The Prevention Services in particular qualified as essential services under health quarters. It was really an effort to clarify and provide clear guidance to the c. B. O. And other prevention providers in particular around how to provide services safely and develop resources for home testing, for example, options for people to minimize clinic visits and looking at low barrier approaches to delivering some of the services. Zoom doesnt work for everyone, but are there other ways to continue to provide services in a safeway. Next slide. And then off on policies side, there has been, when the shelter in place occurred, all the clinics closed due to activation many of the people were activated for covid response. And also in response to ensuring that staff are safely in these clinical settings. But as a shelter in place has been lifted, there is a need, in particular because of the Prevention Services that have been declining, to reopen and provide care for young people particularly and so this curbside care model was discussed at the last meeting around expanding services for youth, including some of the Nonclinical Services that are essential for a lot of the vulnerable truth in the city. And then there is the task force , the Housing Task Force addressing homelessness and the differential and disproportionate impact on people experiencing homelessness in San Francisco. Next slide. I will defer to the commission if they have questions about that section before talk about ending the epidemic. Commissioners, you have any questions or comments . First of all, thank you for your accomplishments. This is incredible work. I guess i had two questions that are more statistical. I was wondering, given this effect of covid19 on testing and so forth and virus suppression, how you plan on looking at these statistics yearoveryear. In other words, have you thought about how you would correct the unique drops that we see this year so you can see what have been incredibly successful on tread lines trendlines in this condition . I guess, you know, the corlett to that is do you anticipate any increased Disease Burden and we do know not we do not know what the winter holds. I think it will be disproportionate among our populations that are are ready at higher risk of having worse outcomes. And many of the prep clinics, for example, prescriptions were extended for another three months or six months and people miss to the test. But if they stayed on prep, they still maintain high levels of protection. For individuals who might be experiencing difficulty adhering to prep, they might continue to have sexual risk and might discontinue prep. We are seeing that in the clinic there is no question that we will see a decrease in our case findings because the h. I. V. Testing, for example, is a cornerstone of our prevention for Public Health response. It has been negatively impacted by covid. I defer to link for any statistical adjustments that might be made. I also think the highvolume, easy access testing as part of our Public Health h. I. V. Prevention response. That has gone down. There is a concern that it will undercut these efforts we will really try to counteract that as much as we can buy supporting, encouraging and facilitating testing Prevention Services to be restarted and reoffered in maybe a different approach. And for People Living by h. I. V. , ensuring that disruption of care is minimized so, how do we bring for whom zoom doesnt work, into the clinic with capacity where they can also where they could meet their needs . It will not be businesses usual for anyone post covid. But how do we maintain the success that we have had . I think that we are trying to figure out what the best approach for that is. There is no question it will impact our income. All right. Thank you. Commissioner christian . Thank you. Thank you for this presentation. Looking at the viral suppression , the left bullet point had worse viral suppression but did not change after covid. Could you help me understand exactly or why you think it might be, or i am understanding this did they have worse viral suppression, but it did not change after covid. Can you help me understand . There was a disparity that we were looking for. And there was a new disparity that arose post covid and there were disparities that existed that were sent. It existed at ward 86 and it did not worsen. It is about how poverty impacts the ability to maintain adherence in viral suppression and how income and competing needs impacts, particularly for a black individual and for black men in the city. It was present precovid. There was a change seen in the data. So, i mean it was deeply distressing that it was so bad when there were normal Health Situations and it didnt get any worse after covid. Yeah. I totally agree. There has been efforts both at ward 86 and to address this through black health and focusing on what are the ways that we need to adjust and change our care model to meet the needs of black patients, and particularly, black male patients given the disparities we have. I am one of the providers there and there is a nurse, as well as another medical provider working on what are the models that we will shift to try to remove these disparities. Describing them, i agree, they are not positions. We need to have a proposed solution and monitor our outcomes and be held accountable for how we do or do not address those disparities. Right. Systemically it is such a nightmare at base level. It could not get any worse after this pandemic started. As someone who is fairly new to hearing about this level of statistics, it is very distressing. Yeah,. I completely agree. I completely agree with commissioner christian and hope this is something we can hear reports back regularly as we get continued data from getting 20. Next we will go to commissioner dorado. On adolescence . And whether when the access for the youth in the clinics is going to restart. It is not able to see anybody. And what is there a timeline to reopen the clinics and have access for the youth . I know there has been discussions around the timeline for reopening. I know that allie is on the line im not sure if there are updates on this. But if we dont, we can get the timelines and at the information back to you. Okay. Thats great. I appreciate it. Two of the clinics at balboa and burton, i mean those schools are probably not going to open until at least january or february and [indiscernible] thank you. I would appreciate the information. I can speak to that a little bit. Would you like some information now . Just followup would be great i would appreciate it. Okay. The long and short is we are slowly reopening clinics that were closed just because of concerns about air circulation and deployment of staff for the activation. We have a timeline now for reopening as we are able to deactivate some of the clinical staff and bring them back to the clinic once we determine that the sight is safe. Okay. Thank you. Thank you. Commissioner ciao . Thank you for this presentation. Thank you. The first thing i was concerned about was it appears you are still working with the City Attorney to try to assist the input for Community Clinics to be able to feel comfortable in doing h. I. V. And s. T. I. Services i am wondering and im not quite sure they determine to these essential in the beginning and the prevention could be in question. That is just one thing. When you were describing this in the last few minutes, i became similar i have some similar concerns. It is a phenomenon not just that it was h. I. V. , but everywhere. There has been, in general, a resurgence of visits back from [indiscernible] they put this into get to the baseline again. Im wondering if part of that, and you are starting to convey that some of these people are potentially no longer here. Some of them may not need visits because youve extended their medication. And i guess the real bottom line is, how are we going to try to figure out the real impact that you are discussing here in terms of the fact that, you know, intuitively, it will probably get worse in the sense that there are bound to be some people who dont feel like they will get services or didnt feel like the services were as easy to access as before. There is a factor here in which a number of people had continued my cheek medications. Others may not need prep perhaps because of social distancing and isolation. And others have moved out of the city. All of this has been confounding any sort of a normal study, and i recognize as you are having a good look at this, whether or not there is some sort of clarity or some sort of timeframe that maybe we can sort through between people who have stayed on treatment, what havent actually been followed up by us, people who [indiscernible] that is not even asking the question of how many people should have been tested that didnt get tested, right . And the complexity of this. Im wondering what some of your thoughts are in terms of us being able to sort it out. Its something we can take a look again as the commissioners have asked, suggesting they get a followup on this. Well be following this closely and be happy to present an update when we have new data. The way that i have been thinking about it is its a spectrum from prevention through care for h. I. V. There are individuals whose risks change and they dont need prep anymore so they dont need to be on prep and they decide that they made a decision that they dont want to be on prep and they dont go in for visits. And then there are people who are unable to access prep, for example, because they cant get into their visits and they have continued risk and they have breaks in their medication. I think there are people who have who are living with h. I. V. Who are adhering and are able to come in every six months to a year anyway, so it hasnt been a disruption. In particular there is a lot of drop in services that have been for people who are on the margin and those really got disrupted. Its not easy to get into any of the buildings or any of the clinics on the hospital campus, for example. Many places providing support are no longer open. I think we will need to make take a systematic look. There is already a large outmigration of People Living with h. I. V. In San Francisco. And i know it was accelerated during covid. It is a densely populated urban centre. People are moving towards more space and suburbs and other more rural areas in response to covid i think we are, particularly from the surveillance team, there is the ability i have been following up with individuals. And within the prep clinic, there will be a lot of utility i know that is an effort at magnet to provide outreach and educate people. It has been clarified that prevention and Care Services are essential and that has been disseminated to the communitybased organizations and clinics to provide clarity. It is getting communicated into the community. It will be a big next step. Thank you. We appreciate getting feedback on this and to see where we are all standing. Thank thank you. Commissioner green . [please stand by] to that followup testing. So there are people who have been discontinued, not refilled if they havent come in and that is not true. Because, you know, i know well have a lot to learn about level Risk Behavior that occurred during the shelter in place and over the pandemic. It appears as looking at the testing data for example, the bigger institutions like the general or ucsf and other Hospital Systems are bouncing back if terms of their testing. Are we seeing a similar bouncing back of the communitybased organizations that are engaged in prevention and other kinds of services and if not, is there any kind of support that the Department Needs to provide to them . I think it is going to be difficult in the spaces and how its around ensuring staff safety and social distancing and the types of things is going to change the volume that can happen in the clinics. So we are starting to see that and i know that there are efforts to sort of think about doing things differently with home testing for example. So that individuals can do their testing at home. Or dropin testing where there is minimal contact with staff unless there is a need for a discussion for like Sexual Health or other clinical needs. So, yes, things are opening up. Theyre not at the same level they were and there are unique barriers i think that communitybased organizations have that hospitalbased systems can better mitigate. Thank you. Commissioners, any other questions or comments for dr. Scott before we move on . May i make a comment. Director colfax, yes, thank you. I wanted to thank them for their presentations and i think one of the key pieces about this is that our Institutional Response to covid19 has been driven by our institutional memory with h. I. V. And the work weve been doing. The commissioner saw the vaccine presentation two weeks ago. The doctor who has been leading the vaccine efforts, while there are differences, vast differences in how theyre transmitted, i think going to the inequity were seeing here, we need to ensure were doing everything we can to prevent and mitigate very similar inequities that were seeing across the nation and to some extent, hopefully. And just a reminder that while these our focus on these Infectious Diseases is often in the health care system, these are often also socioeconomic and social factors that are at play here with regard to the social determinates of health. At the same time were talking about getting to zero in San Francisco and im hopeful well be talking about getting to zero covid19 infections. Sort of book ending these departments. Thank you. Thank you, director colfax. Commissioner christian . Commissioner christian thank you. Dr. Scott, this is a late question and maybe it might be best answered by dr. Seo, but it is kind of a prep question and follows on the last couple. Looking back at slide 4 if my notes are correct, where the doctor told us that the slide is titled trends and new diagnosis in select populations and that for transwomen, it had increased to 13 . And my notes say lower by transwomen. And my question is why. Were talking your thoughts of why, were talking about the social determineates of health that exist and disparities that drive that. And then you just mentioned the impact of the closing of communitybased organizations on people and how obviously people who rely on them and who are at greater disadvantage than many others are suffering because of this. Do you think that has something to do with the increase in new diagnosis in transwomen . So, i think so if i remember that slide correctly, i think it went from 2 to 7 among transwomen and the absolute number was from 6 to 13. So we have definitely seen a rise in transwomen, new diagnosis among transwomen. This would have been data before the covid19 impact on all of our care and Prevention Services. But, yeah, prep is prep uptake among transindividuals has been lower than snm which is the comparative group. Its not about awareness. Its not about knowledge that prep exists, its about all the other things that are necessary for an individual to take prep, including what is a perspective of prep among peers and other Community Members. There has been more and more data around the impact of prep and hormones. So there is a concern among the community that prep can negatively impact gender hormones and there is more and more data coming out that it does not negatively impact hormone levels. Actually gender performing hormone levels reduce, but not to the point where we think there is increased risk of h. I. V. And there is also where people access prep and is it available in the clinics where the individual might receive gender affirming care. So there is a lot of, think, going back to the social determinates, there is also high rates of poverty and other social determinates are driving the lower uptick of prep among transwomen compared with other groups. Particularly among smn in San Francisco. And could you describe some of the efforts that are being made to overcome as much as possible these barriers . Yeah. So there was a study called the stage study that was really about providing peerbased social support and clinical support for transindividuals, specifically transwomen, to access prep within San Francisco. And it was within several of the transclinics, those providing transspecific care and one in the east bay. Here at bridge h. I. V. , we actually created a clinic here as well for the city, because there were barriers that were people were encountering accessing care that was delaying their ability to initiate prep. So we wanted to provide a very low barrier access strategy for transwomen to access to access prep. So those are some of the efforts. There has been a lot of communitybuilding, Community Education, provider training, provider support, increasing both provider and client awareness around prep for transwomen and also dissemination of the information that we have about the impact of prep on gender forming hormones and the fact that the data do not indicate there is a negative impact. So making sure that we communicate that. And there is an effort here at bridge h. I. V. To develop a prep clinic specifically for transindividuals and focus on transwomen. And well being doing a study which is focused in supporting prep among transwomen using a peer support and genderforming hormone service model. And that will be done here at bridge h. I. V. Commissioner christian thank you. Can you say a little bit about how the Community Education, how youre getting the message out there is no negative effect on the gender forming hormones . So there was during covid similar to the Community Education forum we did around Sexual Health in covid, there was one focused specifically on transindividuals, highlighting transwomen. And talked about prep and talked about the data that was many of the investigators are based this San Francisco have done