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WelcomeReview of the meeting objectives, house rules, packet materials, shared link for presentations - Executive SummaryCalifornia is blessed with having three of the 12 CDC-funded Project PrIDE (PP) three-year demonstration projects (CDC 15-1506), whose goal is to develop, implement and evaluate PrEP services that prioritize MSM of color and transgender women. The funded jurisdictions are Los Angeles, San Francisco and the state of California, which in turn is funding the top four jurisdictions with the highest HIV prevalence in the state outside of LA and SF. These local health jurisdictions are: Alameda County, Desert AIDS Project (DAP), Orange County, and San Diego County. Staff from the California Department of Public Health, Office of AIDS (SOA), San Francisco Department of Public Health and the Pacific AIDS Education and Training Center (PAETC) planned Prep for PrEP: a two-day working meeting for CDC-funded Project PrIDE programs to discuss plans for Pre-Exposure Prophylaxis implementation for California program representatives in Anaheim on November 15 – 16, 2016. Over the course of two days attendees learned together from panels of PrEP consumers, PrEP navigators, PrEP media designers, Project PrIDE staff, PrEP finance experts, clinical provider trainers, and PrEP evaluation strategists, and discussed ideas, successes, challenges, and lessons learned to date. Some of the PP programs were just starting to implement their strategies while others were further along.The meeting objectives were:1. Identify barriers, facilitators and effective strategies, including social marketing, to increase PrEP awareness and uptake among MSM of color and transgender women2. Describe options and resources for financing PrEP services and medications 3. State 3 successful methods to build sufficient provider capacity to deliver PrEP services4. Share current monitoring and evaluation strategies to effectively document PrEP uptake and the factors that affect uptake among MSM of color and transgender women. The following summarizes highlights of the meeting take-away points.The opening Coat of Arms exercise was especially effective in familiarizing meeting participants with the current state of PrEP in the funded jurisdictions. Attention to language and words is very important and necessary to avoid stigmatizing populations and communities that are priorities for outreach and engagement. For example, being a transgender person is an identity, and not a risk behavior. Messaging should emphasize health and connection rather than “risky” or “high risk” behaviors. Labels increase anxiety and pressure.Training and capacity building programs to increase HIV testing should include PrEP information.PrEP services for transgender women should include hormone affirming services as well.Personal stories are great motivators in training and education activities.Even in San Francisco, with a robust Getting to Zero initiative, disparities in PrEP uptake continue to exist. Successful interventions to increase access to PrEP all include the use of navigators to ensure fiscal coverage, develop personal relationships, and provide support.Marketing and social media initiatives are now emphasizing positive, joyous messages, such as PrEP for Love (Chicago) and Our Sexual Revolutions (SF), with “real people” as models in ads.Some jurisdictions (e.g., Orange Co) continue to experience limited numbers of clinicians willing to prescribe PrEP, with primary care providers preferring to refer to infection disease specialists because they see any HIV-related care should be the purview of specialty medical care. Some insurance plans refer patients to ID specialist for PrEP services.San Francisco is experimenting with “academic detailing,” based on the New York City program, to educate clinicians as one means to increase the number of prescribers.There was unanimous agreement that clinicians are generally uncomfortable discussing sexual activity with their patients, but that this is a necessary aspect of good primary care.Domestic violence remains a critical issue for priority communities and needs to be addressed as part of clinical services. One outstanding bias among providers is the reluctance to prescribe PrEP due to the fear of increases in STIs and decrease in condom use.Collection of data through evaluation is essential to monitoring the effectiveness of each stage of the PrEP Roadmap (Marketing, Engagement, Education, Screening, Linkage to care, Initiation and Retention)More detailed notes taken during each meeting session are provided below. Day 1 – Tuesday, November 15, 2016Landscape of PrEP in California Programs: Resources and Activities Presenters: Steve Gibson (CDPH Office of AIDS); Jonathan Fuchs (SFDPH)Presentations:Landscape of PrEP in California Programs: Resources and Activities, by?Steve Gibson (CDPH Office of AIDS)The Project PrIDE Learning Collaborative, by?Jonathan Fuchs (SFDPH)Notes: nothing additional than PPT presentationKey Questions/Comments:-No key questions for Steve-For Jonathan:Q - Is the Learning Collaborative restricted to PrIDE sitesA - Currently, yesC - Desert AIDS Project – response time for questions/conversations has been amazing!Resources: Interactive Overview of Project PrIDE ProgramsFacilitator: Jonathan Fuchs (San Francisco Department of Public Health [SFDPH])"Coat of Arms" Breakout session instructionsSummary of “Coat of Arms” activity Questions/Comments/Resources:CDPH Office of AIDS (OA) Current - Feeling new at this; building a foundation; fiscal resourceFuture – strength; reduce disparitiesStrategies – connecting a constellation of stars; find and share resourcesOpp/Chall – Synergy, continued funding, energy, Federal landscapeLos Angeles (LA)Current – creation PrEP cascade; estimation of potential PrEP recipients; variability within race/ethnicity; address disparitiesFuture – LGBT Center – double # of PrEP participants; increase # transgender women on PrEP; need better markers of adherence; ready availability in a variety of sitesStrategies – marketing/outreach; PrEP NavigatorsOpp/Chall – addressing stigma; unmet needs amongst early adopters; funding – big gaps; insurance/cost of medication; intersection of STDs and PrEPQ – How did LA develop/calculate their rates? A. Came to it two ways; locally and CDC methodQ – Representation of trans women in the survey/data, etc.?A. Trans Summit (today in LA); working to develop better data and strategiesOrange County (OC)Current – Survey of organizations in June (2/194 were working with PrEP); low uptakeFuture – community engagement; providers awareness; diagram of future state; increase ratio 15$/year to 45 of those referred and then successful yon PrEPStrategies – PrEP coalition (recently formed); Prevention and Care Strategies Committee (extension of the Planning Council)Opp/Chall – provider involvement; some not interested & referring out to ID doctors instead; provider comfort level (getting them ready/comfortable with prescribing); Q – Funding of incentives?A. Not sureQ- Used data from social media appsNot so farAlameda CountyCurrent – pioneer in PrEP – Oakland CRUSH, working with MSM youth of color, holistic approach; cautious uptake of PrEP amongst African-Americans; no Latino outreach yet; private providers – telling people they “don’t need PrEP”; few providers that feel comfortable prescribing with trans folksFuture – culturally competent providers; increased provider comfort with conversations about sexStrategies – testing programs to include PrEP Navigation; media campaign )radio spots)Opp/Chall – many PrEP advocates are HIV+; community inputSan Diego County (SD)Current – tip of the iceberg; lots of work to be done; Stages of Change – in “contemplation”; Future – laying a foundation; the “lightbulb”/a-ha momentStrategies – multi-media; provider engagementOpp/Chall – cost, stigma, insurance, trustDesert AIDS Project (DAP)Current – no research/data analysis – no way to know; ~10 active prescribers across 5 major institutionsFuture – 100% of MSM of color/trans women aware/informed about PrEP; no barriers to access/careStrategies – built infrastructure with medical providers/clinics – education with clinic staff, etc. through public health detailing; all negative testers get PrEP ed.; targeted 40 provider settingsOpp/Chall – improve HIV testing risk assessment capacity/build infrastructure; how to reach higher risk individuals – structural changes, etc. to reach out versus waiting for them to come in; provider/community resistance; leverage the get tested Coachella Valley networkSan Francisco (SFDPH)Current – strong momentum, stigma reducing; recent strong update of PrEP; continued decline of new infections; disparities still existFuture – Zero HIV Transmissions – Getting to Zero; all prescribing providers knowledgeable; new ways of administering (e.g. injectables)Strategies – ambassadors (Popular Opinion Leader (POL); public health detailing, social marketing, data to PrEP; strengthen referral systems; increased integration with Getting to Zero; Treatment as Prevention team connectionOpp/Chall – legacy of focus on sexual health; opportunity to revolutionize how providers interact with patients around sexual healthKey themesProvider capacity buildingMoving people through the cascadeMedia/social marketing campaignsResources:See Proceedings posted for our Coat of Arms Photo GalleryBREAKPerspectives from PrEP ConsumersConsumer Panelists: Donnie Frazer (HIV/PrEP Advocate & Advisory Board Member, Young MSM/Lesbian Gay Bisexual Transgender Center of Excellence, Los Angeles); Diamond Electra Star (PrEP Advocate, San Francisco); Efren Chacon (PrEP Advocate & Patient Care Navigator, Southern California Men’s Medical Group, Los Angeles)Moderator: Shannon Weber (Pacific AIDS Education & Training Center [PAETC])Notes:What are some barriers for people of color? (Donnie)Public health communicates that getting PrEP is easyThat’s not the experience when you come inLong waits for appointmentsLots of unexpected testsDon’t walk out with PrEPDisconnect; causes lots of anxiety at the various stepYounger people seeking more immediate gratification in generalHow do providers make you feel welcome? (Diamond)History of mental health issues; trauma/systemic abuse by individuals/institutionsInvisibility of the trans community; tried to shut out LGBT community – they wouldn’t let me. Started to see a different side of the community – welcoming, open, nice, doctors who were interested, able to get close with the staff – “they were like family”. Thought I could not go to SF AIDS Foundation because I didn’t have HIV – learned that I could; trans group started. “The deeper I gotinto the programs, the more I heard about PEP/PrEP. During situations of risk – not always in control of the situation; feelings of anger. During this time of risk – felt loved and cared for by the Tom Wadell staff. Key Questions/Comments:QHow do you keep someone engaged throughout this process, given the context of more instant gratification?ASet expectations from the beginning about the reality/timeframe of the process. Can focus on adherence strategies; way to keep yourself/kidneys healthy, discuss side effects, discuss the “beautiful outcomes” – how PrEP is an empowerment choice, understanding what “undetectable” means when interacting with HIV+ individuals; knowing to and how to access PEP when there is a slip. Labeling/stereotyping from other individuals within the community – creates anxiety, pressure, etc. Intimate Partner Violence – complicates issues of adherence – what if my pills are stolen, what is my exit strategy? Decisions about condom use, etc. may changeCLife doesn’t stop at 5pm. Need more outreach and engagement after 5pm, especially among trans folks and sex workers. Safe drop-in spaces could be a helpful place to communicate about PrEP.Follow-up:Access for undocumented individuals. Perhaps a discussion in the Learning Collaborative? Resources:Diamond’s story on YouTube: Inspiring PrEP Demand: Focus on MSM of Color and Transgender Women Presenters: John Melichar (SFDPH); Natalie Sanchez (AltaMed); Bruce Weiss (Desert AIDS Project)Moderator: Jonathan Fuchs (SFDPH)Notes:SFDPH - Our Sexual Revolution: Social Marketing to Increase PrEP Uptake Among TFSM and MSM of Color in San Francisco,?Presenter: John Melichar (SFDPH)Our Sexual Revolution / social marketing campaign; launched June 15th “OUR” – implies ownership by all; joyfulness to the campaignFour critical elements (title, website, message, connection to SFDPHData/EvalMeasuring click through from social mediaSignificant conversation rate from Grindr. Doing street evaluation to ask “what actions occurred as a result of the campaign?”AltaMed - How do we Increase PrEP use in MSM and Transgender Women??Presenter:?Natalie Sanchez (AltaMed);Modeling conversation – PrEP and condoms; in PrEP messaging, the “am I at risk” question is important – no one likes to be at risk, easy to resist that label.Desert AIDS Project (DAP)- PrEP Pride in the Coachella Valley,?by?Bruce Weiss (Desert AIDS Project)Leveraged 3-year “Get Tested Coachella Valley” campaign; uses physician spokespersonKey Questions:QWhat would you do differently?ASFDPH-how prominently an STI message should appear in a PrEP campaign; lots of different points of viewAAltaMed - how would/could we make PrEP more visible - huge PrEP pill, posters everywhere – amongst target population and the community at-largeA DAP – look at what others are doing across the country that is effective; how can we integrate that into our work? How to communicate a message around the use of condoms and STIs?QAny success with undocumented folks accessing PrEP?AAltaMed – success through local programming; Center of Excellence; additional desire for primary care – that needs to be on a sliding fee scale – can be confusing for patients – why is this different? Difference between a specially funded program versus insuranceADAP – sliding fee scaleQPlanning / creative process behind the Vaquero – Listo! Video?ACreative team is in-house; staff who are also working front line and serving patients; writing out the messaging/information to convey first; then looking at what visuals make sense and can deepen the messageQIntended target audience of the GTCV video? SF third street campaign was not a good connection to the Bayview; what are you thinking moving forward?ADAP – video targeted at funders, annual celebration of success; not intended to be a “campaign”ASFDPH – not a large MSMS population in the Bayview, really need to rethink the approach.Resources:SFDPHOur Sexual Revolution Campaign - Better World Advertising - - 11 Sexy Campaigns that Spread the Word - AltaMedVaquero – Listo! - Desert AIDS ProjectGTCV - BREAKEngaging with the Community: The Role of PrEP Navigators Panelists: Michael Barajas (SFDPH); Raven Mendez (Desert AIDS Project); Alyssa Haveman (Orange Country Health Care Agency)Moderator: Clark Marshall (CDPH Office of AIDS)Notes:SFDPH - experience originated with the Demo ProjectClose relationship with Gilead – “holding” slots in the MAP programFocused outreach in the Mission – resulting in growth from 2-3 patients to over 30Leveraged STI program in the Tenderloin to engage youth in PrEPCase study challenge learning – sometimes critical to assess, understand, and address other needs before starting with PrEP – e.g. safety, housing, violence, etc.DAPFocused/personal engagement with clientsEngagement occurs before the provider visit, testing, etc. – give an opportunity to get to know them in-depthCase study challenge learning – adherent client, highly emotional situation, engaged with other staff (counselor) to help address the situation – they were able to develop a planOCUnique approach – utilization of public health nursesCase study challenge learning – initial refusal from provider; long wait to see someone different; next provider focused way too much on the side effects, created anxiety; went back again to navigator – got connected to a third provider – and experienced successKey Questions:QStudents still on parent insurance – how are you doing with confidential communications request? walks you through the process of disconnecting communications from parents, masks some of the services (e.g. HIV testing)CNot all insurance familiar with the law in California. Humboldt County experienced some breachesCIn San Diego, some of the university programs have services that provide PrEP; helping to look at options outside of health plansOverall Resources Offer by OA:Dear Colleague letter - needs assessment - Day 2 – Wednesday, November 16. 20168:30 – 9:00Morning Warm-up: PrEP Strengths/Lessons LearnedFacilitator: Mona Bernstein (PAETC)QHow is SF providing meds prior to lab work, etc. for same day PrEP?ADr. Tony Mills in LA using this process.ASF – HIV/HepC rapid at the first visit; send creatinine/viral load, STI testingQGreat communication campaigns! What are some of the evaluations for those campaigns?QExtra emphasis on ensuring we are using “proper narrative” methods, language, etc. to engage with the trans communityQStrategies to reach young MSM who are not as “health conscious”AOne strategy can include use peer-to-peer approaches – meeting the youth more where they are atQChallenging to get providers to make a change in practice; very conservative industry. What “stories” need to be told to providers to get them to embrace PrEP?ACDC has a live risk reduction tool at QDeveloping a common terminology (e.g. “people first” language)CWhen reaching out to providers about HIV testing, also show a short video on PrEP101 – positive response. Use QDiscussion on the overall branding of the work that we do? Some of the language can be traumatizing. How to frame as a gay man’s wellness issue. Moving framing away from “you are at risk” to “how to improve your health”APhenomenon of rational fatalism. Don’t use risk reduction strategies – because they don’t believe they will work. Using empowerment versus fear.QHost of issue related to STI. Barriers to providing PrEP; belief that condom use will be reduced; rising rates of STIs – how to we communicate/address this?CMSM is a risk behavior, but trans is an identity. Bringing together MSM/trans all the time is equating two different things. Need to unpack the trans experience much more deeply.CProviding PrEP to people under the age of 18Lightning Rounds of PrEP Financing OptionsPanelists: Ian Jensen (Los Angeles LGBT Center); Giovan Hernandez (County of San Diego Health and Human Service Agency); Craig Pulsipher (AIDS Project Los Angeles)Moderator: Clark Marshall (CDPH Office of AIDS)Craig - PrEP Cost Analysis for Covered California Health PlansQImagine walking someone with zero experience through this process.ABasic health literacy is essential (e.g. co-pay, deductible, etc.)QNeed for some plans to seek specialty care versus using primary careANot sure which plans are directing folks to specialty providersQCould this be distilled down to a video, slide share, etc.?QHow often are there changes to this?APlans are allowed to change on an annual basis. These are locked in for 2017RaulUse social media (Grindr, Scruff, Growlr) to have conversations about PrEP and PrEP navigationQWritten protocol about how you are using PrEP navigation on Grindr, etc?AGrassroots effort, organic conversations happening around PrEP – joined in with that effort. Do have some best practices.Ian - PrEP Navigation, Overcoming Financial Barriers of the Un/UnderinsuredWhat R U Into? Campaign is located at: Biggest barrier at the center – medication assistanceQWere new patients getting into sexual health services at the West Hollywood clinic getting those services somewhere else before? Or was this a new service for them?ANewly joined the program. Not sure. A number of patients come in who have a lot of peer-to-peer experience/information. Not all of it is accurate.GiovanQEngagement with pharmacists?QDoes the military cover PrEP?AYes. For members and their beneficiariesPrEP financing option scenariosScenario #1 – “Joe”Giovan - Try to get prescription from the previous providerRaven – focus on the STI screening and treatment; have a new PrEP consultation with the patientScenario #2 – “Breanna”Raul – risk assessment; discuss level of comfort in relation to using parent’s insurance; use MyHeathMyInfo; can transition her to MediCal; assist with referral to another physicianIan – online app doesn’t mean having sex. Explore what type of sex she is having. Connect with Trans programs and get into careCraig – Ca Confidential Health Information Act. Can download forms and submit to your health insurance plan from MyHealthMyInfoScenario #3 – “Ben”Ian – provide some education about the window period – rapid test is a preliminaryRaul – introduce the concept of PrEP; review the window period, have him text the friend and tell him he needs an extra 10-15 minutes; refer him to culturally competent services for off-label useGiovan – given marginal housing situation – is PrEP even a priority? Address his immediate needs first, so I can get him to come back.Ian – explore some of the specifics of his situation overallQAny success with youth under 18 ad MediCal?AMediCal will approve the use of Truvada, you would have to find a way to cover their labs, etc.CTrace back and look at why he got referred and “didn’t know why”. Strengthen provider education and internal procedures within the clinic so the patient has more information/specifics at the time of referral.Resources:LA LGBT Center DHSP PrEP Worksheet -"Peter Prepper"PrEP Covered California InfographicPrEP Covered California AnalysisPrEP Flow Chart (Project Inform)BREAKFocus on Providers: Identifying and Training PrEP providersPresenters: Mona Bernstein (PAETC); Alyson Decker (SFPDH); Shannon Weber (HIVE & ); Phil Meyer (Los Angeles AETC);Moderator: Mona Bernstein (PAETC) - Focus on Providers: Identifying and Training PrEP ProvidersAlyson - Academic Detailing Efforts in San FranciscoPublic Health/Academic Detailing resource: Shannon - Directory located at: ; Update on 12/1/16PrEP locator launching with Emory University; CA PleasePrEPMe will share data 2x/mo to keep basic info consistentOnline chat with Project Inform launching on 1/10/17CA statewide PrEP Navigator group (outside of the PrIDE counties) with Project InformPhil - CLINIC X: A case studySophie Wong – HIV guide for Providers – located at: portal (CEUs available) - QProvider trainings – can there be a portion that includes information about PrEP and hormone treatment/potential concerns?AOne resource – CoE – Primary Care for Trans Populations. No information that shows interactions between PrEP and gender affirming hormones. CoE toolkit and campaign materials located at: QInterested in knowing about call for training, etc. that originates from LA (or any of the PrIDE counties)QCold calling model with Public Health/Academic Detailing?AHas not been tried so far. NYC model does do this with their program. NYC Action Kits are located at: QAny resources for providers that you would recommend?AEngaging Black Men Who Have Sex with Men (BMSM) in Los Angeles in HIV Pre-Exposure Prophylaxis (PrEP) located at: AMedscape training (free) - Preventing HIV Infection in the Primary Care Setting:?The Role of Pre-Exposure Prophylaxis (PrEP) located at: LUNCHPresentation: PrEP-4-Love: Chicago’s PrEP CampaignPresenter: James Pickett, Director of Prevention Advocacy and Gay Men’s Health, AIDS Foundation of ChicagoChicago Prep4Love campaign located at: (Includes links to Instagram, Facebook and Soundcloud sites)QHow many people were you trying to reach and what geographical location?ADidn’t have a goal for how many. Focused transit ads on the Southside; located where people go, go out, etc. Need to dig more into the data. Most popular link is the PrEP Provider page users spend an average of 3 min on the page. Looking at further metrics/analysis.QAnything that you may have done differently?A:Better handle on the Facebook/Instagram situation. Caught us by surprised when it was banned from Facebook (the boy ads)Chicago Transit approved the campaign, resulting in millions of impressionsClosely following the Facebook guidelines for ads (e.g. %copy/%image) and were surprised by their rejecting of the “boy ads”Originally targeted to launch in the fall – but the ad buys, etc. were too expensive due to the holiday season. Postponed to February – made it work tying it in to Valentine’s Day, Black History Month, etc. “Take what you got and figure out how to make lemonade out of it”. Review and learn from each element/mistake, etc. DO it differently/better the next time. Don’t give up. Main lesson: advertising agencies are everywhere and they want to do pro-bono work. Seek them out! “They can become your allies – they are hungry, they want to do something that feed’s their soul.”Monitoring and Evaluation StrategiesPresenters: Kolbi Parrish (CDPH OA); Sheryl Lynn Williams (CPHD Office of AIDS); Montica Levy (SFDPH); Shoshanna Nakelsky (LA County DPH)Moderator: Sheryl Lynn Williams (CPDH Office of AIDS)SherylCDC Framework for Evaluation resources located at: KolbiJust released ver 1.2 of the data collection tools. 1.3 will be coming soon based on feedback from the CoE to make the materials more trans friendly.Any questions or need any assistance – please contact the OA Evaluation TeamMonticaThe targets for the social media campaign are iterative – not set in stone. Main challenge of the difference in measurement between CDC (individuals exposed) and standard social media metrics (impressions). On-going discussion about how to bring these two numbers together.ShoshannaQHow are you using the CHIS at the state level? AIt is on the wish list to have them add questions to the existing survey. If we can do that, then we hope to have some information.QFocus groups at the state level?ADon’t currently have a hard plan for focus groups at the state level.QHow did SF differentiate the Latino and trans women numbers?ALeft some of the data off the slide around population estimates from the NHBS. The process for Latinos and trans women were calculated the same way as for MSM and AA MSM.QAny research/information on the interactions between PrEP and other medications that trans persons may be taking?ACoE has some information. Upcoming study looking more at trans women, results in a few yearsQWhy are we not talking about trans men who have sex with men?AIn SF services – trans men are not excluded, they are included in the services for MSM.QCan we get the outreach form or screening document? ACurrently don’t have plans to create that type of tool. If there is an interest, please email us and we can discuss and see if there are resources. QWorried about not be able to use LEO and have to use EvaluationWeb insteadAHuge unknown right now. Don’t have a CA data collection system for PrEP. Trying to build that capacity and infrastructure. Unknown where they will reside in the future.Next Steps and EvaluationFacilitators: Amy Kile-Puente & Clark Marshall (CDPH Office of AIDS)TakeawaysIdeas around checklist cards for providersIdeas for campaign in our clinicsMotivating, helpful, moving, empoweringLots of great resourcesWill follow-up with other participants to get materialsSee where everyone fits in the continuumInspired to focus on the providers who are resistant around sexual healthGreat peer to peer learning experienceGetting to know others more personally/face to faceAny other ways SFDPH CBA can support peer to peer learningStarter kits for providers to do more rectal STI testingVery well planned/comprehensiveLike the “pleasure centered” approach.PrEP user panel and Provider training panelGo back and do more focus groups with our population – steal tools that others have usedLooking forward to hearing process in the next year for everyone’s programsExpanded perspective – see how others are approaching similar situationsUsing the Learning Collaborative to work on challenges with each otherHearing the personal stories from consumers/navigators, etc. ................
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