of providers to provide prep as well as to get the word out to individuals who might benefit from using prep. and you'll hear again some more about some innovative prep programs in just a few moments. but we do -- are concerned, again, about issues of disparities. and in particular, we looked at data from our significant prep program here in the city through our s.t.d. program, through city clinic, which provides probably the most diverse array of preparation provision in the city, and you can see that when you separate it out by african american, latino, white, and asian, and you go from left to right in each cluster, from 2014 to 2017, we've increased everyone who might be elibility for prep, but if you look at the increase just in the prior year, we're not doing as well in the african american group, which is lagging behind, so

again you'll hear about some innovative programs to improve uptake in that population. there were data presented this summer that were very exciting that supported a letter that the c.d.c. issued last week about you equals you, and you equals you equals undetectible means untransmittable, and that means that people who are on h.i.v. treatment for a period of six months and fully virally suppressed cannot transmit h.i.v. to their sexual partners. there's data now on 150,000 sex acts and no transmissions have occurred in all of those episodes, so this is very important to get the word out to individuals, and it's a very important antii go in aum campaign so that people living with h.i.v. recognize that they are not infectious.

unfortunately, h.i.v. in many parts of the country are criminalized, and we need to reverse some of these criminalization laws. i'm going to end talking a little bit about homelessness. as dr. sheer presented, 14% of our diagnoses are homeless. you've seen also that the word viral suppression rates are in people who are homeless, and homelessness is also a substantial contributor to death among people living with h. h.i.v., so i'm going to show you two pieces of data. this is from an innovative analysis done of patients being seen at ward 86, in which if you go from left to right on your screen, from most stably housed, renting and owning, to being in a rehabilitation

program, being in an s.r.o., hotel, couch surfing or staying with friends, shelters, and living in the streets or being outdoors, the proportion, the bars show the proportion of people who are virally suppressed. you can see as you become more marginally progressively housed, your viral suppression goes down, and the average viral load, that red line, goes up. we know that having a higher viral load is bad for the individual in terms of their health and bad for the risk of transmitting to others, so we know that homelessness is a major driver of new transmissions, and that we need to get to zero, to get to zero h.i.v. infections and zero h.i.v. associates deaths, we need to reach our homeless populations. this is an evaluation done under dr. shear's leadership in which we look the at 50

individuals who had recently died in the last couple of years who had been living with h.i. vichlt in section to see what portion of their had substance abuse, or homeslessness. you can see that 60% who died in this subgroup, 60% had substance abuse as a contributing factor, 34% had mental illness, 30% had homelessness, and 68% or over two thirds, had one or more of these contributory causes. so it speaks to what we need to do in getting zto zero, and i' going to turn it over to traeyy packer about more of the initiatives that we have. >> good afternoon, commissioners. i'd like to speak to you on two areas that we're working onto

address the disparities that the doctors described today. you know, and san francisco is doing an amazing job, and we've really seen such change in these years, but there are really important populations that we're not reaching, so that's been our focus. that's what we've been really talking about now, is how can we reach the group communities that we haven't been able to reach successfully. so we applied for a grant, the c.d.c. grant. it was competitive. it went along with our core grant that we've gotten in san francisco since 1991, and this was a competitive grant that was awarded to san francisco. we were one of two jurisdictions across the country that received $2 million each year for four years. and what we applied for specifically was to reach people who are homeless or otherwise disconnected from the systems that we have here in san francisco. you'll see that the -- we've named it project opt in because

we always need cute names for everything, and it's better than calling it component b-e which -- b, which is actually what we often call it. we just got started in july, but we're rolling. but what we'll be doing is outreaching and engaging people who are homeless. i want to stop and talk about we are engaging people who are homeless, and we know that addressing homelessness is a really important part of this, so we have strong partnerships for those who are in the best city departments. so outreach and engaging people who are homeless, and this is a grant that's addressing h.i.v. and hepatitis c. we've found that people being offered hepatitis c testing and treatment is actually motivating to maintain their hiv treatment. so it's including treatment of

hiv, help tpatitis c and stds, figuring out how to reach those in greatest need for prep and treatment, and you've heard the data that's not spirinspired t. and then, thinking about how we can change the system that we have to make it more accessible, so it's coming from two angles. one is outreaching with people and then making a change in the system. we already have some experience -- i think you've heard about our heath fairs " we've been doing in homeless encampments, and you'll see some of this in the report, the way that we've been able to start some of them on prep and

provide health care. so we'll be addressing substance use issues, mental health, in addition to homelessness, and we're working -- show you this slide. this just demonstrates the interventions within interventions. i think what's really important is we're working already with whole person care. also, behavioral health, and their work, and the san francisco health net work to look at how we can shift the system -- you know, build on the strong system that we already have to reach this population. so that's project opt in. and then, the second thing i wanted to talk with you about is the road map. this was actually inspired by director garcia. in 2018, we received our grant

from c.d.c. we received a significant decrease in funds, and while the -- your support and the city's support and the board's support has been incredible to backfill those dollars, we know that that will not always be the case, and that there will be a time when we see significant decrease in funds, and so director garcia commissioned us to figure out what we're going to do when that happens. so we came together, and we developed a plan for how to address three diseases really coming from a people-centered point of view and not a disease-centered point of view. the idea is not just to get to zero but to stay at zero, and that's not free. that does cost funds. the key thing what this slide is telling you is it's very much a community input process.

so we developed ideas and thoughts, and then, we went out to the community, and we had six or eight meetings with different community groups -- actually, it's probably up to ten now with our h.i. vichlt community planning council, and uses something called scenario planning and got input on what needs to happen out there in the community to address the dais parities that you heard today. -- disparities that you heard today. we're work og that, but left lane be in the r.f.p. that we're going to put out for community based services in the very near future, and that will address the disparities that you heard about today. so that's it for me. and now i'd like to introduce nicole trainer. she's a little bit new with us in the health department. she started with the pride department and she's now the director of community based services for getting to zero and she's going to go into depth on the program that's

have been developed to provide prep to the communities, and she's been an amazing champion with these programs. >> good evening commissioners, how are you. as tracey mentioned, i'm nicole trainer. i've been working with city clinic for about ten years, but i've had the pleasure working with dr. susan phillips and tracey over the past two years. so for the next few slides i'm just giving you a brief overview of our san francisco prep funded programs which provides prep provision and also prep referral programs. as dr. bucklinder mentioned, the prep services that are directly funded to our c.b.o.s are one of the pillars that are influential to getting us to

zero. so to increase our access around san francisco, we have collaborated with multiple community based organizations nard to our primary -- d.p.h. primary care clinics, city clinic, and also some of our private partners such as kaiser to expand our prep services here. we've learned that working in our individual silos, we just can't get to getting to zero, so it truly takes a village and all of us working as a partnership to ensure that everyone has access, specifically for communities of color, we find that when we work in our silos, communities of color tend to fall through the cracks. our current data shows that individuals who are interested in accessing prep, they will seek services at at least three of our community organizations or our d.p.h. care clinics,

whether that be for health education, or a direct bridge to prep services at three of the agencies that are listed there before they actually decide to get on prep, so our data shows that one client may go to lyric first, to see what services are about. then they may go to sf aids foundation, and then, their final stop may be the aids clinic to where the prescription is written. so it's important that all of our organizations are working together so that individuals don't fall through the cracks as they're trying to access services. one of the highlights that i'd like to mention is our new partner which is a pharmacy delivered prep program, ad -- mission wellness pharmacy. so in collaboration with mission wellness pharmacy staff

and director and owner maria lopez, san francisco was one of the first cities to implement a pharmacy deliver prep program. this was modelled after a program in seattle, washington. this program, mission wellness pharmacy is located in the heart of the mission district in san francisco with a capacity to provide same day prep provision at little or no cost. mission wellness pharmacy also provides a full panel s.t.d. testing, h.i.v. and hep-c testing for clients absolutely free. so this is unique in that you don't need to go to a clinic or see a provider to access services. you can go to this pharmacy. this is a community based pharmacy and they are well connected to the community.

so far, mission pharmacy laurchled lunched in 2018. seven of the patients are within the priority population, three are african american cis men. one is an african american cis woman, and one is a white cis man. and although 12 may seem very, very low, for this unique location and the fact that maria and her staff are reaching what we deem as hard to reach, or folks who perceive themselves as low risk, this is really a significant number here, and it's continuing to grow. so in addition to our other existing new pharmacy prifr prep program, i'm pleased to announce of we've launched our second iteration program. this launched in february of

2018. i'm hoping that many of you have seen this campaign around the city where you live or digitally. we have this posted on social media platforms, and we also have some commercial spots as well in private tv shows which reached a lot of our folks in our priority population. this particular prep supports campaign focuses on the african american community. so after careful analysis of our successes, our challenges, and some of our lessons learned from our last campaign, we realized that over sexualized images of people of color portray a negative narrative of the message we are trying to convey. so thus, during our second iteration, we hired some experts to help lead our efforts. so prior to the creative design process, we used the

ethnography method to gain insights. they conducted local and digital ethnography, along with indepth interviews with the community and stakeholders and they also did community observations. so prep supports has a strong community voice along with strong positive images of people of color, as you can see. the photo in the upper, i think left to you, it's prep support to the powerful. this is terrence wilder. he is a community activist and currently works at the san francisco aids foundation. that's one of our most popular images that really resonated with the young men in the bayview-hunters point area. in addition to the mission wellness start-up, we've launched -- it's not in this power pet yet only 'cause we're

just getting it underway, as sunnydale, san francisco department of public health is supporting testing at sunnydale community center, so right now they don't have a place for the community members to get free s.t.d. testing. they will either have to go to southeast or third street or come downtown. so within the next month or so, you will be also able to get a full panel h.i.v., s.t.i. and hep-c testing in sunnydale. to move forward -- so in addition to our prop supports campaign, sfdph partners with i.f.r., also known as the latino wellness center. this particular campaign was home grown, meaning that all

the staff brought their talents together to create this campaign. one of the staff members also participated in the prep supports campaign, and what we wanted to use is the foundation of the images and the platform from prep supports to use as v viva prep. if you see both of these campaigns in the same area, they're not competing for the same thing. they have the same messages, be they resonate exactly to the people we're trying to speak to. these images are of the community, and the image to your left is a mother and her son and her son's partner, so it really resonates real life stories, as well. so moving forward, the prep support and viva prep will have a second launch later this year. the prep supports will include more cis women, also cis men, youth, and couples, and all of

this with feedback from the community that they wanted to see a variation of images. so we heard that th-- them, an we're going to put that out more in the next few months, as well. so the last slide here illustrates the number of folks starting prep, and i just want to make a clarification on dr. bucklinder presented more of the entire city. these numbers that i'm presenting here are the starts that are within our prep network, so these are agencies who are either directly funded through us or have subcontracted through the agencies that are directly funded. so currently, we have over 1300 prep starts, 513 came from our community based sites, and 879 came from the clinical sites.

we have these broken-down with our priority population. a total of 133 black m.s.m., a total of 376 latino m.s.m., 214 young m.s.m., and 252 trans women. please note that number does not include our subpopulations as the total number includes prep starts of folks that are not included in your priority population. one thing i also want to point out is prior to the release of the prep supports campaign and the viva prep campaign as of january 2018, there were only 658 prep starts. and since the campaign has released, that has doubled. not to say that we can contribute all of the efforts of new prep starts to the prep supports campaign, but we can say with confidence that it did have an influence on the number of new prep starts after the campaign was released. so thank you very much.

if there's no questions, i would like to turnover the remaining of the presentation to dr. susan philips. >> okay. we'll proceed with the next presentation, then, we'll get questions. thank you. >> thank you very much, commissioners, for the opportunity to come and talk. and it's going to seem like i'm shifting gears here to talk about the s.t.d.'s, but we have to remember that h.i.v. is an s.t.i.u. i think it's important that we're presenting together, because we can't separate the work that our groups are doing. they're incident every twined, and as you heard, a --

>> interview: intertwined. a lot of work is happening through san francisco clinic, so the work really is all together. so looking at -- at s.t.d.'s, the non-h.i.v. s.t.d.'s in san francisco, unfortunatelily, the story is not as happy and rosy as it is for h.i.v. and a lot of that is because of the immense power of biomedical h.i.v. prevention, and how strongly all the partners have worked to get prep and treatment into the hands of people that need it. we still have a long way to go, as you can hear, we're work og tha th -- working on that. it's not really a consolation, but our colleagues all over the state, the country, and quite frankly, the world, are seeing

the same thing. many of us just came back from the national s.t.d. prevention conference run by c.d.c. last week in washington, d.c., and there's a lot of press focusing on talking about how this is the fourth year in a row of the highest numbers of chlamydia, gonorrhea in the country. there are ways in which there are very effective tools to prevent pregnancy, prevent h.i.v. that don't always necessitate condoms. and we have data in san francisco to really show that behavior has changed over time,

and i think that these data are really useful. this is from the national h.i.v. behavioral surveillance survey, which is run here in san francisco by our colleagues in the center for public health research that's in the population health division. and this is a survey that's done on a period of every three to four years in a scientific way as a c.d.c. study. and every three to four years they survey h.i.v. uninfected m.s.m. and who have sex with men in san francisco. and who you see here is over time, just a selection of the variables that they look at. you can see the green line there for reported prep use. the red line is steer sorting, which is choosing a sex partner based on knowledge of one's own status, and the partner's status, and consistent condom use. you can see prep use reported by these participants was very,

very low through 2011 and then really increased in 2014 and especially in the most recent wave in 2017 of the survey. at the same time, steer sorting, which was another h.i. vichlt prevention strategy employed by the community was increasing and then decreased in 2017 down to 21.4% reporting that strategy. and consistent condom use has been decreasing that entire time, so it's important to point out that that preceded people reporting use of prep. we see that condom use was declining even before prep was reported being on the scene as a significant factor. and so, you know, with these advend, just as for h.i.v., we really are focused on the disparities, and focusing on key populations who are at the highest risk or suffer the

highest concentrations. that includes day men, young transgender, people who are jail. show you a little bit of the numbers of s.t.d.'s for people who are in jail, and then pregnant woman, trying to prevent congenital syphilis. this is one of the most devastating consequences of having an s.t.d. it can be transmitted from a pregnant woman to her baby if it is not treated. can lead to severe abnormalities up to and including stillborn and/or neonatal death. it can be prevented by screening and treating infected women with pencillin.

we are really prioritizing female patients with syphilis for this very reason. now the percentage of women as these cases increase in san francisco, the percentage of women who have it is very low. it's under 3% of the total early cases are in women, but the absolute number is growing. and in fact through july of this year, halfway through 2018, we already had more cases in women than we did in all of 2017, so that means that we're really prioritizing our d.i.s. resources, our investigation resources towards this population to prevent congenital syphilis. so we are doing in lieu of interesting really effective biomedical tools, which we'll show you that in the last slide, we really feel that there are two approaches that we need to take. one is to use the resources and

the tools that we have now more effectively, and the second is to engage and get community insight into how we should be dealing with these issues. all this is incorporated how we approach getting to zero, how we are looking at our road map, and we are looking at very news to approach this. just focusing on being more efficient with what we have. like the rest of the department, we are really undertaking lean and found that it has had some benefit for our disease teams. syphil

this tdsa is now engrained in what our teams do. the important part is that that same time, it saves resources into allowing the d.i. to engage with the people they're serving, their clients, and to engage people who use or services and benefit from them. we know that the sooner people get their test results, the sooner we can reach out to them or have them come in for effective treatment, and the sooner they are cured of that infection and not unwillingly or unwittingly transmitting that to sex partners.

cla midi can -- to allow for 90 minute gonorrhea and chlamydia testing and that's really been done with his help and the work of dr. stephanie cohen and her team at city clinic. so this allows for results in 90 minutes. this began in the spring, and during the short time that we've evaluated so far, 92% of the patients that were screened for chlamydia received same day treatment, so that's a big increase over what we were able to do before, so we think this has promise in selected situations. we're not able to do this for everyone because it does take quite a bit of time and expense, but we think it's a great tool and for testing and strategies. while we're very excited about having that technology at city clinic, where i'm most excited

about potentially rolling it out is in partnership with our jail do jails. this is to really think about having a satellite clinic -- sorry, a satellite laboratory at the jails which has not been done before and takes quite a bit of doing to get a certification at the jails. but if we can do that, we think we're going to have great public impact. so if you look here at these data, you see there is a public that's screened, females age 15 to 30, but the males age 15 to 30. it suggests we should be screening more people and potentially able to treat them. concerningly, if people are screened at the jails they're very often not able to be treated because they're released because we're not able to find them. we're unable to locate people because they have very

incentive for providing locating information when they're in custody, so we think that this technology that allows a 90 minute turnaround, it will be really excited, and we're excited to see how this works. one of the reasons that we're very involved is because city clinic is our kind of bell wether for how things are going. we're working very hard to make sure that data is accessible to us after the conversion. we're also seeing a lot of great opportunities. with the roll out of uniform

soji, questions for appropriate patients, we'll be able to try and offer clinical support for doing the screening and reminders, so we think it's going to be a great thing overall for the health net work. another concrete thing that we've done with the tools that we have now, limited as they are, is to really try and make sure that we are being appropriate and inclusive on the data that we are collecting and to be able to understand better the sexual health needs and health needs of transgender individuals. so previously, we did not have -- this is a confidential morbidity health forms, which is required diagnosing many conditions, but chlamydia, gonorrhea, and sfilz as report roed to -- stils yphilis as red

to us in sf health. we think we'll have better data to review and to report and to understand with this in place. so i talked a little bit about improving what we have and work wg what we have, but we also want to do better and innovate, and we know to do that, we've got to talk to community. so how do we think about improving our partner syphilis services in we're trying to reduce waste, but what do people want and staff want in terms of that, which prevents ongoing syphilis transmission in the community? we've collaborated with ucsf and some researchers there and have completed some interviews, and that happened with both our former supervisors and staff with the d.i.s., and former clients who have worked with us, who have declined to work with us, so we've done a really good job. the staff at city clinic have done a great job of recruiting

people to talk it us. we're -- talk to us. we'll have some information to share later this winter and certainly next year when we report back to you, as well. for young women, there's a planned young women's sexual health advisory board as well that we would really -- are excited about, and we really want to see the information that comes out of this. so this is a follow up to some pilot interviews that we did with a doctor from ucsf, and we saw that condoms were available when she talked with a small number of young people, and we are specifically talking about the southeast neighborhoods. condoms were available but not always accessible. so we really want to go more in depth and understand, and the advisory board leads for the department will be jackie mcwright and also nicole trainer here. and it really dovetails with

our bahi chlamydia work group, which i chair with shavonne nester. one thing we like to do is think about a social marketing campaign with young people of color, to think about sexual health holistically. there's really not no longer a blur. we want to make sure that all of these populations are understanding sexual health opportunities, tools, and know that the department is concerned about their sexual health and wants to make everyone have as strong as sexual -- as sexually healthy a life as possible. so finally we don't have biomedical tools at the moment, but we have to keep working towards them. we don't have these things yet. we don't have a vaccine for

gonorrhea, for syphilis and chlamydia, but san francisco clinic is going to be an important site when they are being tested. fingers crossed and we'll stay tuned and hope that n.i.h. continues to get its funding because we really need these tools in order to combat the s.t.i.s. thank you. >> thank you very much. i want to thank all the presenters because we have talked about trying to present together the h.i.v. and the other s.t.d.s, and i think we've finally done that. commissioners -- there was no public comment? okay. so commissioners, questions? at this point, commissioner guer mow? -- commissioner guillermo? >> yes. unlike the h.i.v. presentation, there was no data on ethnicity, and so that's one question i

had, will you have that, especially given the prioritization of communities of color. the other is in terms of the increase in syphilis for women, is there any indicators of risk factors relative to housing or homelessness and any other social condition? >> yeah. thank you. thank you, commissioner. yes. we do have data related to race, ethnicity, and i'm happy to share this after this presentation. so what we see is that rates are highest in black, african american and latina women -- young women. that's sort of the priority populations for increasing screening. >> and even with syphilis, when we correct for population, rates are higher for black african american men who have sex with men compared to white

men who have sex with men. and then, your second question was -- >> on the increase in. >> syphilis in women. >> yeah. >> so there have been associations with behavioral health issues with marginal housing status, and we're actually working to look through all the different factors at the moment. and our first priority has been to mobilize to make sure that we are doing everything we can to engage and make sure that the women are treated and we're in parallel of the process to look at especially what's happened in the first six months of this year compared to last year, so we will have more information to share about that. >> commissioners, other questions at the moment? i had one on the continuum of h.i.v. care on the slide, that's about one, two, three. and it had to do with the

difference between -- and this is the one that begins with a new diagnosis. it was especially trying to understand that in the lowest block, you have in terms of retention of related to -- the retention of care for three to nine months after linkage, and there, even in this last year was at 71%. yet you're able to show a viral suppression amongst all new diagnosis of 85%. so how -- how do we sort of account for those people who actually have left, and yet, we're showing within 12 months that there's viral suppression? >> i don't any that they have left -- think that what they've left. i think what we find more and more is most people don't have a second care visit after their first care visit. so they get the care, they get on treatment, and then, at --

it may be -- it may -- it -- that might be their only care visit after diagnosis, so a lot of people sort of clinically have decided that they can be well maintained on their treatment without a second care visit. >> so you don't consider them as being retained in care -- >> it's just a -- really a surveillance definition of what retention and care is. so -- so what -- ideally, we would like people to be tested every six months, but some people don't feel like they need to do that. some people who have been maintained on their treatments for a long time, even in conjunction with their provider, don't feel they need that. that's why you do see, even among people who are living with h.i.v. versus people who are diagnosed, he see they've had a link to area, they're virally suppressed, but they

haven't had two or more care visits in that year. >> and yet you're able to get them back in 12 months and find out that they're suppressed. >> yes. >> okay. i'm pleased that you're working together to try to bring the message of s.t.d., that is the gonorrhea and syphilis issues at the same time we're doing the h.i.v. educations because i recall a year or two ago that we were talking about why these were all separate. and although the syphilis presentation still turns to be a little more separate in terms of -- of the approach at the moment, but -- but at least we're kind of bringing these together, and speaking about them as -- as you say as one set of s.t.d.s and trying to also hit the target populations, which i think what -- at least about a year

ago, we were hearing that was -- that was a need, and i appreciate that -- the presentation is showing that we are beginning to approach those needs and showing those results. okay. commissioner loyce, were you next? commissioner bernal? >> sure. my question is regards to the stigma pillar of getting to zero and undetectible versus untransmittable efforts. i know the big aids conference, they're asking departments of public health, other organizations to sign on with a declaration or statement in support of the findings. have we done that, as well? >> we have. >> we have been more integrating it into our message when it comes to the stigma. >> yes. tracey is actually launching a campaign within the health department of u = u.

it's a program that's being launched in part of the same way the prep part was being done, we have a campaign, and i think that's being launched later this year. >> okay. thank you. >> commissioner guillermo, did you have another question? >> i did, actually. this is a question for nicole. you had mentioned that in the slide that talked about the prep services that there were at least three contacts that somebody would make prior to actually starting the prep regiment. how do you track that there were three contacts with -- is that an individual patient -- i mean individual following or how is that data collected? >> yes. so what we've done is using or data prep programs, four of the prep programs are directly funded by d.p.h. in addition to

their subcontractors, we meet every thursday to talk about challenges and so forth, but one of the other things we've implemented, we have prep performance measures, and there's also data collection methods and tools, so each of the organizations have revised their variables within their individual health care or e.h.r. systems to align with the variables in -- for our prep performance. so each agency is collecting the same data. so every quarter, the agencies are required to send client level data to our department, which is then validated and decoded and deduplicated. and so within that, each client is coded. we can see that one client -- it's -- they enter prep services through a prep care continuum, so we have community engagement at the beginning of the prep care services. so any individual who goes to a community health fair, comes

into the clinic, and the prep provider is able to get enough demographics from the information, they're considered to be engaged in that particular program. then, that person may then go onto bridge to prep services, meaning, they want to access prep and get started on prep. so all of that information is then given to us, so i can see where a person starts at community engagement at one clinic, so they don't have a first dose. but i did see that the first dose happened as another clinic visit because it's dated in chronological order, and it's client level data, so that's how we can see that. >> that's anonymous. >> client level data that's anonymous. >> i mean, is it individual, unique identifiers or is it -- >> they have to report to us, so we conditiononly can see th information, and it's reported

directly from the c.b.o.'s to the health department through encrypted systems. >> commissioner loyce? >> first of all, thank you for your stellar work. i appreciate it. i have a comment, and then, i may have one, two, or three questions. i'm not sure. the comment first is that i'm glad to hear that you're using a form model for developing strategies in community and particularly around prep in s.t.d. work. i'm impressed with that because i know we've had that conversation. in relationship to the jail piece, at what point are people incarcerated that they're given the screens for s.t.d.s? is it when they arrive? is it 24 hours later and then they're out in 25? can you say a little more about

that? >> yes. it varies. there are some people that are offered it initially upon entry, and that's the situation upon which someone may be released and then a test result comes back and we're not able to treat them. there are tests that are offered as people that are in jail as well, and we're much more likely to ensure that those people are treated. but our goal would be to offer screening as many people as come through the jails and be able to treat the people who come back at positive. it's going to take a while to ramp up the process and the work flow to see really reach that -- work flows to really reach the lofty goal. >> okay. thank you. appreciate your comments. another comment. i'm really troubled by this conversation. this notion that most young black women are not worried about h.i.v. and s.t.d.s and we

don't have a strategy to inform our community how important it is to address s.t.d.s and h.i.v. and the common use, and the engagement of prep is important. but some of these young women are engaging in relationships with men coming out of the prison system who may have been infected in the prison system through tattooing, through sex with men in prison, and they may not infected with transmission early in the epidemic. that's what used to be true. i don't know if it's still true, but early in the transmission, we knew that men were coming out of prison and infecting the community. is there any connection that as well as those who have been in jail for a while? >> we don't have that information, but i think that's

really one of the reasons that we're looking forward to having this young women's advisory board, so the numbers i showed you were based on a limited number of people saying what they and their peers have been saying. it leads us to say we need to learn more from people that are really experts that are young people who are experiencing this and are talking with their peers and so on. so i don't think i have the information right now to answer that, but we're hoping we'll get more information in particular how to engage people to understand what all the sexual health options are, to understand what the s.t.d. related issues are. and then, people have sexual health priorities and people have strategies, and the primary strategy may not to not acquire h.i.v., and that's

wonderful but people need to be able to access what they need to at any point in time what they need to for their sexual health until we have multiplex tools that can prevent pregnancy, h.i.v., s.t.d.s. that's really what we need, but what can we do in the meantime to be effective. >> thank you. i yield to my colleagues because i could do this all day along. >> thank you, commissioner loyce. commissioner chung. >> thank you, dr. chow. maybe commissioner loyce and i can do this after the meeting all day long. the questions i have is around st stigma and campaign on u k= u. i actually know the group that

started the u = u cam tapaign. if we focus on saying undetectibles are the ones that won't transmit, the kinds of message that goes to those that are not virally suppressed by not by choice -- >> you're raising a really valid point, which is not everybody is able to be virally suppressed. >> and the reason why when you were sharing the viral suppression rate, homeless, and we have a 32% viral suppression rate. so -- and -- and, you know, and to have these kind of messages out there, you -- how are we going to, like, trying to address that? >> so it's a really good point, and i don't know if that's being addressed in the campaign or not. one of the challenges is that people have other life circumstances, and sometimes they also have resistance. and so resistance to the antiretroviral drugs, so not

everybody is virally suppressed. and we don't want to be a a situation where there are good people with h.i.v. and there are bad people with h.i.v. the bottom line is whether you have h.i.v. or don't have h.i.v. doesn't mean you're good, bad or otherwise. there's so much stigma with h.i.v. is there are people who can't transmit. we've got to get out that message without undermining people who are somehow virally suppressed that somehow they're a negative group. i don't know whether that's part of the current campaign or not but that's something that we've certainly -- in the groups that i've participated in with the group that's doing the campaign, that's something that we've said loud and clear that we need to be really careful, that we don't make it a good h.i.v. group and a bad

h.i.v. group. we want to get the news out, but we don't want to further stigmatize a group living already with h.i.v. >> people living with aids, that's a great turnover, so congratulations. >> commissioner green. >> thank you so much. your work is incredible. i have two questions. i went on a jail tour, and if i understand correctly, people can opt out of jail testing, so i wouldn't what kind of programs are in place to encourage people to participate more while they're incarcerated even if it's for a short time. my second question is if you have any expectations about all of the wonderful homeless initiatives, what do you think will happen in terms of the rates of viral suppression and

the other metrics you're following? do you have any sense of what would be a win and what's realistic? well, for the jail issue, i think one of the things is that dr. lisa pratt and her entire team have really worked on making sure that they're accessible and appropriate services. there's a great team that does h.i.v. and integrated prevention services, so they really focus on kind of broadly h.i.v. and hepatitis and offering it, as you said, very broadly, and allowing people to opt out and understand that -- that the health services is entirely different than the -- than the corrections, a piece of their experience. so i think that that gets us -- gets us a lot of the way there. and then, the technology on top

of it will additionally help. so i think that the basis of the staff and the type of work they do, and the fact that it's the department of health that's provide these services is really going a long way to get our foot in the door to have the trust and have the out comes we want in terms of introducing the h.i. vichlt piece and maintaining the h.i.v. and hepatitis testing. >> your program, the links program, which is getting people who have fallen out of care back into care, the rates of viral suppression in the homeless went from 32% to 61% once they got into the program, so there's real improvement when we have these programs for -- when we provide additional for even for the most vulnerable population. >> do you have further question snz. >> yes. i hope you don't mind if i add a couple of things. there's so many of us and we're so enthusiastic, but i wanted

to mention that h.i.p. has reached out to us, and we are able to find funding for an additional person for this team that's going to be providing hepatitis c. testing. the medications are better, and that motivates them to have an h.i.v. test, as well, so that integration is really helpful. around homelessness, i just wanted to mention when we go out to do the fares in communities, people have really expressed gratitude. people -- they had told us that these are the things that they needed, and then, the health department responded. i think people are really grateful when they're offered the care that they've asked for in a way that can work for them. so while that doesn't predict whether it will contribute to viral suppression, i do believe that -- i've been at many of the health fairs, and people are very engaged and really

wanting to take care of themselves. there are other priorities for them, but if we can make it work that their priorities can be met at the same time as their health care, then i think we can make a change. >> thank you. >> thank you. commissioner sanchez? >> yeah. i would just like to -- of all the commissioners that have spoken, i would just like to say this was really an exceptional update. a number of these agencies and prams -- programs, it was very neat to see how it was charted over the years. in the mission district, it's always been on the radar, but sometimes it's been under funded. it's a fact that some of our key institutions of the mission

have hung in there, and i really think it speaks again to the department's outreach, inclusion, to provide these unique services for our young population. as an example, many years ago, the border area health education centers, which funded programs here all the way down to the border, funded the urban area and helped the mission neighborhood health center to begin to look at some of these issues then. some of key people were from the school of pharmacy at ucsf and then did the work in the valley and move odd to other places. -- move odd to other places. funded came out of u.c. general to take a look again at these populations you're now servicing, so they're sustained energy, uniformity pertaining to data collection, and the fact that