That's all I get, just a small little, good morning everybody. Oh, that's, thank you. That's what I'm talking about. I need to wake up and something like that would probably wake me up. So, due to unprecedented registration numbers for the AAMA annual conference this year, the AAMA would like to remind conference attendees that seating at all events, including CE sessions, is on a first-come, first-served basis. Please find a seat if you are standing in the back. Raise your hand if you have a seat next to you that is available. Fire codes will not allow overcapacity in a room standing outside in the hallway. There's nobody back there. Or is there? That's the question of the day. Just a few reminders as well. Remember that badges must be worn at all events. Attendance is required for 90% of the session to earn CEUs. Please silence all cell phone devices. Ready for the good part? Yeah. Are you ready? Yes. Thank you to the ladies over here who yelled yes. It is my pleasure to introduce Dr. Monique Brown. She is an assistant professor in the epidemiology, excuse me, epidemiology and biostatistics department in the Arnold School of Public Health at the University of South Carolina. She is also a faculty affiliate in the South Carolina Smart State Center for Healthcare Quality, the Rural and Minority Health Research Center, and the Office for the Study of Aging. Her research focuses on the epidemiology of HIV and clinical HIV studies. Dr. Brown has published work on psychosocial factors among people living with HIV and clinical HIV research. Dr. Monique Brown. Good morning, everyone. Good morning. It's great to be here. Thank you for the invitation to speak. So we'll be talking this morning about HIV-AIDS. We'll be talking about the epidemiology of HIV-AIDS, screening, and provider-patient or patient-provider communication. So to give you an outline of what we'll be talking about today, I'll be talking about what is epidemiology, the epidemiology of HIV, looking at it globally, nationally, and in South Carolina, and we look at screening and patient-provider communication. So let's talk about epidemiology. So what is epidemiology? Anybody has an idea what epidemiology is, especially now that we're in the pandemic? Yes. So health statistics and analyzing, yes. The makeup of it, definitely. Yes, so epidemiology has become more popular, especially that we're in the COVID-19 pandemic, and so it's really the study of the distribution and determinants of health-related states and events in specified populations. So when we say study, we're talking about the scientific study, the systematic or data-driven study, the frequency and pattern. When we talk about the distribution determinants, we talk about causes of health-related events or risk factors, and when we think about, sometimes when we think about epidemiology, we think about diseases, but it's not really just diseases. It's health-related states and events, even events such as violence, intimate partner violence, when we think about other health states such as obesity. So not really only diseases, but these altogether health-related events. And then we talk about that with respect to populations where we're looking at neighborhood, school, city, state, country, or globally. So there's some public health problems or events. So, for example, we have environmental exposures that we study as public health problems, such as air pollutants or other asthma triggers, lead and heavy metals, infectious diseases, of course. So we have the flu, foodborne illnesses, HIV, and, of course, COVID-19. Injuries such as domestic violence that I mentioned earlier, increased homicides in a community might be a public health problem or even increased suicides in a community might be a public health problem. We have non-infectious diseases such as major birth defects, natural disasters. We just had Hurricane Ian, which destroyed certain parts of Florida and other parts of the U.S. and other countries as well. We had Hurricane Katrina, for example. Terrorism. So all these, when we think about epidemiology, epidemiology can cover all these public health problems and events. So we're going to now talk a little bit more about HIV-AIDS epidemiology. So globally, in 2021, worldwide, there were approximately 38 million people living with HIV. So this is worldwide. And people are still dying from HIV-related causes, even though we have come a long way in terms of HIV treatment. But people are still dying from HIV-related causes. So worldwide, 650,000 people died. And over 1 million people acquired HIV in 2021. But we see that people are accessing antiretroviral therapy or HIV medication or ART. So this results in around 75% of people living with HIV accessing antiretroviral therapy, and where we see one in four do not have access to ART. So even though we have access to ART pretty comfortably in the U.S., in other countries, it's not as accessible. So let's just remember this from a global perspective. And then women and girls accounted for close to 50% of all new infections in 2021. And since the start of the HIV epidemic, 84 million people acquired HIV, and 40 million people died from HIV-related illnesses. So let's look a little bit closer to home. So when we think about HIV in the U.S. in 2020, over 30,000 people received an HIV diagnosis. So people are still being diagnosed with HIV today, as you all know, as you work in the healthcare field. At the end of 2019, 1 million people were living with HIV. 87% knew of their diagnosis. And this results in approximately one in eight being unaware of their diagnosis. So people are living with HIV but sometimes are unaware that they are living with HIV. So this map shows rates of persons living with HIV in the U.S. in 2019. And the darker colors represent the higher rates or the highest rates in the country. So what is this map telling us? The darker colors represent the highest rates. Where is the burden of the epidemic? Southern U.S.? California? Yes, so we see that the rates are, we see that the southern U.S. has some of the highest rates. We see towards the western part as well. So this is showing us that there are geographic disparities in HIV-AIDS in the U.S. And then I was able to look at data from the Centers for Disease Control and Prevention, the CDC. And this shows us the areas with the highest incidence and highest prevalence. So the highest incidence, as we know, are the new cases. And the prevalence refers to people who are living with HIV. So we see that new cases, we see that D.C. has the highest incidence, so highest new cases. The rate of new cases as well as the rate of, in terms of the prevalence rate. We see Georgia, Florida, Louisiana, Mississippi, those have the highest incidence rates. And then for prevalence rates, so once again looking at people living with HIV, we see New York, Maryland, Georgia, and Florida have the highest prevalence rates. So these are the top five states or areas in the U.S. with high incidence and high prevalence of HIV. So there are also disparities by age. So this shows us new HIV diagnosis in the U.S. in 2020 by age. And we see that people are being diagnosed as early as 13 to 14 years old. And we see people are being diagnosed at 15 to 19, 20 to 24, et cetera. So we see that, let me see if this is working great. So we see that the highest number of cases here, the 6,000 plus, is 25 to 29. And then we have other rates as well, other numbers of diagnoses of new cases in these other age groups. But it's very interesting because people tend to think, sometimes people tend to think that older adults might not be sexually active. But we see that older adults are also being diagnosed at sort of older ages. 65 and older we have people being diagnosed and so forth. So this shows us that there are age disparities. We have very young people being diagnosed as well as older adults being diagnosed as well. So we're going to now look at new HIV diagnoses in the U.S. by race, ethnicity. So this graph shows us different racial and ethnic groups and new diagnoses in 2020. So here we see that the black population actually has the highest number of cases. And then we have the Hispanic or Latinx population and then white population. So we see that there are racial, ethnic disparities also with regards to HIV diagnoses. And we have some diagnoses among American Indians, Asians, Native Hawaiians and other Pacific Islanders and multiracial groups. But we see that black populations have some of the highest rates of HIV. So let us look by transmission category. So there are different ways in which a person can acquire HIV. So we have male-to-male sexual contact, injection drug use. This table also looks at male-to-male sexual contact and injection drug use, heterosexual contacts, perinatally and other. So we see that for males, the male-to-male sexual contact is the transmission method by which they have the highest diagnoses. But for women, we see that heterosexual contact is the way by which they acquire HIV in terms of heterosexual contact. So we see that injection drug use also plays a role among males and among females. So among females, it's the second highest. Among males, it's the third highest. And we see that heterosexual contact is also one of the methods for males but not as compared to male-to-male sexual contact. And then we see that there are a few diagnoses perinatally as well. So just to keep this in mind that there are different transmission categories and this differs by males versus females. So when we think about a little bit closer to South Carolina, we're in South Carolina today. We have the sixth highest incidence in the U.S. at 12.6 per 100,000 population. We also have the tenth highest prevalence in the U.S. And this graph shows HIV incidence, prevalence, and deaths. So we see that the incidence, which is towards the bottom here, has not really changed that much over the years from 2001 to 2020. It hasn't really changed that much. But because people are living longer with HIV, we see the prevalence increasing. So the number of people living with HIV increasing with the incidence sort of remaining the same year after year. And deaths remaining pretty low year after year. And then when we look at HIV by race, ethnicity, and gender, we see that here we have black men accounting for approximately 50% of diagnoses. And we see that black women also accounted for the highest percentage of diagnoses among women. So once again, we see the gender and the racial ethnic disparities even in South Carolina. So one important factor that we should consider, and that I'm sure you think about on a daily basis as you care for your patients, is the HIV care continuum. So the HIV treatment cascade is basically the series of steps a person with HIV takes from being diagnosed with HIV through successful treatment with HIV medication. So here we see that if a person is diagnosed with HIV, the next step is that they should be linked to care. And if they're linked to care, then we're hoping that they remain engaged in care and they are retained in care. And then in care, they will be prescribed antiretroviral therapy. And by being prescribed antiretroviral therapy, we really hope that they will adhere to the antiretroviral therapy. And we'll talk about the importance of adherence. So when they're prescribed antiretroviral therapy and adhere to antiretroviral therapy, it is very important because this helps them to achieve viral suppression, as we know. So viral suppression is a desired outcome for people living with HIV, where the level of HIV in the blood is low, the risk of transmission is greatly reduced, and around 90 to 95% ART adherence is required to obtain viral suppression. Okay, so are there any questions about the epidemiology before we get into screening? And we'll have some time at the end for questions as well. So we can move on if that's okay. And we'll now talk about screening. Yes. Yes, yes. So viral suppression, yes. So it means the level of HIV, level of virus in the blood is low. And we're also going to talk about this campaign, U equals U, which some of you may have heard about, undetectable equals untransmissible. And this was declared by the CDC that when you have an undetectable viral load, you have effectively no risk of transmitting the virus to your partners. So we're going to talk about that as well. So that's a great question. Yes. That's a good question. So in terms of the, let's go back. Yes, so, yes, so because that's a very big difference, right? So in terms of nine, we have nine boys and 51 girls who were diagnosed perinatally. I don't know if there is a physiological reason for that, but that's, it's very interesting that, you know, the numbers are so disparate for, for the, for the gender, it's for perinatal transmission. Yes. Yes. Yes. Yes. Mm-hmm. Somebody else? I think I saw a hand somewhere. Okay. Okay. Great questions. So we're going to talk a little bit about screening. So HIV testing, based on the epidemiology that we've seen, we know that HIV testing is very important. And in the U.S., it's estimated that approximately 158,000 people are unaware of their HIV status. And it's estimated that nearly 40% of new HIV infections are transmitted by people who did not know that they had HIV. So there are some cases where the partner might know that they have HIV, but research has shown that up to 40% of cases, the partner who had HIV did not know that they had HIV. So testing is very important. It's the first step in preventing HIV transmission and maintaining a healthy life. So data has shown that if you're tested and diagnosed early, then there are clear benefits to starting treatment right away. And the study also highlighted the importance of routine HIV testing and impact on better health outcomes. So people with HIV who know their status can get HIV treatment and remain healthy for many years as we know. HIV treatment reduces the viral load, reduces illness, and prevents transmission. And this is what I mentioned earlier, the U equals U, where people with HIV who take HIV treatment as prescribed and get an undetectable viral load or stay virally suppressed have effectively no risk of transmitting HIV. So it's U equals U, undetectable equals untransmittable. So people who get tested and learn they don't have HIV can make healthy decisions about sex, drug use, healthcare that can help prevent HIV. Taking HIV medicine, also called pre-exposure prophylaxis or PrEP, is highly effective for preventing HIV, and we'll talk about PrEP in a few slides. So the CDC has some screening recommendations. So they advise routine HIV screening of adults, adolescents, and pregnant women in healthcare settings. They recommend HIV testing for everyone between the ages of 13 and 64 at least once as part of routine healthcare. And they advise testing every three to six months for gay and bisexual men. And then they also recommend testing once a year if you have any of these factors. So if you're a man who has had sex with another man, if you've had anal or vaginal sex with someone with HIV, if you've had more than one sex partner since your last HIV test, if you share needles, syringes, or other drug injection equipment, if you've exchanged sex for drugs or money, you've been diagnosed with or treated for another sexually transmitted disease or infection, and you've been diagnosed with or treated for hepatitis or tuberculosis, and if you've had sex with someone who has done anything listed above, or someone whose sexual history you don't know. So they recommend testing once a year for any of these factors. They recommend routine HIV screening in healthcare settings, HIV testing 13 to 64 at least once, and then every three to six months for gay and bisexual men. So what do you think, based on your experience, what do you think are some challenges with the CDC recommendations? Let me go back to that. Yes? Yes, that's very interesting, because the U equals U, as we know, so we actually did a study on looking at the perspectives of U equals U among older adults living with HIV. So we wanted to get their perspectives in terms of what do you think about this U equals U that the CDC has come up with or has established for people living with HIV. And they said that one of the, we did a qualitative study, so we had interviews, in-depth interviews, and some people say, I know that's what the doctors say, but I don't believe that one. And they said, I'm still going to use condoms, and that was their perspective, that they were still going to use condoms, they were still going to practice safer sexual practices. So that was very interesting. But yes, so U equals U, it can be a little bit controversial. As a researcher, and our research team definitely promotes condom use, even with U equals U being out there. So that's, yes, so that's very interesting. So that's one of the challenges with the recommendations. You said one of the, okay, yes, yes. So that's another challenge, is if you're 17 and under, and your parents finding out that you're sexually active. So yes, so that's another challenge, yes. So if you're 17 and under, and your parents finding out that you're sexually active, is it a good idea to use condoms? And if you're 17 and under, and your parents finding out that you're sexually active, is it a good idea to use condoms? Yes, yes. So if you're 17 and under, and your parents finding out that you're sexually active, is it a good idea to use condoms? Yes, definitely. So the stigma with living with HIV or doing an HIV test, what does that mean? And also, in terms of talking about same-sex relationships. So definitely, that's a challenge as well. Yes. Yes. Okay. Okay, wow. So in terms of age differences or thinking about if you're 17 and younger, your parents finding out, it was stated that there are some that might differ by state. And there are some states or some areas where you can seek sexual health services if you're like 12, you said? 12, 12 and older. So that is dependent on states. Yes. Yes. Okay, okay. It's still billed to the parents. Right. Okay. Oh, interesting. Okay. And then in some states, they bill it to the health department. So I'm just repeating. So those in the back can hear as well. So we have differences by state. So sometimes it's billed to the parents, sometimes to the health department. Sometimes even if it's billed to the parents, there are certain codes that they use where you're not able to tell what is being billed for unless there is like enhanced access that the parent had requested. Okay. Okay, great. Thank you so much. This is great. I'm learning a lot today too. So yes, so with some of the other challenges with the CDC recommendations, so they recommend testing at least once for people age 13 to 64. But what about adults older than 64 as we saw from that age chart? So we see that adults older than 64 are being diagnosed with HIV. We know that adolescents sometimes younger than 13 are also sexually active and so forth. And we've also discussed the other challenges with the recommendation. So just keep these recommendations in mind. But we also have to be careful in terms of dealing with our patients at the one-on-one and at the individual level as well. And then for pregnant people, so testing pregnant people and treating those who have HIV has significantly decreased the number of babies born with HIV. HIV treatment is most effective when started as early as possible during a pregnancy. So as we know, people can have HIV or be diagnosed with HIV, but they don't, but their children can be born HIV negative or without HIV. So when HIV treatment is started early, then it's most effective. However, if it's even treatment that started during labor or shortly after the baby's born is also effective as well. If a pregnant person gets HIV treatment early in their pregnancy, the risk of transmitting HIV is extremely low, 1% or less. So pregnant people who test negative may also talk to their health care providers about pre-exposure prophylaxis depending on the factors that they may have. So in terms of HIV tests, they're very accurate. No test at present can detect the virus immediately after infection. How soon a test can detect HIV depends on the type of test. And there are three types, the antibody test, antigen antibody test, and nucleic acid test. So the antibody test look for antibodies to HIV in a person's blood or oral fluid, can take 23 to 90 days to detect HIV after exposure. Most rapid tests and the only FDA approved HIV cell tests are antibody tests. And those tests that use blood from a vein can detect HIV sooner after infection than tests done with blood from a finger stick or with oral fluid. And then with the antigen antibody tests, these look for both HIV antibodies and antigens. So as we know, antibodies are produced by a person's immune system when they're exposed to viruses like HIV. Antigens are foreign substances that cause a person's immune system to activate. So when a person has HIV, an antigen called P24 is produced before antibodies develop. And these tests are recommended for testing done in labs and are common in the US. And for these tests, if they're performed by a lab on blood from a vein, can usually detect HIV 18 to 45 days after exposure. And there's also a test that is done with a finger stick, and the test done with blood from a finger stick can take 18 to 90 days after exposure to detect HIV. And then we have the nucleic acid tests. So these look for the actual virus in the blood and should be considered for people who have had a recent exposure or a possible exposure with early symptoms of HIV and have tested negative with an antibody or antigen antibody test. And these can usually detect HIV 10 to 33 days after exposure. So how long does it take for HIV test results? So some of the self-tests take 20 minutes with a rapid antibody test with blood from a finger stick or oral fluid. Results can be in 30 minutes or less. The rapid antigen antibody test with blood from a finger stick can take 30 minutes or less. And it may take several days to receive your test results with the nucleic acid test or antigen antibody lab tests. So some testing considerations. So an initial HIV test usually will be with the antigen antibody or an antibody test. If the initial HIV test is a rapid or self-test and it is positive, usually the person should go to a healthcare provider to get follow-up testing. If the initial HIV test is a lab test and it's positive, the lab will usually conduct follow-up testing on the same blood sample. And although HIV tests are generally accurate, follow-up tests allow for confirmation of the result. So these are usually accurate, but then if there is testing that's done in a lab, for example, they usually conduct follow-up testing to just confirm that the results are accurate. Yes, that's possible. So that's why they suggest that you go to a healthcare provider after doing the self-test. No, you don't want to. They usually suggest not breastfeeding if you're living with HIV. Yes. Well, that's a great question because I know that for when you have, for example, if you have HIV, they do recommend, they don't recommend breastfeeding, so that will be a challenge for the mother in terms of trying to find, you know, food for the baby. But yes, but they definitely don't want you to breastfeed. Yeah. Are there any other questions? Great. Thank you so much. So for the HIV testing considerations, I think we went over that. Yes. So no HIV test can detect HIV immediately after infection due to the window period, and that's the time between HIV exposure and when a test can detect HIV in your body. The window period depends on the type of HIV test, and we saw where the nucleic acid test can usually detect HIV the soonest, about 10 to 33 days after exposure. So if a patient thinks, however, that he or she or they have been exposed to HIV in the last 72 hours, they should talk to a healthcare provider, an ER doctor, or an urgent care provider about PEP, or post-exposure prophylaxis, right away. And we'll talk a little bit more about PEP. So post-exposure prophylaxis, so this means that you're taking medicine to prevent HIV after a possible exposure and should be used only in emergency situations and must be started within 72 hours after a recent possible exposure to HIV. So example of situations of HIV exposure, so for example, during sexual intercourse and if the condom broke, through sharing needles, syringes, or other injection drug use equipment, or sexual assault. So the sooner the patient starts PEP, the better, every hour counts, and if the patient is prescribed PEP, they'll need to take it daily for 28 days. so PEP is not really a substitute for regular use of other HIV prevention. So it's not the right choice for people who may be exposed to HIV frequently. So if a patient is at ongoing risk for HIV, such as through repeated exposures to HIV, they should talk to a healthcare provider about pre-exposure prophylaxis. And we'll talk a little bit more about that. So if taken within 72 hours after possible exposure, PEP is highly effective in preventing HIV, but to be safe, other actions should be taken to protect partners while the patient is taking post-exposure prophylaxis. This includes always using condoms with sexual partners and not sharing needles or injection drug use equipment. So there might be some side effects to post-exposure prophylaxis, nausea, fatigue. Usually these side effects can be treated and usually they aren't life threatening. And I had a little video here. So let's hope it plays. How do I do the... Let me see. Do I do that? Okay. Let's talk about PEP. Knowing all the HIV prevention options available to you is an important step to take... In addition to condoms... And PrEP or pre-exposure prophylaxis, there is also PEP or post-exposure prophylaxis. Let's start with the basics to help determine when and if PEP is right for you and tell you how you can access PEP. The word prophylaxis means to control or prevent the spread of an infection or disease. So PEP means post-exposure prophylaxis or taking medication after you may have been exposed to HIV to prevent getting HIV. PEP must be started within 72 hours or three days after you may have been exposed to HIV. But the sooner you start PEP, the better. People are exposed to HIV by coming into contact with certain bodily fluids of a person with HIV, including blood, semen, and vaginal fluids. This usually happens through anal or vaginal sex or by sharing needles. PEP may help the body's immune system to stop the virus from replicating in the infected cells of the body. The infected cells would then die naturally within a short period of time without producing more copies of HIV. If you're HIV negative or don't know your HIV status and in the last 72 hours you may have been exposed to HIV during sex, for example if the condom broke, or shared needles or works to prepare drugs, or were sexually assaulted, then talk to your health care provider or an emergency room doctor about starting PEP right away. Your health care provider will test you for HIV. If your health care provider prescribes PEP, you'll need to take it once or twice daily for 28 days. It's important you follow your health care provider's advice about how to take your pills. PEP is safe, but may cause side effects like upset stomach and fatigue. You should immediately tell your health care provider if these or other symptoms become severe or do not go away. If you're prescribed PEP and you cannot get insurance coverage, then your health care provider can apply for free PEP medicine through the medication assistance programs run by the manufacturers. PEP is effective in preventing HIV, but not 100%. PEP is not a substitute for regular use of other proven HIV prevention methods, such as PREP, using condoms the right way every time you have sex, and using only new sterile needles and works every time you inject. PEP is for emergency use only. If you find yourself using PEP multiple times, ask your health care provider about taking PREP, which is a medication you take every day to prevent HIV. For more information about PREP, visit cdc.gov slash stop HIV together slash prevention. PEP is highly effective in preventing HIV, but if it doesn't work and you get HIV, the most important step is to get in care and start HIV treatment. For more information about HIV treatment, visit cdc.gov slash stop HIV together slash treatment. Remember, you're in control. Get informed. Make the right choice for you. Thank you. So, yes, so now we'll talk a little bit about pre-exposure prophylaxis. So as they mentioned and as I mentioned previously, so pre-exposure prophylaxis is a medicine that also reduces your chances of getting HIV from sex or injection drug use, but this is more for HIV prevention. The PEP is more for emergency situations. So when taken as prescribed, pre-exposure prophylaxis is highly effective for preventing HIV. So there are two pills and one shot approved for use. So one pill is for people at risk through sex and injection drug use, and the other is for people at risk through sex, not for people assigned female at birth or at risk for HIV through receptive vaginal sex. So these, you can definitely look up the names, but these are, so there are two pills and now they have a shot that has been approved for use as PEP. So how effective is PEP? So PEP reduces the risk of getting HIV from sex by about 99% when taken as prescribed. So there's also information about how effective PEP pills are among people who inject drugs and research has shown that PEP pills reduce the risk of getting HIV by at least 74% when taken as prescribed. So currently the shots are not recommended for people who inject drugs, and if it's not taken as prescribed, it's less effective. So in terms of how long does it take PEP to work, so for receptive anal sex, PEP pills reach maximum protection from HIV at about seven days of daily use. For receptive vaginal sex and injection drug use, the pills reach maximum protection at about 21 days after use, and we don't have data currently on PEP pill effectiveness for insertive anal sex or insertive vaginal sex. We don't know how long it takes for PEP shots to reach maximum protection during sex, so we're still doing research on that outcome. So there are some side effects from PEP like diarrhea, nausea, headache, fatigue, stomach pain, these side effects that are listed here usually go away over time, but for the patients, if they continue to have these side effects, they should definitely let their healthcare provider know. And then there is on-demand PEP, so taking PEP pills only when you're at risk for getting HIV is known as on-demand, or intermittent, non-daily, event-driven, or off-label. So these are some of the ways in which we see on-demand PEP. And then there is one that has been studied which is called the 2-1-1 schedule, so where you take two pills, two to 24 hours before sex, one pill 24 hours after the first dose, and one pill 24 hours after the second dose. So there is evidence that this schedule provides effective protection for, again, bisexual men when having anal sex without a condom. We don't know how on-demand PEP works for heterosexual men and women, people who inject drugs, or transgender persons. So although the updated PEP guidelines provides information on the 2-1-1 schedule, it's important to note that this has not been approved by the FDA, it's not recommended by the Centers for Disease Control and Prevention. So taking PEP as prescribed by a healthcare provider is currently the only FDA-approved schedule for taking PEP to prevent HIV. And anyone considering PEP should, of course, discuss with their healthcare provider on how to take PEP. So we have also done research in terms of PEP interacting with birth control methods. So there has been no evidence that PEP interacts with birth control methods such as the pill, patch, ring, shot, implant, IUD, or PEP does not interact with hormone therapy as well. So it's very important to note, right, so one of the attendees mentioned condom use. So PEP provides protection from HIV, but does not protect against other sexually transmitted diseases or infections, and it does not prevent pregnancy. So that's very important to remember. And condoms can help prevent other STDs that can be transmitted through genital fluids such as gonorrhea and chlamydia. They may be a little bit less effective at preventing STDs that can be transmitted through sores or cuts on the skin like human papillomavirus, genital herpes, and syphilis, but we always recommend condom use with using PEP, and also we talked about the U equals U, so we definitely recommend condom use for that as well. And sorry, are you there? I have one more video. HIV. PEP is for people who are HIV negative and at risk of getting HIV. This includes people who have a sex partner with HIV, people who don't always use condoms, or people who have been diagnosed with an STD in the past six months. PEP is also for people who are HIV negative and sharing needles or other drug injection equipment or have a drug injecting partner with HIV. PEP is highly effective for preventing HIV through sex or injection drug use. PEP does not protect against other sexually transmitted diseases. Only condoms can protect against STDs such as syphilis or gonorrhea. Visit your health care provider to see if PEP is right for you. If you decide to take PEP, you'll need to take it every day or it's prescribed by your health care provider. For more information about PEP, visit cdc.gov slash HIV. Thank you so much. Now we're going to talk about patient-provider communication. I know this is a very important topic in terms of the importance of communicating well with your patients as well as those who are living with HIV. So first we're going to talk about patient-provider communication in general and then we'll talk about it specific for your patients who are living with HIV. So when we think about patient-provider communication, it's the shared and mutually understood exchange of information between a patient and their provider. So without this joint establishment of meaning, patients are at increased risk of adverse events during medical care. So achieving successful patient-provider communication promotes shared respect, preserved dignity, empowered autonomy, and meaningful interaction in a health care context. So communication between the patient and the provider should be conveyed and comprehended by the most accessible means, including access to sensory aids, spoken language, written text, picture or photograph symbol representation, gestures, facial cues, other physical behaviors or nonverbal communication methods, use of augmentative and alternative communication tools and strategies, and language interpretation or translation. So patient-provider communication must support patients and family members with respect to their cultural preferences, age, cognitive and physical ability, and health literacy level. So we're going to talk about four models of provider-patient relationship. And while this was, when this was published, they talked about physician-patient relationship, but some of these models definitely apply to your roles as medical assistants and health care providers with your patients as well. So there are four models of patient-provider communication. So there's the paternalistic model, the informative model, the interpretive model, and the deliberative model. So these are four models of patient-provider communication. And we're going to talk about them in a little bit more detail. So when we think about paternalistic, and as the name suggests, it's sometimes called the parental model. So in this model, the health care provider discerns what is in the patient's best interest with limited patient participation. So there is tension between the patient's autonomy and well-being, between choice and health. And here, the main emphasis is on health and not so much on choice. So the health care provider acts as the patient's guardian, articulating and implementing what is best for the patient. And the patient autonomy's conception is more patient assent to the provider's determination of what is best. Then we have the informative model. So that was the model I just described was more of the paternalistic or the parental model. The informative model here, it's sometimes called the scientific model, consumer, engineering. So here, the provider gives the patient all the relevant information. And then the patient selects the interventions that he or she or they want. And the provider executes the selected interventions. So here, the provider provides technical expertise, providing the patient with the means to exercise control. So in the informative model, the provider provides the information. And then the patient takes control over the decision-making. And then for the interpretive model, there is an elucidation of the patient's values and what they actually want and to help the patient select the available interventions that realize these values. So similar to the informative model, in the interpretive model, the provider provides information on the nature of the condition, the risk, the benefits of possible interventions. However, here the provider assists the patient in determining what medical interventions best realize the specified values of the patient. So the provider does not dictate and the patient ultimately decides the course of action. And then the last model, the deliberative model, the aim of this interaction is to help the patient determine and choose the best health-related values that can be realized in a clinical situation. So coercion is avoided and the provider and patient engage in deliberation about what kind of health-related values the patient could and ultimately pursue. So here the provider acts more as a teacher or acts more as a friend, engaging the patient in dialogue on what course of action would be best. And the conception of patient autonomy is moral self-development. The patient is empowered to consider implications for treatment. So there are four models and then here we just have a summary of those models. So we have the paternalistic or parental model, informative, interpretive, and deliberative. And then we have the patient values, the provider's obligation, conception of patient's autonomy, and conception of provider's role. So the patient values are objective and shared by provider and patient under the parental model, defined, fixed, and known to the patient, conflicting and might require elucidation, and open to development and revision through discussion. And then we're going to look at the patient's roles. So the conception of patient's autonomy, assenting to objective values, choice of and control over medical care for the informative model, self-understanding relevant to medical care for the interpretive model, and moral self-development relevant to medical care. And then the provider's role for the paternalistic acts as a guardian, for the informative, more like a technical expert, the interpretive more as a counselor or advisor, and the provider's role is more as a friend or teacher with the deliberative model. So there is one model that is not in the table, but this is a model that has been used. But here, it's not, we're not considering this model to be significant because patients, in the instrumental model, patient's values are irrelevant, and that's, we cannot state that patient values are irrelevant. So this model was not among the four that we focused on. The instrumental model, the provider aims for some goal independent of the patient, such as furthering scientific knowledge. Do we have any examples of the instrumental model where healthcare providers actually furthered scientific knowledge without considering the patients? Anything in history that sparks a? Yes, exactly. So the Tuskegee syphilis, yes, syphilis study, yes. So that was an example of the instrumental model, where they wanted to further scientific knowledge, and the patient values were not relevant at all. So we're not going to focus on this model, but I think it's important to note that it existed, and we're hoping that it does not exist anymore. So those are some of the Tuskegee syphilis experiments, and then there was another one, Willowbrook hepatitis study. And there are other, definitely other global and national examples of this. So we don't want to do the instrumental model. So going back to the four models, so once again, these are the models that we're focusing on today. So for, let's say we have a case study. So let's say we have a 43-year-old premenopausal woman, and she has recently discovered a breast mass. Surgery reveals a 3.5-centimeter ductal carcinoma with no lymph node involvement that is estrogen receptor positive. So tests reveal no evidence of metastatic disease. The patient was recently divorced and has gone back to work as a legal aid to support herself. So we're going to look at this case study in terms of things that different providers might say to this patient. So for the paternalistic model, sorry, it's kind of small, but for the paternalistic model, so a parental or a paternalistic provider might focus on looking at the two alternative therapies to protect against the recurrence of cancer and state that we now know that survival with lumpectomy combined with radiation therapy is equal to that with mastectomy. Because lumpectomy and radiation offers the best survival and the best cosmetic result, it is to be preferred. So the provider has asked the radiation therapist to come and discuss radiation treatment. We also need to protect you against the spread of the cancer even though the chance of recurrence is low, you're young, and we should not leave any therapeutic possibilities untried. And then may talk about recent studies involving chemotherapy and suggest that these suggest improvements in survival without recurrence of breast cancer, talks about the NCI recommendations, and then state that chemotherapy has side effects. Nevertheless, a few months of hardship now may be worth the potential added years of life without cancer. So these are things that a paternalistic provider would say. The informative provider, on the other hand, is going to provide all the information that the patient needs to know. So they talked about local control and systemic control, they talked about for local control, the options are mastectomy or lumpectomy with or without radiation. From many studies, we know that mastectomy and lumpectomy with radiation result in identical overall survival. Lumpectomy without radiation results in a 30% to 40% chance of tumor recurrence in the breast. Then the provider will talk about systemic control, chemotherapy prolonged survival for, excuse me, premenopausal women who have auxiliary nodes involved with tumor. And then the provider also mentions that the NCI suggested, that's the National Cancer Institute, suggested that chemotherapy can have a positive therapeutic impact, talk about clinical trials, the benefits of chemotherapy, and talk about the possibility of enrolling in a study and will be happy to give any further information. So if you recognize the informative provider here does not really include any of his suggestions. He's just giving the client or the patient the information that he has at hand. And then the interpretive provider will provide all the information as the informative provider, but will also talk about trying to elucidate the patient's wishes and try to think about what the patient would like. So here they talk about, it sounds to me as if you have conflicting wishes. Understandably, you seem uncertain how to balance the demands required for receiving additional treatment, personal affairs, maintaining your psychological equilibrium. And then he tries to express a perspective that might fit her position. Fighting cancer is important. Health is self-image. Quality time outside the hospital is important. Undergoing radiation therapy might be compatible with those factors. A lumpectomy maximizes chance of surviving. Radiotherapy fights your breast cancer without disfigurement and so forth. So this interpretive provider is trying to elucidate, is giving his perspective and trying to get what the patient wants. And then I'm not going to go through all of this, but the deliberative provider basically provides the information, but also acts as a, more as a partner in the discussion and talks about different reasons why she might undergo radiation therapy and so forth. So at the end here, it says by enrolling in a trial, you participate in a tradition in which women of one generation receive the highest standard of care available, but also enhance the care of women in future generations. Cause he's encouraging her to maybe, to go into a clinical trial. So the deliberative provider is acting as a partner in the discussion as well. So there are challenges with all these models. So remember as healthcare providers, there are challenges with all these models. So the paternalistic model may be justified during emergencies, right? So in the parental model, where the physician or the healthcare provider is definitely taking a stance in what should be done. So this may be justified during emergencies because beyond such limited circumstances, it is no longer tenable to assume the provider and patient have similar values and providers rarely advocate for this model as ideal for patient provider interactions, but in an emergency, it may be justified. The informative model where the provider is just given all this information and not really including perspective, it lacks somewhat of a caring approach and patients expect providers to have a caring approach. So they may see their providers as technically proficient, but if they're detached, they may see them as deficient. And in this model, the provider does not want to impose their will on the patient. The provider does not want to compete for decision making control. And some of the qualities, the ability to assimilate medical facts, prior experience and intimate knowledge of the patient's view are not really considered here. And so this model might not be ideal. The interpretive model, however, providers may unwittingly impose their own values under the guise of articulating the patient's values and overwhelm patients who sometimes might not be sure of what their own views are may accept this imposition. So this may actually push the model towards the paternalistic modeling practice. And autonomy viewed as self understanding excludes evaluative judgment of the patient's values or attempts to persuade the patient to adopt other values. So it may constrain the guidance that a provider can offer. However, in practice, providers often attempt to persuade patients to adopt particular health related values. Providers usually urge patients with high cholesterol levels, for example, who smoke that they should change their diet, quit smoking, begin exercise before starting drug therapy. And for example, providers often encourage patients living with HIV to adopt safe sex practices or injection drug use practices, safe injection drug use practices. So by excluding evaluative judgments, the interpretive model seems to characterize inaccurately ideal patient provider interactions. The challenges with the deliberative model is it proper for providers to judge patient's values and promote particular health related values. It is likely that the provider's values and view of which values are higher might conflict with those of other providers and their patient's values. So there's a deliberation between the provider and patient, and this will depend on the values of the provider. And this model misconstrues the purpose of the provider-patient interaction. Patients expect their providers to provide healthcare, not to really engage in moral deliberation or to revise their models, and this can easily turn into the paternalistic model. So when we think about practical implications, so as I mentioned before, in emergencies, where if there's a delay in treatment, this might irreversibly harm the patient, the paternalistic model correctly guides the patient-provider interactions. In situations where there's a one-time provider-patient interaction, maybe for example, like in an urgent care setting, the informative model is probably justified. But for patients with clear but conflicting values, the interpretive model is probably justified. So the deliberative model more embodies our ideal of autonomy. In this model, the provider is caring. Autonomy, there's also room for patient autonomy, and this requires that individuals critically assess their own values and preferences and then be free to initiate action to realize these values. So the ideal provider integrates information and relevant values to make a recommendation through discussion, attempts to persuade the patient to accept this recommendation as the intervention that promotes overall well-being. So for this model, this embodies the ideal autonomy. The provider is caring, and we see that there is more discussion and deliberation, and the provider makes a recommendation, but also considering the patient's choice as well. So the deliberative model is not a disguised form of paternalism. The deliberative provider attempts to persuade the patient of the worthiness of certain values, not to impose those values paternalistically. The provider's aim is not to subject the patient to their will, but to persuade the patient of a course of action as desirable. And provider's values are relevant to patients and inform their choice of a provider. And sometimes disagreements can occur between providers and patients. There are discussions over which values may be more important. When disagreements undermine the patient-provider relationship, a patient might seek care from another provider. In the informative model, the grounds for transferring care to a new provider is based on sometimes ignorance, and sometimes if there is a sense that the provider is not competent, patients may switch providers because they do not like a particular provider, or they do not like the attitude or approach. So the provider should not only help fit therapies to the patient's values, but should also promote health-related values. So once again, we talked about promoting safer sexual practices for patients with HIV, or limiting alcohol use for patients in general. Patients are willing to adjust their values and actions to be more compatible with health-promoting values, and more training may be needed on how to articulate these values, underlying recommendations, and how to persuade patients that these values are worthy. But once again, we're also thinking about the patient's autonomy. And if this model is most appropriate, the deliberative model, we're including a caring approach, stress understanding rather than mere provisions of factual information as we see in the informative model. In the time you spend with patients, not only spend more time in communication, but to find out and articulate the values underlying medical care decisions. Recognize that developing a deliberative provider-patient relationship requires time. So if, so for example, as we mentioned before, that if the model, the informative model, might be more justified for a one-time, seeing the patient once and that's it, for example, if you're working in urgent care. But if you're going to see the patient over time, this deliberative model requires time. You'll have that time and then you can incorporate that caring approach. So the patient-provider communication has sometimes focused on two extremes. So sometimes we hear about patient autonomy, such as the, in terms of like just what the patient wants and not necessarily thinking about the expertise of the provider. And sometimes we've heard about paternalism where it's just what the provider wants and not considering the patient's autonomy. But many have stated that providers tend to be paternalistic and should empower patients to control their own care, such as the informative model. But this model just reduces the provider's role to a technologist and not really to what a healthcare provider can add to the situation. So the essence of providing healthcare is knowledge, understanding, teaching, and action. So that is what, when you're providing healthcare, that these are four components that are very important. Knowledge, understanding, teaching, and action. The caring provider integrates the medical condition, health-related values, makes a recommendation on the course of action, tries to persuade the patient of the worthiness of this approach and the values it realizes. So the provider with the caring attitude is the ideal embodied in the deliberative model, the ideal that should inform laws and policies and that regulates patient-provider interaction. So I hope by learning about these models that we will aim to be more deliberative in our communication with our patients. And now we will talk a little bit about HIV patient-provider communication. So going back to the treatment cascade, because this is very important in thinking about how we're dealing with our patients living with HIV. So once again, you're diagnosed with HIV, you're linked to care, you're retained in care, you're prescribed antiretroviral therapy, and then you achieve viral suppression. So research has shown that low trust in providers and poor patient-provider relationships have been associated with lower retention in care. So that makes sense. So if a patient does not trust their healthcare provider, or if the patient-provider relationship is poor, they might not attend their clinic appointments. So that leads to lower retention in care, which as we see from the HIV care continuum, if they're not retained in care, then they're not able to get their antiretroviral therapy, and they're not able to attain viral suppression, which is the desired outcome. There is also research that shows that low trust in providers and poor patient-provider relationships also result in lower satisfaction with the clinic experience. So it is important to build supportive relationships with patients that improve their health and HIV treatment outcomes. So when we think about retention in HIV care, which is very important, so remember, not only being linked to care, but being engaged and being retained in care. So help patients modify behaviors that lead to poor retention in HIV care. So the best way to go about this is to communicate with the patient non-judgmentally. Learn what they know about the importance of retention in care. Identify skills that the patients might lack to remain in care, such as problem-solving skills. Guide the patient to identify possible changes that would eliminate or reduce the barriers they face. Congratulate the patient when they're able to lessen these barriers. Strategize with the patient to identify new goals and healthy behaviors. And actively refer patients to relevant clinic support services as needed to provide additional support for retention. It's also important to foster patient trust. So be direct, but be non-judgmental and be supportive. It's also important that we use open-ended questions to involve the patient in the decision-making, thinking back to that deliberative model, regarding their HIV treatment and overall care. So helping to foster patient trust is very important. Allow open communication and collaborative decision-making. So it's very important to educate patients about their options. Ask what questions come to mind when considering those options, to encourage informed conversation as part of the decision-making process. Encourage discussions on subjects about substance use, sexual behavior, and mental health. And it's also important that you provide referrals when appropriate and assess patient willingness to complete the referral. There are so many barriers to HIV care. And some of the ways in which we can address these barriers to care. So if possible, if you have a role in this, offer more flexible appointment times, extend office hours one or more days per week, maintain accurate patient contact information and update it at every visit, use patient tracking systems to determine whether a patient has dropped out of care, and contact patients promptly to reschedule missed appointments. So if an appointment is missed, it's very important that the patient is contacted right away to determine what are the barriers and how we can get them back in for their appointments. So help patients to find resources to address unmet needs and barriers to care. So when possible, connect patients with childcare, transportation, or other services, and other co-location of primary care and social services. So for example, there is an immunology clinic in Columbia, South Carolina, and they actually provide transportation services for their patients. So if you're able, if you have a role in that, try to connect patients with transportation and those other services. Encourage patients to access substance use or mental health services. We know that depression is one of the most common mental health challenges, and this is also true among people living with HIV. Substance use is also another factor that is a challenge among patients living with HIV. So when warranted, encourage them to access these services. Encourage patients to identify friends and family who can help with encouragement, support, and attend medical appointments with them. So this bullet point in terms of identifying friends and family who can help with encouragement, support, and attending medical appointments, this brings up the challenge of HIV disclosure. So sometimes people living with HIV might disclose their status or they might not. And I would need another hour to talk about HIV disclosure, but there are pros and cons with HIV disclosure. So when you disclose, you can have the social support that's needed, but sometimes you're ostracized from your family and friends sometimes if you decide to disclose. But a lot of times the patients who are living with HIV and who decide to disclose their status, a lot of times they do get that support. So that's something that the patient has to consider and determine if that is something that they should, if that they want to do in terms of disclosing their status to their family and friends. And if they have disclosed, then encouraging them to include the friends and family in their social support system. So that's very important. Assisting with referrals and resources. So talking with your patients at each visit allows healthcare providers to reinforce positive behaviors, uncover those barriers to successful long-term treatment, and facilitate access to services and resources as needs change over time. So these are some of the things that you can mention to your patients. For example, I know it can be difficult to keep all your appointments, but it's very important. And you can tell them about the importance of keeping the appointments, being retained in care, getting their antiretroviral therapy, adhering to their antiretroviral therapy so they can be virally suppressed. And then you can ask, what can we do to make sure you keep your next appointment? You can also say people with HIV do better overall when they come to their appointments on a regular basis. How can we work together to help you stay as healthy as possible? Or you can say it's been a while since you last came in, let's talk about what has been keeping you from coming in for your HIV care. And with your patients living with HIV, it's also important to have safer sexual behavior discussion. So brief conversations about sexual behavior can help patients living with HIV adopt positive behavior changes. And these have been linked to decline in condom-less sex, fewer sexual partners, and decline in other STD acquisition such as syphilis, chlamydia, and gonorrhea. And sometimes healthcare providers talk about the difficulty about talking about sexual health with their patients. And sometimes the clinician might be uncomfortable with this subject. Healthcare professionals cite several barriers to discussing sexual health. So sometimes there is an overall discomfort discussing sex and sexuality, believe that discussing sex will take a lot of time, believe that patients are uncomfortable discussing sexual health, concerns about cultural differences or saying the wrong thing. And as I said, I kind of mentioned this earlier, that sometimes there's a belief that older patients are probably not having sex, which is not true. So we see that there are certain barriers to discussing sexual health behavior with your patients, but it's very important to discuss sexual health behavior with your patients across the age spectrum and in spite of these factors. So encourage other healthcare providers to talk about sexual health. Yes. You're right. So I think it's important to talk about sexual health with your patients and to talk about sexual health with your patients and to talk about sexual health with your patients and to talk about sexual health with your patients and to talk about sexual health with your patients and to talk about sexual health with your patients and to talk about sexual health with your patients and to talk about sexual health with your patients and to talk about sexual health with your patients and to talk about sexual health with your patients and to talk about sexual health with your patients You're right. So in terms of discussing sexual health, so it was mentioned that sometimes the patients don't want to discuss sexual health with their providers. Sometimes they might not be truthful or not be forthcoming about their sexual activity, which is true. I think it's also important. So at least we should give them the door. So if they want to walk through that door, that's fine. If they don't want to, then there's not much you can do about that. But we should be, as healthcare providers, you should definitely be open to talking about it. But if they're not willing, then there's not much we can do about that. But that's a good point, yes. Because sometimes people are not forthcoming about their sexual health and sexual behavior. Anything else? Yes. Yes. Yes, so I think there are, I think there are supposed to be new pills that are on the market that are not that big, but I don't prescribe, so I'm not sure specifically, but I've seen them being advertised where they look like they're sort of the regular size. But you bring up a good point in terms of the barriers. So you say take with food, but sometimes people don't have, sometimes they don't have food. And sometimes I remember there are certain individuals where living with HIV might be secondary because they have to think about homelessness, they have to think about where they're getting their next meal. So you raise a very important point that there are so many barriers to accessing, not only accessing ART, but what are the other challenges that they're facing that's preventing them from adhering to their antiretroviral therapy? Yes, so that's, you raise a very good point in terms of the barriers, the structural barriers that may prevent someone from adhering to their antiretroviral therapy. But in terms of the size, I think, because I know I've seen them advertise, and I know that now they're thinking about the getting like the shots in terms, like maybe once every two months or something like that, where they can get that from their healthcare provider. But I think for now, the pills are more common, yes. Okay, did you have something? Oh, they have the injection. Right, so yes, so it was mentioned that definitely talking to the healthcare provider about the side effects, and trying to see if there is another pill that would help with, that will not have those side effects. Yes, yes, yes, yes, yes. Yes, ma'am. Yes. Yes. Right, right, yes, so you can take, I think it was the PEP, you had to take it for 28 days, and then they will test you again, and then by that time, depending on the test that they provide, they will be able to determine if you're, if you're hopefully negative, HIV negative. Yes, mm-hmm. I think there was, yes, ma'am. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. right, yes, I think that's very important. So I know that there are some clinics that do offer mental health services like the clinic that I work very closely with in Columbia. I know they provide mental health services in that clinic. So it's very, but that is so important because if you have depression or if you have these other mental health disorders, then you're really less likely to adhere to your therapy or adhere to your appointments. So it's very important. And I think, and even in terms of, even if you don't have the mental health services in-house, but making that referral and trying to ensure that the patient follows up with that referral. Yes, thank you. Yes. Yeah, that's a good question. So I know they, as you said, they used to monitor kidney and kidney function and so forth. So I think they're still trying to determine in terms of long-term use because since PrEP is relatively new, so we're still not, to be honest, I don't know if we're absolutely sure in terms of 20-year use, 30-year use, but I know that they're still recommending PrEP for people who are at risk or who have continued exposure to HIV. But that's a very good question and a concern, I think, that in terms of long-term use, we're still trying to figure that out. Yes. Yes. Okay, okay. Right. Right. That makes sense, yes. So if you didn't hear that, so there are providers who check liver and kidney function three months, every three months if their patients are on PrEP. Ma'am, you had your hand up for a while. Yes, so that's a great question. So that's just dependent on the individual in terms of if they stop, because you have to remain on treatment for you to remain undetectable and you're expected to go into the clinic and get your test to ensure that you're still undetectable. But in terms of how long it will take, like if they miss, I don't know if we have any specific numbers and I think it's dependent on the individual because each person is different. And so if they're not able to take their medications for, if they miss medications, because I think based on the research that has been done, 90 to 95% ART adherence is required. So once you're missing, so if you're taking so for like 100 days, so if you're missing like 10 days, then that's a problem, yeah. So. Yes, so I'm not sure if the, so the new medications, I think they still, I think you can still be, you said resistant. Right. Right, right, right. Yeah. Right, so I'm not sure. I'm not sure about that, yeah. That's a great question. Yes, ma'am, you had your hand up. Yes. You mean PrEP? No. No, it's not for men only. There is actually PrEP, pre-exposure prophylaxis for, so women can take PrEP too. So there are some, because I think in one of the slides, they have two kind of PrEP medications. So one you can take if you're a man or a woman, but then there's one that's specific to men, but there is one that women can take as well, yes. Yes, yes. Any other questions? We have, oh, we have like 10 minutes, 12 minutes. Any other questions? Yes, ma'am. Well, I know that for PrEP, and I know for PrEP there are systems in place where, for example, the people who make the drugs, they have like a payment system in place. So you can, even if you don't have insurance, you can get PrEP payment or help with the PrEP payment. Yes, I know that for sure. Yes. Yes. Right, so what, so in terms of being undetectable, so if you have an undetectable viral load, so the CDC states that you're not able, you have effectively no risk of transmitting the virus to your partner if you have an undetectable viral load. But I think I mentioned earlier that there are some, but it's a little bit controversial because people might say, are you saying that they should use condoms? But as a researcher, I am a proponent for condom use, so in terms of, but that's what the CDC states, that you have effectively no risk. Yes, yes, yes, yes. Yes, ma'am. Yes, ma'am. Right. Yes. Right, so there are definitely systems, and that's for people living with HIV who have to get medication. Yes, so there are definitely insurance systems in place for people living with HIV to get their antiretroviral therapy. Yes. Right. Right, right. Yes. Right, patient assistance, yes. Okay. Oh, wow. Yeah, so yes, so the patient assistance programs are definitely in place to help people living with HIV and also for PrEP, so we're hearing that sometimes, even if you make, if the family income is 80,000 a year, you can still get patient assistance. Yeah. Right, right, right. Right, right. Right, right. Okay, great. Any questions or comments? We're coming down to the wire. Okay, I just had a few. This, we have around eight minutes, so I wanted to actually talk about, let me see. Okay, so some of the things that you can discuss with your patients living with HIV, we talked about the importance of adhering to antiretroviral therapy and ongoing medical care, even if your viral load is undetectable, that was mentioned. Communicating HIV status with others, so we talked about HIV disclosure, the importance of that and the decision-making in determining if someone should disclose or if they want to disclose their status to others. We talked about condom use, which is also important. Negotiating condom use, even in, you know, sort of the heat of the moment. Assessing relative risk of HIV transmission associated with various sexual activities. So for example, oral sex is less risky than receptive anal sex, for example. Discussing how alcohol and or drug use can impair judgment. Using PrEP for some HIV negative partners, including women planning to become pregnant if they're exposed to certain risk factors. Using PEP for emergencies and so forth. So we talked about that. So in terms of retention in care, factors that may predict patient inconsistencies with regular ongoing care. So younger people tend to be, tend to not be retained in care. Women, racial, ethnic minority groups, if you're of lower socioeconomic status. Health insurance, lacking health insurance. Medically insured via public health services or recently changed insurance and patients with drug, alcohol dependence and untreated depression. And we talked about the importance of mental health services and substance use, substance use or substance use and abuse services. And then there are some barriers to retention in care, such as patients' personal or cultural beliefs, cognitive abilities, health status, including comorbidities, poor mental health or substance use, structural barriers, we talked about homelessness, job, transportation, health insurance, and also even sometimes food that can be a barrier to being retained in care. And we have five more minutes. So I'm going to talk more about HIV preferred language. So it's very important. So there is a, you know, one of the main drivers of the epidemic today, the HIV epidemic, continues to be stigma. So, and it's very important how we talk about people living with HIV, the words we use. Sometimes the words we use can be, sometimes we don't mean to, but it can be, it can be hurtful. And so I just wanted to spend the last few minutes to talk about HIV preferred language. So we try to stay away from these phrases, such as HIV infected, or AIDS patient, or HIV carrier, or positives, or HIVers, or terms like that. We instead try to use a person living with HIV, or a person with HIV. So we try to stay away, so try to stay away from the term HIV infected, or the term infected, so to say. So these are some of the phrases we try to stay away from. And then we also try to stay away from died, if a person died of AIDS, or to die of AIDS, we say HIV-related complications, or AIDS-related complications, to die of AIDS-related illness, or end-stage HIV. And then I've heard this term being used sometimes, full-blown AIDS, so we try to stay away from that. AIDS virus, because remember AIDS is the diagnosis, if you have one or more opportunistic infections due to HIV, or opportunistic health outcomes due to HIV. So it is a diagnosis, but AIDS is not the virus. So the virus is HIV. So we say HIV, we don't say full-blown AIDS, or we can just say AIDS, or stage three HIV. And I know that we're also trying to think about getting to zero new cases, but so I know I've heard the term zero new infections, or HIV infection, we talked about HIV infected, number of infections. So we can say zero new HIV transmissions, zero new HIV cases, HIV case, HIV acquisition, diagnosed with HIV, living with HIV, and so forth. Instead of saying HIV-exposed infant, or serodiscordant, so you might hear the term serodiscordant referred to having a couple where one is living with HIV and the other person is not, so they say a serodiscordant couple. So we try to say serodifferent, or a mixed status couple. I guess serodiscordant, the word discord sorta seems like there is something not right about the situation, and we try to stay away from that. And instead of HIV-exposed infant, can say infant exposed to HIV, or infant born to a person living with HIV. Okay, so I'm right on time. So in conclusion, so in conclusion, HIV continues to be a national, global, and public health challenge. So I remember someone asked me what did I do for work, and I say, you know, I do HIV research, and they're like, oh, that's still a problem? And I was just, I was taken aback, but it continues to be, especially for healthcare providers and people who are in the field, we know that it continues to be a national, global, and public health challenge. And screening for HIV continues to be crucial in allowing for early prevention and treatment. How you communicate with your patients is extremely important in helping them to achieve optimal HIV treatment outcomes. And your role as medical assistants is crucial in helping people living with HIV to live healthier lives and to attain and maintain a great quality of life. And that's it. Thank you so much, you've been great. Thank you so much. Thank you. Thank you. Thank you.

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