this called a [inaudible] this is perfect for someone who [inaudible] because it can easily fit in their [inaudible] and holds 20 syringes. >> so, [inaudible] would you actually be listing wallgreens or is this not for public- >> this particular flier is just for community meetings but in a different flier that we have for participants of the syringe sites we list out all the different places they can dispose of syringes and wallgreens is listed on that >> commissions any other questions you might have? >> no we have relationships with the fire department for restroom access and maybe we can include the fire department on this list. i think people may be more likely to go in the fire department. >> that is a great idea and

something that is own the list of trying to expand our relationship so i mean that is great idea and think that we should move forward with trying to expand the relationship with the fire department and other first responders. >> do clinics have these too or not? >> clinics are disposal sites and that is listed on a flier for the clients, but we didn't put disposal boxes on that in particular. >> do we know exactly why people dont use the disposal services and is there a reason maybe they need an incentive like we do with refundable cans

or what not? >> that is a good question and one wree discussing internally a lot. in the next few weeks we will have focus groups with injection drug users and they are the questions we'll ask of what is not working and what can we do to help us come up with ideas that will be more effective. anecdotally, i think it seems like people are getting moved around a lot so they leave their packs behind or drop stuff and-but you know, education about proper disposal is a key component of the service. i think what we are working on internally is that our syringe programs have more of a system that ties the board of education process of like every time you have the one on one of like, do you understand the importance of

proper disposal and the mechanism for proper disposal, so we are working on enhancing that. >> >> is there a downside of having hundreds of these disposal boxes? >> eighty-one one of the challenges with outdoor disposal boxes is we found it takes a good 6 months before people start using the boxes and there is always different-someone may not cross the street for whatever reason, so >> no different than using a garbage can, if you walk down the street to through it away it is easier to toss it. there may be a downside for having lots and lots of them, but if they are ubiquitous it is easier to not just drop them. >> i think a challenge is that in

placing the disposal boxes we have to get a community process and community input. that can also be the biggest challenge because while someone may support disposal box, they don't want it across from their house or their neighborhood, but we are-it is ongoing conversation about increasing boxes. it is just whether or not it goes through-it meets the criteria and goes through the different mechanisms to get placed. >> i was going to ask if infact there is a optional unit now, mobile unit or 2 and there sole function is to go throughout the city when different calls request for service pertaining to this area-as a example it says park and rec and syringe clean up, but let me

tell you, the movement of people. you go out to the park this morning you will have more than 20 tents out there even around the play ground and conservatory and aaround the academy of science. [inaudible] move people when activities move and the same time when there are functions that park or in the communities [inaudible] there are different activities a lot of the next day or that evening i have a number of syringes and other things close to buena vista school and rafael school and you get complaints from the teachers and they are afraid to work through and call 311. we have like one or two units and the major function is work the pick up and educate at this

point. >> that is something the rapid response team because their sole function is clean up syringes and provide that education and that is what was miss ing before. the funded providers all do sweeps of syringes and in our office we respond to calls as well but it is not our sole function so i think having this team of 3 out there and being able to be proactive and respond will make a difference, because one the challenges now is if you see syringes on the street and call 311, it can take up to 2 or 3 hours to pick them up. >> commissioners we hope we will be hiring as rapidly as we can the 3 individuals on a temporary basis and annualize that in the budget and maybe have to grow that team if we see they are very busy during the time period we have them on, so this is a

important team that we just put together to respond to this issue. we'll give you an update as we see that. >> it is dark side of a very successful program so i look at it as somewhat of a blessing we are having this problem. >> we know clean needle distribution saves live jz have to deal with the outcome of that by insureing the public has-there is concern for their safety fraurm dirty needles so hope the response team is part the solution but scr lots of partners helping as well. >> thank you very much. look forward to the update but the department is moving forward to respond to this issue that is in the papers recently. >> shall we move to the next item? >> yes. item 4 general public comment and i received no request so we move to

item 5 which is report from finance and planning committee. >> thank you, in place of commissioner chung and was privileged to chair it with commissioner pating and we went through monthly contracts report and are reviewed that and are prepared to ask you for recommendation just as a brief discussion, our san francisco community health authority is asked to continue to administer the healthy kids program and we'll provide the private providers which is the second contract. the third contract includes not only administrate was services but developing the sub-city program infrastructure for our program that we had voted on the bridge to coverage. that amount of money is not

just merely for administration of healthy san francisco, but the expanded healthy san francisco and the covered options that we had passed under the bridge to coverage program. lastly, is the contract for the regions of the university for [inaudible] care of the amount of 2.1 million which is the same amount that we have set aside in the past and it does serve about 800 different services for us per year. so, for those services that we don't have as of general. we reviewed the year revenue and expenditure report and we are positive the first quarter. it is only the first quarter and mr. wagner pointed out the big unknown will

remain. the 1115 waver formula-we are scheduled to get a update on that in the early part of next year, but at this point in time they are continuing to use the same formial through the rest of this year through december. i put into risk for the second half of the year, the first half of the year, the first quarter is what was estimated at this time. the third item that we took up was a review of the san francisco annual report outline and we'll look at that and have added comments. lastly, we are in discussions of updated the contract review process. we are very pleased that under the new process that we are able to actually be more

diligent on the large contracts to represent 90 some odd protect of the contract dollars and yet we will be able to have a list of the other contracts and understand those services. so, our recommendation on the consent calendar is to pass the contracts report. >> that leads to item 6 which is the consent calendar. >> if there are no questions in that we'll move on to item 6. we are prepared for a-the committee put forth the proposal for the passing of the 4 contracts so we are prepared for the vote if there is no extraction of the items. all in favor say aye. opposed? the consent calendar is

approved >> item 7 is getting to zero update. doctor >> good afternoon, [inaudible] direct bridge hiv which is based in the helt department and the steering committee getting to zero which is a broad consochium of [inaudible] working to get to zero hiv infections-just looking for my slides. here we go, zero new infections and zero stigma and discrimination. today is world aids day and we made substantial progress and appreciate you inviting me back to speak. so, i thought that i would begin by saying where does getting to zero fit in the strategic plan

and it is how [inaudible] item 6 on that graphic of the strategic plan, but we do also have impact on our others in particularly the issue of black african american health because african americans are disproportioninate ly effected by hiv throughout the u.s. and san francisco is no different but we are doing better. i will show briefly updated slides and i wanted to remind that this beautiful annual report that susan sheer who is sitting in the audience who heads the [inaudible] group she and her team put out year. if you would like hard copies we can get your hard copies and it is on the website and it has interesting data soben that wants to dig into

this in more detail, if you like hard copies let us know. i believe i may have shown this at the summer meet ing which shows we are at the lowest number of new diagnosis in 2014, [inaudible] and deaths living with hiv [inaudible] the death rate is lower. this is new diagnosis by race, ethnis te. this is the total number of new diagnosis per year from 2006 to 2014. the blue line is white individuals, the nob nub line is black individuals and you can see there is a significant decline in both groups. if you were to adjust this for the size the population, however, again we still have a

disproportioninate impact on african americans and latinos. the good news is that in 2014 we only had 14 new diagnosis in women so we are making headway in most populations but still have room to move. i showed woe had 177 among people living with hiv. what you see is the decline in blue on deaths among that population that are hiv associated that are caused by hiv and non hiv deaths in raed so we tremendous progress in the hiv associated death. i want to show the non hiv causes of death over time and point out the green line is drug overdoses and the purple line are suicides. both of

those are increasing and so we are doing a very detailed analysis now of what has happened with those individuals with drug overdoses and suicides and be happy to report back to you if you would like to hear about that the next time i present, but again, doctor sheer and her team have been doing a fantastic job of digging into the data. >> is that [inaudible] or opiates? >> it is both. it is both. it is methadone, it is-it isn't heroin, it is methadone, senththeticopeoids like oxy conten and different kinds of stimiants and it ask also unfortunately benzodiazepines. in the green line is san francisco. i don't know how-they ratio up differently on your

handouts. the middle line is california and the yellow line is the entire united states and what you can see if you start with the group infected, we only have 7 percent of those lichbing with hiv in san francisco who is unaware of the infection. we are doing better receiving care and prescribed [inaudible] and viral surepress so wree at twice the rate that exists in the united states but still have room to move, so i wanted to then talk very briefly about getting to zero initiative. preexposure, [inaudible] these are brief updates-we have now prep nav gators at 3 dph clinics and dh money allocated for nav gators at community clinics

will be announced this month. we got a 1 .9 million dollar a year grant for 3 years from cdc under doctor urgone and doctor phillip who are heading this effort for prep scale up and out reach particularly with emphasis on people with color and transjnder individual. we are dog doing a lot in building capacity and building awareness and building a tracking system to measure impact and we'll see the first data from the tracking system after this worlds aids event. rapid has been shown to make a significant impact on time from diagnosis to vieral suppression and a protocol is developed and implemented city wide. in terms of retention and quer the same cdc grant had nearly a million dollars a year for retention. i think you aware

of the [inaudible] grants given of 500 thousand dollars specifically for retention nav gators that are in the field and we are looking into the data on oferndose suicide and deaths. we will never get to zero without dealing with thes issues of stigma and disrimination so we have a committee that is formed that has a plan in place. i will-these are the collaborations i know we are short on time so don't want to take time away from other peoples presentations but just to let you know there is a fast track city that is highlighted on the website. many people-many cities are signing on, our mayor signed on to it, we are the furcher north american city to be signed on to this website so we have a lot to be proud of. are there questions i can answer?

>> thank you. commissioners, questions or comments? i do think since our other fellow commissioners are not here if we can get a copy of the hiv report you eluded to that is helpful >> if is hot demand this year. it is a beautiful thing each year so glad it is getting so much use. >> [inaudible] so proud of this initiative and what we accomplish. i still share with the visions that don't believe it and say you have to be kidding. we are turning the [inaudible] the possibilities-building a sense that the amount of what we accomplished and the number of heads that we still can turn with this is amazing and the response i get where people see what is possible is more

than amazing. they get very excited for us and our nation and thank you for leading the way. >> it is the whole department that has done this from the beginning and under director garcias leadership. we are partnering now with alameda county. >> could you on the slide of the hiv [inaudible] 93 percent where diagnosed and aware we had 69 percent under treatment, so what happened to the other segment? is it lots to follow up or is there opportunity there to be helpful? >> nationally that is the biggest drop off. for people that are newly diagnosed, it is like 83

percent i believe who are linked to care within 6 to 9 months and are working on making that better. that is points otrapid. the issue is getting people to stay in care. when they get into care all most everyone is in treatment among the people in care, but the challenge is keeping people in care and so this is representing all of the people in san francisco living with hiv. i will say there is a underestimate because there are people that moved out of san francisco. >> this is a great example of collective impact and the fact this is in the long haul, this isn't a short term that the department is part of this whole agenda for a long time and it is exciting to see it pay off. y i want to recognize susan phillip and susan sheer and tracey packer,

they are working diligently towards this effort. >> very good. thank you again. commissioners, item 8 is std update. >> there is no public comment? >> not for that item. >> okay, next item. good afternoon and thank you commissioners. i am susan phillip director of disease prevention and control and std controller in san francisco and want to thank you for inviting me back to speak with you again about std and glad to do it on world aids day along with my colleagues doctor buck binder and all the others we work with closely. this is the same framework. there is

specialized expertise with std that resides [inaudible] we have the biomedical std clinical work as well as work with clinical providers and disease intervention i control which i lead and then we have important community engagement and assessment eeffort that are happening with the [inaudible] branch led by tracey packer. if we look-those are the specialized areas but where std prevention lies? it goes beyond that throughout the department and community och providers and everyone at risk in san francisco. if we look at the cross utcutting efforts std work is important in black african american health, mu turnl and adolescent health and health for people at risk living with hiv. when we think

fwt std we need to understand what drives transmission of std and any infexs disease because if we understand the factors then we taylor or nrtd ventions to group together to address any of these. if we take the example of infexs syphilis, the likelihood of transmission has to-do with several areas. one is how likely is someone exposed to a infexs partner. those can depend on what the local std epidemology is, how privilege are the infections and what is the sexual behavior people are uner taking and screening and treatment that this includes notifying partner and getting preventive treatment out to people. we also want to impact how long a partner might be infexs and screening and treatment is the primary way we are

addressing that. how many people have partner jz sex with partners without condoms. factors that influths that are how accessible are condoms and it goes back to sexual behavior and do people choose to use condoms if they are available. what we are trying to impact is the population curfb. what are the std rates and how to bring them down and i showed them to you in the past so i want to take a step back-that is what we care about, but as a department and a branch within a population health, we also need to be aware of and work on quality and improvement on the factors that we do control. this is looking from 2010 to 2015 at the speed with which we initiate internally contacting a person who we are notified through a laboratory provider has a case of infexs syphilis. the standard is contacting within 3 days. that

is the red line and you see we increased from over 50 percent to 94 percent which is good but we can do better. we are focusing on contacting within one day because sooner contact is better. it is fresh in the mind and may be able to remember part ners and show there is improved #ub89 ability [inaudible] we are focus on contacting with 1 day and up to 78 percent and will try it do better than that and try to get that to 85 percent. this is a internl performance measure to work on to contribute to the larger goal oof decreasing std's. i will turn focus to look at a couple populations that are of highest priority because they have disproportioninate risk of std and the first group is men who have sex with men. this is a similar relate today the slide you saw earlier.

superimposed hiv and std curves now. the gold bars are hiv diagnoses and they are declining. superimposed are the std rates for gonorrhea, chlamydia and syphilis. what is true is std and hiv are very much linked in a couple ways. one is it is critical to understand the std work is essential to getting to zero work and thank doctor buck binder for the acknowledgment of work for the peoplet thado std function. one way we know from our epidemiology and colleagues around the country having infections, particularly rectal like gonorrhea and syphilis and chlamydia [inaudible] a person that is

hiv uninfected those are the people we want to perform hiv testing on and if they are positive get them linked into car and if negative we should offer prep. the other effort is partner services so for infexs syphilis we attempt to interview all cases and interview the partners. those people are offered hiv testing and this is a wiwe do case finding and integrate sexual health services [inaudible] the biomedical advances that allow us to get to zero, also will allow people at times to have sex without condoms and have seen that is reported in surveys over time there is decrease condom use so at the same time the biomedical advances allow decrease in hiv there is

decrease in condom use. that is true opprep but primarily true of prevention that are hiv positive. [inaudible] as a result we need to think differently and think about new approaches to decreasing std's because the old advise of using condoms for hiv and std are nolt always applicable. the decreased condom use is reported, but we do need to increase our efforts to promote condoms, understand when condoms are acceptable and make sure they are available and reinvigorate the conversation around condoms. this is important to understand this isn't something that is happening in san francisco in isolation, it is happening national and throughout california. we are on the leading edge of this in large part because of our success with

biomedical miv re prevention. the rest the country is looking for us to lead this. we are working closely with cdc and partners throughout cities and state and the nation coalition of std directors and are looking to for our input. we are invited to tog about our spaerns at national panels and we are one of few cities invited to present at a syphilis consultation at cdc next month. because we don't have prep for std and vaccines but we very much hope thaes become available in the future we have to fall back on behavioral intervention and sexual health behavior. using condoms and working us to notify partners. those are the key things that will lower rates

and will take new expertise and be anal to understand how to motivate people to do those things and how we can make those activities easier. make them the default. we will engage with a [inaudible] and they will build on the work we have done with focus groups and town hauls. summaries were in the background materials. we understand that this engagement work andmunity activation work and feedback will be the key for std among gay men. so, some the new actrivties and the groupings here have to go back to the slide to show what the key interventions would be based on what causes infection to transmit in the community. we want to have this behavior come on board and anticipate that will happen in january is whatory target date is. we are thinking about new condom education and std

education campaigns in the first quarter of 2016. in terms of decreasing time a person is infexs we continue to do base line efforts and supporting san francisco aids foundation at magnet and other sites and increase community base screening by the [inaudible] brarn that happens where people congregateer bars and gyms. how do woe get people to think about increased condmom use? some hof that work is done with community engagement and town halls. we will try to coordinate with all the efforts happening around getting to jeero including the cdc grant doctor buck binder mentioned. [inaudible] leverage of new dollars to think about sexual health broadly and

includes std [inaudible] and do retention and hiv clinical care. here is a quick post thorf town hall we had in july to give their input of what we can do better. the second group at highest risk are young women particularly young black african american women. we are thinking ways to decrease likelihood of exposure. some of this is overlapping and will try to leverage but the messaging has to be slightly different because the communities are not overlaps and want to make sure twee are relevant and culturally comprehensive. so, in partnership with san francisco health network [inaudible] is a really critical piece of this and the [inaudible] in just a moment we'll hear more about that. to decrease

the time is a person is infexs we want to think about a pilot and one way is home based screening that way they don't have to come to a clinic and increasing condom use. [inaudible] focus groups and particularly town halls and try to do parallel wurb with behavioral hemth consultancy in order to really understand what the needs are and what the key messages might be and where we can assist and provide information. i'll turn it over to my colleagues doctor bennett who is a board satisfied pediatrician and interim medical director for [inaudible] foundser and exectev director of the [inaudible] >> okay. i think we have 7 minutes, so i'm going to let myself be very

brief and let you expand me with question because that i think will maybe get us out of here in a timely fashion. there i go and i learned how to use it. our goal is all the 15 to 25 year old women in the city will be screened appropriately so not just testing women who are symptomatic but women who came with a cold and haven't got screened will get screened. the things that underlie that are somewhat different dependent on the clinic. we have youth spinge clenics that operate different thanly the childrens clinic mpt the questions are the same, the answers may be quite different. what are the current screening rates? getting data from the emr to work with data from city clinic and making sure we

are aware who is infected and due to screening. they were not as simple as you may imagine and work on it and hope within the next few weeks we will have good baseline data. susan ask i have for years have some collaborations from site to site but how can we do a better job around these issues to have every clinic have good robust reslaigzships with population and who they are screening and are there resources to ugment impact of screening and letting them know they are infected [inaudible] will people be able to use condom and willing to use them and what are the behaveer and resources in the communities that change the

diseases [inaudible] that isure cbo's and schools and there are other actors in this outside of this. so, our first steps are coordinating with planning planning and preconception helths. [inaudible] is director of family planning. the title 10 program , office of family planning with state have a intense interest in chlamydia screening but those services are not necessarily coordinateed well with the clinic so suvon, myself and susan hopefully will be the network prevention and population and those programs together to talk about a coordinateed approach. we get the baseline data in the next few weeks to month. we are looking where we are doing well. the youth testing centers have a higher testing rate. there are fewer competing issues in the health of the

population. we are not trying to do this as well as diabetes care but they developed more robust [inaudible] we document what those are and trying to create some solutions to the barriers or ways those practices can be operationalized in other places. part of that is doing pilots on how to improve testing and make it easier. is that giving a testing packet for something at home or picking up at wallgreens or rapid [inaudible] do their sample and drop it off as a wellness center. we will test all those. third street is the ink baiter and that is in place before i got vauchbed and will take time but we hope as we move through had process we will approach clinics to look at their individual issues and offer them a menu

ways we know we can tweak the system to make them better at completing this task and let them know the standard we expect them to get to. that is the [inaudible] brauject. those pilot projects and there are several we will try to get done, we are not sure which will work, maybe they won't send in the mail and get them in the drop off and be incorrectly collected. we will have to work through and see what will work and then we will know what we can offer. any questions? >> are you done-- >> that is susan continuing. >> we need to same biomedical prevention like we have for

hiv. people have said we are not worried about std and worry about hiv andinate others. we do worry because there are cases of ocular syphilis and in seattle some have permanent visual loss. [inaudible] the great work that is happening for treatment but treatment is expensive and don't people to get these infections if they don't need to. we need it think about advances and are on the forfront of that so we need vaccines and rapid tests for std's. we need prep for std's and we don't have that now. we need condoms people want to use. there are no advances in condom science in the entire condoms have existed and need to be at the forfront och all that chblt we vagreat resource here in the department here and that is sit a clinic.

people want to come to us to test new treatments and new diagnostics and work with those areas to try to advance for the people of san francisco so we are grateful for the staff and the patients that come to try to get treatments and diagnostics. city clinic is at the forfront and are trying to do std prevention and have great partners like doctor bennett and the rest the network and leadership of director garcia, i think we will make strides in this area, but there are challenges as well. thank you and either of us are available to take questions. >> questions? >> what is the timeline for the [inaudible] >> please come to the like mike roophone. >> the larger project the

timeline will differ from the other focus areas. for ours we hope to get through the pilot phase and document the best protects thaz youth clinic in the next 4 to 6 months at the most and over that time talk to the larger clinics but what their barriers are so we can start looking at implementing some type of intervention towards the later part of next year. >> some of the ideas will also test out with the men who have sex with men earlier part of the presentation? that type of overlap. >> what we really want to do is get the behavioral health consultant expertise to help us understand what-yes, that concept of pilots and trying new things is important but we want to know what we should try and where to put the emphasis. we are trying to [inaudible] making sure we have screening

and emphasize condoms and what would help turn the dpurfb with std's is help the community inform us. we have a lot of hope because this is a community that turns hiv around in san francisco and think 23 they put their mind to it and commit to it we will be able to achieve the goals for std's as well. >> commissioner sanchez, >> i think it is a excellent report and follow up. i just-one area that is always a ongoing challenge and that deals with 15, 16,-[inaudible] founded child abuse and had integrated services in schools there were a lot of misconceptions about where the cohort would be and at that time we had military basis around and one

of the initial studies done the largest cohort was children of ranking military officers. these were some of the cohorts that were brought to the center and a couple folks at that point and who started the program and it was shifted so forth and so on, but when you deal with this type of information and protocols and whatever, especially with our unique populations and many refue gees coming. it doesn't matter if you are irish, italian, latin, we have to be aware and respectful and at the same time provide some or think about how could we if we do get something on the radar how do we make sure there is a positive intervention protecting--still make a

positive impact for the community because it is tough and it is really hard because of the uniqueness of our communities and as you said so well, the different cultures within the communities. a lot of the communities are no longer white and whatever, they are diverse as they have always been but the community shift jz gives the schools and health clinics that are very very necessary another unique eye to look at how kids are being treated and what we can do to provide interventions if requested >> i think that is why we are trying to be flexible and keep our cbo partners, the schools and other people in the loop and as part of our response because that immigrant child where we have confidentialalty issues and what the family thinks they are

doing, those are kids maybe we should contact at the school in the wellness center and dhat is the only way we have contact with them. the traditional age use have other issues where they have access. it will be have to be tailored to the population in each clinic but that means people have to be nimble and know their options and now i don't know if we have a good enough menu of options to be flex #b89 ability. >> i have so many questions but i think what i'll ask is we heard this at the community population health committee but may ask we come back sooner to get a more details assessment. i have always known std issues are important from a public health perspective but relative scale of overdose obone end

and getting to zero on the other, the community thought is my hiv is being treated, so std's, what does it matter, i can get a pill and take my pen sellen and be back in the game or community so where think it is falling off and messaging is important. i want to ask if you can speak to the importance of this a little clearer and secondly what is your thought about our ability to flatten the curve. i guess i want to ask specifically with regards to msm is rising and probably related to hepc, but what about with african american women, is it rising at the same rate? >> we are on a down slope, it is not helping to decrease the disparity greatly because everyone else

is on a down slope. young african american have quite a peak. there was quite a peak that is coming down but that gap persists regardless. yes, there is some improvement, it is not rapid enough. >> [inaudible] african american women there is a big disparity there. terseiary syphilis and gonorrhea and in infants [inaudible] are we seeing a lot of sequelae or do those come down? >> we are not seeing a lot of sequela in san francisco. syphilis is not primarily in women, it is ovwellmingly in men. we have not had a

congenttle syphilis case since 2009 to 2014, so the sequela are not as apparent. i think doctor bennett was saying the disparities are so striking and even though they are coming down it is unacceptable disparity and the fact it is associated with public infamitary disease and [inaudible] women ithis age range so we want to make sure we follow those and pay the most attention with the groups with the highest disparity and here that is african american young women as in the other parts the country. >> i also think sequela [inaudible] that person by the time they are 20 are flirting with a life of infertility at a time in their life where that

doesn't seem important but will seem more important at 30 and that is true of the added [inaudible] of hiv and other sex wale diseases [inaudible] women getting hurpys and hiv those are not as dramatic and interesting and don't trickle to the community to add lat level of fear. >> [inaudible] so many at risk behaviors it seems this is worth while. reducing std's and reducing everything associated with that in terms of affiliated consequences and associated disease, that is why we brought [inaudible] because we integrate the project with pregnancy prevention parts the department with pregnancy access to help of young women center around a few

issues that go together. >> thank you very much for helping me understand that. >> what i would like to do because this is a very important topic we have been following for several years and at this point it looks like we have taken a number of new steps to try tobound this curve back down or continue the downward slope of chlamydia in the african american community. is that as commissioner pattings we have a follow up to see how well we are doing or where we at the committee level and perhaps in 6 months we can hear futher. i think the documentation of focus groups call for a integration and with your consultant that would be something i would hope we can hear that is moving forward because the message

remains the same and seems clear on the side of the men with men that they are not recognizing the importance of the std's in their lives. those that have gone through even before-i wasn't there before penicillin but pretty close, recognize the importance of trying not to consider that these are just colds that can be taken care care of. there needs to be all that type of education and the fact you are getting a conceltant will be helpful. on the practical side they did have comments about the availability of the city clinic after hours and i hope that would be addressed and be looked rep. at committee level to be more responsive to the community or if those are flukes. i think you are right, a lot

of people rely upon it and looks like woo can be more responsive to answer the immediate needs rather than [inaudible] some problems with the phone exchange. >> if i can focus-interested on the educational strategies and messaging and the other is access issues, access of condoms and clinics, access tothe relevant-whatever the key elements in the screening to detection streement. >> we think this is a good start that we have heard that we are taking a new initiative, bringing a consultant and work with our hiv partners where is where the sexual message will get out and using our consultant expertise to really make that as effective as possible so thank you from the committee side we follow that and will have it back at the commission in about 6 months then and-doctor garcia

would you like to make comments? >> i want to thank the staff. we challenged them to come from a new direction and think they have done that. particularly i like the initiative where we are using public health side to influence the direction of our clinical services and i know it takes time because of the issues we talked about that the clinics are focused on the whole person care and that is a lot of different services at least in the youth clinics we can give this a focus. alameda county started a initiative like this as well so we should look to them as the work they have done as well but want to acknowledge both of their works and think we will see progress in quirking to the community. >> i appreciate our intimately the 2 divisions are working on this. i know this is something we are

working towards and to see it is great. >> [inaudible] >> that is where we are trying to get to. >> one logo-you can connect one bridge to the other bridge. >> be careful. >> [inaudible] we just had conversations about that >> thank you. really appreciate your presentation and you can see that we are very interested to make sure that we can move the needle on this- >> i very much appreciate the commissions interest. this is important area that doesn't always capture attention so appreciate the opportunity the think through this with you. >> any other public comment? >> no public comment to this item. >> due the the issue of timing, commissioner sanchez has to be at the foundations-thank you to the

donors today this afternoon that we would recommend deferring the remainder the agenda to the next meeting with jour consent and is there any other public comment that we need to take at this time? >> i did not rev requests >> we prepared for vote for adjournment >> all in favor say aye. opposed? the

>> engineering relates to internship. as you can see we are at 64%. 16 out of 25.

the third one is 50% of new entry level of new candidates of our system training program. we are challenged on this one. this deficit is due to a citywide shortage particularly in apprentice ironworkers in this sector of construction right now. that being said, going to the final one which is the big number with the project when it relates to construction and that deals with the percentage of trade hours for union journey men and apprentices. you can see the slide we are at 34% of work hours performed by san francisco residents. that's a good number.

so, just quickly i know there is a lot of interest what neighborhood folks are coming from to take advantage of these opportunities. we have the breakdown here with the largest 18% which is two neighborhoods. we go by zip code. 94-1-10 at 18%. 91434 at 12%. i think it's consistent with the kind of clients we serve and neighborhoods that tend to have higher poverty rates and higher unemployment. so that's construction. i'm going to move to the permanent jobs. the end use jobs. the development work fund, a program year or hiring

year august through july. we are going to report on that. the goal is 40% entry level positions with system referrals for each hiring year and then it says if they don't make the 40% then it gets rolled over into following year. if there is a hundred hires in a year, 40 of those hires need to be through our system and in 30, they have that 40% requirement and that 10% deficit and that following gets 40 plus ten people. that's kind of the nice feature this development if in any year they are unsuccessful, it rolls to the next year. just again the highlight and development agreement, there is priority neighborhoods. western addition, tenderloin, mission,