask people themselves which should always be the no. 1 response and we are doing that. people also thought that it would be good to find out what other organizations are doing youth empowerment for black african american women kits sent home and mailed

back. it's been done in studies before. and it's being done in los angeles. it might be something we consider here and clinician support such as electronic consultation and referral through city clinic that would be available to all providers throughout the city. potentially people had some ideas about new comers programs about young gay men who move to san francisco who help provide support around sexual health there as well. lots of ideas have come up. we know there are some very basic things we would like to work on improving our screening, improving our treatment and then really focusing on the upstream outcomes, the upstream effects that make the outcomes as good as they can be. so we are going to continue to work on std's within the connections of getting to zero and the efforts of getting to zero are not

mutually opposed with std's and certainly prep to std work as well and it's all around sexual health and methods for hiv and we'll continue to work on our std rates as well. so thank you very much to the commission for your continued support and interest in this work and i'm happy to take any questions. >> thank you, we do have one public comment. michael patlrilis. thank you. hi, michael patrilis again, i want to remind this department how you create a stigma. this ad, syphilis is a time bomb we can

diffuse, it's a walking ticking time bomb. that's not a way to tell a person with syphilis to tell them they are a walking time bomb and we have this ad about aids and gonorrhea going up. let's continues with these horrible ads you hoisted upon us. don't be a -- use a condom. remember that ad by this department? there have been decades of fear driven negative campaigns from this market and your partners. a lot of us have tuned out, we've closed our eyes to whatever you want to say because you have spent decades demonized gay men who are sexually active and the way you have done it is

by keeping the bath houses closed. you send a message that gay men cannot be trusted behind closed doors because the bath houses remain closed here but never shut in texas even though it had an anti-sodomy statute. now you are coming along saying it's horrible. the std rates are going up and you know what we don't get? we never get a social marketing campaign praising us for not only surviving a plague and the authority which the department did not endorse. you have not said a damn good thing about gay men controlling this epidemic and through screaming and demonstrating getting money for all of these departments and organizations. how many more infections of

std's? how many more years have to go by before san francisco of all cities the health department says, hey, gay men, surviving this plague. thank you for bringing down these rates. i want to know what you are going to finally say something positive how gay men have contributed to controlling this plague and controlling these std's. we have been through an epidemic, a plague, and you have never spent a cent to say thank you to us or congratulate us for surviving. >> thank you.

>> you are going to give us public testimony on this case. >> i have notices a resurgence of the healthy penis again and i guarantee millennials stuck to their social media. you need drop it. it was a bad idea when it first came out even though it contributed to my collection of multi-racial sex reduction toys that sit on top of my computer at home to remind me of the deemization that michael patriles talks about. you need to drop the waste of money on

the healthy penis campaign. it's really insulting. >> thank you. is there further public comment? >> not that i'm aware of. i have not gotten any request. >> commissioners? commissioner chung? >> thank you for the presentations. i have a few questions. the first one when we talk about treatment as prevention, we are talking about someone who are adhering to their hiv medications. for a long time we also talk about community viral load. do you have any analysis on how the declining trends are attributed to aids, a decline in community viral load? >> yes. the idea of community viral load was originally to look because

viral loads are portable to the health department so we would add the viral load to what the population is in the city. really what we and the epidemiologist is what is the percent of persons per population that are suppressed in all the neighborhoods. the reason is because that is something that translates into understanding how well we are doing to reducing transmission and the numbers in the community viral load less so. it's the same idea. in terms of how many with virus, but how many with virus levels that are so low that would be considered suppressed and not at risk to transmitting to others. that is being done and worked on. i believe when you are getting to zero presentation in july, that those data can be part of that. there are maps and other ways of looking at that throughout the city. we know that what we want to do, the next step

which is going to be the next part is try and work with and support the areas and the people who do not yet have a suppressed viral load to make that even and suppressed throughout the city. >> we have to wait until july to see those numbers. >> i'm sure we can get with the commission before then. >> another question about how we engage other populations looking at you know i think i appreciate mr. patrelis talk about how gay men have been in the forefront leading the effort and i think that's something out there community might not be as aware of for

instance. as we look at these trends whashgs it looks like for young gay men of color 15-24 and for transgender women and will we actually have some of those numbers that is unpacked from the larger? >> yes. we should be able to do that. whenever the numbers are in small sizes then we try not to release those because the people can then be potentially identifiable if we break it down too small data packages. the larger ways of looking at the data in smaller packages nor different combinations could be done. if you are able to let us know what it is you would like to see, we can work on pulling this together and giving them to the commission for review.

the last question i have is you mentioned the is viral load can be reported. if someone on medi-cal or medicare does not engage in public health clinics, do we have ways to track those as well? >> yes we do. those viral loads are reportable to the health department and it's funded by cdc to do monitoring which follow ups on cases on hiv and follow up on cases and do data on people in care and out of care. it was limited to people in care and will help us gain understanding to the factors involved with being out of care. >> i think if we have those pieces will help us get a better picture of what contributes to the reductions

and hiv new hiv cases in this city. i could be wrong. it could be the changing demographic and everybody being celibate and now who knows. thank you. >> commissioner singer? >> thanks for your presentation and your work. i have two questions. the first is, we were now it appears coming out of the period where we've had lower rates of transmission and now we are worried about those rates increasing. is there anything about the pathology of the diseases that's different today than it was when rates were high? when the rates were high years ago? >> in the past is there anything consequently and different about the data? >> no. there has been concern

that we've been monitoring for this idea of a potentially drug resistant gonorrhea. but actually the cdc data over time looks like that risk is decreasing probably because patients and providers are doing a great job of giving the recommended treatment and that has effectively reduced the risk of having that emerge. for a while we thought that gonorrhea might be changing but it doesn't appear to be so. from everything we know there is no biological reason. i think that is a reasonable thing to think about and we will continue to monitor for that. it's a good point. >> as more people are treated and their population of infection agent is suppressed. my second question is in your focus group data you presented it was limited for sure in what we saw. maybe you can talk about this phenomenon for

a second. it seems like people they decided to have definitive view for the risk ratio with their behavior. let's just take that as absolutely truth. how does that impact their educational material in terms of raiseing the cognition of the risk, i guess? >> i think the challenging thing, i think we need do a better job of people understanding the potential risk. it can be a serious infection. but for most people what the focus group people said is correct. it maybe easier. they are cured once treated as opposed to the virus like hiv. they are very savvy

about std's. as a department we want to make sure we are giving accurate information and recognizing that we have a very knowledgeable population. we don't want to over below the risk or the concerns around std's. that's one of the things where we are weighing. if we have people acting as rational economic actors and really weighing the risk benefit as you said, how do we give information in a way that doesn't over below the risk or minimize the risk and give the right information at the right time that they need to make decisions and recognize that with that information people decide to make decisions that might put them at increased risk for std's because it's not their priority at the time. we are hoping as we might understand this that we might learn from the people themselves what maybe helpful to them and their friends. we are having to go back and look at sexual health in a different way and understand

that hiv prevention and std prevention can't be packaged together. condoms certainly prevent both but condom use is going down in san francisco. what can we do but to make them available and make sure they are effective and for people who do not use them what we can do to prevent them from contracting std's. we need to try to figure out the help of people we are working with and for. >> thank you. >> commissioner? >> thank you for your presentation. as you unroll these interventions over time, i suspect we'll be get anger update -- an update on which ones worked. this comes from the community public health committee. so i know i'm not part of that anymore, but

just the idea of getting a feel of what are the publicity campaigns , social media campaigns to stay abreast of that would be great. >> i would like to comment on mr. patrelis comments. i would like to see more positive ads. i think we need to have a different approach to some populations and there is a population that still needs access to care and we need to focus on being the expert of std's for the health network and ensuring the health network looks at this as an important issue to manage within their population as well. she does some incredible work of the providers but she's right in and this is one of the bridge activities

i want to see from the public health division to the network so that dr. phil ips expertise and knowledge can be provided to the network. i know there is a commitment to make that happen. >> thank you, i had several comments. and thank you for the report. sadly, the report from the last time as you have already noted is not any better over the past year. and i think most of the comments here are really appropriate for what we need to do. i'm first struck by the fact that i can't get my handle on where the real problems are. first i don't know if we take other men and females in your reports as to whether that's also a problem. is it too high, too