Transcripts For SFGTV Health Commission 20200124

just to go over a few items in the director's report. details. we are monitoring the new coronavirus outbreak, very carefully. cdc has begun to screen passengers at s.f.o. arriving from wuhan, china, where the epicenter of the epidemic is occurring. and this actually needs to be updated as date of writing of the directors' report. 45 people have been sickened with coronavirus that has been from would you hahn and there -- wuh wuhan, i've ask the doctor to give you a specific update, because this is the rapidly evolving situation and i believe breaking news this morning, was the first coronavirus case was reported in the u.s., in washington state. but the doctor can give you an update including the measures we've launched in the health department to ensure we're taking proper surveillance measures. good afternoon. thank you. i am the health officer of san francisco. the reports first started coming out in december 31st. the world health organization reported an outbreak of a novel coronavirus, they're called 2019 coronavirus. it's similar to the virus we had back in 2002 called sars. then in 2012, which was referred to as middle east respiratory syndrome. initial cases had about 45 cases. the cdc is reporting as of today, today's call, over 300 cases and mathematics are estimating that the case numbers are between 400-4400. so they're estimating about 1700 cases. so wu han it looks like there is human to human transmission. the question is how sustainable and there are reports that health care workers are becoming infected. the world health organization is going to have a meeting tomorrow to see if they will declare a public health international emergency. the cdc has put out a travel notice to persons what is called level 2, which is enhanced precautions for people travelling to that area. they've implemented entry screening in san francisco, los angeles, j.f.k., and they're going to be adding two other parents. and eventually -- airports. and eventually all flights will be processed through those five airports. they have a health alert notice sent out on the 17th. and they've developed a test for the virus, that only can be tested right now at the cdc, but eventually we'll be able to test for it at the state. as dr. colfax mentioned, there was a case in washington state. a 35-year-old gentleman who returned from wuhan, who when he came in was fine, but then later that day was diagnosed. we're monitoring travelers in s.f.o. we're reviewing all the guidelines for health care professionals. the most updated guidelines from the state and the cdc, focusing on infection control. we're reviewing guidelines for home care for persons who come for a diagnose but not sick enough to be hospitalized, how should they be cared for at home. we're reviewing laboratory guidelines. and the last thing we're doing is we're going to be focusing on our communications director, will be focusing on how do we develop communication to affected communities. this happened with sars when people in the chinese community became very concerned, not just because their community was affected, we want to have good communications so there is no discrimination. that happened back at that time. and we're also going to be working regionally with the health officials in the bay area to make sure we have consistent communication. so when we send out a message, we all send the same message so people are not confused. those are the key things happening. everything is changing rapidly. we have to be patient of more information comes out. >> so in the interest of the fact that this is a rapidly evolving situation, i thought we could pause here and see if the commissioners have questions specific to this issue. >> thank you, doctor. >> thank you. >> and then just another key issue. the governor newsom on january 10th released his $222 billion budget proposal for fiscal year 2020-21. this is a 2.3 increase over last year. the budget, the proposed budget includes a strong focus on health-related issues, including proposals to expand medi-cal to vulnerable populations, and also to invest in the intersection between homelessness and behavioral health. so these are very much parallel and commensurate with where the department is focused. you have a number of proposals detailed for you in the report. i won't go into them today, but you will see in your review that there is a lot of focus on expanding health care coverage for the most vulnerable. and then really, using health care dollars in innovative ways to address behavioral health and homelessness. there are few other issues in the director's report i'll allow you to read. i'm here to answer any questions you have about them or other things in the department. thank you. >> commissioners? >> shall we move on? >> next item. >> thank you. >> item 4 is the general public comment. and i've not received any requests. i believe we can move on to item 5, report back from the committee and public health committee. >> the community public health committee met immediately before the meeting. we had two items on the agenda, the first was update on the security management plan and the annual assessment as which point we had learned about the progress that had been made in ensuring security in san francisco's various clinics and other units of the department of public health. and the security response procedures for each clinic. some of the accomplishments in providing a safe and secure environment for workers and patients and others was installation of electronic security and access control enhancements, as well as security barriers, investigations on different threat events, which included various events of assault and battery and they'll work with the sheriff's department. the other presentation we received was on the retail tobacco rules and regulations, specifically as it relates to e-cigarette sales. as you may know, san francisco health code article 19 has a number of provisions about smoking in public places, but the new recently approved provisions going into effect on january 29, include no tobacco sales on city property, sales of unapproved e-cigarettes and sales and distribution of tobacco products in general. there was a 30-day public comment period that closed yesterday and the provisions are going into effect at the end of the month, on january 29. >> commissioners? >> next item. no public comment to that item. item 6 is the resolution honoring james e. loyce, junior. commissioner bernal, i believe? we usually don't read the resolution. if you would like -- >> sure i would like to take a moment, read the resolution honoring our distinguished president, james loyce, someone we all have tremendous respect for. should we go down the line? >> whatever you like, commissioner. commissioner chung? >> commissioner chung: okay. whereas james loyce junior was appointed to the san francisco health commission by mayor ed lee in 2016 and will attend his final commission meeting on january 21, 2020. and i guess -- >> whereas commissioner loyce was elected health commission president in 2019 after serving for vice president for one year. during his tenure, he served as chair of the public health committee and member of the joint conversation committee. and -- >> whereas prior to his tenure on the health commission, mr. loyce dedicated decades of service as a valued department public health staff member. in 1978, he began working as a substance abuse counselor and soon became the director of the county drug and alcohol services. after a short stint as a director, overseeing services to homeless individuals, he was promoted to the director of the aids office, administering $50 million of health services, research and h.i.v. prevention services. beginning in 1998, he held the role of d.p.h. dep director of health for nine years. his responsibilities included serving as directors of all h.i.v.-aids programs and administering the department's budget across a vast array of innovative, public health programs and health delivery systems. and... >> mr. loyce, has also made significant contributions to the san francisco and los angeles social service communities. he moved to los angeles to serve as the chief executive officer of aids project los angeles. the second largest h.i.v. support organization in the united states. from 1994 to 1998. after his retirement from the d.p.h. in 2007, mr. loyce was appointed as executive director of the black coalition on aids, an organization he cofounded decades earlier. a sampling of the other community involvement include board member, local homeless coordinating board member, transgender law center member, hospitality house board member, hunters point family board member, co-chair h.i.v. planning council, founding member of the african-american healing alliance and the san francisco aids foundation board member. and... >> whereas during his lifetime, mr. loyce has contributed in many ways to many underserved communities through effective leadership, empathy and compassion. be it resolved that the san francisco health commission honors james e. loyce junior for his many years of dedicated public service and the impactful contributions he's made to the residents of the city and county of san francisco. [applause] >> president breslin: thank you. thank you. >> commissioners, there are several public comments for the item before you get into chents yourself. -- comments yourself. comments y. -- comments yourself. first, we'd like to call up former commissioner roma guy. >> good afternoon, commissioners, president loyce, and members of the commission. it's an opportunity to be thankful to present to you today how much we honor commissioner loyce. as a member of the community and the beginning of the aids epidemic that had no name, he was there. he was there and brought the issue of equity and lack of it in our community broadly and all of its nuances and he was bold. therefore, a little controversial. [laughter] and we are deeply thankful for this. our whole city, our whole department, our state and our nation. and it's really wonderful to be able to thank you, mr. loyce. and welcome you to the new issue that you brought forth to the health commission that is still undone. and that's equity in relationship to incarceration. that health care needs to infuse itself and its leadership in problem solving in equitable incarceration in our community. you led on it and we welcome you back to community leadership on it at your choice. we thank you for the many years that brought you fewer black, white hair, glasses, and i welcome you to the aging process. [laughter] >> thank you. kate monica klein. >> good afternoon. commissioners. i'm here to speak to mr. loyce myself, but i am also reading a statement from coleen, current director of the al ami alameda county health department. she says, i'm so sorry i can't be there in person to honor jimmie loyce. his service to the san francisco department of public health have had tremendous impact on the lives of so many. jimmie introduced eme to the role of public service more than 20 years ago. i was hired to be assistant at aids project l.a. back in 1994. as the head of one of the nation's largest h.i.v. aids organizations, jimmie led with passion, purpose and the urgency that the pandemic required. i was fortunate to be able to learn from him what it means to put our clients first when we make decisions. what it means to lead a team of diverse individuals toward a common mission and what it means to lead with your heart. jimmie has always been generous with his time, his knowledge and his wisdom. as is evident by the recognition he's receiving from the health commission today. despite retirement, jimmie has continued to serve san francisco, serve the department of public health, and serve his community. when i interviewed at d.p.h. in 1998, i had no idea it would be the introduction to the calling of my career. he saw something in me that i didn't see in myself. for more than 25 years, he has supported me in my public service. and i know he has served in this mentor role for many others and those who have gone on to become leaders among us. so the reach of jimmie's contributions to public health are many. they include the people that we are all committed to serving every day. the communities and generations that are better off because of jimmie's leadership. and people like me, who owe their public service to jimmie's keen insights and sound counsel. thank you, jimmie, for being a model for me and for so many others and for your service to our community. colleen put this so beautifully, i'm not sure what to add, except that we're excited and looking forward to the contributions you'll make in the community looking at jail and incarceration issues. thank you so much. >> thank you. michele long. >> i'm speaking at a d.p.h. employee and a citizen and native of san francisco. jimmie loyce was a mentor, a supervisor, as well as a friend. and i recognize his many contributions to the health commission. but i also want to recognize his contributions just as a citizen of san francisco with amazing expertise. as a commissioner and as a employee, he would go to places no one else could go. he went. he had the expertise, the finesse and the experience to go and help all citizens of san francisco. he did not turn his back, he did not turn away. he has a knack for talking to people and conveying information to them in a way that is palatable, so he can reach down to our clients as well as to all of our staff. and i learned an awful lot from him. i learned how to speak to the health commission from jimmie loyce. he is an amazing asset to the board. he will be missed. we appreciate all of your efforts to move forward all of the initiatives that would benefit the citizens of san francisco. so i'm speaking to tell you, well wishes, i know you're not retiring. tried that before. that didn't work. but we appreciate your efforts. and look forward to what you will do in the community and in the world after this position. thank you. >> thank you. seeing no more public comment, commissioners? >> commissioner guillermo: i wanted to add my voice to those who have spoken already and to the accomplishments and the legacy, i think, that jimmie loyce leaves. not only in public health, and not only locally, but in all things san francisco, bay area, and in all health issues that we are all concerned about. you have been a friend and a mentor here for me on the commission. and i am eternally grateful. thank you. >> commissioner chung. >> commissioner chung: commissioner loyce, it blew my mind to realize i have known you for over two decades. and you left a really strong impression ever since i met you when i was on the h.i.v. service planning council. and you know, your often stubbornness, when you put your foot down, impressed me in so many ways. you're not only a colleague, a mentor, you're also a friend. with the work you've done, we've intersect so many times before, be it on the transgender law center and now on the health commission, i'm pretty sure you and i will cross paths soon again. and hopefully, next time, we're going to do something even more exciting. >> commissioner green: i certainly don't know commissioner loyce as many of you in the room has, but i feel like i i have. because when i came on the commission, his warmth helped me get over the nerves and the fear and be able to do this job the best way i could. he has been an inspiration. what strikes me is both his humility and humanity. i didn't know much about the other commissioners and i got this notebook from mark and i read all the things he's done. my god, his accomplishments are so profound and far-reaching, and yet this man is so easy to speak to. and just so intelligent and so thoughtful. of course, humanity, you've all said that. that goes without saying. i appreciate you being a role model. it's funny, about every two weeks i'll run into someone who knows jimmie. every time i see him, i know -- and every person, regardless of what they do. we have quite a few from all kinds of different areas. you say the name jimmie loyce and they light up, because this man has meant so much and done so much for so many people. so immensely grateful. will take all the lessons i learned from you and use them at all times. and so grateful and hope we can reach out to you and continue our friendship and relationship with you. >> i'm very new at this and grateful to jimmie for welcoming me as a new person on the board, encouraging me to speak up and speak out because i was a bit reticent to do this, not just the commission, but to be vocal. and he just said keep going and keep asking questions. and i really appreciate your support and encouragement that you have done for so many years to so mean people. i'm grateful that you are able to share that with me in my short time here. thank you. >> before recognizing director colfax, i wanted to say a few quick words. i moved to san francisco in 1999. and i quick lelearned that one of the first names i needed to learn in san francisco was jimmie loyce, as someone living in h.i.v. when i moved here, i learned of your leadership and extraordinary work. your leadership, you've seen leadership and earned respect and credibility across so many communities and across so many of the most difficult issues that we face here in san francisco. i mean, if you look at just from -- if you look just at the resolution, substance abuse, homelessness and transgender, h.i.v.-aids, it's appropriate we're having a report on h.i.v.-aids surveillance tonight. but you've brought so much leadership, brought us so much closer to where we need to be. we all know your leadership is going to continue in these areas. you have a wick ed sense of humor, which i'm sure everyone here has experienced. it's been a great privilege for me to serve with you, learn from you. you lead by example and lean into the heart of the issues and that's something we respect about you very much. thank you very much. director colfax. >> thank you, commissioner. and i just want to express my gratitude and on behalf of the department for your contributions, commissioner loyce. the department is a special place because of you. and san francisco is a special place because of people like you. it's been wonderful to return to the department and work with you again for the last 11 months. it was incredibly meaningful to work with you in the aids office, for, i think, 10 years. you're one of those rare people who let the people you're supervising, including me and others, do our work and then be there when we need help. and you had an incredibly strong skill of knowing when to be there for us, and when not to be. and i was going -- some people say that's intuition, but i think that takes a lot of work to figure that out. i want to thank you for letting us doing our work and supporting the department going forward. i think you've continued to do that with me and others in the department in the last 11 months that we have been working together. a lot of words about mentorship and wisdom and gratitude, which are certainly resonate, but i want to thank you for cutting through this vast bureaucracy in these meetings and others. and asking how is this best father the patient, the client, the people we serve? you always bring us back to that center. and i think that is key in everything we do. because as we get caught up in paper, and words that may not matter to the people that we're trying to serve, we lose sight of that. along with that, you focus us on outcomes. you're always asking -- often asking, including in these meetings, how does that make a difference? something incredibly important, making sure that we're making value. we're extracting the highest value from our work. i think you're focused not just on the individual, but the community. and i'm particularly thankful for your focus on intergenerational aspects and leading proponent of the trauma-informed system which is still under development, but your wisdom, guidance and vision will continue. and i know you'll continue to push the department to do better as we go forward. and again, i'm just grateful on behalf of 8,000 employees of the department, the many people you've mentored and your guidance and legacy will continue to live on. we'll see you back in these chambers, i'm sure, as you continue to push us to do better. >> i want to thank all of you for your kind words and support of this commission and certainly of me over the course of my career. i want to particularly take the time to acknowledge someone who has been with me for 33 years. and who pushes me, who challenges me, and who has guided me through some of my most difficult decisions and who has corrected me when necessary. and that would be my wife, nancy rueben, who is in the audience. [applause] thank you, nancy. i am also very glad to be alive to hear these things. [laughter] i don't know what happens on the other side, whether you get to read this stuff, so this is not obituary, this is something. so now when i go, i don't have to worry about what you might say. thank you, all. my colleagues on the commission, i know i've been -- it's said that i mentored you, but obviously you've all mentored me. you've all given me something to grab ahold of, to learn from and i'm greatly appreciative of that fact. it doesn't happen in a vacuum and there is no such thing as a horizontal organization. there is an organization that is vertical, but everybody is lifted up. that was my job for 40 years. to lift people up and make us all equivalent. and to -- you know, sometimes i hear people talk about empowerment, our job is to empower people. that's nonsense. people have power. our job is to help them express their power. to help them identify their power and then to exercise that power that they have. and that's what i think the health department does and i think we do it well. we have to learn some things. i'm not gone, folks, i'm like a bad penny, i keep turning up. thank you all for your warm wishes and go forward with work in the health department. [applause] okay. so the resolution is before us. so we go ahead and take a vote. all those in favor? resolution passes unanimously. >> and everyone for the beautiful words. very lovely. give me one second to find the agenda. >> of course. >> commissioners, gather around. >> okay. the next two items are related, but they are separate. so we'll need action on both. the first is a resolution authorizing the department of public health to recommend to the board of supervisors to accept and expend a gift of 79,453 to the laguna honda gift fund to the friends of laguna honda. >> hello, commissioners. friends of laguna honda made two generous donations, cash donations, totalling $79,453 to the laguna honda gift fund. they specified the donations go to two programs, one to the art program and the other being what we call the centers of excellence wish list. the first one, art with elders, the $42,653 will fund one year of an existing professional services contract that we have with art with elders. it's important to note that the contract is fully funded this year. so we have our purchase order that pays for their services and those monies are encumbered, so the money that they do nated this year will be applied next year. the wish list, the center of excellence wish list will allow us to increase our budget from $25,000 and add the 36 to that and that's going to be our next item. we'll discuss that there. but what we do with the centers of excellence wish list, we allow the departments and the resident neighborhoods to make requests for equipment that is consistent with the work of the various special programs at laguna honda, for example, palliative care, end-of-life care, respite care, general skilled nursing, and rehabilitation. so we'll be able to increase that. so we are asking that you pass this resolution recommending to the board of supervisors that they authorize the acceptance and expenditure of this donation. >> and commissioners, if i may, you have in front of you a slightly revised corrected resolution. there were additional zeros and several lines that the amounts in the introduction and in the agenda are correct. >> yes, i'd like to thank mark for catching that. and apologize for you for making that mistake, not once, but twice in the document. i do apologize for that. >> it was actually commissioner green, to give credit where credit is due. >> thank you, commissioner green. >> and there is no public comment request for this item. >> commissioners, you have the resolution before you. any questions or comments about the resolution before i call for a question. is there a motion? >> i'll move. >> second? >> second. all those in favor, say aye. great. thank you. the next item again is related, it's laguna honda fiscal year 19-20 gift fund budget modification. >> as i explained, the friends of laguna honda have made this donation and that will allow us to increase the budget. our gift fund management policy requires that the health commission approve our annual gift fund budget, which you did i believe in june. any modification to that budget requires our approval. i explain to you what we do with the wish list. on the back of your document there, you will see the approved budget and then the proposed revision. so it's all the way down at the bottom that we're asking for the increase to that budget, consistent with the donation that has been made. >> any public comment? >> no public comment. >> commissioners, it's in your hands. >> i move approval of the resolution. >> second. >> all those in favor, aye? thank you. the next item is h.i.v. and stds in san francisco. good afternoon, commissioners. i'm director of h.i.v. surveillance. it is an honor to be here with my colleagues to provide an update on h.i.v. and stds in san francisco. for today's presentation, i will provide highlights from the nu h.i.v. surveillance report. dr. scott will discuss getting h.i.v. to zero. and then addressing disparities in hepatitis-c. and then finally susan philips will discuss progress in addressing stds. we'll take questions at the end of each presentation. the h.i.v. surveillance data presented today are from the 2018 h.i.v. annual report that was released last september. this report shows encouraging trends and some continuing disparities. the program collects and anal e analyzes h.i.v. case in laboratory reporting data, to track h.i.v. epidemic and monitor h.i.v. care outcomes that are used for prevention and care programs, planning and evaluation. i will start with data showing our success in improvements. 94% of persons living with h.i.v. in san francisco are aware of their diagnosis. this is high compared to 86% in california and the united states. the number of new diagnosis decreased 13% between 2017 and 2018 as shown in the green line. since 2012, the number has declined by 58%. in comparison, nationally, the number of new diagnosis has declined only 7% since 2012. no children under the age of 13 were diagnosed since 2005. nearly 16,000 san francisco residents are living with h.i.v. at the end of 2018. people with h.i.v. are living longer and we have an aging h.i.v. population with two-thirds of persons living with h.i.v. are over the age of 50. and 30% over the age of 60. the number of deaths, the pink line, fluctuated in recent years, but we've been stable. the number of deaths in 2018 was not available when the report was published, but now we know the number is 250, similar that of 2017. it this slide shows the continuum of h.i.v. care. among new diagnosis, we look at linkage to care, retention in care, and viral suppression. the proportion of new diagnosis who are linked to care within one month of diagnosis increased to 91% in 2018 from 81% in 2017. this timely linkage to care is very impressive. since we started to manage the care outcome. the proportion in care after linkage fluctuated between 2013 and 2017. and the proportion virally suppressed within 12 months of diagnosis represented an overall upward trend in the same time period. we have also observed a faster time to each care indicator. from diagnosis to first care visit, from care to therapy, nrt initiation, and from a.r.t. to viral suppression. between 2013 and 2017, the median time from diagnosis to virus suppression has decreased by more than half, from 135 days in 2013, to 62 days in 2017. this slide shows causes of death among persons with h.i.v. in three time periods. h.i.v. is the leading cause of death, but the number in proportion of h.i.v.-related deaths has been declining over time it from 52% to 38% in the most recent time period. in 2017, 33% of deaths are h.i.v.-related. women and latino persons have higher proportion of aids-related death. in the proportions increased over time. african-americans have a higher proportion of death due to non-aids cancers. accidents, including drug overdose is the third leading cause of death. people who inject drugs, pwid, men who have sex with men and also have drugs, have higher proportion of death due to accidental drug overdose. heart disease is also a common cause. as h.i.v.-related deaths are decreasing and with aging h.i.v. population, cause of the death that are associated with older age, such as non-aids cancer and heart disease are increasing. which is expected. now i'm getting into the disparities in new diagnosis. when we look at the numbers by race ethnicity, we see a bigger decline among whites since 2012. the top yellow line. there is a small and steady decline among asian pacific. between 2012 and 2018, the number of new diagnosis increased among african-americans and latinx exceeded the number of whites in 2018. when looking at select populations, more closely in recent years, including latinx, african-americans, homeless people, people who inject drugs, pwid, women and asian pacific islanders. this is a little busy, but i wanted to point out between 2015 and 2017 there have been some increases in either the numbers or proportions of new diagnosis in these population groups. in 2018, four populations have increases from 2017. including latinx, african-american, homeless and people who inject drugs. three populations had a decline in the number of new diagnosis in 2018. including msnpwid, women and asian pacific islanders. when taking into account the population size, we calculate the diagnosis rate per 100,000 population. african-american men have higher h.i.v. diagnosis rates than men of other race ethnicity. somehow the line is not showing those african-american men. but it's above the latino men. so in 2018, the rate for african-american men is 145 per 100,000 population, followed by latino men, 89 per 100,000 population. the diagnosis rate for white men and asian pacific island men in 2018 are lower, 27 and 11 per 100,000 population respectively. in recent years, the rates are increasing among african-american and latino men, and declining among whites and asian pacific island men. among women, the h.i.v. diagnosis rates are much lower than among men. african-american women have the highest rate in 2018, 35 per 100,000 population. which is slightly higher than the rate of white men, 27 per 100,000 population. in this slide, we show how disparities in survival after aids. overall, 89% of people diagnosed with aids survive three years or more in 2012 and 2016. three year aids survival is lower among african-americans. 82%. and people who inject drugs. 79%. >> in this slide, we look at the disparities in viral suppression. overall, 74% of persons living with h.i.v. were virally suppressed in 2017. viral suppression rates are lower among women, trans-women, african-americans, latinx persons, younger people under the age of 50, and people who inject drugs, including non-msnpwid and trans-women who have sex with men, pwid. only 33% of homeless persons were virally suppressed in 2017. there is a concerning trend in new diagnosis among homeless persons. the number and percent of homeless persons diagnosed with h.i.v. has increased from 25, or 11% in 2016, to 40, or 20% in 2018. i want to show you the characteristics of homeless persons with h.i.v. this table shows homeless person at time of diagnosis compared to all diagnosis in the last ten years are more likely to be women, 13% women among the homeless versus 7% among all diagnosis. homeless persons diagnosis are also more likely to be trans-women, african-americans, and people who inject drugs. there is no apparent difference by age. the table on the right shows people living with h.i.v. who are experiencing homeless or living in single-room occupancy during 2018. this gives us information about current housing status on homeless or sro, in addition to homeless at time of diagnosis. similar to homeless at diagnosis, people who are homeless or live in sro in 2018, compared to all persons living with h.i.v. are more likely to be women, trans-women, african-american, and people who inject drugs. we also found a higher proportion of latinx in age 30 to 39 years among homeless sro people in 2018. so this is my last slide. in conclusion, we see overall new diagnosis are declining. treatment and viral suppression continues to improve, however disparityings remain. officially among african-american, latinx, people who inject drugs and the homeless. next you will hear more about the programs and efforts to address disparities in effected populations. and before i turn over to dr. scott to talk about getting to zero, i can pause for questions. >> commissioners? commissioner giraudo. >> commissioner giraudo: my question is, i thought in your slide on viral suppression and your last slide on the diagnosis for homeless folks, do you have other data for age of diagnosis or the broad population that you're serving other than this slide that shows the homeless population? >> this slide shows the virus suppression among person with h.i.v. and the age shown here is their age at 2017. we also look at virus suppression among new diagnosis. you asking about viral suppression among new diagnosis? >> commissioner giraudo: i'm asking for age at diagnosis. so, for example, in the last slide, there were 67 homeless people in age 18-24 at diagnosis. do you have statistics of age at diagnosis of those that are not homeless? that are in -- that are not homeless when they're diagnosed? >> yes, we do. >> commissioner giraudo: that, i would be interested in. in the age breakdown at diagnosis. homeless can be a category, but i'm interested in -- >> non-homeless, sure. so this is homeless compared to all diagnosis, but we do have information for non-homeless. >> commissioner giraudo: that's what i'm asking for. so we can get the information on homeless and non-homeless. at diagnosis. >> sure. >> commissioner green: thank you. this data is really wonderful to review. one of my questions is, do you have any data about what the entry point into the system of these various individuals is? because i think that's so important, especially as we talk about jail health and people who come into the e.d., so we can better understand how we reach people. and also do you feel we're missing people? in other words, we've identified certain individuals, the 237, the 4,000 is part of our other initiative with homelessness and mental health, and i'm wondering if you have any sense of how these groups might overlap where this population fits and how we really -- how they find access to us? >> the entry point to the system will be when they're diagnosed with h.i.v. so then all our follow-up, their link to care and suppression are found the kind of h.i.v. diagnosis. and we do have the ability to look at the overlapping population and like demographic versus risk and we can look more closely for homeless population. this shows the characteristic of the homeless population. but in terms of the trend, for example, we see increase among african-american and in latinx persons. we look closely, they're -- the mode of transmission, we see that among african-american, it's more sexual transmission, while in latinx, it's sexual transmission and drug use. so we can look at the overlapping population. >> commissioner green: do we have data -- they get diagnosed, but through what portal do they enter the system to reach the point of diagnosis? >> you're asking about the facility of diagnosis? >> commissioner green: do they end up coming in the emergency room, the street health team, do they see one of the clinics? are they diagnosed when they are brought into the jail? do you have any sense how that distributes? >> yes, we have information on diagnosis, which i can look into and get back to you. but you know around 45 to 4050 -- 50%, comes from testing site. but of course, general hospital is a large site and kaiser is another large site, with but we have information on that. i can get back to you. >> thank you for the information. i'm really impressed with the three year survival, especially when looking at transgender women, with 98% with three-year survival rate. i was wondering if we add homeless back to the variant, what would that look like? what are the survival rates of these populations who are homeless compared to those who are not homeless? >> yes. definitely, we can look at the survival by housing status. thank you. >> commissioner bernal: thank you, for your great presentation. i would start by saying it didn't go unnoticed by president loyce and me that the light blue line that shows the increases in infection among african-american men and women are not visible as these are populations not visible as we try to address this epidemic. that was telling and we have more work to do. you mentioned a great number i wanted to hear one more time. the reduction in diagnosis in san francisco versus the rest of the country, i believe, since 2012. what was that number again? >> 2012, the number of new diagnosis in san francisco has declined by 58%. and nationally, the number of new diagnosis has declined only by 7%. >> commissioner bernal: that's like, nine times the decline. that's a testament to the great work you and your colleagues are doing here in san francisco. a couple of things, these are maybe issues that we'll see later on in the presentation, but noticing there were significant increases in the cause of death, alcoholic liver disease and assault, wondering if there are interventions put in place there. [please stand by] >> i have one quick question, and that question has to do with in the early stages of development of treatment and art and etc., there was a concern of folks in the community about the address of hiv as well as what the effect long-term retroviral would have on persons physically, and would that be a contributor to the cause of death, and if that is true or not true, i'd like to see in data in relationship to that statement. because there had been misconcern, and i don't know if that concern went away. >> yeah. so we're examining our cause of the death data more closely, but the -- the new drug inhibitor that was available in more recent years, it's more potent and durable. mov more people have started on this newer drug, and that can contribute to the higher mode of suppression, so we will take a look at that in terms of the long-term viral therapy. >> there are two other presentations coming forward. this is the surveillance presentation so it's not as focused clinically as some of the other questions, and i think going forward, some of our presenters will be able to better answer them. but just to emphasize, one of the presentations that we bring around going on treatment, you saw that the virus is far worse than any side effect of the drug. and that is not to say all drugs have side effects. the reasonable side effects and side effects on bone, but these can be reversed and they're not worse than the viral side effects. we need to continue to reach out to communities that have missed the benefits that you saw today. >> i have one other questions. do you have any of this data according to health coverage? in other words, do people with kaiser do better because they have a prepaid system compared to medi-cal, compared to unsured, and how does that compare with all that san francisco has tried to do to promote coverage either on outcomes or causes of death based on coverage? >> yes. thanks for the question. we do have information on health insurance at time of diagnosis and that is included in our -- in the report. and -- and i want to say just one of the figures here shows pacific islander and transgender women were less likely to be insured, so that may affect access to care and lower percentages of care. so i will look at this data and get back to you with more information. >> i appreciate this report but i want to point out that if in fact the hiv status of african americans is not declining, it's going up, then there's a direction correlation in my mind to the medications because when we first started on medications, i'll never forget it, tuskegee studies were out again, and they went away from it. i just want you to be mindful, because this is one of these things where we talk about being culturally relevant and understanding, all of the different variables that are associated with disease and the burden of disease, and in the african american community, we're always overrepresented and undertreated in some ways in some of those. but no one would argue with the statement that the virus is much worse, because it is, than the treatment that we've provided, but there is a psycho social dynamic that we need to understand, as well. >> okay. thank you. >> thank you. >> any other presenters who are presenting, if any of you have questions or responses to questions that have been asked, please include that in your presentation. commissioners, i apologize. the line were on the slides, and it was existing when i received it, and it was existing when i e-mailed it. it just didn't transfer, and my apologies. >> we have the chart, the faster time to care indicators, and we have that broke down by year. if we could see that broken-down by ethnicities, that maybe would be helpful. it's the bar chart on page 5. [inaudible] >> you do? okay. great. >> so thank you for the opportunity to present on some of our work getting to zero. my name is jaime scott. i am the medical director at san francisco aids foundation. i'm going to talk about getting to zero on the steering committee. it's really based in this idea of collective impact, which is really focused on a common agenda with common progress measures with reinforcing activities, using communication strategies that facilitate collaboration and also having a backbone of organization to manage the collaboration across the multisector consortium that is getting to zero. and getting to zero is really building on the incredible work that happens in san francisco. it brings together department of public health, the hiv community planning council, community-based organizations, provide sector for which kaiser is one of the largest contributors, ucsf as well as other organizations and advertising groups. in relation to prior isolated intact approaches where programs w programs were dedicated to achieving goals but were disorganized, getting to zero tried to organize that to achieve the common measures that we have all outlined as being important and are really guided by the annual report which really holds us accountable for the work that's happening in the communities. so as i said, the foundation in san francisco is robust and tremendous and is really the foundation for all of the work that we do. and the getting to zero builds upon that, but the pillars of the work which includes a citywide prep program, initialation of antiretroviral treatment hubs, supportive engagement in retention and hiv care, and reducing the stigma out of an issues that young people face, we have a committee that's focused on that work, which is really sort of cross cutting. and each of these committees develop an action plan, metrics, and milestones, and the steering committee helps to steer and guide the liaison through this work. and a big initiative for the upcoming year is going to focus on disparities and how each of the committees in the work is focused on each of these areas in san francisco. so i want to talk about prep, i want to talk about rapid, as well as retention and reengagement and care as well as what's happening in those committees. so prep care is really focused on individuals who might be at risk of hiv, ensuring that they have awareness, access, use prep if it's indicated and appropriate and then stay on prep if they have ongoing risk. so this is some data that looked at the cascade, and looking at where the differences are in the cascade. so there was a lower awareness of prep among trans women compared to m.s.m., and the gap sort of widened as compared to what group of individuals used prep. only 15% of trans women and 40% of m.s.m. used prep. over time, 10% of trans women compared to 35% of m.s.m. so one of the approaches, one of the projects that was really focused on supporting prep awareness and use among trans women was the state study, which was a demonstration project focused on outreaching to trans individuals, trans men, trans women, gender nonbinary individuals, using community members to tell their story. so this was about stay, stay magical, stay aware, stay knowledgeable, and provide wraparound services for those individuals to both initiate prep and stay on prep within the clinic, so this is within several d.p.h. clinics, and we also expanded to our clinic at bridge hiv as well for individuals who were not connected to a clinic. and there's some data that's going to be presented hopefully in 2020. and then, it's also going to focus on strategies to improve prep delivery. one of the things that we're doing within the health department is working on a project to support panel management. so across five of the clinics, they're able to order labs and help them stay on prep. and then we've integrated some prep support tools into a pharmacy delivery service that would allow individuals to start and continue prep and continuing it without ever coming into a clinic, so they can actually have their tests sent to them -- i'm using dry blood spots and s.t.d. testing and being able to give the pharmacist access to fill and refill prep medications. and supporting individuals to use that who particularly might not want to take a daily pill for people who have sex infrequently and don't want to take a daily pill. so switching to our rapid, and their data that it reduces hiv illness and death and become the standard of care, so start a.r.t. initially after a diagnosis. it reduces the transmissions, and it empowers patients for disclosure and allows them to take control of their health. so the rapid disclosures that are outlined in this pamphlet for local implementation as well as being shared in jurisdictions across the u.s. is really transportation, putting individuals in taxis or ride shares, ability to meet with m.d.s and social workers, baseline labs, psycho social assessment, and an a.r.t. starter pack. so ward 86, i've done this several times with patients, and it is quite impactful to be able to hand somebody a retroviral therapy two hours after they're diagnosed and have them take it and in the room with you, and the engagement that individuals have. there's a lot of qualitative going into what this is like for patients as well as impact on our retention and care. so moving to retention reengagement, we've seen this is one of the toughest steps in the cascade. so we've really been focused on reaching individuals who need more support, so our links program show progress in links, which is really about reaching some of the hardest to reach population, providing case management, scaling some of the barriers to providing care, supporting individuals with employment. and really supporting these individuals who are sort of at the front line with our clients and our patients. and one of the things for many of us who travel and looking for cell phone charges, being in spaces where you're not able to charge your cell phone makes it more difficult for care providers to reach individuals who might need help, so there's a program to support ensuring that there are cell phone charging stations as many of the organizations -- at many of the organizations across the city that support our patients. so these are links that look at viral suppression and the populations both overall and those that are taken care of by lynx. and lynx is really about reaching individuals who are out of care for more than 12 months or individuals at danger of falling out of care. they're individuals who are often homeless or drug use. their rate is much higher than overall within san francisco, and there are some areas where there are more gaps, for example, with young people, 13 to 24-year-olds, and then similar rates for 24 to 29 african americans. another factor that we have not seen a decline is death, and there's been a real extensive evaluation of what is -- what are the causes of death for individuals living with hiv? and these are the three factors that come out as really important contributions to cause of death, including substance use, mental abuse, and illness. and then, when you look at them, say were any of those three involved in contributing to death, it was 68% of the deaths had at least one of these causes. and so i think these are really a highlight for our efforts to reduce h.i.v.-related deaths is really addressing these three core issues which would -- are contributing to the vast majority of deaths of people living with h.i.v. in san francisco, so these are data that are being used to plan program attic interventions to intervene these main contributions to death. i wanted to highlight -- this doesn't show up very well, but this is san francisco. the green line is people moving in, and the red line is people moving out of san francisco. people are moving out into our surrounding counties, so alameda is a -- where the largest number of people moving to, and san mateo and contra costa. and i personally, i'm in west market, and it's easier for me to get to oakland than it is to get to parts of hayes valley. i think people that are in our community and people that live and play in our valley are highlighted in that snap, as well. but also, the epidemic is going to be affected by this outflux because of the cost of living. now because of the cost of living in the east bay and oakland, they're moving to contra costa county and coming into the city to work and play and other reasons. so we wanted to highlight some of the efforts and: collaboration getting to zero effort. we've seen some great progress, however, we'd like to continue to highlight the disparities that remained. there are more programs for people who inject drugs, including safe injection sites. we are also focused on integrating interventions with hep-c programming and intervention. our data indicates we need a broader based effort to achieve our goals. so i'll pause there and take any questions from the commissioners? >> thank you for your great presentation. i wonder if you could comment further on slide 19 because it's striking the disparity, people who are prep aware and people who use it and are there recurrent. i wonder if you have any goals to bring those numbers more in parity and i'm wondering what the reasons is for the all off on these numbers might be? can you order them and say what the most concerning and what the effort will be to kind of change this equation? >> yeah. so the datas indicate that there's several key elements that sort of cause this drop off, particularly from awareness. because in san francisco, awareness just continues to rise. i think there's an awareness about prep but not necessarily an appreciation that is something that is for me. so i think you have to see yourself as somebody that might benefit from prep, and pretty universally, individuals don't see themselves at risk. and do you want to take the medication every day? do you want to go through -- and particularly for young people who might not have access to or sort of primary care provider on a regular basis, it's a -- a hassle to go into clinic every three months when at 25, you might not go in for five or six years. and then, there's a cost element of it, as well. so there's a perception that the retail cost of prep is really high, and so there's insurance and coverage concerns that individuals have. and so -- and then, there's some community norms and conceptions and misconceptions about prep, so i think there's a variety of reasons why, and so a particular individual might not want to be on prep. one of the things that we've seen, is that community norms and in particular your partners, sex partners, can have a really big influence on decisions we make for prep. but i think we appreciate the barriers that are structural from cost elements, but ensuring that providers for prep make prep clients feel comfortable and don't stigmatize them for using it. we're driving awareness really high, but we're still not seeing people using it and staying on it in a way that we would hope. >> thank you. >> commissioner gerardo? >> i'd like to just follow up on your slide on retention and reengagement. one of the things that you noted was the scale up of intensive case management. in practicality, is that possible within budget, etc., to practically scale up intensive case management towards your goal? >> so i think within budget is the question. so i think that there has been work both with lynx to try to triage individuals to different areas of case management, so intensive case management for those individuals that need to serve the highest acuity, and then shifting individuals who may have lower acuity or have benefited from intensive case management to sort of triage down to sort of less intense. but i think that often there is going to be new resources to support the efforts to reach and support the individuals for whom the system haven't been meeting the needs of for so long. so i think that some levels, yes, there is a possibility. >> with regard to rapid, i had a question about some of the baseline labs in getting people early into prep. it includes tamofivir, and that's used to treat a hepatitis b infection. so if somebody has hepatitis b or contracts hepatitis b while they were on prep, for example, is there screening for hepatitis b in the base and monitoring periods for someone before they discontinue? >> yes. so we recommend doing hepatitis b screening before initiation and prep. there was a really great presenter from new york that suggested with the rapid h.i.v. test alone and drawing of other labs and some screening for medical canontra indications, there is some risk, but it's not a contra indication to initiating prep. we also recommend that if individuals are not immune to hepatitis b, that they receive vaccine ja vaccinations, and then individual screening for individuals who might be at risk. >> commissioner guillermo. >> thank you. and thank you for a very informative presentation. i want to go back one more slide to the new strategies that you described to us. i wanted just a little bit more meat to those bones, especially given the questions that my colleagues up here have been asking. what is sort of the, i don't know, the attitude that you're encountering around that, the kits, and does it have any issues around the effects of retention and the cascading? and just tell us a little bit more detail about some of these apps that are coming and how they're being rolled out, where they're coming from, who decides what the apps are, and what your impression of how useful they are? >> yes. i can start with the first one. the first one, it's intervention call prep optimization intervention. it's working with the clinics, the medical director as well as the prep champions within the clinic. universally, providers feel like there's no time to do more of this work. particularly, i think prevention has a higher threshold for people to have to do and it falls a lot on the prep council. to ordering the baseline labs, and i'm one of the consultants that sort of supports it, but there's a concerning question that coming up, we give the providers support. and then, there's a panel management component of it, as well, which tracks and gives reminders when individuals are due for their follow-up visits. it flags anyone who has a creatinine clearance. and if somebody, for example, has h.i.v. behaviors, it'll flag that for the providers. it's really about working within the structures to make it easier for patients to access prep, and some of that is -- is really just sort of having the coordinators really funnel the patients through, ensuring that there's appropriate medical oversight review of patients and their labs are done. [please stand by] >> thank you. and just one more question. slide 25 i think it is. the contribution data. is this broken down, or do you have it by race or ethnicity. >> it does exist by race ethnicity. we just have african-americans, but we can get the other demographics. >> commissioners, any other questions? thank you very much. >> hello. i'm a part of the community health equity promotion branch. i've been leading our request for proposal process. so i'll talk a little bit today about how we're addressing disparities in the community. so as a part of the getting to zero process, as a part of getting so zero there is community-based work that addresses h.i.v., help c and stds and that's done through our community funding. so by creating requests for proposals for our community-based organizations to apply for funding to deliver services. so the vision -- let me back up a little bit -- we released a request for proposal in september of 2019 and we're still in that process. and so the vision for the r.s.p. is to ensure health equity among all communities focussing on the populations that disproportionately affected by h.i.v. and stds, including disparity in funding and being in line with h.i.v., help c and std road map engagement, stakeholder engagement process. what that was, a process we went through to engage our providers, community members, our h.i.v. community planning council, and other branches to determine how we basically would move forward these next couple of years with h.i.v., hep-c and stds. so one of the frame works that came out of the stake engage -- stakeholder process, was health access point. and so what our stakeholders said they wanted was basically a whole-person care model. what this model includes is testing, drug user health. it addresses basic needs. also health education and counseling. prep, navigation and linkage to care. what we wanted to do was ensure that our community would have access to all of these services in one location. and also, that they would be able to access through multiple pathways, so through outreach, through a community-based organization or through going through a clinic that one of our community-based organizations partner with. >> it could be single location or multi-location. we want to say it's low barrier. and that it's population-specific and i'll talk about that more in the next slide. so through this r.s.p, we're funding health access points for seven different populations. latino, latinx, our trans-women, people who use drugs, including injecting drugs, gay and other men who have sex with men, asian pacific island community, young adults and african-american. there are other populations that we're addressing through other mechanisms, so that is our gender women population, our homeless population, native americans, and incarcerated. the total available funding for this r.f.p. is about $8 million, with 50% of those funds going to latino and black african-american population. and before i turn it over to dr. philip, any questions. >> commissioner giraudo: under -- on the slide on health access points for the r.f.p., do you have specific targets for outcome data that is included in your r.f.p.? >> yes, we do. so we created performance measures, so for each of these, what are kind of called -- they're building blocks in the r.f.p. here, we have created performance measures for each of those, so within each these blocks are required elements and preferred elements and we've created some targets that we want our community organizations to reach. >> is it possible to send that to me so i can forward that to the commissioners? >> sure. >> thank you. >> commissioner guillermo: just a couple of questions about the grant. so when do you anticipate them being awarded? and the number of grants? and the duration of the grant? >> so we're still in the r.f.p. process, so i can't answer that question. >> none of it? are they one-year grants? >> anywhere from one to five to ten years. so this last grant that we had, it went a full 10-year cycle. >> okay. >> so the funding sources is the cdc and general fund. so from one to five to ten years, you expect -- not you personally, but the department expects to fund at this level or greater level for one, five, ten years? >> from what i know, i believe so. >> i see shaking your head. okay. thank you. great presentation. >> thank you. >> and commissioners, i was reminded because this is r.f.p. you wouldn't normally look at this until it's funded, so when the decision is made, i can get that information, but until then, you usually stay away from this process until the decisions are made. >> the idea there will be outcomes, we can ask that question? >> for sure, in terms of me asking for the performance measures, i apologize for my mistake. >> thank you. good afternoon. my name is susan philip, i'm the director of the control branch and the controller in san francisco and see patients in h.i.v. primary care at san francisco city clinic, which is our municipal std clinic. it's wonderful to be up here and share the presentation with all my colleagues. i think what you have just heard regarding the r.f.p. really shows how we're trying to take an integrated approach to sexual health. it's no accident i'm here to talk about stds in the same presentation as we've been talking about h.i.v. i also want to say, although i have the pleasure of presenting to you, i'm doing that on behalf of many, many people who do the work, including many of my colleagues in this room. i wanted to say that. there are a lot of challenges with std prevention work here in san francisco. but that's true also nationally and throughout the state. a lot of success that we've had with h.i.v. attributable to community action, providers, public health, academia and there are really wonderful tools for biomedical prevention for both treatment and prevention of h.i.v. with prep. we don't have those tools yet with stds. so the challenges are still there. because it's such an integrated approach, because there are so many parts of the health department and even within the public health division that are needed to address the problems, we about a year ago had an opportunity to use state funds to really try tyke an integrated framework approach to think being how we're going to tackle these tough problems. and we really appreciate that some of you commissioners within the last year have had an opportunity to weigh in on how we should be doing this. the key theme was working across the population health division branches for public health effectively. and what came out of the process that included multiple interviews as well as in-person meetings of internal and external stakeholders was really a great vision and mission, which you can see here. the mission i'll read, for san francisco where all people have safe, healthy sexual lives. not just stds, but reproductive choice, h.i.v. prevention and healthy and pleasurable sexual lives. and that kind of work was really important in the last year because there are huge challenges with stds. and not just in san francisco. but nationally and in california as well. and all of the reportable stds, which include syphilis, chlamydia and gone rea are increasing. one of the most devastating potential outcomes of any std can lead to mortality, including still birth and fetal demise and infant demise. so this has been increasing in the united states largely. you can see a graphic there from cdc in the past year. congenital syphilis is preventable with simple penicillin treatment to a pregnant woman. it treats and curing her infection and prevents transmission of syphilis to the baby. the director of the cdc, who used to work here in san francisco, has really called a case of congenital syphilis a failure and a signal of a failure of clinical systems and public health. so both of those are true and both of those institutions and simms have to work -- systems to have work together. what we know is increases in syphilis in women always precede increases in congenital syphilis in all areas. california has among the highest number of cases an and the highest rates in the united states. so what we've seen here in san francisco really was a period from 2013 to 2017, where our number of cases of syphilis in women remain steady. then in 2018, we saw very large 95% increase among cases in women. we had no congenital syphilis cases. no cases among babies in 2018, but seeing the signal and knowing that this was increasing the risk for congenital syphilis, we took some action and really took strong measures to try and get ahead of this and turn the curve. and the rate, the preliminary rate for 2019 is continuing to increase, so i'm going to spend time talking about those efficients to try to -- efforts to try to treat women infected with syphilis and prevent congenital syphilis. it's important to note that over 90% of syphilis remains among men. we also wanted to try and get ahead of these numbers before they became very large. so this chart really shows, again, just in a bar chart form, that same numbers of cases in the gray. you see there is the number of cases among women. you see the large increase from 2017 to 2018. we have a team at city clinic. you hear the name links, related to h.i.v. linkage and navigation. and the same larger team also does this syphilis work. and the blue represents really, of the cases assigned that team, how were they able to assure treatment of the women? and you see that even though the cases have increased in such large number, it's really amazing work and coordination. they've been able to assure 93 to 95% of these women have been treated. the other large part of the work that must occur is ascertaining pregnancy status with women. if she is pregnant there is more of an urgency in ensuring she receives adequate treatment. the team has done better over the years as the total number of cases have gone up. whereas in 2014, there were only 47% of cases where we knew the pregnancy status. in 2019, and the graph you see here, it was down to only 11% where we did not know pregnancy status. so really, really concerted efforts. then with the information, what we learned is that in 2018, there were seven cases of syphilis among pregnant women and six cases in the first nine months of 2019. so the data i'm going to focus on among those cases in pregnant women are 2018 and in the first nine months, the first three quarters of 2019. and this graph is quite a busy graph. it's very rich with information. it's very, very useful information. and this was a graph that was created by one of our stellar epidemiologists. this is 13 cases i was talking about during this time period. and you see the individuals across the top there. light blue if they were diagnosed in 2018. and dark blue is diagnosed in the first three quarters of 2019. the second line is really the bottom line is what we're trying to ascertain. what is the outcome of the pregnancy of the women diagnosed with syphilis. blue means that the pregnant woman was treated and was cured of syphilis and then treated so there was prevention of congenital syphilis in her fetus. orange is a case where we were unable to avert congenital syphilis. there were three cases of congenital syphilis between 2018 and three quarters of 2019. all of these were in 2019. green really, at the time this chart bhasd, the data were -- was made, that was an individual still pregnant, but adequately treated. we expected the green dot will turn to blue. but what is most useful about the chart is the ways that we looked at some of the other challenge in the lives of these individuals who are being diagnosed with syphilis. i think you'll see this is a theme you've heard earlier with the h.i.v. data and otherwise with larger efforts of the department and as a city in working with people that are having multiple challenges with experiencing homelessness, with substance use, and behavioral health needs. so what you see, if you focus on the orange dot, who were the individuals who we were not able to treat in time and where there was a case of congenital syphilis? they were all lacking in prenatal care. they didn't have any. they were experiences homelessness and using methamphetamine. so a lot of life challenges in these populations. again, i want to give credit to the incredible wofrkt teams at city clinic, clinical providers, because each of those blue dots -- i'm sure you can imagine how much effort, coordination was needed to achieve that good outcome. the three orange, those are unacceptable. that is a tragedy that we should be able to prevent. so we're working together to find new ways of trying to support care fort vulnerable individuals. so, to that point, when we started seeing the signals of increases, early in 2019, in may, we put out our first provider alert to really let providers throughout san francisco know that there have been increases among women and to really make a change made of what california reported overall as a state to change routine screening to include pregnant women already, it's recommended in the first tri-mester, but then we added the third as well, to try to detect and avert cases of congenital syphilis. the links team has made women with syphilis as the highest priority. they go above and beyond, up to and including, providing treatment in the field. if we are unable it link a person into care. and further more, you know, this is really bigger than anything that city clinic, no matter how amazing and dynamic our teams are there, and the leadership there was able to do by itself. so the department activated the incident command system in june to really bring in more support and to recognize, again, that this has got to be a combined approach of population, health and health network and to also spread that through san francisco as well. so here's some of the things that have happened as part of that. key accomplishments we were able to do is a partnership between mcah public health nursing and city clinic links. all of these are in process. it's hard to learn now work flows and partnerships, but we're grateful at the opportunity to work together and improve outcomes for those populations. there has been new rapid syphilis testing in jailhouse services, so the network is really bought into the idea of trying these new technologies in order to diagnose people more quickly. a lot of training has happened with the city clinic and links, talking with big focus on the emergency department and urgent care, but also with the ob-gyn teams there at zuckerberg. and again, it's been important to have leadership, both at city clinic, but also at the department leadership level and then also with the sfsg as well. we had a case conference in july to review the missed opportunities, what went well, what didn't. where does or system have gaps that we need to identify even if we can't patch them immediately? and then arches, which is our epidemiology and surveillance team at ph.d. and i.t., really came to work together to try it measure what is happening with syphilis screening among women, especially those experiencing homelessness. and that's a work in progress as well. we went through two 12-week activation periods and now we're transitioning -- trying to think of this as an a3. it is led by dr. bennett, i'm participating and there are many people in the department working on this as well. and i'm sure we'll be back reporting more of how we are viewing the changes that may need to happen, or will need to happen, to try to meet the needs of women where they are and provide more access to screening treatment prevention for syphilis. i want to switch gears just a moment. much of our attention in work has been on syphilis, but we haven't forgotten about chlamydia and gone rea. they started in may of 2018. and really have focused on the persons coming in for prep, where it's recommended they have routine gonorrhea and chlamydia and syphilis testing as well. the whole goal is to quickly treat the patient. you want them to not necessarily have any of the complication from untreated gonorrhea and chlamydia. if this is scaled up, it could have impact on city level rates of transmission. to show you the data and how impressive the changes have been. the blue is the period before the new testing platform came into place. along the x axis, you see days to treatment and then cases. and then the average time was 6.4 days before this technology for the people who were tested with it, it went down to 1.7 days. it's striking to see the column where it's zero days. somebody was diagnosed and treated on the same day, which wouldn't be possible with a lab-based test. so it has significantly decreased the time to treatment and that was one of the outcomes we wanted to see. now, not only are we doing this at city clinic which is a priority population because there are people coming there who are at high risk for stds, they know that is a place for sexual health care, but we also have a place for the population by jailhouse services. we've had a strong collaboration with pratt, augerwall and their teams and we took this step and we're fortunate that dr. god fred was willing to do this. putting this machinery in jail, the jailhouse system, really took unprecedented moves of creating a moderate complexity laboratory at jail health. which had not existed before. and as you know, there are lots of regulatory and paperwork requirements to doing that and we're able to do that because the doctor, he extended his authority and his license as a public health lab director in california to do that. we're very excited about that, because what we were seeing, 20-30% of people diagnosed were leaving before they could even be treated, which begged the question, were we helping them by doing the screening. that was with a laboratory-based test where they had would have to go to 101 grove. this has ramped up slowly and there is lots of work flow issues and trying to figure this out, but it's reason been amazing to partner with jail health to see this data. it should say july to december of 2019, but traditional lab-based testing, the average number of days, 2.5. with rapid testing, 0 .2 days. there are other outcome measures we would like this see that is pending in terms of the new technology, but it's very promising to begin with and we're looking for future data to share with you about this as well. another key population that is a priority is young african-american youth. and the reasons are the disparities that occur in multiple areas of sexual health, chlamydia is no exception. 2018, young black african-american women had eight times higher rate of chlamydia than the white peers did. the san francisco black african-american health initiative has a chlamydia work group. that work group is co-chaired by nestor and i am one of the co-chairs with her. and that group, we have focused on trying to increase bringing in the network clinics and nestor is also working to put on a reproductive justice summit that will happen later this spring, really, again, as a community grassroots effort to really address some of the racial disparities and the racial injustices that contributed from the racial health disparities. dr. boyer had partnered in 2017 with the check branch to lead a qualitative study with youth, parents and provide they're tried to identify, what are the barriers? so population health convened a group of young black african-american women to review the findings and make their own recommendations to address the barriers. the outcome was called slay. and this is really led by jackie taylor in the chep branch is not able to be here today, so i'm presenting on her behalf. this was with the help of many other people, nicole trainer and dr. boyer. this was done through a grant from the state std branch as well. so the goal was to establish youth leadership council to really have this be young, by young black women, for black women in san francisco, to try and address these disproportionate rates. so the first group was convened last spring and summer. this was a two-hour weekly sessions for 16 weeks. there were six young women from bayview and western edition neighborhoods. you see the images there. and they were given a weekly stipend. they were considered consultants to us. they were provided with transportation and food. and the recommendations that they gave us were really several, but you know, to really do better jobs of sex education and in-school resources, to support youth. they wanted slay to continue. they considered that an important opportunity for them. they liked being part of the what the department is doing and many reported back, several of them are off to college and they're the experts on sexual health in their dorms, which we think is wonderful. that has all been very positive. and then they said, you know, we should develop sexual health training for parents and guardians and trusted adults and this played a part efforts to do reproductive justice. we should be educating adults in communities as well youth. they told us that we need to engage differently. that we need to think about instagram, social media. we need to have a website that is youth friendly if we want to do this work. so the next steps we have to move forward in all of those areas, and the evaluation plan will include social media and web analytics, so there will be outcomes from those things. i think there will be a new -- there will be a new second council in the fall. we'll also see about trying to assess knowledge and attitudes and skills in the groups before and after. and then finally, this is my last slide to say, you know, really kind of relevant to what the young women told us parallel to their work, this work had been going on really led again by dr. stefani cohen, frank strewna, assignee to us in std. they led amazing revamp with many other people who provided content and input to the city clinic website, which has always been known as a resource for sexual health, nationally known website. it was getting dated. it was hard to find things if you were a provider or individual. so this is revamped to serve our two audiences. everybody in san francisco. because not everyone can be seen at city clinic. we don't have the capacity, but everyone can access the information and resources on the website. secondly, for providers to be able to give them the state-of-the-art information and integrated std, h.i.v., linkages to resources there as well. so i thank you very much for your time and attention. i'm happy to answer any questions. i think we're always happy the commission takes such an interest in the std work. it's challenging. i wanted you to see the depth and the breadth of the work over the past year. >> thank you for that report. commissioners? you did such a good job, we have no questions. >> never happened before, but i'm always happy to come back. >> too soon. >> commissioner bernal: first of all, thank you for the excellent presentation. you're correct that the chart has a lot of information on it, but it's incredibly useful given the intersection of experiencing homelessness, lacking re-natal care and methamphetamine -- prenatal care and methamphetamine use, the mayor has put into place a number of initiatives, are these issues being brought -- is this particular issue addressed in the task for, or is this something that you're screening for? are you screening for syphilis when people come to the meth -- would come to a meth sobering center? >> thank you very much for that. and yes, i didn't want to skip over that too quickly. i think this is exactly where we need to integrate this particular piece of work, which we see with particular urgency, into the larger efforts that are undertaken with urgency throughout the city. i don't have that particular connection yet, but i think this is part of transforming into this a3, what can we do internally, what are the extern pieces, who are the other partners we need to inform? we see this slotting into the larger work that is happening throughout the department and the city, with the same population of individuals who are experiencing homelessness, substance use, behavioral health needs. so, yes, we'll make sure that it's integrated into the entirety of the work that is happening. >> thank you. and again, excellent data, thank you. >> commissioner green. >> commissioner green: thank you so much. energized and incredible presentation. i had one simple question. is there an issue with the sensitivity of these rapid tests? >> the rapid tests for syphilis or gonorrhea and chlamydia? all three of them? the syphilis is a point of care waived test. there is one f.d.a. test. the challenge is really, that it is a specific test, trepassey people inial, and it stays positive life long am so for populations that had syphilis before, it's a less useful test. but there are certain instances it would be incredibly useful in san francisco that has not had a lot of syphilis, such as pregnant women. it's been useful in that way, but it has limitations and has its challenges, but in general, it is a fairly good test as long as we're using it in the correct population. and the gonorrhea and chlamydia tests are quite good, quite accurate. i think one of the drawbacks is the cost of it. but there is cost involved with not being able to treat someone or having ongoing infections. what is challenging is quantifying what is the cost effectiveness of doing the particular test in that way? but we feel it's a good profession of con -- proof of concept to show, are we able to reduce the time to treatment? can we treat people otherwise who wouldn't be treated? when people leave jail health services, they don't want to give a lot of information, so we want to provide the services there. and again, partnering with the team and their leadership has been an eye-opener. as far as i know, it's the only system in the country that uses the test in this way, so it's a good way to maximize the potential you utility and benefit to the health. >> with the jail health, do you have concerns about the individuals that might agree to the testing? that's been a barrier in the past, and whether you were developing protocols, to try to increase the interest in compliance. >> i've only had informal conversations about this with dr. aggerwall, but that was not my impression, that there were challenges with that. i think there are challenges in having enough coverage to offer the test to every single person, every single time they get admitted into the jails. that would be the goal, but i think we want to start small. it's not insignificant in terms of work flow changes, staffing needs, et cetera, so we wanted to show a proof of concept and make sure you were all happy with the direction things were going and go from there. >> thank you. i just wanted to thank the team for the great presentations today. i think throughout, there was a theme of equity. move our systems, our investments to more equitable systems in mind. i think particularly with the r.f.p. mentioned, we are significantly increasing resources to the communities where the h.i.v. rates, std rates continue to be highest. just to point that out. the other piece, the intersectionality is with regard to the connection between health and homelessness and housing is a key health intervention and let the commission know we're working hard with our colleagues and partners at department of homelessness and supportive housing to ensure that we collaborate, so that people get the housing they need to improve their health status. in this case, improve the health of the community at large since these are transmittable diseases. >> doctor, comments? >> thank you. just to answer your question, dr. green, first i think in the jail tour that you did with us, i probably mentioned that when people are first booked, they're not really excited to engage in a relationship with us initially. people tend to be kind of mad or they're still high or drunk or they're mentally ill. but in the course of those hours when they are down through the booking process, and normalize experience of collecting urine samples to run the test, that's just going to be another thing we do, just like getting vital signs. again, it's a big change in the work flow, so it's been slow to ramp up. i also want to mention that it was really dr. philip who looked at this data and said, 30% of your people are leaving without treatment. and you know, there is a lot of sort of, oh, hand waving and sort of disempowerment around control of people as they move through the criminal justice system. we don't know when people are going to leave the jail. we can't plan for that in the way we need to and susan said we have a way to fix that. we can affect how we treat people in the jail. i imagine as soon as this is published widely, people -- other municipalities and counties will do this as well, because it's a brilliant idea. it is not cheap, but neither is untreated disease. and so i just want to say thank you to the commissioners for supporting this, to dr. colfax for his interest in it and for the brilliance of the std division in solving this problem in unique ways. thank you. >> thank you. >> next item. >> may we have a round of applause for the amazing work of this group? [applause] item 10. dph strategic priorities which were introduced at the january 7 meeting. this is an action item. you've already had the presentation and had discussion. it's up to you today to simply, if you have any clarification questions for dr. golden and then decide whether you will vote yes or no. >> commissioners? >> i don't think there are any questions on the item. >> and no public comment request for the item. >> we're prepared to move on to a vote by the commission. is there a motion? >> so moved. >> second. >> all those in favor? thank you. commissioners, because of the late hour, you can choose to go through the other two items and defer the joint conference committee report and go to adjournment? >> commissioners? >> we will do that. >> just a suggestion. so now consideration for adjournment >> so moved. >> there has to be a motion. >> motion to adjourn. >> i second. >> all those in favor? we are adjourned. - working for the city and county of san francisco will immerse you in a vibrant and dynamic city that's on the forefront of economic growth, the arts, and social change. our city has always been on the edge of progress and innovation. after all, we're at the meeting of land and sea. - our city is famous for its iconic scenery, historic designs, and world- class style. it's the birthplace of blue jeans, and where "the rock" holds court over the largest natural harbor on the west coast. - the city's information technology professionals work on revolutionary projects, like providing free wifi to residents and visitors, developing new programs to keep sfo humming, and ensuring patient safety at san francisco general. our it professionals make government accessible through award-winning mobile apps, and support vital infrastructure projects like the hetch hetchy regional water system. - our employees enjoy competitive salaries, as well as generous benefits programs. but most importantly, working for the city and county of san francisco gives employees an opportunity to contribute their ideas, energy, and commitment to shape the city's future. - thank you for considering a career with the city and county of san francisco.

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