5 Most Beautiful Insects You Won’t Believe Are Real

5 Most Beautiful Insects You Won’t Believe Are Real


5 Beautiful Insects You Won’t Believe Are
Real. Number 5. Dactylotum bicolor looks like it’s one of
those “paint-by-numbers” projects with all those amazing colors! In reality though, it’s called a Rainbow Grasshopper
or Painted Grasshopper. Native to the United States, Canada and northern
Mexico, this grasshopper grows to an average length of about 20 mm (0.8 in) for males and
35 mm (1.4 in) for females. It is mainly black with distinctive reddish
and yellowish markings, a pale green prothorax and pale green wingpads. The tibia of the hind leg bears six to eight
spines, and this species does not develop wings and is unable to fly. Number 4. The spiny Flower Mantis, or Pseudocreobotra
wahlbergii, is a beautiful and colorful flower mantis with natural range in sub-Saharan Africa. They are white with orange and green stripes,
and as adults they have a beautiful patch of color on their wings that looks like an
eye. An easy way to tell males from females is
to look at the length of their wings: A female’s wings will reach to the end of her abdomen,
while a male’s wings will extend past it. Number 3. There are a number of Ruby-tailed wasp species
that look very similar and are difficult to tell apart. They’re all beautifully coloured, with red,
blue, green and bronze metallic colours. These wasps are solitary, meaning they don’t
live in large social nests. Being barely 10mm in length, they can be difficult
to spot. You can often see them running restlessly
over walls and tree trunks, constantly using their downward-curving antennae to pick up
the scent of their host insect. As a parasite they require another species
for part of their life cycle, Chrysis ignita mainly parasitizes mason bees and other solitary
bees. Number 2. Maratus speciosus, sometimes called the coastal
peacock spider, is an Australian species of jumping spider. They are only known to inhabit the vegetation
of the coastal sand dunes of southwestern Western Australia. Like other Maratus spiders, the males of the
species engage in a courtship display during which they raise their third pair of legs
and their abdomen, presenting their colorful opisthosomal plate
to potential female partners. Unlike other Maratus, however, the males of
this species have a set of bright orange hairs (setae) along both edges of the opisthosoma
which only become visible during this display. Number 1. Greta oto may sound like the name of a silent
movie star from Eastern Europe but is in fact the scientific name for one of the most exquisite,
and little known, species of butterfly on the planet. This butterfly’s claim to fame is that its
wings, spanning up to six centimeters, are almost completely transparent. That’s right, you can see just about right
through them. The common English name for this remarkable
butterfly is glasswing, which in itself speaks volumes about the appearance of this small
but unusual insect. However, it takes the romance languages to
step in and give the butterfly the name which, for many, suits it best. The Spanish name for the glasswing is “espejitos”. Literally translated, this means little mirrors. Just a glance at the insect in question and
one can imagine the thrill of pleasure when the moment of inspiration that came to its
Hispanic name giver.

Changes in Clinical Diagnostics and Tracking Infectious Diseases

Changes in Clinical Diagnostics and Tracking Infectious Diseases


>>Thank you for joining us. I’m Dr. Phoebe Thorpe and it’s
my pleasure to welcome you to CDC, Public Health Grand
Rounds for October 2016, “Changes in clinical diagnostics and tracking infectious
diseases”. We have a very exciting session. So let’s get started. But first, a few
housekeeping slides. Public Health Grand Rounds has
continuing education credits available for many disciplines,
physicians, nurses, pharmacists, veterinarians, health
educators, and others. Please see the Public
Health Grand Rounds website for more details. In addition to our website,
we’re also available on social media and we
are live tweeting today. So please use
#CDCGrandRounds for all your tweeting needs. We also have a featured video
segment on YouTube called “Beyond the Data” which is
posted after the session. And we are partnered with
the CDC Public Health Library and Information Center to feature scientific articles
relevant to this session. The full listing is available
at CDC.gov/scienceclips. Here is a preview of our upcoming Public
Health Grand Rounds session. Please plan to join
us live or on the web. In addition to today’s
outstanding speakers, I’d also like to take a moment
to thank the many contributions of the individuals listed here. Thank you. And now for a few words from
CDCs Director Dr. Tom Frieden.>>Technology continues
to advance, change and improve our lives. One example is a new
generation of Culture, Independent Diagnostic
Tests or CIDTs. These CIDTs make it possible
for healthcare providers to determine which pathogen
is causing a patient disease, often while the patient is
still at the doctor’s office. When a specific cause is known
quickly, patients benefit from faster diagnosis
and targeted treatment. CIDTs are available
for many infections, including tuberculosis
and chlamydia. They can confirm infections
that weren’t easy to test or culture before such as
legionella and C. difficile. But as with other
technological advances, there are unintended
consequences. Although, CIDTs provide
rapid diagnosis, there is no organism
available for further testing, including by traditional
culture. If clinical care ends
with the CIDT results, we may not get answers
to important questions. We can’t determine whether
one person’s illness is part of a larger outbreak. Whether a bacteria is
resistant to antibiotics and how likely it is to
cause severe illness. Information that’s
key to understanding where infections come from and how they spread is
especially important in the case of infections spread
through our food. Additional laboratory testing is
still needed for positive CIDTs, without it the food
supply will be less safe. Every year, 48 million
Americans get sick from food borne illness; 128,000
are hospitalized and 3000 die. Twenty years ago, along with
our partners CDC established PulseNet and FoodNet
to track the spread of food borne diseases
and work with partners to trace illness back
to contaminated food. Over that time many
outbreaks have been stopped, but not before infecting too
many people across the US and in other countries. In 2015, there were 35
multistate outbreaks of foodborne disease. And each year, the number
of outbreaks increases. Only by connecting these
individual infections can public health investigators trace
illness back to the source and stop further spread. Without cultures and
detailed genetic information, connecting affected individuals in multiple states is more
difficult, takes longer and leaves contaminated
food on the shelf. As you’ll hear today, our scientists are using
many approaches including collaborating to
develop new technologies to help address these issues. But these advances take time
to implement and until they’re in place, public health will
have to continue to rely on cultures to detect, trace
and stop foodborne outbreaks, and keep our food supply safe.>>And now for our
first speaker, Dr. Chris Braden.>>Good afternoon. Today I will be giving you an
introduction to the advances in Culture, Independent
Diagnostic Tests. Culture-based diagnostic
tests have been used for over 150 years, having
been invented by Louie Pasteur. More recently, culture
independent tests have been developed with antigen-based
tests coming into wide use in the 1980s and 1990s. These tests detect
antigens which are specific to a certain pathogen type. In the 2000’s, molecular
detection test based upon polymerase chain reaction
methods were developed. These tests detected short
genetic sequences specific to a single pathogen type. Since 2010, we have seen a major
expansion in the production of multiplex PCR
panels which detect one or multiple pathogens
simultaneously. These panels are often designed
around disease syndromes such as gastroenteritis,
respiratory diseases, meningitis, or bloodstream
infections. Though we will be focusing
mainly on diagnostics for enteric bacterial
pathogens today, culture independent
tests based upon antigen or nucleic acid detection
have been applied to many different
types of pathogens and are often the only practical
way to detect viral pathogens. For enteric pathogens
the number and type of culture independent
diagnostic tests have increased rapidly. In the last 5 years there
has been an increase from 5 antigen-based
tests for Campylobacter and Shiga-toxin-producing
E. coli or STEC to 8 antigen-based tests, several laboratory
developed PCR test used in large commercial
laboratories, and to date 5 multiplex PCR
panels have been FDA cleared. Still others see CIDTs including
multiplex PCR panels have been FDA cleared for respiratory,
meningitis and bloodstream pathogens. FoodNet, a network
covering about 15% of the US population
monitors CIDT use as part of its surveillance activities. For the bacterial
infections tracked by FoodNet, on average 7% were diagnosed
by CIDT in 2012 through 2014. As depicted by the blue
bars in this graph. This more than doubled
to 16% in 2015. Uptake of CIDTs in clinical
laboratories varied by pathogen and the use of multiplex
PCR panels is growing. The use of CIDTs may
impact surveillance trends. Compared with the average
incidents in 2012 to 2014. In 2015, the incidence
of Cryptosporidium and non-0157 sugar
toxin producing E. coli almost doubled. This increase might,
in part be caused of increased use of CIDTs. As you can see from this
graphic, the workflow and CIDTs including multiplex
PCR panels is relatively simple and fast. The clinical specimen
is prepared for testing in a sample tube containing
reagents, which is inserted into the automated
diagnostic instrument. Detection of specific PCR
products yields a positive result for one or more
pathogens included on the panel. Automated analysis
can produce a result in as few as 1 to 2 hours. Reflex cultures should be
done to provide an isolate of the pathogen for
additional testing such as conventional
identification, antimicrobial susceptibility,
and pathogen characterization. More on why this is
important in a moment. However, conducting
reflex culture of CIDT positive specimens
may not always be clinically necessary and entails
additional costs. If reflex culture is done
for public health reasons, it is not clear whether
the clinical or public health laboratories
should conduct the culture testing and bear these costs. Also, in some instances,
it may not be possible to conduct reflex cultures. For example, if the original
specimens obtained with a swab, the entire specimen may be used
and inactivated when transferred to the sample tube
with reagents. Test procedures should include
the option for reflex culture from the original specimen. The benefits of culture
independent diagnostic tests are impressive, especially
for clinical care. They can provide
much faster results for targeted early treatment of
infections, including whether or not antibiotics are needed. The panel test can detect or
rule out multiple pathogens in a single test and are likely
more sensitive than culture. These tests may provide
faster information for local public health action. However, CIDTs alone do not
provide cultured isolates. Isolates are needed to
characterize the pathogen. In addition to the
clinical utility of antimicrobial susceptibility
results to tailor treatment, hospitals and public health
programs need this information to track resistance trends in their facilities
and jurisdictions. Determination of virulence
factors can inform clinicians and public health officials of
the likely severity of illness. Serotype and genotype
information is used to identify specific strains, whether a strain is
causing an outbreak and possible routes
of transmission. Genotype information has been
used extensively in programs such as PulseNet to connect
cases, identify outbreaks and prevent over 270,000
illnesses each year. PulseNet is in the
midst of transformation to more detailed DNA
fingerprint analysis to facilitate outbreak detection and investigation using
next generation whole genome sequencing technology. But this technology also
requires cultured isolates. Each year, 48 million people get
sick, 128,000 are hospitalized and 3000 die from
foodborne disease. Public health programs
need to enhance efforts to make our foods
safer and we need to conduct DNA fingerprint
surveillance of foodborne pathogens to do so. Other possible drawbacks of culture independent
diagnostic tests are related to the difficulty interpreting
test results in some situations. Because DNA from dead microbes
can produce a positive test result, clinicians may not know
a patient is still contagious and public health officials
won’t know if it is safe for a patient to return
to work or to daycare. Also, a single test may
detect multiple pathogens, some of which may not
be causing illness. A study of one brand of a
multiplex PCR GI panel found that over 30% of positive
tests detected more than 1 enteric pathogen. This may lead to
diagnostic confusion and unnecessary treatment,
and to confusion for public health
surveillance systems. CDC has strategies to meet the
surveillance challenges posed by culture independent
diagnostic testing. First, we need to support
the use of reflex cultures for positive CIDT samples
by encouraging states to update referral and
reporting guidelines and loss. We also need to decide who performs the reflex
culture and who pays for it. We can develop expedited
isolate recovery methods to make culture simpler and
cheaper, and we need to work with the diagnostic
device industry to make sure specimens can be
cultured using our procedures. Second, in the short term, we need to implement a whole
genome sequencing technologies for surveillance. Though this will also
require continued use of isolates from
reflex cultures. Developing large whole genome
sequence databases will allow the type of research
and development required to achieve the third tier of
our strategy for the long term, the development of
metagenomic diagnostic tests. Meta-genomic technology
has the potential to provide both the
essential clinical and public health information
direct from specimens without the use of cultures. Dr. Besser, will be
providing some insight on different methods
for metagenomics, including amplicon sequencing,
and shotgun metagenomics. As technology advances,
we must pursue a path that benefits both patient care
and public health surveillance. The solution includes
building a broad understanding of the issue among many
partners, including experts from public health,
clinical medicine, diagnostic device makers,
Congress, regulators, and insurance officials. In 2012, CDC convened a
multi-stakeholder forum to raise awareness of
the impact of CIDTs on public health programs. In 2013, the infectious
disease Society of America published
specific recommendations to improve diagnostics for
infectious diseases in a way that also benefits public
health surveillance. FoodNet partners are tracking
the growing use of CIDTs in evaluating changes over time. And The Council for State and Territorial Epidemiologists
is discussing how best to count infections
identified by CIDT and public health surveillance in updating surveillance
case definitions. And now I’d like
to turn the program over to Alicia Cronquist. [ Applause ]>>Good afternoon. CIDT is having a major impact
on surveillance in Colorado. Our most recent data show that 15 labs are using
multiplex PCR testing. To put this in perspective 40% of enteric bacterial pathogen
cases reported in Colorado so far during 2016 have
been tested using PCR, 89% of the salmonella Shigella and Shiga-toxin-producing E.
coli are xTAG tested using PCR have also had a reflex
culture tested performed either at the clinical lab, or the
state public health lab. In Colorado laboratories of
various sizes and from urban and rural settings are adopting
multiplex PCR since 2013. And we’ve been busy
responding to this switch. Our activity falls
loosely into 3 categories, ensuring accurate
case reporting, facilitating isolate recovery and adapting our day-to-day
public health practice in light of the new types of
cases being reported. Until recently surveillance for enteric bacterial
pathogens captured only culture confirmed cases. The classification scheme
we use in all 50 states, or the case definitions
have been modified to incorporate CIDT positive
results as probable cases and we need to adjust
accordingly. We monitor the local
uptake of CIDT by regularly serving
clinical laboratories. It’s important to know the
types of tests each lab is using so we can understand the
surveillance information we receive from them and
ensure we’re receiving that information correctly. We started this in late 2009 when a few Colorado laboratories
began using antigen-based tests to detect Campylobacter. Currently, we survey
laboratories within our FoodNet
catchment area which is the 7 county Denver
metropolitan area, twice a year. We do a similar survey once
a year with laboratories in the rest of the state where
resources are not as robust. While this activity
is very important, it is also labor-intensive. Knowing which labs are using see
CIDTs is only the first step. Next, we needed to modify our
disease surveillance database to capture the new tests, and ensure data are properly
exported when queried. For us, this required working
with our IT department. We have discovered there are
many ways in which errors in reporting culture
independent results occur. And we continue to work
with disease reporters to improve the quality of the
CIDT case reports we receive. For example, some labs using
electronic lab reporting needed to change their electronic
settings so that CIDT positives
flowed to us correctly. Other laboratories had trouble
modifying printed reports they sent to us. They would report culture
positive for salmonella, for example, when we knew
they were no longer performing culture for salmonella. And finally the thorniest
issue is one of incorrect test
interpretation and reporting. Some multiplex panels
include pathogens that are not reportable, but sound like conditions
that are reportable. We continue to have cases
incorrectly reported to us. Shigella, Shiga-toxin-producing
E. Coli or STEC, and Plesiomonas shigelloides
sound similar, but only two are
reportable in Colorado, and each is a different
pathogen. We’ve created guidance documents
and held several meetings and webinars with infection
preventionists, laboratories and local public
health partners. We reach out individually when
we identify a particular issue and we continue with
frequent stakeholder outreach. We feel we cannot
over communicate with our partners
about these issues. Of course case reporting is
only one part of surveillance, we need isolates for
subtyping for cluster detection and monitoring trends. The big question for us is
where the culture happens. We’ve taken a hybrid approach
to isolate recovery in Colorado. Historically, we have had
excellent relationships with our clinical labs. We received approximately
95% of the isolates needed without having any regulations
for isolate submission in place. We’re building on these
established relationships to find a path forward. We prefer when isolation
is performed at the clinical laboratory. Culture results are available
faster, it decreases concerns about transit of raw
specimens, and the chance that pathogens will
die in transit. It also means that susceptibility testing
can still be performed at the clinical level where
it could impact patient care. We encourage each
lab that adopts CIDT to perform reflex
cultures at a minimum for salmonella, Shigella
and Vibrio. We review our isolate submission
protocols with them to ensure that any isolates that
are generated are sent to the public health lab. When reflex cultures
are not done, clinical laboratories are asked
to forward clinical material which is generally
stool, that tests positive to the state public
health laboratory, where we can then attempt
to isolate the organism. A lot has gone into
creating a workable plan. First we had to prioritize
pathogens. We chose STEC, salmonella,
Shigella, and Vibrio. These organisms have
the highest likelihood of public health action based on confirmation or
subtyping results. Next, we sought and continue
to seek additional funding to perform culture which adds
considerably to our costs. To ensure we would receive
specimens we ask the Board of Health to modify our
disease reporting regulations to require submission
of isolates or clinical material
for select pathogens. This is the first time specimen
submission has been required rather than voluntary
in Colorado. We’ve also worked to
facilitate rapid delivery of viable specimens to the
state public health lab. We reviewed the courier
service we provide to ensure couriers are regularly
going to all labs that need it, and we provide transport media
and written guidance about how to ship clinical material to us. This is an area that’s evolving
as APHO is performing studies to determine the best
methods for isolate recovery. However, none of
this is perfect. Despite all this effort are
specimen submission rate has dropped to 90% and we continue
to see a range of issues. For example, stereotyping during
an outbreak investigation was substantially delayed when
one rural lab mailed clinical material instead of sending
it to us via the courier. The final area is the one where we still need
to do the most work. With CIDT, the data we’re acting
on has changed and we need to figure out how to use
the information we receive. We see an increase
in case reports with less certainty
about each one. Reporting is faster
with respect to the time between specimen collection
and public health notification. However, we now have
a longer period between the time public
health first learns of a case and we have subtyping
information to pair it with. First off, we need to implement
the new CSC case definitions to classify and transmit
surveillance data correctly. To do this, we routinely
collect more detailed test data. In Colorado, we attempt to
collect negative results when they’re pertinent. For example, if a
PCR is positive and culture was negative,
we try to capture that in our surveillance data. We’ve worked to train internal
and local public health staff to appropriately
assign case status based on the new criteria. This includes creating new cheat
sheets and guidance documents for information that’s
ever more complex. We’re working to establish
and evaluate guidance for which cases should
be investigated based on their case status. While it would be great
to interview all suspected and probable cases, we need
to consider local resources and prioritize across
the spectrum of diseases they are
asked to investigate. For example, a suspected, highly infectious respiratory
case would be a higher priority than a probable PCR
positive Campylobacter case. The timing of case
investigation is also critical. For the case categories
we decide to investigate we launch
an investigation based on PCR results and
don’t wait for culture. Other jurisdictions might make
different choices about that. When should we initiate
worker and childcare exclusion or restriction for
PCR positive results? We have chosen to treat a PCR
positive the same as culture in terms of excluding
or restricting workers. Yet, is that’s the right choice? For follow-up testing we accept
a PCR or a culture result. Although culture is
often the test used, since much of the follow-up
testing is performed at the SPHL at no charge to the patient. And how do we handle patients
who are CIDT positive for 2 or more reportable conditions. From a public health
perspective, we need to decide what type of
exclusion might be necessary and which questionnaire to use. Our guidance is currently to choose the disease control
measures for the pathogen with the greatest
risk of transmission, and to interview the patient
using the pathogen specific questionnaire that is
most comprehensive, or merge the 2, when applicable. For example, when a patient is
supported with a PCR positive for Shigella and Campylobacter,
we instruct local public health to follow Shigella exclusion
policies, and interview with a questionnaire that’s
a blend of the Campylobacter and Shigella questionnaires. But clearly much more
research is needed. We have focused our response to
CIDT on accurate case reporting, isolate recovery and
adapting public-health actions to the new types of
cases being reported. These areas have
several factors in common which are a critical assessment
of resources, prioritizing based on public health
goals of detecting and mitigating disease risk and
frequent ongoing communication with partners using a variety of modalities including
guidance documents, phone calls, and training sessions. Thanks. [ Applause ] And now I’d like to introduce
Brad Spring.>>Thank you Alicia and
good afternoon everybody. I’m going to be representing
industry, although I work for BD. I do represent an organization
called AdvaMedDx which I’ll provide
a little bit more detail later. But I’m going to give you
the industry perspective on how we develop tests,
but also how we can partner with public health and other
stakeholders to solve some of the challenges we’re seeing. So, as described earlier,
we do have advantages and challenges of CIDTs. Multiplex PCR test can be
more sensitive than culture and provide results
in a few hours. They may also save costs and significantly
improve healthcare. But because PCR tests require
the organism to be lysed, or the cells be broken apart
to extract the DNA or RNA, we don’t have viable
organisms available for surveillance purposes. Companies do recognize
the need to partner with public health agencies and
FDA to collaborate on solutions. And AdvaMedDx which is an
association represented by over 50 diagnostic companies, can leverage our
strong relationship with lab communities,
government agencies and public health laboratories
to work towards a common goal of providing rapid diagnostic
solutions while meeting the public health needs. So I just want to give you an
overview of how we develop tests in the industry by covering our
product development process. And we typically use what’s
called a phase gate approach. And as you can see here we
start in the concept phase, go through definition,
development, qualification of the validation stages, and
then we’ll launch the product. But the first step in concept
and then through definition is to conduct what we call voice
the customer activities. And this is where we build
upon what are the requirements for the new test. And this is really where we
come up with the ideas and some of the challenges our customers,
or future customers may have and how to address them. So as we do these voice
the customer activities, we gather requirements. And the requirements
may not be specific. A customer may say I want
a test that’s easy to use. May provide fast results. Or it’s small in size. Now these aren’t measurable. So we translate those
requirements into specifications. So for example, a fast result
may be translated into a result within 2 hours including
specimen processing. And we go back to the
customer to verify that essentially
meets their requirements. But certain needs may only be
met by existing technologies that could create what we
call conflicting requirements. So for example, to
achieve a fast result, PCR may be the technology
of choice. And in the cases we’re
discussing here today, you’re not able to get a viable
organism when you use PCR. But just because we have
a conflicting requirement, meaning using PCR doesn’t allow
us to culture the organism, at least from the PCR specimen, we don’t abandon
these requirements and we try to find workarounds. So while requirements
may conflict, that doesn’t mean we just
give up as an industry. We try and find other
ways to address them. So I think, you know going
forward, and even looking back on previous product
development activities, we need to encourage engaging
public health laboratories, CDC, state labs, and others in these
voice of customer activities. So as another example, we
may go to a clinical lab, gather the data, but
rarely are we getting data that says we need to be
able to culture the organism for submission of public health. And then we go to public health,
we’ll hear, well we’ve got to make sure that the
organism’s cultured. So, I’m going to cover too, a couple of potential
opportunities to solve this problem and I think the other speakers
will be addressing these as well. So one example is our
instructions for use need to remind laboratories that
they have to follow state and federal requirements for
collection and preservation of organisms needed
for epidemiological or the public health purposes. So in those instructions for
use, and a customer needs to follow those instructions
for use, we will hopefully achieve a
little bit better compliance to state requirements. There are opportunities in product development
for new technologies. As you’ll hear more about later. There are some on the horizon that will help reduce
compatibility issues between CIDTs and public health. Metagenomics holds the
most promise, today, as it may be possible to
both detect the organism in a metagenomic specimen
and differentiate strains for epidemiological purposes. However, there is much
work still required to develop this technology and you’ll hear more
about this later. One thing to consider, though, is when an industry actually
may decide not to create a test for manufactured test
for clinical lab, a clinical lab may create
that test on their own. So there are a number of lab
developed tests out there today that are basically put in
place to meet an unmet need. So, if there is an
enteric pathogen that isn’t currently
detected using one of these multiplex PCR
tests, a lab may create that test on their own. So as we look at
culturing organisms, it’s not just the industry
instructions for example, they might have to
change, we have to do more to educate the labs on what
their requirements are, especially for LDTs or
lab developed tests. So, just to kind of cover in
more detail the instructions for use opportunity here. Some manufacturers, not all, do put specific precautions
in their labeling. And under the clinical
laboratory improvement amendments, which
are regulations that govern laboratories,
CLIA does require that labs follow
manufacturer’s instructions. So if our instructions
state, for example, the APHL recommended language around laboratories must
follow state and/or local rules pertaining to reportable
pathogens, the lab must do that. Otherwise they during
inspection may get observation regarding that. So going forward, you know we
as an industry do agree we need to put such labeling and
standardize it, these statements in our labelling going
forward and that will help. It doesn’t do everything,
but it will help with the public health
labs and ensuring that these pathogens
are also cultured. So we believe this type
of information is one step in the right direction. We do believe there are
continuing opportunities on these collaborations. So we will, as an
industry, work with CDC, other public health laboratory
agencies, as well as FDA to discuss efforts to
explore additional measures to aid in the surveillance. So, you know, we’ve
talked about the labeling. There may be other
opportunities that we can, as we come together
collectively, figure out how best to
meet this challenge. We have conducted
and will continue to conduct educational outreach
meeting with key stakeholders. So like I said, the
public health labs, other microbiology groups
such as maybe the IDSA, ASM and through other
industry meetings. And as a manufacturer, you
know we have a salesforce, a pretty large salesforce
out there. And we currently use those
salesforces obviously to, not just sell our products
but to also educate customers in a variety of issues. One example being the get smart about antibiotics week
coming up here in November. We’ll distribute material to our
customers to help educate them on antimicrobial resistance. So this is another opportunity
to at least increase awareness and educate customers. And then finally, one thing
we are looking at is just to provide better informational
resources and we’re talking, collectively talking to FDA
about posting a list of approved or cleared molecular
diagnostics on the FDA website. It will serve essentially as
a one-stop shop to finding out what CIDTs are out there
and what are the procedures used to conduct those CIDTs. So, and thank you very much. And now I’d like to
introduce Dr. John Besser. [ Applause ]>>Thank you Brad
and good afternoon. I’m going to be speaking today
on efforts to develop tests for characterization of
our public health pathogens that can be done
directly from specimens. I’m going to be focusing on the
bacterial enteric pathogens, our PulseNet pathogens. And I will be attempting
to squeeze a graduate level in molecular biology
into 8 minutes. So let’s see how that goes. But first why are
we developing tests. Well, most importantly we want
to ensure continue compatibility between our public health tests,
and the commercial systems even if the specimens are
biologically inactivated. And the second compelling
reason is that these tests have the
potential of being quick, which is of course one
of the same reasons that makes CIDTs desirable
for clinical diagnosis. The process of detecting
outbreaks through pathogen
based surveillance, can be a lengthy process,
as illustrated here. Cases must be identified
and linked to other cases, food vehicles identified,
and depending on how a direct specimen tests
are implemented they can have the potential for significantly
reducing the amount of time to an actionable result,
which in turn means that more outbreaks would
be solved more quickly. More illnesses prevented. Developing direct tests for public health is
not a trivial task. Stool is an immensely
complex environment, containing a wide variety of
different DNA and RNA species. There could be significant
human DNA from white blood
cells, epithelial cells. All the food that
you eat, the plants, the animals they all have DNA. There’s bacteria,
parasites, viruses, fungi. Every one of us has an average
of 1000 species of microbes in our gut at any one time. And every gram of stool can have up to 100,000 organisms
per gram. And of particular
concern to us is that many of our PulseNet pathogens are
virtually identical to some of the commensal flora. Every line in this figure
represents the genome of a bacterium that
might be in our gut. The commercial developers
need to find a marker which is conserved within
the species of interest. And specific to it. Meaning, that that marker
doesn’t appear in any of the commensal flora. For public health tests, we must
also specifically detect the pathogen, but also detect
other markers for strain type, resistance virulence, and
also detect variability within those markers so that
we can detect differences between strains, illustrated
here in the colored bars. And these should not be
confused with similar sort of regions in our pathogens. Of course, when we’re
actually doing these tests, we don’t have any
of that information. In fact, what we’re actually
dealing with is many millions of pieces, little pieces
of DNA or short reads as in some of our assays. And there’s two major
problems that we confront. One is signal-to-noise,
finding our pathogen which may be very
rare when compared to the background flora. And the second is
called phasing. Getting all the pieces together
that we find of the pathogen, specifically connected
to the marker, and not including any
pieces that may be from some of the commensal flora. There’s three general
strategies that we’re pursuing to accomplish this task. The first is called
amplicon sequencing, a method that’s been around, especially for the viral
pathogens for quite a while. We believe that this can be
accomplished using technology that is readily available today. And we’re currently
pursuing two approaches. The first, we’re
looking at for STEC, we’ve identified a
heterogeneous region in Shiga-toxin-converting phage,
which is normally integrated into the circular chromosome. And here is a map
of the phage genome. Within the phage is a region
containing the regulatory genes, and also the Shiga-toxin gene,
which defines the pathotype, which helps us solve
the phasing problem. Our scientists have developed
a multiplex PCR assay using conserved primer binding sites which yield overlapping
amplicons covering an 11 to 17 KB region. These amplicons can
then be assembled into a single continuous strand
of DNA or consensus sequence, also known as the contig. The contig, then can be compared
to sequences from other patients to find genetic differences,
represented here in red, which in turn can be used
to assign strain types. And the strain type
information is what we use to detect clusters
and are used as part of epidemiological
case definitions. For salmonella, we’re taking
a slightly different approach, since it’s less related to
commensal flora of an STEC. We’ve developed a pipeline,
or a series of processes that are listed in the bullets
here, to identify specific and informative targets to approximate a whole genome
multilocus sequence typing or wgMLST. The second major strategy that we’re pursuing is
shotgun metagenomics, as was mentioned earlier. What is metagenomics,
it’s the sequencing of all the nucleic
acids in a sample. This is widely used already to characterize the whole
microbial community, or microbiome. In our case, the
stool environment. Researchers here at
CDC, and elsewhere, have shown that it is possible
to both detect pathogens and differentiate strains for
epidemiological studies directly in stool using shotgun
metagenomics. However, the method is
still fairly insensitive, expensive, slow. It produces a lot of data
that has to be handled. But the potential power of metagenomics really
can’t be overestimated. It likely will make it
possible to find solutions to a whole array of
public health problems that are currently
difficult to address. Our group, and other groups, here at CDC are exploring
multiple approaches at various points in the
specimen to sequence process, to solving these signal-to-noise
and phasing problems, some of which are listed here. These approaches, if successful
should also reduce the amount of sequencing and data for
public health surveillance. We’ve also begun to explore
with external collaborators, droplet based single cell
sorting or barcoding, which should allow us
to obtain the same type of information we’re
currently obtaining through whole genome
sequencing of isolates. Individual cells
are encapsulated in the lipid droplets which
are subject to PCR and run through a high-speed
cell sorter. In this animation, there’s
a laser below the red arrow, which elicits a signal
from PCR positive cells. Positive cells, which are
shown here as solid circles, are then routed down a different
path from the other bacteria, shown as empty circles. At least in theory, this
technology could result in a tube of cells
from a single pathogen, which could then be subject
to whole genome sequencing. In summary, direct from
specimen tests could increase compatibility between CIDTs and
our public health activities. And we believe that the current
technological limitations will likely be overcome with
research that’s occurring with multiple partners. And in the end, we
believe that all of these advancements
will make PulseNet and our food supply safe, more
efficient and more effective. In summary for our
entire session today, CIDT technology has been used
for improving patient care and as Dr. Braden has showed
us, and public health is in the process of adapting to these changes in
a variety of ways. Advances in technology
in the public and private realms will make
our lives safer in general, but we must pursue a path that
benefits both patient care and the public’s health. Now I’d like to turn the podium over to Dr. Braden
again, thank you. [ Applause ]>>Well I’ll stay here at the
panelist desk and as we go into the question and answer
session, so first of all I would like to know if we
have any questions from the external audience.>>We do, thank you. Reports are being
charted as final results at some facilities, and I suspect they should be
considered screening tests. On average do these panels
have acceptable sensitivities and specificities, precision
and accuracy, etcetera?>>I’m going to turn to
Dr. Besser and Brad for comments.>>There are some
studies in the literature that address the sensitivity
and specificity of these tests. Frankly, we don’t
know all the answers. Some kits are more specific
and sensitive than others. And this actually has
created some problems in creating the probable and confirmed case
definitions with CIDTs. But I think as time goes
on we will learn more and it’s incumbent upon
us to encourage studies of the performance
characteristics of these tests so that this question
can be answered.>>Yeah, just a comment
on industry. So our tests do go through
the FDA review process and the FDA looks at
what’s our intended use. Is it for screening,
diagnosis, and the sensitivity and specificities related
to that intended use. So FDA would not
approve or clear a test that didn’t meet a
certain threshold. That said, I think
the FDA and industry, as well as labs will
look at is it better than what we have today. So I think when you
look at that, it’s hard to say
is it good enough, but at least it may be better
than what we have now, so. Can’t quite answer on that
on the screening tests.>>However, to add from a
disease reporting perspective, it it’s a reportable condition that the person asking the
question is asking about, then yes, we would still
want that reported to us, along with what type
of test was performed. We need to have all
of that reported to us so we can understand
what’s going on with disease surveillance
and with these tests.>>I would also add that
as the tests, culture and diagnostic tests
have advanced over time, I think the sensitivity and
specificity has improved. And these new multi-analyte
PCR panels have been shown to be quite sensitive. Another question? How about from the audience? Yes, Steve.>>I’m Stephen Rose
Associate Director for Laboratory Science
and Safety. My question is really directed
toward Alicia and falls on the previous question about
sensitivity and specificity. And I think if I heard
you correctly you said that if the CIDT only,
then it’s a probable case. Do you code the cases
that you alluded to that are CIDT positive,
culture negative any differently from one that is CIDT only?>>We try to collect
that level of information and we strongly encourage
laboratories to report pertinent
negatives to us. So if it’s antigen positive
and culture negative, we surely would like to have that culture negative
piece in our dataset. From a coding standpoint to
meet case classification, those would both be
coded as a probable case.>>Peter Gunersmidt from Enteric Diseases
Laboratory branch here at CDC. This is more a question
for Dr. Spring I guess. The metagenomics that
we’re working on trying to develop some methods. Those methods, they
really belong in the clinical laboratories,
don’t they? So my question to
you is where are the, what are the diagnostic industry
doing with this technology and how far are you before
we can implement metagenomics in the clinical laboratories.>>Yeah, I’m probably not going to give you the answer
you’re expecting, which is I don’t really know. But I will say this, that
there are companies out there, and most of the time
they’re startups, right. They’ll get venture capital
funding to investigate this. And I know there is one
company at least that I’m aware of out there that does
provide testing services using metagenomics. I don’t believe they have a
commercial kit for laboratories. I don’t know how
far away we are. Again I haven’t seen
any come through FDA. I think FDA has to set
up standards for these. You know how do you
validate them analytically and clinically. So I think they’re probably
going to be shown more in a laboratory maybe as
an LDT before they show up as a commercially
available assay.>>I believe that metagenomics
will be used regularly, sooner rather than
later for specimens from normally sterile
sites like CSF and blood. And I think that
in the short term that probably will
occur in laboratories. But I would imagine in the very
long-term it’s probably most appropriate for this to happen
in the clinical setting. And then the state and local
public health agencies retrieve information that they need, federal agencies
retrieve what they need. But it seems closer to the patient the more
efficient the system gets. But I think the technology
is a long way from operating at that level.>>Do we have another
question external?>>We do from Twitter. Are there any national
summaries on CIDT surveillance and impact on patient care?>>So there are some summaries
of CIDT use that are provided by the FoodNet publications. Every April FoodNet, as a surveillance system
provides interim reports of the previous year’s
surveillance data and within that data there is
reports of CIDT use. However, we don’t
gather the information about how it’s affecting
clinical care, which I think is the other
part of that question. Putting on my clinician’s hat, you know if I can get the
information about the pathogen that may be causing an illness
faster, same-day or even within hours, that makes
a lot of difference. And so I just, you know in that
antidotal way it really does improve what we can
do with patient care. Any other comments?>>There’s a very good
publication by IDSA [inaudible] on CIDTs and clinical care
that one can find for free on the web, that’s
worth reading. Another question from
the external audience.>>We get laboratory
reports indicating more than one positive on
the same specimen. Do you know if the labs are then
obligated to perform cultures, serology tests, etcetera,
depending on the microorganism?>>Brad, do you know that? Or Alicia?>>I’m not sure I
understand the question. It seems like the laboratories,
if the condition is reportable, they need to report,
I would guess all of the conditions is
that correct Alicia?>>Yeah. Yep. So from a public health
standpoint, they would need to report anything
that was positive. And depending on the state
where they’re located, they might be required to
perform reflexive culture. Or, they might be
required to send some of the clinical material to
the state public health lab, depending on the state
and the pathogen. But I think the question is
more from a clinical perspective and asking about determining which pathogen is
making the patient ill. And I think that’s a
very difficult question that I believe clinicians are
trying to sort out as well.>>As we are hearing from the
community that the incidents of multiple positive signals
from CIDTs is fairly hard. And I think there are
many aspects of CIDTs that we’re going to need
to resolve over the years in interpretation,
that being one of them, and it could be the
polymicrobial infections are much more common than
we knew, or perhaps some of these findings are spurious and we just don’t know,
and time will tell.>>I think, there’s
not some kind of regulatory responsibility
for the laboratories to do more testing to see which
pathogen may be causing illness, but certainly the
physician may follow up with additional tests
requested in order to clarify.>>Any other questions
from the audience?>>David Bell, Division
of Viral Diseases. Could you say anything
more about the role of quantifying some
of these results and assisting with
the diagnosis? You know in PCR we have CT
values and I don’t know as much about the other, but in some
of the issues you raised, it might be relevant if
the pathogen was present in a higher quantity as
opposed to a lower quantity. You know some of these
dual findings and so on.>>So just one comment,
that I mean as you look at the microbium
and normal flora, you know sometimes you
have to distinguish between what is the causative
agent and what is normal flora. So quantification, or
quantitation is required for some of these assays, because you may be actually
detecting a healthy level of some bacteria. So it depends on the test, and depends on what the
treatment options may be. But I think there is
value in quantitation.>>If you’re referring to
clinical diagnosis, is that? Or the? Is that what
you’re referring to?>>Well, well both. Also surveillance because
it’s not clinically relevant. It may or may not be public
health, but it’s both.>>Sure, I believe most of the,
or all of the CIDTs operate with thresholds built
into the system already. So the positive result you
get is a quantitative result. In the area of metagenomics,
and sequencing, and shotgun metagenomics,
quantification is, quantitation is an approach
that we’re exploring extensively to help with phasing, have been
re-binning clinical quantitation of pathogens to align our
various bits together. So for characterization of
our pathogens, what we call in situ pathogen
characterizations, quantitation is an important
part of our overall strategy.>>So to follow up on David
Bell’s question on quantitation and the issue of exclusion
either from workplace or daycare, and of course, my
experience is with norovirus where it’s quite clear that
the virus is detectable much, much longer than somebody
is probably a real risk for transmission. And so is there any thought
of using quantitation in making those determinations
about when somebody is or is not excluded from the
workplace or from daycare?>>It would be great. I don’t know if it’s at all in
the horizon, but even before that I think that some follow up
studies are desperately needed to track how long people shed. I think that we exclude
people fairly routinely from occupations if they have,
say E. coli 0157 or Shigella, we will exclude them
from their jobs, which has a tremendous impact
on them and their lives. And so form a public
health standpoint, we are very concerned
about doing that based on a PCR positive and are very
eager to participate in studies, perhaps where stool is
collected, and both cultured and then put through
a multiplex PCR so we understand that better. I don’t believe those
studies have been done yet.>>Do we have another question?>>FoodNet depends on public
health lab surveillance to describe changes in
illness incident rates overtime and the incident rates
have targets that come from healthy people 2020. How has CDC incorporated
the impact of CIDT in tracking illness
incidents overtime and marking our progress in meeting foodborne illness
national health objectives.>>I will start and
Alicia may comment also. So there were a couple of times,
and especially Alicia alluded to the fact that CSTE is
revising case definitions. When we revise case
definitions it is going to affect the surveillance
data trends. What is going to have to occur
is to the extent possible to take the data that we
have about the increase in specificity and sensitivity
of some of these tests, and apply that to the
models that we use to then generate our
surveillance trends to be able to translate what
we’ve seen before with what we’re seeing now. That’s not an easy task, but
it is something that a number of groups are trying to do. So that we can then determine if
we are actually still on track with meeting our
goals, or we’re not. Alicia?>>As Dr. Braden alluded,
we’re working on a variety of data collection projects and
thinking about different ways to model the data to assess
the impact of these changes on our trends so that we can
accurately say whether disease is going up or down to meet
these national objectives. One key piece of information
that we didn’t have time to discuss during the formal
presentations, is another way in which we hope to partner
with clinical microbiology labs, which is the collection
of information from them about how much testing
they’re performing and who they’re performing
testing on. And this is absolutely
critical information, so that we can understand the
data that’s flowing to us. One area with CIDT it’s possible that more testing
is being performed, or testing is being performed
on different groups of people than it used to be performed in. And we need to understand that to understand the
surveillance data that’s coming to us. So in addition to the
partnerships that we’ve talked about with clinical microbiology
labs and submitting isolates or clinical material to state
public health laboratories, another key area for
participation in partnership between public health
and clinical micro labs in the near future is going to
be working with us to figure out how to obtain this, what
we’re calling test volume data.>>Another question
from the audience.>>Hi. Lee Katz
Foodborne Diseases Laboratory branch. I was wondering from the panel if there are any products being
used for source attribution. So in Dr. Besser’s
presentation, he noted that some food
might also be in a sample, in a stool sample, if there
are products that might be used to detect them that are being
in research and development. And if those food sources
are detected, I’m wondering if at Colorado and other state
health labs, if it might be used to inform epidemiology.>>That’s a very good question. No there is no such test
out there that I’m aware of, but it’s an excellent
suggestion. If you were able, I’m sure
that if Alicia were able to tell her cases what
they ate and ask them where they got it from,
that would be very helpful.>>I think there are
some technologies that may adapt a
clinic test, right, and maybe a sample preparation
that has to be modified and then allow it
to work in a CIDT. I know there are some
next generation sequencing technology, well the technology
itself of NGS is used in say in some food screening. I know they even use it in like
looking for male and female eggs in selecting, you know which ones go forward
and which ones don’t. I think they’re also using those in detecting potential
pathogens.>>One area where this
technology has been used for a while has been
in food fraud. So for instance, fish,
the fist that you buy at the supermarket may or may
not be what it says it is. And the FDA has been using
technology of the sort to confirm the identification
of seafood.>>Thank you so much for joining
us and I’d like to take a moment to thank our speakers. Thank you very much. [ Applause ] And please join us next month
for Public Health Grand Rounds.

See How Termites Inspired a Building That Can Cool Itself | Decoder

See How Termites Inspired a Building That Can Cool Itself | Decoder


In 1991, architect Mick Pearce had a
problem. An investment group in Harare, Zimbabwe hired him to design the largest
office and retail building in the country. But they didn’t want to pay for
the expensive air conditioning needed to cool such a large building. So that left
Pearce with a seemingly impossible challenge: How do you design a building
that cools itself? This is a termite mound. Millions of termites live inside these structures, some of which stretch an astonishing 30
feet high. Although these termite skyscrapers may
look solid from the outside, they are actually covered in tiny holes that
allow air to pass through freely. Like a giant lung, the structure inhales and exhales as temperatures rise and fall throughout the day. This termite ventilation inspired Pearce to use an approach known as biomimicry, imitating the ingenuity found in nature
to solve human problems. Meet the Eastgate Centre. The building is made from concrete slabs and brick. Just like the soil inside a termite mound,
these materials have a high “thermal mass”— which means they can absorb a lot of heat without really changing temperature. The exterior of the building is prickly like a cactus. By increasing the amount of surface area,
heat loss is improved at night, while heat gain is reduced during the day. Inside the building, low-power fans
pull in cool night air from outside and disperse it throughout the seven floors. The concrete blocks absorb the cold, insulating
the building and chilling the circulating air. When the morning comes and temperatures rise,
warm air is vented up through the ceiling and released by the chimneys. Thanks to this innovative design, temperatures inside
stay at a comfortable 82 degrees during the day and 57 degrees at night. Not to mention, it uses up to 35 percent less energy
than similar buildings in Zimbabwe. Since opening its doors in 1996, Mick Pearce’s 90% natural climate control system has made the Eastgate Centre a global landmark for sustainability. So, we must ask ourselves: if an architect could design a self cooling building with termite inspired climate control, what other innovations can Mother Nature
inspire if we just paid closer attention?

Jared Leadbetter (Caltech) 1: Termites and Their Symbiotic Gut Microbes

Jared Leadbetter (Caltech) 1: Termites and Their Symbiotic Gut Microbes


I’m Jared Leadbetter and I’m at the California Institute of Technology. And, for some 24 years now, my research has sought to clarify the relationship between termites and their hindgut microbes. Now, of particular interest to me is the metabolism of hydrogen that is generated during this fermentation of wood, but today I want to give you a broad overview on microbial diversity and on some of the essentials of termite hindgut microbiology. So, I want to talk about biological diversity in general, because many who are interested in biology are missing, actually, some of the full diversity that we see in the microbial world. And, then I also want to comment about how some of this diversity is surprisingly abundant in certain areas of the world, and that we must understand what that diversity does and how it functions. So, this will bring me to termites and the symbiosis they form with their hindgut microbes, and I want to introduce you to several major groups of termite hindgut microbes, the cellulose decomposing protozoa, methane producing archaea, and a group of abundant and unusual bacterial called spirochetes. I’m going to then touch on how we can study different termites and learn about different events that may have occurred during this symbiosis in the past, and then I’ll give you some conclusions. I wonder how many people who are watching this have grown up thinking about three kingdoms. Up until the 1960s, I think most people grew up thinking that there were animals, plants, and fungi, and that maybe, depending on their education, even up through current years, most enthusiasts of biology understood there to be between three and five kingdoms. Maybe you had the bacteria as a fourth and the protists as a fifth, But, starting in the 1960s we had a revolution in the study of the relationships between different organisms, and started to realize that many things that we were seeing, and also not seeing, are very, very different from these three major groups. So, for example, if you look at a key gene that is present in all known organisms, you can make comparisons between this gene and from that infer how those organisms are related to each other. The thing I want to point out on this slide is that you have the fungi and the animals and the plants, and those are just three twigs on a branch that has many other twigs. Really? If those three twigs and the length of those lines denote evolutionary relationships, then there are more than three kingdoms. There are easily a half-dozen. The other thing I want to point out here is that if you think about “plant metabolism” there are some organisms on this tree which also carry out photosynthesis, let’s say the kelp or the red seaweed, but those branches are actually very different from the plants. They are as distantly related to plants as you and I are from plants, and I think that’s very important. Also, when we talk about single-celled eukaryotes, like protozoa, we realize, oh, Paramecium and the protozoan Babesia are actually two very different organisms, again, as distantly related to each other as we are from let’s say the yeast that you use to make beer and bread. So, the number of kingdoms or major divisions of life already gets more complex than those three that we know. The truth is actually much more complex than that, because this is now just a snippet of a branch of a much more complex tree. You’ll see that I have just blown up this section of a much larger tree. One of the things I want to point out on this slide is that there are many, many branches on this, easily 100 which are more distant from each other than the distance between corn and animals, and what that suggests, then, is that we have a lot to learn about the differences between these different groups. So, for instance, everything that is lying outside of this circle is a microbe, the single-celled organisms which are smaller than you can see with your naked eye. So, for as much as we can appreciate biological diversity that you can see, the true diversity of life is beyond the resolution of the human eye and we have to use other methods to really understand how it works. The second thing I want to point out is how different the way of living is for corn, or a plant, and ourselves, or from a yeast that’s used to make bread and beer. If the length of those lines, which is comparatively short, and the differences of these organisms is so great, imagine the possible differences in the ways that these organisms live. So, we are potentially really missing out, not just on the diversity in terms of how things are related, but also missing out on the diversity of what organisms are actually doing in the environment. And so, if we’re to understand the environment, we really have to learn more about what these other organisms are doing. Let’s come back to this tree. Let’s come back to this organism kelp. I want to illustrate another point: it’s not just that there are many, many organisms out there which are different from the organisms we’re most familiar with, but in some environments those organisms are present and very, very abundant. Take the kelp – you can find kelp forests off the coast of California, and those kelp are performing what we might call “plant metabolism”. So, they are the primary producers in those environments, but, keep in mind, they’re not plants. So, the story of these coastal ecosystems is in a large part driven by an organism that’s very different from a plant, and so if we want to understand those coastal ecosystems part of the story is understanding the biology of kelp and understanding in what ways they are similar and different to the terrestrial, or land plants that we study. Now, I want to shift from the oceans to my own research, which is study on termites and their hindgut microbes, and I want to point out that the termite hindgut is an environment. It happens to be an environment that lives in a small insect, but we can compare and contrast that environment with, for instance, a very rich marine environment like the Sargasso Sea. There are certain reasons why you might want to study a small environment like in a termite. The Sargasso Sea is a wonderful and amazing place, and very important to study, but it’s a thousand kilometers across, and there’s only one of the them. The termite hindgut is only about one cubic millimeter in volume, and yet it contains hundreds and hundreds of microbes that you find no where else in nature. Just if you were to take the top millimeter of the Sargasso Sea, the volume of that across those thousands of kilometers is 19 orders of magnitude greater than the volume of that one termite. So, we can actually bring a termite into the laboratory and be able to study an entire environment. The hindgut… it’s tiny yet complex… many hundreds of species and some of those species are yet unstudied, so it is still bewildering complex, and it’s well-bounded. We know that the gut lining and the outside of the termite are where you might define the boundaries of that system. The Sargasso Sea is wonderful, but there’s only one of them, and its boundaries are a little bit user-defined. We think that it’s, you know, the currents that are intersecting here and there are what bound that region, whereas in the insect it’s very well-bounded. And, of course, the termite is available in large number of replicates, so we can, in a laboratory, have that one environment that’s tiny and well-bounded replicated in termite, after termite, after termite. So, we can start to do some comparative studies and perturbation studies which are just not possible with a large environment like the Sargasso Sea, for which there’s only one. So, I study a very particular termite that we find in ponderosa pine that’s fallen in the Angeles National Forest of southern California, and here is one of these ponderosa pines and two of my former students, who have peeled off some of the bark from this log, which has been on the ground for probably five or ten years, and if you look a little bit more closely you can see that just on the underside of that bark are a number of termites of different, what we call, morphological castes. These ones with the dark mandibles are actually soldiers. Rather than eating wood, they have big mandibles that they can use to attack, for instance, another termite or an invading ant. So, this is termite that we study, for the most part, in my laboratory. It’s the Dampwood Termite, Zootermopsis nevadensis, and it’s about a centimeter in length. It’s one of the larger termites that you’ll find on Earth. Now, this is what we call a worker, and from another specimen I’ve extracted the hindgut tract, and that is shown here. And, what you’ll observe is that there is a long tubular region, which is somewhat analogous to our small intestine, and then you have this hindgut paunch, which is somewhat analogous to our large intestine, and it’s in this paunch that really you find a lot of things that excite microbiologists. You find a density of microbes you find nowhere else in nature, and they represent all three domains of life. Earlier on that slide, I’d shown you that the tree of life, where you actually have three major subgroups, and those are the archaea, the bacteria, and the eukaryotes. You find single-celled relatives of all three of those groups, comprising hundreds of species, in this hindgut paunch. So, before I tell you about termite gut microbes, I want to tell you a little bit more about termites. There are about 3000 species of termites on Earth. Termites are related to cockroaches and to the mantids, like the praying mantis, and they’re actually, although insects, quite distantly related to ants, wasps, and bees, which are also social. So, this is an example of where society, or sociality in insects, has arisen in two different groups of insects which are very different from each other. So, termites, and those 3,000 species of them, can be subgrouped into several different families, and their closest relative in the insect world is what we call the Wood Roach, which is a non-social but wood-feeing insect that you find in the Carolinas and the Pacific Northwest and in parts of China. And, many of the microbiology… the features of the microbiology in the Wood Roach are actually shared with the termites, and so it’s thought that many of the microbial processes that arose arose in the last common ancestor of this roach and termites. Now, the termite that I study, Zootermopsis, belongs to this one groups in the Termopsidae. So, over time, we can start to ask, are any of the patterns that we see here present in some of these other groups? Now, if you extract the gut from Zootermopsis, or another termite, and you take a cross-section through that gut, what you’ll see is that the insect tissue itself is actually very, very thin. It’s only about 10 microns in diameter, so 1% of a millimeter in thickness. The bulk volume of that is comprised by the gut contents, and what you see here, these larger objects, are single-celled eukaryotes called protozoa. Now, historically, until the mid-1990s, this region, this environment was thought to be completely anoxic, so, devoid of oxygen. Many of the microbes that you find in the core regions of this gut are poisoned by oxygen. Really? Here you have this insect, which is living in the aerobic world and wandering around on its six legs in a piece of wood or on a piece of wood, containing microbes which are poisoned by oxygen. The story is actually even more complex, because it turns out, through studies that were performed by Andreas Brune and John Breznak in the mid-1990s, the oxygen actually diffuses across the insect gut wall and then is consumed by biological processes in the periphery of that hindgut, and it’s those biological processes in the periphery which lead to the lack of oxygen in the core, which protects some of those oxygen-sensitive microorganisms. So, not only do you find organisms which are unique to the termite gut habitat, that you find nowhere else on Earth, but many of these are poisoned by oxygen and are very sensitive to desiccation. So, their life outside the termite is very, very limited. So, what you have are microbes that are very dependent on their host and, because of their processes, which allow the host to derive nutrition from wood, makes the host very dependent on their microbes. And, when a termite emerges from its egg, it doesn’t have these microbes in its gut. It’s fed those microbes by other of its littermates or by its parents, and if those microbes don’t take hold that termite will fail, and if that termite fails those microbes will also fail. So, when we look at one termite that’s walking around on a piece of wood today, we are looking at over 100 million years of having this microbial community passed from one termite to the next termite to the next termite, generation to generation to generation. It’s quite a remarkable story of a journey that’s been taken between many, many organisms together. So, if we go and look at a little bit of a higher magnification of what’s inside the gut, this is what we call a DIC image using a microscope of some of the larger protozoal cells. These are about 60 microns in length, so roughly 20 of these laid end to end to end would be a millimeter of length, and some of these are the primary agents of wood degradation in this termite. You also see some smaller cells which are also protozoa. So, these are single-celled eukaryotes, of which there are about a dozen in this one termite that you find nowhere else in nature, and their closest relatives are in other termites. There are some interesting associations that you find between these protozoa and certain bacteria. For instance, if you look at the surface of one of these, at higher magnification, you’ll see that those protozoa are covered with long lines of grooves, and in those grooves you see these little black objects? Those are bacteria. So, the surface of that single cell of eukaryote is arrayed with a very regular group of a very specific bacterium and, without knowing much more about, the notion you might have is that there is something that that protozoan is getting from that bacterium and vice versa. So, there are associations between the microbes that live in the gut, and there are associations with those microbes and their host. So, there are many levels of biological interactions which are occurring in this environment. Another example of a protozoan that has a bacterial association is this organism, which is called Streblomastix strix. The eukaryote, the single-celled protozoan, is actually very, very slender and running through the center of this. That protozoan is covered with a blanket, or a coat, of long, thin bacterial cells that are creating those ridges that you see. We know very little about the interaction between this protozoan and the bacteria and what they’re doing for each other, but clearly it’s a very specific and interesting interaction. There are many cases of protozoa and the bacteria that occur in these environments, of which we have much more to learn in the future. Now, there’s an opening line to a book by the biophysicist Howard Berg. His book is called “Random Walks in Biology”, and the opening lines are that biology is wet and dynamic. What does that mean? I’ve just showed you these still pictures, but I think that the still pictures don’t do this environment justice. Really, when you’re looking at this environment live, this is now some of that gut fluid which has been diluted. It’s even more densely packed than this inside the termite, but if you dilute that fluid and put it on a microscope slide you see some of these protozoa and coursing unamongst them, lots of bacteria which are moving so quickly you can barely focus on them. I can just look at this forever, and you can look at it using different types of microscopy to show different details on some of these cells. The point here is that when I go to work every morning I go to work in what I call a miniature Alice in Wonderland. That it is, just from a naturalist’s standpoint, a very wonderful and diverse place that begs lots of questions. So, what is the interaction that termites have with their gut microbes? I want to give you an overview of some of the major things that we’ve learned over about the last 100 years on the association between the insect and its gut microbes. Now, microbes have a huge challenge in life. The challenge is, how do you eat something larger than your head? If you are the size of one thousandths of a millimeter, how do you gain access to nutrients in a 2×4 or in a big log? So, you have a really wonderful association with an insect that has jaws and grinding mandibles, which are very, very hard, that can then take a large block of wood and grind it into really small particles, and then bring them into the gut in a very controlled and wonderful environment in which these microbes can thrive. Now, in the hindgut, these protozoa that I showed you have enzymes of their own, and enzymes that they recruit from the insect, to start breaking down the polysaccharides in wood… the cellulose and another component which we call xylan or the hemicellulose… and these protozoa perform a very unusual fermentation. It’s a fermentation that differs from the one that you use to make sauerkraut or that you use to make beer and wine. What those protozoa do is they break down the hexoses in cellulose, primarily to acetate, so, neutralized vinegar, and that acetate builds up in the hindgut of the termite and is absorbed by the insect. So, the insect is actually absorbing the acetate and using it as its biofuel. It is the source of carbon for the insect and the source of energy for the insect. Now, those protozoa also produce hydrogen gas, so think the 1930s, this classic picture of the Hindenburg blimp over New Jersey, blowing up in fire. It was filled with hydrogen. There’s a lot of energy in hydrogen. It’s not just combustible; it’s an energy source that can be used by different microorganisms. So, in the termite, and in many environments which are non-marine and devoid of oxygen, hydrogen and CO2 is converted into methane by a group of organisms called methanogenic archaea, and this methane is emitted by the insect. It is sort of lost calories. So, as we know, we can burn methane, we use it as a fuel, and that methane which is emitted by the insect, then, is a fuel, a potential energy source, which is lost from the system. So, we can use a form of microscopy to observe these methanogenic archaea in the termite. Several years ago, I was trying to find out, where are those archaea present in the system? And what I learned is that they are colonizing the gut wall of many… inside the gut wall of many termites. So, if you dissect out the gut, you cut open the gut, you wash away all the contents, and you sort of open that up and look at the internal surface of it, you can look for a type of fluorescence called F420 fluorescence. These organisms that make methane contain a vitamin, and when you shine UV light on that vitamin the vitamin turns blue. And so, with a proper microscope, you can start to see a number of different cell types, which are blue, that live on the inside of this gut wall. And, in this image you see that there are three different morphologies of organisms. Now, I’m somebody who likes food, so I like to say that this one long one looks like long, blue spaghetti, the curves rods look like basmati rice, and some of these straight rods look like regular rice. Now, termites emit up to 4% of global methane every year. So, by studying these organisms in their environment, and also culturing them and bringing them into the lab, we can put a face on the process, at a single microbial cell level, for actually a very significant source of global methane… not the most significant source of global methane, but a small but significant source. I like to show this slide, of a paper mache cow, because I knew that when I first got to Caltech I was having some impact on undergraduate life there, because when I talked about termites and processes that occur in a cow the next Caltech Ditch Day, that occurs every spring, the students had made this large paper mache cow and filled it with chocolate pudding, Easter grass, oatmeal, and Easter eggs that were filled with clues on where the students should go to their next puzzle. And, you can see here, the students trying to find those eggs. The point I want to make here is that cows lose about 20% of their electrons in their food as methane. It’s a huge waste of energy. And, although termites contain methanogens, and emit methane, it’s only a very small amount of this hydrogen and CO2 that is lost to the system as methane. On a global scale, it’s significant, but, actually, on a global scale, the methane emission by termites would be much more significant if this hydrogen and CO2 was not being consumed by a different group of organisms which we call CO2-reducing homoacetogens. So, many termites contain microbes that completely push these methane organisms out of the picture, or push 90% of them out of the picture. So, many termites will take… have microbes that convert hydrogen and CO2 into acetate, and this acetate then goes into that pool in the gut and is absorbed by the insect. So, up to a third to a fifth of the acetate which is used as the biofuel by these insects is derived from carbon dioxide and hydrogen by way of the activity of those protozoa, and by way of the activity of these organisms here. So, I have long been interested in the interaction between organisms competing for this hydrogen and CO2 that make acetate and that make methane from those… to understand how they compete with each other, how has this process come to pass in termites, why doesn’t it occur in the cow rumen, and how do these hydrogen consumers interact with the organisms which are producing the hydrogen, the protozoa. So, CO2-reductive acetogenesis is a bacterial activity. The process involves the fixation of two molecules of carbon dioxide… one, two… with four molecules of hydrogen… one, two, three, four… and in the process, those two carbons are joined and reduced to form the acetate, and this metabolism actually yields energy for the bacteria which are performing it, in addition to yielding the acetate which can be used by the insect. So, it’s a mutually beneficial metabolism that takes hydrogen produced during this fermentation, turns it into additional fuel for the insect, meanwhile supporting the activity of the bacteria that perform it. But, for years, we did not have a very good understanding about what bacteria in the termite are actually catalyzing this process. We had some ideas, but, over the years, we’ve been trying to learn more. Now, if you look in the hindguts of termites you’ll even see, on some of these protozoa, that there are very abundant spiral-shaped organisms, which can be attached to the protozoa and that can also be seen living and swimming amongst the protozoa, and in most termites these organisms we call spirochetes are some of the more abundant bacteria that you’ll see swimming in and amongst these protozoa. If you go to another portion of the gut, maybe you’ll see that there are even more of these spiral-shaped organisms. So, starting in the 1990s, scientists at Michigan State and in Germany discovered that these spirochetes are actually very closely related to Treponema pallidum. That’s one of the most famous organisms in microbiology. It’s what causes syphilis. Actually, all these bacteria in the termite are species that belong to the same genus as the agent of syphilis, and yet you always find these organisms present in happy and healthy termites. But we didn’t know what they did because, like syphilis, they had never been cultured in vitro. First observed in the 1860s, over a century went by before we had actually learned about what any of these do, and I would still argue that we are still in our infancy of understanding what the full breadth of the different roles of the hundred or more species of spirochetes that you can see in an individual termite hindgut. But, a number of years ago, I really endeavored for a very long period of time to try to coax one or two of these species into laboratory culture so that we could ask what they do, and I had an idea: maybe some of these are these acetogens that can take hydrogen and CO2 and make acetate. The problem with that is that activity was not known to occur in any spirochete, and none of these spirochetes from the termite had been cultured. So, it’s an idea, but what you really need to do is get one of these into the laboratory and ask it, are you capable of doing that? And, if not, what do you do? So, what is a spirochete? This is a political cartoon from the early 70s, and will sort of shoot right over the heads of almost all of us, but I still include it because it’s a little bit of American history that Richard Nixon’s first vice president, Spiro T. Agnew, sort of had to leave office for some misdealings that he had, and this was before even the Watergate scandal blew up. So, when I say spirochete, I’m not talking about a spirochete, but a different organism, and these are bacteria that have a very unusual body plan. So, many bacteria can swim and they have flagella that extend into the extracellular milieu and act like propellers, but spirochetes have flagella that extend not out of the cell, but out past the first membrane, but lie in between the inner and the outer membrane of the bacterial cell, and actually will wrap around the cell, okay? If you look at a cross-section, you can see what I mean. These are the flagella that lie in between the inner and the outer membrane, and when those flagella turn the entire cell becomes a propeller, as opposed to being attached to the propeller, and spirochetes are known to be able to move into very thick, viscous environments, and are sort of the world record holders in the microbial world for being able to wiggle into really thick and tight places. And, all the organisms that have this body plan are also related to each other, so it’s both a related group by genetics and by their body plan. So, these are microscopic images of the first termite gut spirochete that was isolated. We call this organism Treponema primitia, and the first thing we wanted to ask was whether it was really a spirochete, and what I want to point out here is that if you look at it with a whole-cell negative stain by transmission electron microscopy, or a thin section, it has these hallmark flagella that are lying in between the inner and the outer membrane. Now, the second thing we learned about Treponema primitia is that it is actually a hydrogen+CO2 acetogen. Hydrogen stimulated its growth and it consumed hydrogen and made acetate in the expected four hydrogen to one acetate stoichiometry. You could also grow this organism under radioactive carbon dioxide, and when you do that it generates radioactive acetate, so it’s fixing CO2 into organic carbon, and when you ask, are both carbon positions of acetate labeled? They were. And lastly, there are enzymes associated with this pathway, and this organism exhibits them all. So, it is a bonafide hydrogen/CO2 acetogen and, although a close relative of the organism that causes syphilis, this organism actually plays a key role in the fermentation of food in the termite, and in taking some nutritional value of that wood and passing it back on to the termite. Now, we have been studying this organism for almost 20 years now, and one of the things that we’ve done is really looked at its genes for this pathway, and used our study of these genes, in red, to do comparative studies in other termites and also in this particular termite and ask, can we learn if this is the only acetogen, or if there are other species, and who are those other species? So, we can take an approach, now, where we can take a look at the diversity of these genes for this pathway in this one termite, but also in members of these two other major subgroups of the termite line of descent, and also in the Wood Roach. And so, we’ve been learning a lot about the diversity of organisms that can carry out that metabolism in a diversity of different species and actually major subgroupings of insects that eat wood. Now, we’ve also been able to isolate a second spirochete from Zootermopsis. This one we call Treponema azotonutricium. Now, this organism plays a very different role in the symbiosis with the termite and its hindgut microbes. So, if you think about it, wood is not only tough to eat, it’s not a very good source of protein. You know, at best, it’s like a potato, right? It’s got a lot of polysaccharide, a lot of carbs, but not a lot of nitrogen. So, you can be degrading that wood and providing the calories to the host, but that’s only one of the hosts major problems in life. The other problem is to make protein, and so if you ask what’s going to limit the ability of this insect that’s eating a block of wood, or your home, what’s going to limit its proliferation, part of the story is on protein. So, it turns out that some 35 years ago John Breznak, at Michigan State University, discovered that termites contain microbes that can take atmospheric nitrogen, which is bathing all of us in the atmosphere all around us, and can take that and turn it into protein, that can then be fed to the insect. And, this particular spirochete, when we got it into culture in the laboratory, we could show can do that same activity. So, this is one of the organisms that we say can exhibit diazotrophic growth. It can grow with N2 gas as its sole source of eventual protein, and it shows several activities which are associated with that activity, and therefore it’s playing a role in taking a very abundant but unusable source of nitrogen around the insect and actually feeding the insect protein-level nitrogen. I’ll mention too that this particular organism is unlike the first. It’s not an organism that can consume hydrogen and fix CO2 into acetate. It actually degrades sugars and produces hydrogen that it can feed to the other spirochete. So, it plays different roles in this symbiosis. So, I’ve talked to you about some protozoa, about some methanogenic archaea, and about just some of the many, many bacteria that you can find in a termite. There are many other stories I could tell you, but I want to leave off with my talk by just pointing out that we’ve talked about these three major groups in this environment. That environment is dominated by members of diverse groups which are very different from the host itself. So, just like the kelp forests, these are environments which are dominated by genetic groups and groups performing physiologies which are very different from sort of the paradigms of biology, and that we learn a lot by studying them. So, I think with that, I’ll close this introductory talk on termite gut microbiology. There are many, many general aspects that we could discuss, and of course can go into many other aspects in great detail. And so, I’d like to point out that there have been many research groups and scientists that have been working on termites for well over a century, and I’ve tried to encapsulate some of their findings, as well as the findings of my own laboratory, into the presentation that I have given you today. Thank you very much.

Tobacco Use Epidemic in the U.S.: Is 50 Years of Progress Enough?

Tobacco Use Epidemic in the U.S.: Is 50 Years of Progress Enough?


RADM Lushniak: Hi, I am Rear Admiral Boris
Lushniak, Acting United States Surgeon General. One of the duties of the Office of the Surgeon
General is to take the best information available and to share it with the American public,
and that’s what we’re doing today. I have a story to tell you; it’s a story that’s been
progressing over the last half century. Fifty years ago, the Surgeon General at that time,
Luther Terry, put out a report. It was the first ever report on smoking and health. And
it’s conclusion was quite simple. It said that cigarette smoking is a health hazard
of significant importance in the United States to warrant appropriate remedial action. What
does that mean? That means that cigarette smoking was deemed bad, and that we have to
do something about it. In fact we have fifty years of incredible work and achievements
that we’ve gone through. We have to look back in terms of how we’ve done. One of the things
that we’ve really done is change our social norms. It wasn’t that long ago, when in fact
physicians were part of the problem. They were in cigarette advertisements saying that
Brand X is better than Brand Y. Or this brand is less irritating than that brand. It’s almost
unimaginable right now in the twenty-first century for us to think that physicians played
a role in this. Even in the world of athletics, a little over a half-century ago, Americans
planted the flag of our nation up on Mount Everest, incredible achievement. But look
at the fact that somehow tobacco companies felt as if they were part of that achievement,
as if a mountain couldn’t be climbed without nicotine or tobacco aboard. Once again our
social norms looking at cigarettes have completely changed. Over these last fifty years, what
has been done? Well, out of the office of the Surgeon General, we have put out thirty-two
reports on smoking and health. Some of these have been very, very specific: looking at
smoking in women, smoking in youth, looking at the problems of second-hand smoke. So there
has been progress in terms of us getting the information out. This past year, we’ve issued
the 50th anniversary report. And it’s called Fifty Years of Progress. It’s pretty neat,
to think that we’ve had fifty years of progress, and there has been progress. We’ve gone from
a smoking rate of forty-three percent in this country to eighteen percent right now. That’s
great, that’s progress. And yet I have to emphasize that the problem isn’t over. We
really have to get together and work to try to solve this tobacco problem in our nation.
Because right now we still have bad statistics. Right? We look at this, and one out of every
three cancer deaths could be prevented. Back in 1964, we had one cancer that was identified
and was associated with smoking; that was lung cancer in men. Now we’re up to thirteen
different cancers. We keep finding brand new diseases: diabetes, arthritis, erectile dysfunction,
macular degeneration that causes blindness, all directly associated with smoking. Each
and every year, 480,000 people in the United States die prematurely because of tobacco-related
diseases. Beyond that, there’s incredible economic effects as well. Do you realize each
and every year, 289 billion, that’s billion with a B, billion dollars are spent on tobacco-related
diseases in this country? Sometimes people say, Well after fifty years, isn’t eighteen
percent of our population, isn’t that good enough, isn’t that an achievement? I gotta
tell you that if I accepted the current trends, if the Surgeon General said, Okay that’s good
enough, we would in essence say that five-point-six million kids who are now alive, it’s okay
if they die prematurely from smoking-related diseases. Do you realize that’s one out of
every thirteen children out there? Is that acceptable? In reality we can’t accept that.
We realize that even after fifty years, although we’ve had achievements, the struggle remains.
We have to still push forward and our mission is a bold and noble mission. Our mission is
really to have a tobacco-free generation within a generation. That is achievable: we have
tobacco-control measures that do work. We have to get more aggressive in utilizing and
implementing them in our society. So what’s my vision? My vision is that twenty-five years
from now when we issue the 75th anniversary report, that in fact we’ll have a lot of zero’s,
when we look at smoking rates in this country. And certainly, fifty years from now, when
the 100th anniversary report is out, what are we going to see? We hope we see that we
look at smoking strictly as a historical disease, a disease that used to occur in our society,
and somehow that society accepted a deadly product as a given. Fifty years from now we
hope that the problem is solved. That step by step we approach this, and say, twenty-five
years from now we have to have achievement in terms of a tobacco-free generation. We
have to take the passion, we have to take yes, I daresay a little bit of anger into
this, and in essence say we can solve the tobacco problem. We have to boldly work under
a flag, and a new mission. And, with a certain amount of anger, say when it comes to tobacco
use in this country that enough is enough!

DAY 1, Part 2: Ending the HIV Epidemic: A Plan for America

DAY 1, Part 2: Ending the HIV Epidemic: A Plan for America


>>GREAT SO TAMMY I THINK WE
WILL KICK THIS OFF TO YOU TO INTRODUCE OUR FEDERAL LEADERS TO
TALK ABOUT THE PLAN SO PRESENTATION ON ENDING HIV
EPIDEMIC.>>THANK YOU VERY MUCH.
I AM TAMMY BECKHAM AND I’M DIRECTOR OF OFFICE OF HIV/AIDS
AND INFECTIOUS DISEASE POLICY AND I’M THRILLED TO BE HERE
TODAY AS WELL AND THANK YOU DR. MCCRAY FOR SETTING THE STAGE
FOR THE NEXT PRESENTATION THAT WE WILL HEAR.
I THINK YOU OUTLINES SEVERAL OF THE CHALLENGES AND HAVING THE
DATA BEFORE THE PRESENTATION WILL BE GREAT.
IT’S MY GREAT PLEASURE TODAY TO HAVE THE OPPORTUNITY TO
INTRODUCE OUR NEXT PANEL WHO ARE THE AGENCY LEADERSHIP AND WHO
HAVE SET THE VISION FOR THIS PLAN AND THEY’RE GOING TO SPEAK
TODAY ON ENDING THE HIV EPIDEMIC, A PLAN FOR AMERICA.
SO THEY’RE GOING TO PRECEPT TO US AND THEN WE WILL HAVE THE
OPPORTUNITY TO DISCUSS AND ASK QUESTIONS AND I WILL START BY
INTRODUCING OUR PANEL MEMBERS TODAY.
WE HAVE ADMIRAL BRETT GIROIR WHO YOU HEARD EARLIER, ASSISTANT
SECRETARY FOR HEALTH. DR. ROBERT REDFIELD, CENTERS OF
DISEASE CONTROL AND PREVENTION. DR. ANTHONY FAUCI, DIRECTOR NIH
WITH NIAID AND DR. GEORGE SIGOUIN, AS, HEALTH RESOURCES
AND SERVICES ADMINISTRATION AND DR. MICHAEL WEAHKEE ACTING
DIRECTOR INDIAN HEALTH SERVICE AND WE ALSO HAVE DR. ELINORE
Mc CANC KATZ,.>>THANK YOU FOR THAT.
I THINK THIS WILL BUILD ON THE CONCEPTS YOU JUST HEARD.
MANY OF YOU KNOW THIS INFORMATION BUT WE FEEL IT’S
IMPORTANT TO HEAR FROM THE PRINCIPALS AT THE AGENCY SO WE
HAVE THE SAME COMMON FOUNDATION. SO WE WILL GO THROUGH THE EARLY
PART OF THE PRESENTATION RELATIVELY QUICKLY BECAUSE IT
BUILDS ON THINGS YOU’VE HEARD, TALK ABOUT WHAT’S GOING TO
HAPPEN AND THE STATE REGULATOR STATUS OF THE PLAN MOVING
FORWARD FOR THE $291 MILLION IN RESOURCES AS WELL AS THE ONGOING
RESOURCES WE HAVE AND HAVE AN OPPORTUNITY FOR QUESTIONS AND
ANSWERS. GOOD, I CONTROL MY OWN SLIDE
DESTINY. THATYA REALLY GREAT.
YOU JUST SAW THIS SLIDE BUT IT IS A SLIDE SET THAT WE HAVE BEEN
USING FOR SEVERAL MONTHS TO SLIDE AND IT JUST SAYS WHAT IT
SAYS, 700,000 AMERICANS, 400,000 PEOPLE WILL LIKELY GET INFECTED
OVER THE NEXT TEN YEARS UNLESS WE MAKE AN IMPACT.
AND YOU’VE ALSO HEARD DESPITE THE PROGRESS IN 1980S TO THE
2000S WE HAVE REALLY HIT A PLATEAU.
SOMEWHERE IN THE NEIGHBORHOOD OF 40,000 CASES A YEAR THAT REALLY
UNDERSCORES THE REASON FOR THIS NEW INITIATIVE.
THAT A PLATEAU ACCEPTANCE OF 40,000 CASES A YEAR IS NOT
ACCEPTABLE. WE ALL HEARD THE PRESIDENT, WE
ARE PROUD OF THE MOMENT WHEN HE DID INDICATE HIS SUPPORT FOR
THAT INITIATIVE AND THAT MOVING FORWARD AND MUCH WORK WENT INTO
BEFORE THAT ANNOUNCEMENT WAS HAD AS YOU MIGHT IMAGINE BUT THE
WORK JUST REALLY JUST BEGENERATEDS.
SO THE MEAT OF THIS AND EACH OF MY COLLEAGUES WILL GO INTO EACH
OF THESE POINTS VERY SPECIFICALLY, BUT IT IS VERY
CLEAR THAT THE TIME IS NOW, IT HAS BEEN PREPARED FOR THE PAST
THREE DECADES TO GET TO THIS POINT, BUT THE TIME IS EXACTLY
NOW BECAUSE WE HAVE THE RIGHT DATA, WE HAVE THE RIGHT TOOLS
AND I WOULD ALSO SUGGEST THAT WE HAVE THE RIGHT LEADERSHIP TO GET
THIS DONE. EPIDEMIOLOGY CRITICAL,
DR. REDFIELD WILL TALK TO YOU ABOUT HOW HIV INFECTIONS OR ARE
CLUSTERED. BOTH HE AND ADMIRAL WEAHKEE WILL
TALK ABOUT HOW THEY’RE CLUSTERED GEOGRAPHICALLY.
THERE’S NO BETTER PERSON IN THE WORLD TO TALK ABOUT THE
EFFECTIVENESS AND THE OPPORTUNITIES OF THE
ANTIRETROVIRAL THERAPY AND PREP THAN DR. TONY FAUCI, PROVEN
MODELS OF CARE AND PREVENTION, RYAN WHITE AND A NEAR MIRACLE TO
THIS COUNTRY AND WHO IT HAS ACHIEVED AND IT’S CONTINUING
TO,A CHIEF AS WELL AS WITH HEALTH CENTERS COUPLED WITHEY
DETECT AND RESPOND STRATEGY AND WE WILL HEAR AT THE END HOW THIS
FITS TOGETHER, WHERE WE’RE GOING, MOVING FORWARD, AND
DR. KATZ IS COMMITTED TO THIS. SHE’S THE ASHES CYST ANT
SECRETARY AND DIRECTOR OF SAMHSA, BUT HAD BE AT A
WHITE HOUSE MEETING THAT WAS VERY IMPORTANT FOR HER TO DO BUT
SHE IS FULLY INVOLVED AND ENGAGED.
SO WITH THAT INTRODUCTION, LET ME TURN IT OVER TO DR. REDFIELD.
>>YOU’VE SEEN THIS MAP BEFORE BUT IT’S IMPORTANT, WHAT WE DID
HERE–FORMERLY TRAINED EPIDEMIOLOGY, YOU KNOW THE MAPS
WE’RE USING IS OCCURRENCE PER HUNDRED THOUSAND AND WHEN YOU
LOOK AT A MAP LIKE THAT IT’S PRETTY SPREAD BUT HERE’S WHAT WE
DID WAS THE PROGRAM MAPPED OUT EACH CASE WHERE IT OCCURRED,
WHAT JURISDICTION IT WAS IN AND THEN WE ARBITRARILY BUILDING ON
SOME OF THE EXPERIENCES THAT DR. FAUCI HAD WITH PEP FFAR AND
SOME OF YOU IN THIS ROOM, LET’S ELECTRIC AT WHERE 50% OF THE NEW
CASES ARE OCCURRING AND WHAT YOU SEE HERE ARE THE 48 COUNTY
JURISDICTIONS OUT OF MORE THAN 3000 COUNTIES IN THE UNITED
STATES THAT ACCOUNTS FOR MORE THAN 50% OF THE INFECTIONS, WITH
THE ADDITION OF WASHINGTON AND SAN JUAN PUERTO RICO.
THESE WERE ALL URBAN AREAS, FAIRLY POPUMENT THE URBAN AREAS
AND OBVIOUSLY AS HAS BEEN ALLUDED TO WE RECOGNIZE THE
CHALLENGES IS IN RURRAAL AREAS ALSO AND IN ADDITION TO THAT WE
LOOK AT THE UNITED STATES TO TRY TO DETERMINE WHERE THE HIGHEST
OCCURRENCE, INCIDENCE OR DIAGNOSE IN THIS TWO YEAR PERIOD
AS EUGENE ALLUDED TO, WHEREVER THE MOST RURAL INFECTIONS?
AND YOU SEE WHAT WE CAME UP WITH WAS ACTUALLY SEVEN STATES, SOUTH
CAROLINA, AND YOU CAN SEE THE STATES HERE.
SARK SARKS, KENTUCKY, ALABAMA, MISSOURI, ARKANSAS AND OKLAHOMA.
AND SO THE COMBINATION OF THAT AND I WILL TELL YOU THAT WHEN
DR. FAUCI AND I THINK SAW THAT MAP, WE LOOKED AT IT AND SAID,
WOW, THIS IS A REAL FOCUSED CHALLENGE AND IF YOU COULD JUST
TARGET RESOURCES INTO THOSE 50 JURISDICTIONS WE COULD REALLY
MAKE A MAJOR IMPACT AND I THINK WHAT THE ADMIRAL AND MYSELF AND
TONY HAVE SAID FOR YEARS WHICH MANY LOOKED AS AN ASPIRATIONAL
GOAL TO END THE AIDS EPIDEMIC ALREADY WHEN THIS MAP CAME UP
PEOPLE SAID, INCLUDING OUR SECRETARY, WAIT A MINUTE, THIS
IS DOABLE. OKAY, THIS IS DOABLE, PUT
TOGETHER A PLAN. HOW WILL WE DO IT?
SO VERY IMPORTANT. THAT’S THE POINT I WANT TO MAKE.
NEXT SLIDE. THE SECOND SLIDE IS SOMETHING
MANY OF YOU ARE VERY FAMILIAR WITH AND CDC CAME OUT WITH THE
WRECK MENDATIONS IN 2006 TO ENCOURAGE THE MEDICAL COMMUNITY
TO ROOTINIZE THE DIAGNOSIS OF HIV IN THE MEDICAL SETTINGS AND
AS THE NEW CDC DIRECTOR WHEN I SAW THIS, I COULDN’T BELIEVE
THIS WAS THE STATE OF AFFAIRS IN 2018.
BUT YOU CAN SEE THAT IN REALITY SEVEN OUT OF TEN PEOPLE WHO WERE
DIAGNOSED IN THAT PERIOD, 2018–YOU KNOW 16, AND 17, YOU
CAN SEE THAT SEVEN OUT OF TEN PEOPLE HAVE BEEN IN HEALTHCARE
FACILITY IN THE LAST 12 MONTHS BUT THEY WEREN’T DIAGNOSED.
MORE DIFFICULT FOR ME TO COMPREHENS IS THAT ONE IN FIVE
PRESENTED WITH AIDS. YOU REQUEST SEE ONE IN FOUR
BASED ON MODELING AND ONE IN TWO WERE INFECTED FOR MORE THAN
THREE YEARS AND THAT’S WHY EUGENE USE THAD TERM OF
DIAGNOSIS VERSUS INCIDENCE, WE’RE NOT MEASURING INCIDENCE
WE’RE MEASURING DIAGNOSIS. BUT THE SUBSTANTIAL NOW THE
DIAGNOSIS THAT WE’RE MAKING ARE IN PEOPLE THAT HAVE NOT BEEN
DIAGNOSED FOR MULTIPLE YEARS. I WAS SURPRISED.
THE OTHER ANALYSIS THAT’S BEEN DONE IS DETERMINED THAT
APPROXIMATELY 87% OF THE NEW INFECTIONS WERE SOMEHOW LINKED
TO PEOPLE THAT WERE NOT DIAGNOSED OR PEOPLE THAT WERE
DIAGNOSED THAT WEREN’T–THEY HAD NOT RETAINED IN CARE.
JUST UNDERSCORING THAT SO ONE OF THE BIG CHALLENGES WE ALL HAVE
TOGETHER WOULD BE INTERESTED IN MANY OF YOU THAT HAVE BEEN IN
THE FIELD IS THIS SORT OF DIAGNOSTIC COMPLACENCY THAT’S
SORT OF COME INTO MANY OF THE HEALTHCARE SYSTEMS IN OUR NATION
TODAY. AND THEN THE NEXT SLIDE.
I THINK THE OTHER THING THAT MADE IT AS THE ADMIRAL SAID
REALISTIC THAT THIS GOAL COULD BE ACCOMPLISHED WAS THIS IS NOT
JUST GEOGRAPHICALLY HIGHLY FOCUSED IT’S DEMO
PHOTOGRAPHICALLY VERY FOCUSED. LARGELY IN AFRICAN AMERICAN AND
WELL TIN O MEN WHO HAVE SEX WITH MEN AND BETWEEN THE AGES 25-34.
REALLY IMPORTANT AREA, THE OTHER THING TO HIGHLIGHT IN THIS AND
I’LL TURN IT OVER TO MY COLLEAGUES, IS THAT WE DO HAVE A
SUBSTANTIAL IMPACT OF THIS CURRENT OUTBREAK IN THE SOUTH.
I’M TKPHRAD WE INCLUDED SEVEN SOUTHERN STATES TO BE A FOCAL
POINTS TO SEE IF WE CAN MAKE SURE THAT THE STRATEGIES THAT
ARE DEVELOPED IN THE PRESIDENT’S INITIATIVE NOT ONLY WORK IN
URBAN CITIES, BUT ACTUALLY CAN WORK IN THE RURAL SOUTH,
INCLUDING THE TRIBAL AREAS.>>DR. REDFIELD, WE WANT TO DO A
DEEP DIVE INTO ONE OF THOSE DEMOGRAPHIC HOT SPOTS WHICH IS
THE AMERICAN INDIAN, ALASKA NATIVE.
AT THE INDEPIDEMIOLOGIC HEALTH SERVICE WE’RE VERY EXCITED TO BE
PART OF THIS ENDING THE HIV INITIATIVE, RESERVE A RELATIVELY
SMALL SUBSECTION OF THE U.S. POPULATION, AND WE WE’RE
GRATEFUL FOR THIS OPPORTUNITY TO ADDRESS HIV IN INDIAN COUNTRY.
THE PRESIDENT’S BUDGET FOR FISCAL YEAR 2020, WE’RE ASKING
THAT THERE BE AN INVESTMENT OF $25 MILLION IN THE CONTINUING
PARTNERSHIPS BETWEEN IHS AND NATIVE COMMUNITIES TO END THE
HIV EPIDEMIC AND INDIAN COUNTRY. THIS BUDGET PROPOSE ESTABLISHING
HEPATITIS C AND HIV/AIDS AND INDIAN COUNTRY INITIATIVE TO
PROVIDE TREATMENT AND CASE MANAGEMENT SERVICES TO PREVENT
INFECTION AND ENHANCE HIV TESTING AND LINKAGES TO CARE IN
SUPPORT OF THE ADMINISTRATION ENDING THE HIV EPIDEMIC.
AND AND BY OUR AGENCY BEST PRACTICE TO ASK THE COMMUNITIES
THAT WE’RE SERVING HOW WE SHOULD PUT THIS MONEY OUT AND HOW IT
CAN BEST BE USED SO WE’LL BE REACHING OUT TO THEM TO ASK HOW
BEST TO USE THESE NEW FOUND FUNDS TO SERVE OUR AMERICAN
INDIAN AND ALASKA NATIVE COMMUNITY.
I WANT TO,A NOUNS FOR EVERYBODY THAT NEXT WEEK IS NATIONAL
HIV/AIDS AWARENESS KAY ON WEDNESDAY MARCH 20th AND THIS
SERVES AS AN OPPORTUNITY TO INCREASE AWARENESS OF THE IMPACT
OF HIV/AIDS ON AMERICAN INDIANS AND ALASKA NATIVE AS WELL AS
HAWAIIANS. IT ALSO WELCOMES THE OPPORTUNITY
FOR PEOPLE TO CREATE A GREATER AWARENESS OF THE RISK OF
HIV/AIDS TO THEIR COMMUNITIES AND REMEMBER THOSE WHO HAVE
PASSED AND ACKNOWLEDGE THOSE THAT ARE EFFECTED BY HIV/AIDS,
MARCH 20th CAN BE USED AS A CALL TO ACTION ACROSS INDICAN
COUNTRY TO GET TESTED FOR HIV TO CREATE MORE ACCESS TO TREATMENT
AND CALL FOR INCREASED RESOURCES IN OUR TRIBAL COMMUNITIES.
OUR GOAL WITH THE IHS TO TO INSURE ACCESS TO QUALITY HEALTH
SERVICES AND THOSE LIVING WITH HIV AND THOSE WHO ARE AT RISK
FOR CONTRACTING HIV. EMPLOY DINNER RECOMMEND AND
WE’RE USING INNOVATIVE TOOLS SUCH AS TELEMEDICINE AND THE
EXTENSION FOR COMMITTEE HEALTHCARE OUTCOMES AND THE ECHO
MODEL TO EXPAND ACCESS TO HIV OR CARE AND CONSULTATION IN RURAL
AREAS WERE HEALTHCARE RESOURCES AND PERSONNEL IS SCARCE.
DID FOR OUR TRIBES AND TRIBAL ORGANIZATION TO IMPROVE ADOPTION
AND UTILIZE OF BEST PRACTICE AND MODELS OF CARE.
AND THESE STRATEGIES ARE ESSENTIAL TO REACH OUR PATIENTS
MOST IN NEED. THE PRESIDENT’S PLAN PLACES
FOCUS ON PROTECTING PEOPLE AT RISK FOR HIV IMPROVEMENT
INTERVENTIONS AND PREP AND OUR MISSION AT THE INDIAN HEALTH
SERVICE IS RAISE THE PHYSICAL, MENTAL, SOCIAL AND SPIRITUAL
HEALTH OF AMERICAN INDIANS AND ALASKA NATIVES SO IT’S A
WHOLISTIC APPROACH. PART OF THAT IS MAKING SURE THAT
OUR COMMUNITIES HAVE THE TOOLS AND INFORMATION THAT THEY NEED
TO HELP PROTECT THEMSELVES. ALSO AT THE IHS, I’M HAPPY TO
INTRODUCE RICK [INDISCERNIBLE] WHO’S CHAIR AT THE BACK OF THE
TABLE ARE PRIMARY ON HIV/AIDS PROGRAMMING.
WE’RE TRAINING CLINICIANS ON THE OPTIONS PRESENTED BY PREP AND WE
HAVE MEDICATIONS ON OUR FORMULARY TRAINING MATERIALS,
AND CLINICAL GUIDELINES FOR HIV PREVENTION INCLUDING PREP AND
TREATMENT. BY INSURING THAT EVERYBODY IS
AWARE OF THEIR STATUS AND RECEIVING TREATMENT THEY NEED WE
CAN SIGNIFICANTLY REDUCE NEW INFECTIONS, THIS IS THE LATE
1980S PROGRESS PROGRESS IS MADE IN THE FIGHT AGAINST HIV BUT
THERE’S MORE WORK TO BE DONE AS YOU ALL KNOW.
NATIONAL INTERVENTIONS HAVE DRIB THE NUMBER OF INFECTIONS DOWN TO
ABOUT 40,000 AS WE’VE HIGHLIGHTED A FEW TIMES THIS
MORNING ALREADY OR THIS AFTERNOON.
BUT IT’S NOT BENEFITING EVERYBODY EQUALLY AS WE HEARD
AND NEW INFECTIONS ARE HIGHLY CONCENTRATED IN BOTH AMERICAN
INDIAN AND ALASKA NATIVE POPULATIONS, AFRICAN AMERICAN
AND WE’VE SEEN HISPANIC LATINO POPULATIONS IN MEN HAVING SEX
WITH MEN AND THOSE WHO LIVE IN THE SOUTHERN STATES.
AND WE WANT TO ADDRESS SIGMA, STIGMA IS A HUGE ISSUE, MANY OF
US WHO DREW UP IN SMALL RURAL RESERVATION COMMUNITIES KNOW
THAT EVERYBODY KNOWS EVERYTHING ABOUT EVERYBODY AND WHEN YOU GET
YOUR CARE ASK TREATMENT FROM THE SAME PLACE THAT YOUR FAMILY
WORKS, IT’S HARD TO KEEP THINGS QUIET.
SO ADDRESSING STIGMA, ENGAGING ALL SECTORS OF THE COMMUNITY,
FAITH BASED ORGANIZATION, TRIBAL LEADERSHIP, ET CETERA, WE CAN
WORK TO ADDRESS THE ISSUE OF STIGMA.
AMERICAN INDIAN AND ALASKA NATIVE GAY AND BISEXUAL MEN MAY
FACE CULTURALLY BASED STIGMA AND CONFIDENTIALITY CONCERNS THAT
COULD LIMIT THEIR OPPORTUNITIES FOR EDUCATION AND HIV TESTING.
ESPECIALLY THOSE LIVING IN THE RURAL COMMUNITIES.
THIS WILL CREATE ENVIRONMENTS NO MATTER BACKGROUND OR RISK
PROFILE WILL FEEL WELCOME FOR PREVENTION SERVICES.
I WILL ASK THE ADMIRAL TO TURN TO THE NEXT SLIDE.
IT’S A PICTURE OF THE INDIAN HEALTH SERVICE AND WE HAVE A MAP
THAT DEPICTS WHERE WE’RE LOCATED–
>>HAVE YOU A DIFFERENT MAP IN THE HAND OUT THAN WHAT’S ON THE
SCREEN BUT YOU GET THE PICTURE? , WHICH IS A BETTER MAP, I
WANTED TO POINT TO A GEOGRAPHIC HOT SPOT, WHO ONE IS THE STATE
OF OKLAHOMA, CAN YOU SEE THE DOTS ON THE MAP, THERE ARE
SEVERAL OF THEM. WE HAVE MANY DIFFERENT TRIBES
AND HEALTH PROGRAMS LOCATED WITHIN THAT STATE AND ALSO FOR
MR. SAPERO, MARICOPA, ARIZONA WOULD BE ONE OF THOSE, THE
INDIAN HEALTH SERVICE HAS A LARGE FACILITY THERE, WHERE YOU
HAD THE PRIVILEGE TO BE THERE MOST RECENT CEO AND THERE AN HIV
CENTER OF EXCELLENCE IN THAT COUNTY.
THE MEDICAL CENTER STRIVES TO BE KNOWN AS A FACILITY WHERE
QUALITY HIV SERVICES ARE ACCESSIBLE, CONFIDENTIAL AND
CULTURALLY COMPETENT. THEY SERVE AS A SPECIALTY
REFERRAL CENTER FOR A FOUR-FIVE STATE REGIONAL AREA COVERING
EVERYWHERE FROM CALIFORNIA AND NEW MEXICO, NAVAHO NATION AND
AND PATIENTS GO TO MARICOPA COUNTY FOR HIV CARE AND
TREATMENT. THEN THE RESULTS IN 2017, PIMC’S
PATIENTS ADHERENCE TO CARE AND 92% VIRAL SUPPRESSION RATES.
THE PIMCHIV CENTER OF EXCELLENCE WORK HAS A SIGNIFICANT POSITIVE
IMPACT ON AMERICAN INDIAN AND ALASKA NATIVE PATIENTS NOT ONLY
STATEWIDE BUT REGIONALLY. OUR AMERICAN INDIAN ALASKA
NATIVE PEOPLE IN ARIZONA WHO ARE LIVING WITH HIV HAVE THE BEST
VIRAL SUPPRESS RATES OF ALL RACIAL GROUPS IN THE STATE
BECAUSE OF THE EFFORT OF THESE HIV CENTER OF EXCELLENCE.
SO THE PRESIDENT’S PLAN WILL ALLOW US TO EMULATE THIS CENTER
OF EXCELLENCE THROUGHOUT INDIAN COUNTRY, THE CENTER PROVIDES
ADHERENCE COUNSELING, CASE MANAGEMENT AND CARE NAVIGATION
SERVICES THAT ARE COMMONLY AVAILABLE IN HIV CARE AND
THEY’VE ALSO INCORPORATED TRADITIONAL INDIAN HEALTH
SERVICES THAT ARE AVAILABLE THROUGH THE CENTER.
SO WITH THE RESOURCES AND TOOLS WE HAVE AVAILABLE TODAY, WE HAVE
AN UNPRECEDENTED TAOUPT TO MAKERS AND A REAL DIFFERENCE IN
REDUCING HIV TRANSMISSION AND WE LOOK FORWARD TO WORKING CLOSELY
WITH OUR AMERICAN INDIAN ALASKA NATIVE PATIENTS, COMMUNITIES,
TRIBES AND URBAN INDIAN ORGANIZATIONS TO ENCOURAGE HIV
TESTING AND TREATMENT AND PROMOTE HIV PREVENTION AND
OPPORTUNITY.>>THANK YOU SO MUCH.
WE HEARD A LOT ABOUT ANTIRETROVIRAL THERAPY AND PREP,
THE RIGHT TOOLS AT THE RIGHT TIME AND NOW TO GIVE THE LINE ON
THAT DR. FAUCI.>>COULD I HAVE THE NEXT SLIDE.
HAVE YOU IT. OKAY.
OKAY.>>WE’RE IN GOOD SHAPE.
>>OKAY, SO TALKING ABOUT THE TWO, THIS IS REALLY ONE OF THE
FOUNDATIONS FOR THE PLAN. I AM LOOKING AROUND THE ROOM I
KNOW THAT SOME OF MY COLLEAGUES WERE THERE FROM THE BEGINNING
AND IF YOU LOOK AT THE EVOLUTION OF THE TOOLS SO WHEN I STARTED
TAKING CARE OF PEOPLE WHO DIDN’T KNOW IT WAS HIV IN 1981, THE
FIRST PATIENT WAS IN THE FALL OF 1981, THE DISEASE DOESN’T HAVE A
NAME IT WAS CALLED GRID, IT DOESN’T HAVE AN ETIOLOGY, WE
HAVE IT YET AND IT DIDN’T HAVE ANY DRUGS AND THEN IN 86, 87 WE
HAD THE FIRST DRUG WHICH STARTED TO GIVE US A CLUE, WE DROPPED
THE VIRAL LOAD SLIGHTLY AND NOT CURABLY BY 1991, WE HAD THE
SECOND DRUG AND THEN BETWEEN 1991 AND 1996 WE HAD A
COMBINATION OF TWO DRUGS, AND THEN WE LET THINGS LOOK PRETTY
GOOD TO BE ABLE TO DROP THE VIRAL LOAD, NEVER TO BELOW BUT
RARELY BELOW DETECTABLE, AND THEN THINGS CHANGED IN 1986 WITH
THE INVENTION OF THE PROTEASE INHIBITOR WHICH GAVE US TRIP
WILL COMBINATION BECAUSE IT DROPPED THE VIRUS BELOW
DETECTABLE LEVEL AND CRITICALLY. SO WE HAD A TREMENDOUS
TRANSFORMATION OF THE LIVES OF HIV INFECTED INDIVIDUALS.
THE DOWN SIDE AS YOU SEE ON THE LEFT-HAND SIDE OF THE SLIDE IS
THAT SOMETIME ITS WAS AS MANY AS 20-25-MILE PILLS TO BE TAKEN AT
MULTIPLE TIMES, WITH MEALS, WITHOUT MEALS, WITH WATER,
WITHOUT WATER, IT WAS DIFFICULT AND THERE WERE TOXICITIES BUT AS
THE YEARS WENT BY, THE REGIMENS BECAME LESS TOXIC AND MORE
EFFECTIVE SO AT THIS POINT WITH THIS SLIDE, WE CAN SAVE PEOPLE’S
LIVES. NEXT SLIDE.
THEN WE FOUND OUT SOMETHING THAT WAS THE GAME CHANGER AS FAR AS
WE’RE CONCERNED ABOUT THE PLAN. IT BECAME CLEAR THAT IF YOU
TREATED A PERSON WHO IS HIV INFECTED AND BROUGHT DOWN THE
VIRAL LOAD TO BELOW DETECTABLE LEVEL THAT NOT ONLY WOULD YOU
SAVE THE LIFE OF THE PERSON BUT YOU WOULD MAKE IT ESSENTIA WILY
IMPOSSIBLE FOR THAT PERSON TO TRANSMIT THE VIRUS TO ANYONE
ELSE. THEN YOU GO TO THAT POINT ON THE
RIGHT HAND SLIDE WHICH ALLOWED US TO SAY NOW WITH THE GOOD
SCIENTIFIC BASIS THAT UNDETECTABLE REALLY DOES MEAN
UNTRANSMITTABLE. GO TO THE NEXT SLIDE AND THEN
SOMETHING ELSE CAME ABOUT. PREEXPOSEURE PROPHYLAXIS, A
SINGLE PILL OF TREVADA FOR SOMEONE AT RISK FOR INFECTION
WOULD DECREASE THE LIKELIHOOD THAT THEY WOULD ACQUIRE HIV
INFECTION BETWEEN 95-97%. SO JUST AS WHEN BOB SAID WE
LOOKED AT THE MAP AND WE SAID OH MY GOODNESS, WE HAVE A COMPLETE
CONCENTRATION HERE THAT WE COULD ADDRESS WHEN WE LOOK AT THE DATA
WE SAID OH MY GOODNESS IF YOU CAN ACTUALLY SUPPRESS THE VIRUS
IN PEOPLE AND PREVENT THEM FROM TRANSMITTING AND GIVE PREP TO
PEOPLE AND PREVENT THEM FROM ACQUIRING, THEORETICALLY, IF YOU
ACCESSED EVERYBODY OR MOST PEOPLE WHO WERE HIV INFECTED,
PUT THEM ON THERAPY, GET THEM TO UNDETECTABLE AND THEN GIVE PREP
TO THOSE WHO ARE UNINFECTED BUT AT RISK THEORETICALLY YOU COULD
END THE EPIDEMIC NOW AND THAT’S WHEN THE REALISTIC THOUGHTS OF
TRULY ENDING THE EPIDEMIC BUT WE’RE REALISTS AND WE’RE TALKING
ABOUT THE IDEALISTIC ISSUE OF DOING IT AND WHAT WE’RE DOING
NOW AND DISCUSSING AND DOING IS TO BRIDGE THE GAP BETWEEN THE
IDEALISTIC WORLD OF WE CAN DO IT TO THE REALISTIC WORLD OF WE
ACTUALLY DONE IT. AND THAT’S REALLY WHAT THE PLAN
IS ALL ABOUT.>>THANK YOU DR. FAUCI, BUT
MEDICATIONS DON’T OCCUR IN A VACUUM THERE HAVE ABOUT KNOW
SYSTEMS OF CARE AND HERE TO TALK ABOUT SYSTEMS OF CARE AND
DR. SEGUNIS, THE LEADING OF HRSA, THE RYAN WHITE PROGRAM.
>>[INDISCERNIBLE] PROGRAMS TO HELP END THE HIV EPIDEMIC
INITIATIVE. THESE PROGRAMS ARE THE RYAN
WHITE PROGRAM THE CENTER PROGRAM AND THE [INDISCERNIBLE] PROGRAM.
JUST AS RYAN WHITE THE HIV PROGRAM PROVIDES CRITICAL
SERVICES FOR HIV CARE AND TREATMENT IN THE UNITED STATES,
THIS PROGRAM HAS BEEN ADDRESSING THE HIV EPIDEMIC IN THE COUNTRY
FOR ALMOST 30 YEARS OR FOR APPROXIMATELY 1.1 MILLION PEOPLE
LIVING WITH HIV IN THE UNITED STATES, THE RYAN WHITE PROVIDES
SERVICES TO 535,000 PEOPLE OR MORE THAN HALF OF ALL THOSE
LIVING OR DIAGNOSED WITH HIV. THE RYAN WOMAN WAS THE RIGHT
RECORD OF SUCCESS FOR ALL THE PATIENTS SUPPORTED BY RYAN
WHITE, PROGRAM, 36% WERE LAST YEAR VIRALLY SUPPRESSED THIS IS
SIGNIFICANTLY HIGHER THAN THE NATIONAL AVERAGE OF 60% AMONG
ALL THOSE LIVING WITH DIAGNOSED HIV.
[INDISCERNIBLE] WILL LEVERAGE THE INFRASTRUCTURE AND SUCCESSES
OF RYAN WHITE PROGRAM TO HELP THE GOALS FOR THE INITIATIVE TO
ENDLET HIV EPIDEMIC IN AMERICA. WHERE IT HAS BEEN PROPOSED TO
RECEIVE $70 MILLION IN NEW FUNDING FOR THIS INITIATIVE AND
HRSA PLANS TO FUND RECEPTIENTS THAT TARGET THE CITIES AND
COUNTIES IN SEVEN [INDISCERNIBLE] THROUGH
COOPERATIVE AGREEMENTS AND PAYMENT INITIATIVE, INITIALLY,
THE QUESTION OF THE FUNDING WILL SUPPORT IMPLEMENTATION OF
EVIDENCE IN THE PRACTICES TO REMAIN ENGAGED AND RETAIN
PATIENTS LIVING WITH HIV IN CARE.
PATIENTS ARE BROUGHT INTO CARE [INDISCERNIBLE] WILL BE JUST TO
PROVIDE IMPLICATIONS AND MEDICAL VISITS AND LABORATORY SERVICES
AND CARE COORDINATION NEXT SLIDE, PLEASE.
COMING NOW TO HRSA’S CENTER PROGRAM.
THIS PROGRAM SUPPORTS MORE THAN 12,000 DELIVERY SITES NATIONWIDE
SERVING MORE THAN 27 MILLION PEOPLE ANNUALLY.
CARE CENTERS PROVIDE AFFORDABLE, ACCESSIBLE HIGH QUALITY AND COST
EFFECTIVE PREVENTATIVE AND PRIMARY SELF-CARE TO MEDICALLY
UNDERSERVED POPULATIONS NATIONALLY.
PATIENTS WHERE THE STIGMA IS VERY HIGH IN VISITING THOSE
CENTERS. IN ADDITION TO PROVIDING FOR
COORDINATED [INDISCERNIBLE] PATIENT-CENTERED CANNED WHAT
CARE SELF-CENTERS WILL DO GREAT A WIDE RANGE OF MEDICAL, DENTAL
MENTAL HEALTH SUBSTANCE USE DISORDERS.
HEALTH CENTERS ARE THE KEY POINT OF ENTRY FOR PEOPLE AND THOSE
WITH HIV, NEARLY 2 MILLION PATIENTS RECEIVE AN HIV TEST AT
THE HEALTH CENTER ANNUALLY. OVER 160,000 SELF-CENTERED
PATIENTS RECEIVE HIV RELATED CARE.
MANY OUTSIDE CONFOUNDED BY THE RYAN WHITE PROGRAM.
ALSO MANY HEALTH CENTERS PROVIDE HIV PREVENTION SERVICES
INCLUDING PREEXPOSURE PROPHYLAXIS, THE SELF-CENTERED
PROGRAM WILL PROVIDE 20 MILLION TO PROVIDE IN 2020 TO EXPAND
SELF-CENTER EFFORTS AROUND HIV OUTREACH, TESTING, CARE
COORDINATION, AND PREVENTION SERVICES ENCLUEDING PREP.
SUPPLEMENTAL GRANTS WILL BE PROVIDED TO 150 DUALLY FUNDED
CENTERS AND RYAN WHITE PROGRAMS TO CONDUCT OUTREACH AND HEALTH
CARE SERVICES, COORDINATION AND LINKAGE TO CARE IN THE
[INDISCERNIBLE] SERVICES INCLUDING PREP TO PEOPLE AT HIGH
RISK FOR HIV TRANSMISSION.>>THANK YOU.
>>I HAVE THE NEW SLIDE FOR C-FAR SO HAVE YOU IT ON YOUR
HANDOUT BUT VERY IMPORTANTLY ANOTHER INFRASTRUCTURE,
INCREDIBLE INFRASTRUCTURE WE WILL LEVERAGE ARE THE NAOEURBG H
CENTER FOR AIDS RESEARCH.>>THANK YOU ADMIRAL GIROIR, SO
THIS MAP SHOWS THE DISTRIBUTION OF THE CENTERS FOR AIDS RESEARCH
WHICH WAS STARTED A COUPLE DECADES AGO, THERE ARE 19 OF
THEM THAT ARE NAOEURBG H CENTERS OF AIDS RESEARCH WITH AN
ADDITIONAL SEVEN FROM THE NIMH THAT ARE INVOLVED IN ISSUES, THE
IMPORTANT CONTRIBUTION OF THESE CENTERS WE FEEL WILL BE
INDEGRADATIONERAL OF THE SUCCESS OF THE PLAN, WE HAVE A LEADER
HERE ON YOUR PACHA, MIKE SAGG, AT THE UNIVERSITY OF ALABAMA AT
BIRMINGHAM AND THE PURPOSE OF THE ISSUES WE’RE TALKING ABOUT
RIGHT NOW WITH REGARD TO THE CENTERS IS TO DO SOMETHING THAT
YOU GENERALLY DON’T ASSOCIATE WITH NIH’S BASIC FUNDMENTAL
RESEARCH. SO WE’RE NOT DEVELOPING DRUGS
WITH THIS, NOT DEVELOPING A VACCINE, WE’RE DOING WHAT WE
TALK ABOUT AS IMPLEMENTATION SCIENCE, IN OTHER WORDS WE HAVE
A TEN YEAR PROGRAM WHERE WE DO NOT KNOW RIGHT NOW WHAT IS GOING
TO WORK AND WHAT IS NOT GOING TO WORK ALTHOUGH WE CLEARLY ARE
OPTIMISTIC THAT MOST EVERYTHING WE WILL DO WILL WORK BUT THE
ONLY WAY WE MAKE SURE OF THAT IS BY MONITORING IT AND
COLLABORATING VERY CLOSELY WITH OUR COLLEAGUES AT THE CDC WHO
COLLABORATE VERY CLOSELY WITH INDIVIDUALS AT THE STATE, LOCAL,
FAITH BASED AREAS TOGETHER WITH THE INDIAN HEALTH SEVENS TO
DETERMINE AS WE GO FROM THE BEGINNING OF THE PROGRAM INTO
THE PROGRAM, WHAT WORKS BEST SO THAT WE CAN RESELF-CORRECT AS WE
GO ON TO GET BEST PRACTICES AND WE HAVE EXPERIENCES WITH THE
LEADERS OF OUR CFAR PROGRAMS NOW FOR SEVERAL YEARS THAT HAVE
ALREADY BEEN DOING THIS. A TYPICAL EXAMPLE OF THIS IS
WHAT I’VE TOLD SOME OF YOU IN THE PAST, THE SUCCESS WE HAD IN
WASHINGTON D. C. WHEN WE HAD A CITY THAT HAD THE HIGHEST
PREVALENCE AND THE HIGHEST INCIDENCE IN THE COUNTRY AND WE
PARTNERED WITH THE DEPARTMENT OF HEALTH OF THE DISTRICT OF
COLUMBIA AND THE WASHINGTON D. C. CFAR TO GET INTO THE
COMMUNITY TO DO THE THINGS WE HOPE TO DO ON A BROADER SCALE
AND THE INCIDENCE OF INFECTION CAME DOWN DRAMATICALLY DURING
THOSE YEARS THAT WE DID THAT AND HOPEFULLY THE CFAR THROUGHOUT
THE COUNTRY WILL DO THAT. NONAPOPTOTIC YOU THE MAP THAT
THE ADMIRAL MENTIONED TO YOU IF YOU TAKE A MAP OF THE CFARS AND
SUPER IMPOSE UPON THE MAP OF THE 48 COUNTIES OF THE DISTRICT AND
SAN JUAN, IT ISN’T A PERFECT MATCH BUT WE THINK IT’S REALLY
CLOSE. SO WE THINK WE HAPPEN TO BE IN
SITUATION WHERE WE’RE WELL LOCATE FRIDAY A GEOGRAPHIC
STANDPOINT.>>SO AS WE’VE SPOKEN SEVERAL
TIMES TODAY, THE GOALS ARE AMBITIOUS GOALS BUT WE FEEL
BASED ON COMPREHENSIVE DATA-DRIVEN EVIDENCE-BASED
MODELING THAT WE CAN REDUCE NEW INFECTION OF 70% WITH FIVE YEARS
AND 90% WITHIN TEN YEARS AS YOU MIGHT IMAGINE, ONCE YOU GET THE
FIRST 50-75%, THE NEXT INCREMENTS TAKE MUCH LONGER,
MUCH HARDER TO REACH THOSE THAT ARE NOT IN CONCENTRATED AREAS.
THE WAY WE DO THIS ARE PRETTY OBVIOUS FROM WHAT YOU JUST
HEARD, VERY KEY IS TO DIAGNOSE ALL PEOPLE WITH HIV AS EARLY AS
POSSIBLE FOR THE REASONS THAT WE’RE OUTLINES BY DR. REDFIELD.
TREAT THE INFECTION RAPIDLY, I WAS A BIT SHOCKED AGAIN AS AN
OUTSIDER, IF A PERSON AS PNEUMONIA, AND I DIAGNOSE THEM,
THEY GET ANTIBIOTICS IMMEDIATELY, WE DON’T SEND THEM
AWAY, COME BACK AND GET YOUR DIAGNOSTIC TEST AND THEN GET
ANOTHER MONTH’S APPOINTMENT TO SEE IF YOU AND GET TREATED,
TREATMENT MUST BE LINKED WITH THE DIAGNOSE AS EARLY AND
IMMEDIATELY AS POSSIBLE. PROTECT BY PREP, WE WILL GIVE
YOU METRICS, RESPOND TO CLUSTER WHICH IS IS WHAT THE CDC DOES ON
A ROUTINE BASIS AND A CRITICAL COMPONENT THAT DR. REDFIELD WILL
TALK ABOUT TWO SLIDES FROM NOW IS BUILDING THE HIV WORKFORCE IN
A COMMUNITY BASED, COMMUNITY DRIP WAY.
SO WHAT SHOULD BE OBVIOUS TO YOU NOW, THE INITIAL TARGET IS ON
HIGH INCIDENCE GEOGRAPHIES AND DEMOGRAPHICS.
WE DO NEED TO EMPHASIZE EARLY DIAGNOSIS AND IMMEDIATE
TREATMENT AND ENGAGEMENT AND FOR OUR MODEL TO BE EFFECTIVE, TO BE
FULLY EFFECTIVE, WE NEED TO INCREASE VIRAL SUPPRESSION TO
ABOUT 90% AND AS YOU’VE HEARD FROM DR. SEIGOUNAS, THAT
ACHIEVABLE IN RYAN WHITE AT 87% AND FROM ADMIRAL WEAHKEE UP TO
97%. IT IS CRITICAL TO INCREASE PREP
FROM TEN TO 20%. THOSE NUMBERS ARE HARD TO GOT A
FIRM NUMBER ON TO AT LEAST 50 AND HOPEFULLY 60 PERCENT, WE
WOULD LOVE TO GET IT TO 50%, THAT IS A GOAL, BUT WHEN YOU
CRUNCH THE NUMBERS AND DO THE TRANSMISSION, IF WE CAN GET PREP
TO 50-60% COMBINED WITH THE OTHER EFFORTS THEN WE MEET OUR
GOAL OF 75% AND 90%. SO WE DO WANT TO SPEND TIME AND
AGAIN SEVERAL OF THE SERVICES HAVE ALREADY TALKED ABOUT WHAT
THEY’RE GOING TO DO WITH THEIR FUNDING.
I WOULD SAY UP FRONT THAT WE DID NOT ASSUME ANY DRAMATIC CHANGES
IN THE LANDSCAPE OF INSURANCE, MEDICAID, ANY OTHER COVERAGE.
WE DID VERY SPECIFIC MODELS BY COMMUNITY, MADE VERY SPECIFIC
EVIDENCE-BASED ASSUMPTIONS OF WHAT PERCENT WOULD BE COVERED BY
INSURANCE, WHAT WOULD BE MEDICAID, WHO WOULD BE UNINSURED
AND HAVE BUILT A FIVE YEAR PLAN OF WHAT YOU SEE THE FIRST YEAR
THAT WOULD PROVIDE COVERAGE TO ALL THOSE IN THE GAP WITH NO
COVERAGE WHATSOEVER EITHER BY RYAN WHITE IF THEY WERE
DIAGNOSED OR BY COMMUNITY HEALTH CENTERS IF THEY NEEDED PREP.
SO IT IS VERY IMPORTANT AS WE DID NOT ASSUME A SCIENTIFIC NEW
MIRACLE, NEW DRUG, NEW VACCINE, NEW APPROACH, WE ALSO DID NOT
ASSUME A PUBLIC HEALTH CHANGE OF ANY DRAMATIC PROPORTIONS BECAUSE
WE NEED TO CONTROL WHAT WE CAN CONTROL AND THIS IS WHAT WE CAN
CONTROL. SO I WOULD LIKE TO GO DOWN, I
THINK YOU’VE HEARD MOSTLY, I THINK HRSA EXPLAINED THEIR PLAN
PRETTY WELL AND IHF, BUT A CRITICAL COMPONENT IS THE CDC IN
THE WORKFORCE WHERE WE AND ARE HOW HAY WILL ENTKPWAEPBLG IN THE
COMMUNITIES ALONG WITH ALL OF US.
>>SO MOST OF YOU PROBABLY KNOW THAT THE CDC REALLY FUNDS A
SIGNIFICANT PART OF THE UNITED STATES PUBLIC HEALTH
INFRASTRUCTURE AT THE STATE LEVEL AT THE TRIBAL LEVEL, LOCAL
LEVEL, TERRITORIAL LEVEL, JUST TO PUT THAT OUT THERE.
CLEARLY THIS INITIATIVE IS TO BUILD ON THAT, PARTICULARLY IN
THE AREAS THAT THE ADMIRAL DISCUSSED TO ENHANCE DIAGNOSIS,
TREATMENT, PROTECTION AND COMPREHENSIVE PREVENTION
STRATEGIES AND THEN TO AUGMENT THE CAPACITY TO RESPOND TO
CLUSTER WHEN IS THEY CAN OCCUR AND WE HAVE SEVERAL CLUSTERS
THAT ARE ACTIVELY OCCURRING AS WE SIT HERE TODAY.
FUNDAMENTAL TO THAT IS TO WORK WITH THE LOCAL JURISDICTION.
THIS IS NOT GOING TO BE A PLAN THAT COMES DOWN FROM THE
ADMIRAL’S OFFICE THAT GOES INTEREST THE 50 JURISDICTIONS
AND SEVEN STATES THIS, IS GOING TO BE BASKLY 50 JURISDICTIONS
INDEPENDENTLY DEVELOPING THEIR PLAN FOR HOW TO OPERATIONALLIZE
A RESPONSE THAT WILL MEET THE GOALS OF THIS INITIATIVE.
SO WE WILL OBVIOUSLY BE WORKING WITH THE COMMUNITY TO HELP DO
THAT BUT I JUST WANT TO UNDERSCORE WHAT THE ADMIRAL SAID
AT THE BEGENERATEDDING, THIS WILL BE LOCAL PLANS DEVELOPED BY
THE COMMUNITY, FOR THE COMMUNITY, IN THE COMMUNITY AND
THE GOAL FOR THAT AT THE END OF THE DAY AND MIKE AND OTHERS KNOW
HOW IMPORTANT THIS IS IS TO DEVELOP AN HIV WORKFORCE.
WHETHER THAT WORKFORCE IS INTRINSICALLY DEVELOPED IN THE
COMMUNITY, FOR THE COMMUNITY, BY THE COMMUNITY OR WHETHER IT
NEEDS AUGMENTATION FROM CDC, THOSE WILL BE INDIVIDUAL
DECISIONS ON HOW THAT WORKFORCE GETS BUT WE–WE ARE DEVELOPING A
WORKFORCE AND THOSE OF YOU KNOW I HAVE AN OLD MILITARY
BACKGROUND TO GET THE MISSION DONE.
AS TONY SAID, THE ADMIRAKA WILLA SAID, THIS IS A REALISTIC GOAL,
WE INTEND TO ACCOMPLISH THIS GOAL AND THE PUBLIC
INFRASTRUCTURE AND ACCOMPLISH THAT GOAL AND THE COMMUNITIES
ARE GOING TO BE ABLE–THEY WILL HAVE TO BE ABLE TO BE RESOURCED
TO DEVELOP THAT WORK FOR US TO GET THE JOB DONE.
I THINK THAT’S THE POINT I REALLY WOULD LIKE TO MAKE.
FOR US, AGAIN, IT’S DIAGNOSIS, AND REALLY HELP PEOPLE GET
LINKED INTO TREATMENT. HRSA AND THE COMMUNITY HEALTH
TRUSTEESES AND RYAN WHITE CENTERS WILL TAKE OVER.
PREVENTIONS REALLY WORK WITH GETTING COMPREHENSIVE
PREVENTION, I WAS VERY HAPPY TO HEAR A COUPLE DAYS AGO, THE
STATE OF GEORGIA HAD REALLY MOVED FORWARD ON BROADER ACCESS
TO SAFE SYRINGE PROGRAMS. WE NEED COMPREHENSIVE PREVENTION
IN THESE JURISDICTIONS BUT THEY WILL HAVE TO DECIDE WHAT THAT IS
AND HOW THEY WANT IT IMPLEMENTED AND ULTIMATELY CDC WILL BE
AVAILABLE TO HELP THE STATE, LOCAL, TRIBAL AND TERRITORIAL
HEALTH DEPARTMENTS TO IDENTIFY CLUSTERS AND TRY TO HAVE THEM
NOT HAVE A NEGATIVE IMPACT ON OUR PROGRESS.
BEFORE WE GO TO THE OTHER AGENCIES, I WANT EMPHASIZE THAT
DR. BECKHAM HAS BEEN WORKING ALONGSIDE CDC AND OTHER AGENCIES
AS I MENTION THAT WE HAVE DEDICATED APPROXIMATELY
$30 MILLION IN FUNDING FROM THE FISCAL YEAR 19 MINORITY AIDS
INITIATIVE IT THAT COMES 32 YOU OURAVEIS TO SPECIFICALLY WORK
WITH CDC TO DEVELOP COMMUNITY PLANS THROUGH COMMUNITIES AND
COMMUNITY GRANTS STARTING THIS YEAR.
SO WE’RE NOT GOING TO WAIT FOR THE NEXT YEAR’S BUMET AND AGAIN
THIS IS NOT REAL MONEY. THIS IS THE PROPOSAL FROM THE
PRESIDENT. THIS HAS TO BE APPROVED BY
CONGRESS IN APPROPRIATIONS. SO THIS IS ASPIRATIONAL.
WE HOPE THERE’S A GREAT AGREEMENT ON THIS BUT WE’RE NOT
WAITING UNTIL 2020. THAT WILL BE STARTED IN THE
APRIL-MAY TIME FRAME SO THAT COMMUNITIES WILL START HEARING
FROM US AND I WILL ALSO GO OFF SCRIPT A LITTLE BIT TO SAY THAT
WE HAD WHAT I CONSIDER A TREMENDOUS MEETING WITH US WITH
THE HIV AND CONGRESSIONAL BLACK CAUCUS AND WE HAD MEMBERS
PRESENT CONGRESSWOMAN LEE, SHEILA JACKSON LEE AND WILSON
ALL FROM VERY HIGHLY AFFECTED DISTRICTS WHO BASICALLY OPENED
THEIR ARMS TO COMMUNICATION AND COLLABORATION AND GAVE US VERY
SPECIFIC POINTERS HOW WE COULD BEST REACH THE COMMUNITIES AND
THE ORGANIZATIONS THAT WE NEED TO REACH.
DOES ANYBODY WANT TO MAKE A COMMENT ABOUT THAT?
, FREIGHT MEETING. YOU’RE ABSOLUTELY CORRECT.
>>SO DR. SIGOUNAS, DO YOU WANT TO MAKE ANY OTHER COMMENTS ABOUT
HRSA AND RYAN WHITE AT THIS POINT?
>>YEAH BY PROVIDING SYSTEM OF CARE THAT INTEGRATES PROVISION
OF MEDICAL CARE, MEDICATION AND ESSENTIAL SUPPORT SERVICES, THE
RYAN WHITE PROGRAM IS ABLE TO REACH THE MOST UNDERSERVED
POPULATIONS. RIGHT NOW IT IS ESTIMATE THAT
MORE THAN 170,000 PEOPLE ARE INFECTED WITH HIV AND THEY DON’T
KNOW IT. SO IN THIS INITIATIVE, THE RYAN
WHITE PROGRAM WILL INCREASE EFFORTS TO ENGAGE AND DETAIN
THOSE NEWLY DIAGNOSED IN CARE. IN ADDITION RYAN WHITE PROGRAM
WILL EVIDENCE-BASE TO ENGAGE AND DETAIN ABOUT 230,000 PEOPLE
LIVING WITH HIV WHO ARE DIAGNOSED NOT RECEIVING CARE
TODAY. THE HEALTH CENTER PROGRAM WILL
EXPAND THEIR WORK IN HIV, PREVENTION, TESTING AND CARE
WITH AN EMPHASIS ON EXPANSION OF PREEXPOSURE PROPHYLAXIS
SERVICES, THE HEALTH CENTERS ARE WELL POSITIONED TO DO THIS WORK
THROUGH THEIR MORE THAN 3000 SERVICE DELIVERY SITES, WITHIN
JURISDICTIONS THAT ARE THE FOCUS OF THE FIRST PHASE OF THIS
INITIATIVE.>>THANK YOU.
ADMIRAL WEAHKEE, DO YOU HAVE ANY OTHER COMMENTS?
>>NOT REALLY, JUST TO UNDERSCORE THE VITAL IMPORTANCE
OF THESE INITIATIVES BEING COMMUNITY DRIVEN AND THE INDIAN
HEALTH SERVICES INTENT TO CONSULT WITH TRIBES AND CONFIRM
WITH OUR URBAN INDRAN PROGRAMS ISSUES THE SOLUTIONS ARE AT THE
GROUND LEVEL.>>THANK YOU.
DR. FAUCI, ANYTHING MORE?>>NO, I THINK WHEN PEOPLE SEE
THE SMALL NUMBER, 6 MILLION, WE–WE HAVE THE WHERE WITH ALL
BY MOVING AREAS INTO CFAR AS SUPPLEMENTS TO GET THEM GOING
FOR THIS YEAR, IN THE SUBSEQUENT YEARS DEPENDING ON HOW THINGS
GO, WE WILL TALK ABOUT HOW MUCH ADDITIONAL MONEY WE NEED BUT WE
FEEL VERY CONFIDENT THAT WE CAN DO THE JOB AT THE CFARS CAN DO
WITH THE SUPPLEMENT SAYS I’LL BE GIVING THEM.
>>NOW ON THIS SLIDE, THERE ARE MAINTAINS CURRENT MONEY, WE DID
NOT INCLUDE THIS NEW MONEY ALTHOUGH THESE WERE NOT IN THE
PRESIDENT’S BUDGET PREVIOUSLY, THEY ARE IN THE BUDGET
NONAPOPTOTIC YOU FOR MINORITY AIDS INITIATIVE, $54 MILLION
THROUGH MY OFFICE THAT’S CHANNELED THROUGH
[INDISCERNIBLE] THAT WILL SEE THIS INITIATIVE IN THE NEXT
COUPLE OF MONTHS. BUT VERY IMPORTANT AND I THINK
MANY OF YOU KNOW BUT MANY OF YOU MAY NOT KNOW THE CRITICAL ROLE
OF SM SA IN INCREASING POPULATIONS THAT ARE HARD TO
REACH, WITH A BUDGET OF $116 MILLION, AND I WOULD LIKE
TO WELCOME ROSE MAR MARY PAIN TO INFORM US ABOUT SMSA’S ROLE.
>>GOOD AFTERNOON I AM HERE ON BEHALF OF
DR. ELINORE Mc CANCE-KATZ, WITH SAMHSA, WE FOCUS ON HIV
PREVENTION AND IDENTIFICATION AND THE TREATMENT OF HIV AND
INDIVIDUALS LIVING WITH SUBSTANCE USE AND MENTAL
DISORDERS. THE IMPORTANCE OF SAMHSA’S
EFFORTS ARE UNDERSCORED BY WELL STOKED LINKS BETWEEN HIGH RISK
BEHAVIORS FOR HIV INFECTION AND INCLUDING INJECTION DRUG USE AND
UNPROTECTED SEXUAL ACTIVITY THAT MAY OCCUR IN THOSE WITH
UNTREATED MENTAL AND/OR SUBSTANCE USE DISORDERS.
FURTHER EFFECTIVE CARE AND TREATMENT OF MENTAL HEALTH
ISSUES AND SUBSTANCE ABUSE PROBLEMS EXPERIENCED BY THOSE
LIVING WITH HIV INFECTION IS CRITICALLY IMPORTANT TO
INCREASING A PERSON’S ABILITY TO ADHERE TO HIV TREATMENT AND
POSITIVE OUTCOMES THAT RESULT IN VIRAL SUPPRESSION, CESSATION OF
HIGH RISK BEHAVIORS AND MAJOR REDUCTION IN THE LIKELIHOOD OF
VIRAL TRANSMISSION. SMHSA FUNDED OVER $100 MILLION
IN HIV TREATMENT PROGRAMS AND CENTERS FOR SUBSTANCE ABUSE
PREVENTION, TREATMENT, AND MENTAL HEALTH SERVICES.
FUNDING FROM CURRENTLY ACTIVE GRANTS HAS SUPPORTED MENTAL
DISORDER USE FOR SERVICES FOR 20,000 INDIVIDUALS.
THESE PROGRAMS EXTEND ACROSS THE NATION INCLUDING THE EIGHT
COUNTIES IN THE UNITED STATES HARDEST HIT BY HIV.
SAMSA’S FUND, CO HIV COUNSELING, HIGH RISK POPULATIONS AND
TESTING AND TREATMENT AND COMMUNITY BASED RECOVERY
RESOURCE PROGRAMS, THESE GRANT PROGRAMS ALSO FUND SERVICES TO
ADDRESS MENTAL AND SUBSTANCE USE DISORDER IN THOSE LIVING LIVING
WITH HIV AS WELL AS TO INDICATE HIV CARE INTO THOSE–EXCUSE
ME–INTEGRATE INTO BEHAVIORIAL HEALTH PROGRAMS OR TO UTILIZE
CARE MANAGERS WHO ASSIST PATIENTS WITH RECEIVING MENTAL
AND SUBSTANCE USE DISORDER SERVICES, TO ALSO GET TO
AFFILIATED PROGRAMS THAT CAN PROVIDE ONGOING HIV SERVICES.
SIMILARLY, HEALTHCARE CLINICIANS AND PROGRAMS THAT PROVIDE HIV
CARE IN COMMUNITIES ARE ASSISTED BY SOME GRANT PROGRAMS THAT
PROVIDE MENTAL HEALTH AND SUBSTANCE USE DISORDER RESOURCES
WITHIN THOSE COMMUNITY PHYSICAL HEALTHCARE PROGRAMS OR REFERRAL
TO COMMUNITY MENTAL HEALTH AND SUBSTANCE USE DISORDER TREATMENT
PROVIDERS WHO WORK COLLABORATIVELY ON BEHALF OF
THOSE LIVING WITH DISORDERS. FINALLY, EDUCATION AND TRAINING
OF PROVIDERS AND THE PUBLIC REGARDING HIV, SUBSTANCE ABUSE
AND MENTAL HEALTH ISSUES AND THE INTERSECTION OF THESE
CONTKEUPGZS IS IMPORTANT TO EXTEND EVIDENCE-BASED TREATMENT
AND INCREASING THE KNOWLEDGE AND SKILLS OF HEALTH SERVICE
PROVIDERS. SAMHSA FUNDS A SERIES OF
NATIONAL AND REGIONAL TECHNOLOGY TRANSFER CENTERS THAT AADDRESS
SUBSTANCE ABUSE PREVENTION, TREATMENT, AND MENTAL ILLNESS
EDUCATION AND PROGRAM IMPLEMENTATION.
PROGRAMS INCLUDING THE STATE TARGETED RESPONSE, OPIOID
RESPONSE T. A. CENTER, PROVIDERS CLINICAL SUPPORT SYSTEM FOR
MEDICATION, ASSISTED TREATMENTS AND THE CLINICAL SUPPORT SYSTEM
FOR SERIES MENTAL ILLNESS ALL HAVE THE CAPACITY TO FOCUS ON
THE ISSUES RELATED TO BEHARIAL HEALTH AND HIV.
SAMHSA LOOKS FORWARD TO WORKING WITH THE PARTNERS WITHIN THE
DEPARTMENT OF HEALTH AND HUMAN SERVICES IN AN EFFORT TO
ERADIATE HIV IN AMERICA OVER THE NEXT TEN YEARS.
>>THANK YOU VERY MUCH. VERY QUICKLY BEFORE WE GET TO
QUESTIONS, WE ARE VERY COGNIZANT THAT THERE IS A TREMENDOUS SURGE
IN HIV AWARENESS ACROSS THE COUNTRY.
ONE OF THE REASONS DR. WIESMAN IS HERE IS BECAUSE OF THE SURGE
IN HIS AREA, WE WANT TO CERTAINTY THESE PROGRAMS, LEARN
FROM THESE PROGRAMS SO THAT BEST PRACTICES CAN BE SPREAD ACROSS
THE COUNTRY AS THEY’RE APPLICABLE TO THE SPECIFIC
DEMOGRAPHIC IN GEOGRAPHY SO THIS IS AGAIN ONE OF THE REASONS IT
IS THE EXACT RIGHT TIME. YOU KNOW WHO THESE GUYS ARE SO I
DON’T NEED TO REINTRODUCE YOU. THE LAST ONE THIS IS A WHOLE
SOCIETY INITIATIVE. WE ARE DOING OUR FEDERAL PART,
STATE PART, COMMUNITY PART, PROFESSIONAL ASSOCIATION, PEOPLE
LIVING WITH HIV, TRIBES AND INDIAN URBAN ORGANIZATIONS,
FAITH-BASED ORGANIZATION, PATIENT ADVOCACY GROUPS,
NONPROFIT ORGANIZATIONS, THE INDUSTRIAL COMMUNITY, VENTURE
CAPITAL PHARMACEUTICAL WE ALL NEED TO BE TOGETHER.
IT’S UP TO ALL OF US TO FIGURE OUT WHOSE NAME GOES IN THAT
YELLOW BOX. BUT WE REALLY–THIS IS A VERY,
VERY LARGE TENT IS AND WE WILL HAVE TO WORK TOGETHER TO MAKE
THIS HAPPEN. AND I WILL LEAN ON DR. FAUCI,
BECAUSE I’M IMPRESSED WITH SO MANY THINGS HOOEY SAYS BUT
WHAT’S DIFFERENT ABOUT THIS EFFORT ORGANIZATIONALLY FROM THE
HHS POINT OF VIEW, AND THEN WE WILL TAKE QUESTIONS.
>>OH I THINK IT HAS TO DO WITH THE PREVENTIVEIOUS MAP YOU
SHOWED ADMIRAL THAT WE KNOW THAT A LOT OF STATES AND INDIVIDUAL
JURISDICTIONS HAVE THEIR PLANS AS WE’VE SEEN WITH WASHINGTON,
CALIFORNIA AND NEW YORK AND WASHINGTON D. C. BUT THIS IS THE
FIRST TIME EVER THAT YOU HAVE MULTIPLE AGENCIES WITHIN THE
DEPARTMENT OF HEALTH AND HUMAN SERVICES WHO ARE COMING
TOGETHER, WORKING TOGETHER ON A PLAN AS A TEAM.
WE’VE HAD NIH DO THINGS, WE’VE HAD CDC DO THINGS, WE’VE HAD
HRSA DO THINGS, INDIAN HEALTH SERVICE BUT THIS IS THE FIRST
TIME WE COME TOGETHER WITH A TEAM UNDER THE LEADERSHIP OF
ADMIRAL GIROIR WITH A SECRETARY OF HHS WHO HAS COMPLETELY BOUGHT
BO THIS SO SECRETARY AZAR IS ENTHUSIASTIC ABOUT THIS WHICH IS
WHY HE WENT TO THE PRESIDENT TO MAKE THE ANOUNMENT IN THE STATE
OF THE UNION ADDRESS. THIS IS UNIQUE.
THIS IS NOT SOMETHING THAT’S SAME OLD BY ANY MEANS.
>>THANK YOU FOR THAT AND ON THAT NOTE, I HOPE THAT EVERYONE
IN THIS ROOM CAN FEEL WHAT WAS JUST SAID IN TERMS OF THIS
COLLABORATION AT HHS AND THE LEADERSHIP WHEN THE EARLIER
SLIDE FOLKS SAID TIME IS NOW, RIGHT DATA, RIGHT TOOLS RIGHT
LEADERSHIP, IT IS BECAUSE OF THE RIGHT LEADERSHIP THAT CARL AND I
ARE AT THE TABLE AS CO-CHAIRS. I CAN SEE PERSONALLY, I’VE HAD
THE BRIEF INSIGHT INTO THE KIND OF WO, THAT WAS HAPPENING AND
THAT IS THE REASON WHY I THINK I NEED TO BE HERE AND I THINK IT’S
WHY THE FOLKS AROUND THIS TABLE ARE HERE, SO THANK YOU ALL.
I KNOW THIS IS THE BEGENERATEDDING AND THERE IS A
LOT OF WORK TO DO. BUT WE ARE GETTING OFF ON THE
RIGHT STEP AND IT IS DUE TO YOUR LEADERSHIP, TO THE YEARS OF
EXPERIENCE THAT YOU HAVE ALL HAD AND THE CAREERS HAVE YOU HAD.
AND SO, WITH THAT, IT’S GREAT TO BE AT THIS POINT IN TIME.
WE HAVE ABOUT 20 MINUTES FOR THE PACHA MEMBERS TO ASK QUESTIONS
OF OUR FEDERAL PARTNERS. WE WILL FOLLOW THAT WITH ABOUT A
15 MINUTE BREAK AND THEN WE WILL HAVE ALMOST ABOUT AN HOUR AND A
HALF FOR PACHA MEMBERS TO TALK ABOUT WHAT WE HEARD AND HAVE
DISCUSSION ABOUT THE PLAN THE CHARGE THAT DR. GIROIR HAS GIB
US AS MEMBERS SO WE WILL SIGNIFICANT TO DISCUSS THAT.
PACHA MEMBERS ALREADY KNOW BECAUSE I SEE ONE PLACARD UP
THAT WE WOULD LIKE YOU TO DO IF YOU HAVE A COMMENT OR A QUESTION
FOR OUR FEDERAL LEADERS TO PUT YOUR BLACK–PLACARD UP ON THE
SIDE AND KAY HAYES WILL TAKE YOUR NAME AND WE WILL GET AN
ORDER AND TALL FOLKS OFF AND WHEN YOU’RE DONE, IF YOU CAN
THINK ABOUT REMEMBERING TO TURN YOUR PLACARD DOWN, THAT WOULD BE
GOOD AND YOU CAN PUT IT UP WHEN YOU HAVE ANOTHER QUESTION.
SO KAYE, I’LL TURN IT OVER TO YOU.
DON’T BE SHY. THERE WAS A LOT SAID AND WE
DON’T HAVE THIS OPPORTUNITY EVERY DAY TO SPEAK DIRECTLY TO
THESE LEADERS. SO, KAYE?
>>THANK YOU JOHN. FIRST QUESTION, MIKE?
>>THANK YOU. THANKS TO EVERYBODY NOT ONLY FOR
THE PRESENTATIONS BUT FOR THIS INCREDIBLEST TO BRING ALL THESE
ENTITIES TOGETHER AND IT’S HARDENING AND SIGHTING TO BE A
PART OF IT AND MAKE IT HAPPEN AND I THINK WE CAN MAKE A
DIFFERENCE. I WANT TO ZERO IN ON PREP AND
GET INFORMATION BECAUSE I’VE BEEN NOT BACK OF THE ENVELOPE,
BUT BACK DOING MATH HERE, WOULD WE SAY THAT THE HIGH RISK
POPULATION ZERO CONVERSION, WHAT’S CALLED INCIDENCE RATE IS
ABOUT TWO% PER YEAR? IS THAT ACCURATE OR MORE?
DO WE KNOW?>>MORE?
, MORE. OKAY IF IT IS TWO% OR GREATER
THEN THAT MEANS WOO VERMEN INFECTED TO TREAT 50 PEOPLE TO
PRESREPT ONE INFECTION IF I’M DOING MY MATH RYE.
SO WHEN YOU–WHEN YOU BOYS ARE CALCULATING OUT THE NEEDS FOR
GETTING PREP AND ACCESSING IT, HOW–HOW CAN WE GO ABOUT
DETERMINING THE INVESTMENT THAT WILL BE REQUIRED TO IMPLEMENT
THIS. OR HAVE WE GONE THAT FAR.
>>LET ME TAKE THE FIRST STAB AT THAT, AND WE CALCULATED THE
INVESTMENT BY CALCULATING THE NUMBER OF PEOPLE TO REACH THOSE
PERCENTAGES WITHIN THE DISTRICTS THAT WE’RE TARGETING AT FIRST
AND ASSUMING THAT THOSE INDIVIDUALS, THE MAJORITY–WHERE
THE COST OF THIS PROGRAM WOULD BE WOULD BEING DRUGS, PAID FOR
UNDER THE 340 B PROGRAM, DONE THROUGH COMMUNITY HEALTH
CENTERS, OR TO THOSE DUAL HABIT COMMUNITY CENTERS IN THE RYAN
WHITE PROGRAM KNOWING RYAN WHITE CANNOT FUND PREP BUT IT CAN BE
DONE THROUGH THE COMMUNITY HEALTH CENTER BUDGET SO THAT HAS
BEEN INTRODUCED INTO THIS–INTO THIS WHOLE EQUATION, I DON’T
KNOW IF YOU WANT TO DEEPER THAT KNOW THAT BUT IT’S A PERCENTAGE
TIMES THE NUMBER OF PEOPLE, TIMES THE NUMBER OF PEOPLE WE
BELIEVE HAS NO RESOURCES. AS YOU KNOW THERE ARE EXCITING
THINGS RELATED TO PREP INCLUDING THE PREVENTATIVE TASK FORCE
RECOMMENDATION, ET CETERA.>>THAT’S GREAT.
IS IT IN THE PUBLIC DOMAIN WHAT PRICING IS FOR PREP.
>>NO.>>I THINK IT IS IMPORTANT–THE
ADMIRAL JUST EMPHASIZED BECAUSE WE HAVE A LOT OF QUESTIONS ON
THIS, THAT THIS PLAN A PLAN THAT IS PLANNED TO PROVIDE PREP TO
ALL PEOPLE, NOT ALL PEOPLE AT A CERTAIN INCOME, NOT PEOPLE AT
ANOTHER INCOME, ALL PEOPLE WHO ARE RISK AND REALLY WHEN DOWN TO
THE PAYOR MIX IN EACH COUNTY, WHERE IT IS, HOW MUCH IT IS,
THERE IS NO MECHANISM THERE, AND WE DID ASSUME NO CHANGE SO, YOU
KNOW IN TERMS OF ANY CHANGES IN MEDICAID, WE SAID NO CHANGE SO
IT’S IMPORTANT TO FOR PEOPLE TO REALIZE THIS WASN’T ALL PEOPLE
WHO HAD AN INCOME LEVEL LESS THAN X, IT’S ALL PEOPLE.
>>YOU KNOW MIKE ALSO, I KNOW YOU KNOW THIS FROM THE
[INDISCERNIBLE] MEETING BUT PREP IS CRITICAL TO THIS PROGRAM.
BECAUSE THERE ARE EXAMPLES IN SEVERAL STUDIES FROM AFRICAN
COUNTRIES THAT WE FUNDED THAT IF YOU JUST DO TREATMENT AS
REVENTION, YOU SAVE A LOT OF LIVES BUT YOU DON’T DECREASE THE
INCIDENTS, YOU HAVE TO DO TREATMENT AS PREVENTION PLUS
PREP. YOU KNOW I I’M WILLING YOU
SOMETHING YOU KNOW BUT I WANT TO SAY IT SO THAT EVERYBODY
UNDERSTANDS THAT PREP IS CRITICAL TO THIS.
>>AND THAT EVERYONE UNDERSTANDS THE 340 B PROGRAM IS A HIGHLY
DISCOUNTED GOVERNMENT PROGRAM THAT’S MADE AVAILABLE TO
COMMUNITY HEALTH CENTERS AND RYAN WHITE AND ELIGIBLE ENTITIES
SOPHISTICATEDY WOO WILL TAKE FULL ADVANTAGE OF THAT IN
IMPLEMENTING THE PROGRAM.>>GREAT.
NEXT, CARL?>>WELL, I WANT TO ECHO EVERYONE
ELSE’S COMMENTS AND THIS IS AN AMAZING TIME AND EFFORT AND
AMAZING LEADERSHIP. ALL FOR WHAT YOU’VE DONE FOR
BEING HERE TODAY AND WHAT WE HAVE AHEAD OF US AND ACTUALLY
SOME OF MY QUESTIONING IS GOING TO BE VERY SIMILAR TO DOCTOR
SAGS, YOU’VE GONE DOWN TO THE COUNTY LEVEL AND THERE’S
[INDISCERNIBLE] AND BUDGET REQUESTS AND I HAVE ON TO SAY
THAT THE BUMET REQUEST FOR THIS YEAR IS SIGNIFICANT BUT I ALSO
KNOW TO ACCOMPLISH THESE GOALS THAT YOU OUTLINES, 75% REDUCTION
IN NEW CASES IN FIVE YEARS IT’S GOING TO TAKE A LOT MORE MONEY
THAN THE FIRST YEAR. SO I’M WONDERING IF YOU WILL
SHARE AT THE COMMUNITY LEVEL, YOU KNOW THE MODELING THAT
YOU’VE DONE, HOW MANY PEOPLE ARE OUT OF CARE AND THINGS LIKE
THAT. HOW MUCH IT WOULD COST AND
ACTUALLY ANOTHER THING THAT I THINK THE AMERICAN PEOPLE AND
THE CONGRESS WOULD BE INTERESTED IN IS IF WE DON’T ACT HOW MUCH
MORE MONEY WILL IT COST THE U.S. GOVERNMENT AND THE HEALTHCARE
SYSTEM? AND THEN SECONDLY, I WOULD LIKE
TO DELVE INTO PREP AS WELL. YOU KNOW DR. SIGOUNAS, WE’VE HAD
MANY CONVERSATIONS AND I THINK THE COMMUNITY IS EXCITED ABOUT
IS HAVING A PAYOR SOURCE FOR PREP, FOR THE UNINSURED WE
HAVEN’T HAD IN THE PAST BUT IN LOOKING AT THE PRESIDENT’S
BUDGET FOR 50 MILLION DOCTORS FOR THE COMMUNITY HEALTH CENTERS
IT DOESN’T SEEM LIKE IT’S NEW MONEY IT SEEMS LIKE IT’S
EXISTING MONEY AND I DON’T–AS I SAID EARLIER, I THINK IT’S GOING
TO RAMP UP THE DOLLAR REQUEST IN THE FUTURE AND I JUST DON’T
THINK IT’S RIGHT TO BURDEN THE COMMUNITY HEALTH TRUSTEESS WITH
ADDITIONAL–YOU KNOW THEY COULD ALREADY DO THIS ACTUALLY BUT
WHY, IF WE’RE GOING TO ASK THEM TO BE THE PAYOR SOURCE FOR PREP
FOR THE UNINSURED THAT WE SHOULD BE ALLOCATING THE ADDITIONAL
FUNDING FOR THAT SO THAT’S JUST AN OPINION AND WOULD BE
INTERESTED IN YOUR RESPONSE AND ANY OTHERS AS WELL.
>>LET ME JUST DO THE FIRST ANSWER THE MODELING THAT’S FROM
THE CDC, IS THAT EVERY NEW HIV DIAGNOSIS ADDS AN EXTRA
ADDITIONAL BURDEN OF $500,000 IN LIFETIME COSTS.
SO YOU DO THE MATH, IF WE ARE ABLE TO SAVE 250,000 DIAGNOSIS
OVER THE NEXT TEN YEARS EVEN WITH THE COST OF THE PROGRAM,
YOU SAVE A HUNDRED BILLION DOLLARS IN FEDERAL EXPENDITURES
SO THE MATH AND THE ECONOMICS GO IN THE RIGHT DIRECTION HOWEVER,
I THINK WE ALL UNDERSTAND IF WE TAKE 100,000, 200,000 PEOPLE WHO
ARE NOT IN CARE AND BRING THEM INTO TEAR IN THE SHORT-TERM
THERE’S A TUBITANTIAL INCREASE IN INPENDITTURES THAT ARE
NECESSARY TO COVER THOSE PEOPLE, WE ALL UNDERSTAND THAT.
WE ARE NOT GOING TO TELL YOU OUR SECOND, THIRD, AND FOURTH YEAR
BUDGETS. THOSE BUDGETS ARE NOT OUT.
WE HAVE TO GO THROUGH THE PROCESS BUT THERE IS A
SUBSTANTIAL INCREASE IN FUNDING THAT WOULD BE NECESSARY AS WE
RAMP THE PROGRAM UP AND BRING MORE PEOPLE INTO CARE.
WE UNDERSTAND THAT. EVERYBODY UNDERSTANDS THAT.
WITH THE RECEPTION WE RECEIVED BOTH FROM THE PRESIDENT AND
CERTAINLY THE SECRETARY AND FROM CONGRESS, WE ARE GOING TO BE
HIGHLY DILIGENT IN THE EXECUTION AND DR. BECKHAM WITH ALL THE
INTERAGENCY HAVE BEEN MEETING AT ALL HOURS OF THE NIGHT PUTTING
AN EXECUTION PLAN THAT NOT ONLY HAS AN ORGANIZATIONAL STRUCTURE
TO MAKE SURE WE DON’T GO BACK TO OUR CORNERS AND DO OUR OWN THING
BUT WE’RE HIGHLY INTEGRATED BUT ALSO THERE ARE LEADING
INDICATORS THAT WE NEED TO MEET TO MAKE SURE THAT WE’RE BEING
HONEST AND ACCOUNTABLE TO OURSELVES AND TO YOU AND IF WE
MEET THOSE, I’M AN OPTIMISTIC PERSON BUT I KNOW WHAT JUST
HAPPENED TO GET THIS PROGRAM ON BOARD THAT IF WE’RE MEETING
THOSE AND WE’RE DOING OUR JOB, I’M HIGHLY CONFIDENT THAT WE
WILL GET THE FUNDING WE NEED IN YEAR TWO, THREE, FOUR, FIVE.
WE HAVEN’T GONE BEYOND THAT BECAUSE IF YOU THINK YOU CAN
PROJECT YEAR BE SIX AND SEVEN IT’S FANTASY BUT WE THINK WE
HAVE A GOOD HOLD ON THE REQUIREMENTS.
AND BOB DO YOU WANT TO ADD TO THAT?
>>THE ONLY OTHER COMMENT WE WOULD MAKE IS THE HEAVY LIFTING
ABOUT GETTING PREP, THE OTHER HEAVY LIFT WAS LOOK BEING WITH
REGULATORY GROUPS TO SEE WHAT THE ADMIRAL JUST SAID, WE ARE
ANTICIPATING THAT OUR 350, FOUR HELPED THOUSAND PEOPLE INTO A
NEW SYSTEM THAT NEAT TREATMENT. MANY OF THOSE WILL NEAT
TREATMENT THROUGH THE RYAN WHITE PROGRAM AND THAT WILL REQUIRE
SIGNIFICANT RESOURCES, THAT SAID IF WE DO THAT, WE ARE ABLE TO
SHOW IN THE LONG RUN, IN THE SEVEN, EIGHT, NINE, TEN YEAR
FRAME, AND BEYOND THIS NATION WILL HAVE AN ENORMOUS AND TAKE
IT OFF OFF THEY SHELF AND END ONE OF THE MOST SIGNIFICANT
HEALTH CRISIS OF OUR TIME. SECOND THING AS YOU’RE HERE AS A
VOICE, I’M SURE WE WILL HAVE PEOPLE THAT WILL WANT TO TAKE
POT SHOTS, IT COMES WITH THE TERRITORY.
WE WILL ANNOUNCE, WE’VE ANNOUNCED A PROGRAM TO BRING THE
OUTBREAK DOWN. BUT WE WILL SHOW THAT THE CAPESS
WILL GO UP BECAUSE WE’RE OPERATIONALLIZING THIS.
WE NEED OUR COLLEAGUES AT PACHA TO HELP WITH COMMUNICATION THAT
THAT’S EXACTLY WHAT WE EXPECTED. THAT’S A LEAD INDICATOR OF
SUCCESS, NONAPOPTOTIC THE FAILURE.
NOW WE’LL OBVIOUSLY BUILD INTO IT AND CDC WILL BUILD INTO IT
WAYS THAT WE CAN LOOK AT TRUE INCIDENCE BUT MOST OF WHAT WE’RE
DIAGNOSING IS NOT TRUE INCIDENCE WE WE WILL NEED THAT FROM THE
BEGINNING, TONY?>>THERE’S A REASON FOR EUGENE
SHOWING FIRST INCIDENT FIRST AS DIAGNOSIS, YOU HAVE TO
UNDERSTAND–WE’RE LETTING YOU KNOW THERE’S A DIFFERENCE THERE.
OKAY? THE MORE YOU LOOK IN, THE MORE
YOU WILL SEE DIAGNOSIS, IT’S THE INCIDENTS THAT COUNTS.
THAT’S WHAT WE’RE TALKING ABOUT, WE DON’T WANT THE DIAGNOSIS TO
GO DOWN, WE WANT THE INCIDENTS TO GO DOWN.
>>LET’S BE CLEAR, IF THERE ARE 60,000 DIAGNOSIS NEXT YEAR, WE
WILL CLAIM VICTORY BECAUSE MORE DIAGNOSED INTO THE SYSTEM.
BE PREPARED FOR THAT.>>GREAT.
THANK YOU ADA?>>AGAIN THEY THINK YOU SO MUCH
FOR THE GREAT PRESENTATION, I HAVE TWO QUESTIONS I’M MORE ON
THE FRONT LINE AND THE COMMUNITY HEALTH CENTER AND HOW CAN WE
BEST BE ABLE TO NOT ONLY GET THE FINANCIAL BACKING BUT WE’RE
STILL GOING TO BE LACKING IN WORKFORCE.
HAVING THE PEOPLE ON THE FRONT LINES TO BE ABLE TO PROVIDE THE
CARE THAT WE NEED FOR OUR PATIENTS AND
OUR COMMUNITIES. THE OTHER CONCERN IS AS WE LOOK
TO USING THE RYAN WHITE FUNDING REMEMBER THAT NOT ALL
INDIVIDUALS ARE ELEDGIBLE FOR RYAN WHITE AND SO WE STILL HAVE
THAT BUCKET OF PATIENTS WHO STILL CANNOT ACCESS CARE AND
THAT’S SOMETHING THAT YOU HAVE TO LOOK AT.
MANY OF THE STATES THAT IS PROFOUNDLY AND
DISPROPORTIONATELY IMPACTED BY THIS EPIDEMIC UNFORTUNATELY DID
NOT TAKE THE MEDICAID EXPANSION. SO WE STILL HAVE A BIG ISSUE
THAT WE NEED TO ADDRESS. THE OTHER ISSUE IS WITH PREP AND
AS WE TALK ABOUT USING 340 B FUNDING FOR THAT ENDEAVOR THAT
STILL DOES NOT COVER A LOT OF INDIVIDUALS WHO BASED ON WHAT
THAT PRICE WILL BE WILL STILL BE ABLE TO ACCESS THAT EVEN WITH
THE DISCOUNTED RATES THEY MAY GET IN THE OFFICE VITVISIT IN
THE COMMUNITY HEALTH CENTERS, THROUGH LABORATORY DISCOUNTS, ET
CETERA SO THOSE ARE A COUPLE THINGS THAT I JUDGE UTV WANT TO
KIND OF THROW OUT THERE AND SEE IF YOU HAVE ANY COMMENTS.
>>I WANT TO GIVE A HIGH LEVEL ANSWER AND THEN TURN IT OVER TO
SEVERAL PEOPLE. NUMBER ONE WE DID NOT ASSUME ANY
ATKEUPGZAL MEDICAID EXPANSION. NUMBER TWO WE TOOK THE ACTUAL
COST FOR THE WRAP AROUND SERVICES AROUND PREP, CLINICAL
TESTING, DIAGNOSTIC AND MOVED IT INTO THE BUDGETS AND AGAIN, YOU
JUST WILL HAVE TO TAKE IT BY SAYING THAT SOME OF THAT IS IN
THE FIRST YEAR BUT THERE IS A RAMP UP PERIOD HERE AND THE
THIRD GENERAL ANSWER IS, WE HAVE AN OVER ALL PLAN AND STRATEGY
BUT THE NEXT PHASE IS TO GET EXTRAORDINARILY GRANULAR AT THE
INDIVIDUAL COUNTY LEVEL. WHAT THE NEEDS ARE, AND TO FOCUS
THE RESOURCES OR BRING ADDITIONAL PROGRAMS OR RESOURCES
WHETHER IT’S MAN POWER, WORKFORCE, WHETHER YOU NEED 50
COMMISSION CORE OFFICERS TO GO IN TOMORROW TO DO TEACHINGS,
WE’RE PREPARED TO DO A FULL COURT PRESS ON THIS, BUT THAT’S
WHY THE COMMUNITY PLAN AT THE NEXT LEVEL, WE GOTTA GET DOWN TO
THAT GRANULARITY. YOU NEED THREE MORE PEOPLE AT A
COMMUNITY HEALTH SORE YOU CAN DO THAT, YOU CAN’T SEE IT FROM THE
LENS WE HAVE NOW BUT WE’RE ABSOLUTELY COMMITTED TO THAT
GRANARRITY BY THE TIME THE BUMET COMES AND BOB AND–
>>WE ASSUME THERE’S GOING TO HAVE TO BE A SUBSTANTIAL
AUGMENTATION OF THE WORKFORCE. WE HAVEN’T DECIDED TO TELL YOU
YES AND YOU NEED TO DO IT THIS WAY, WE WANT EACH COMMUNITY TO
LOOK AT WHAT SOME OF IT MAY BE BETTER COMMUNITY NAVIGATORS,
SOME OF IT MAY BE INCREASED PROVIDERS WHEN WHEN I TALK ABOUT
WORKING AND BUILDING OVERNIGHT BUT BUILDING THE HIV WORKFORCE,
SOME OF US HAVE BEEN AROUND IN THIS FOR A LONG TIME I’M LOOKING
AT MIKE BECAUSE I REMEMBER WHEN I WAS AND TALKED ABOUT THE
SITUATION IN ALABAMA AND I REMEMBER IT WAS RIGHT AFTER YOU
HAD SEVERAL NURSE PRACTITIONERS RETEAR AND YOU WERE DOWN TO A
COUPLE HEALTHCARE PROVIDERS IN YOUR RURAL CLINICS, THERE’S A
LOT OF US THAT HAVE BEEN IN THIS FOR 35 YEARS AND A LOT OF PEOPLE
LEFT AND A LOT OF PEOPLE LEFT BECAUSE THEY COULDN’T SOLVE
THESE PROBLEMS, DAY AFTER DAY THEY SAY PEOPLE WHO COULDN’T
AFFORD ACCESS DESPITE THE PROGRAMS WE HAD.
GOOD PROGRAMS LIKE YOU SAID, PEOPLE FALLING THROUGH THE
CRACKS. I’M OF THE POINT OF VIEW WHEN WE
SAW THE LATE 70S WHEN THE DECISION WAS MADE TO END SMALL
POX, THEY SAID LETTAY GET IN AND DO THIS, WE’RE HOPING THAT THESE
COMMUNITIES ARE GOING TO GENERATE INTEREST AMONG
HEALTHCARE PROVIDERS AND WORKERS AND COMMUNITY GROUPS THAT WANT
TO BE PATIENT-NAVIGATORS THEY WANT TO BE PART OF THE TEAM TO
WIN. BUT I WILL SAY WE’RE COG
NIEHSENT OF THE WORKFORCE AND ONE OF THE TASKS THAT WE HAVE IN
THIS IS TO WORK WITH THE COMMUNITY ON DIFFERENT
STRATEGIES TO ACCOMPLISH THAT ENCLUING AS ADMIRAL SAID PUTTING
THE CDC PEOPLE TO AUGMENT AS THEY BUILD THE WORKFORCE THEY
NEED OR PUBLIC HEALTH SERVICE LEADERSHIP UNDER THE ADMIRAL BUT
I DON’T WANT TO BUT I DON’T WANT TO UNDERHEST MATE THE ADVANTAGE
OF A DEEPLY COMMITTED COMMUNITY THAT REALIZE THIS IS A BIG
POSSIBILITY AND BE ON BOARD AND PART OF THE TEAM TO BRING THIS
TO NEW HIV INFECTION IN THEIR OWN COMMUNITY.
>>I THINK THE CENTERS IN THE RYAN RYAN WHITE PROGRAM, WE HAVE
CENTERS THAT HELP APPROACH IN INITIATIVE, THE FIRST CENTERS
THAT APPRECIATE IN THESE AREAS WILL BE IN THE AREA IN WHICH
WE’RE TARGETING AND THESE CENTERS ACTUALLY ADD DUALY
FUNDED BY BOTH AND THE RYAN WHITE AS WELL AS THE CENTERED
PROGRAMS. SO BY SO BY USING THOSE HEALTH
CENTERS TO START WITH IF THERE ARE OTHER SERVICES WHICH ARE
COVERED BY ONE PROGRAM, WILL BE COVEETED BY THE OTHER PROGRAM
AND WITH THE ADDITIONAL FUNDING WHICH WE’RE PROVIDING WE HOPE
THAT THIS WILL DO VERY WELL AND WILL BE ABLE TO HELP US WITH THE
INITIATIVE.>>GREAT, THANK YOU DR..
NEXT QUESTION, JUSTIN?>>THANK YOU FOR THE INFORMATION
YOU PROVIDED TO US, IT’S A LOT TO DIGEST AND I’M EXCITED TO
DELVE INTO THE DETAILS TO CONTINUE OUR THE CONVERSATION
AROUND THE IMPORTANCE OF PREP, I WANTED TO GO BACK TO THE
PRESENTATION THAT THEY GAVE AND IN ORDER TO GET CLARITY AROUND
THE ABSOLUTE NUMBER OF PRESCRIPTIONS AND THAT
INFORMATION IS AVAILABLE, BROKEN DOWN BY DEMOGRAPHIC GROUP AND
YOU MENTIONED AS WE KNOW, YOU KNOW THERE ARE DISPARITIES AND
SORT OF PREP ACCESS AND UPTAKE AND I WANTED TO KNOW IF WE HAD
NUMBERS ON THAT, SPECIFICALLY LOOKING AT PREP UPTAKE LOOKING
AMONG BLACK MEN FOR EXAMPLE, COULD WE HAVE ACCESS TO THAT THE
DATA AND MY SECOND QUESTION IS JUST AROUND THE JURISDICTIONAL
PLANS AND WHAT TYPES OF STRUCTURES ARE PUT IN PLACE TO
INSURE THAT WHEN COMMUNITIES DEVELOP THESE PLANS AT THE LOCAL
LEVEL THAT THERE IS MEANINGFUL ENGAGEMENT FROM KEY POPULATIONS
IN THE DEVELOPMENT OF THAT PLAN SO THAT WE MAKE SURE THEY ARE
RESENTATIVE OF THE COMMUNITY AND ARE THERE FUNDING MECHANISMS OR
LEVELS THAT ARE PUT IN PLACE TO INSURE THAT HAPPENS.
>>AGAIN WITH CDC BEING AGAIN THE DOMAIN NAPHTH FUNDER OF OUR
PUBLIC SYSTEM IN AMERICA FROM OUR PUBLIC HEALTH POINT OF VIEW,
WE FUND THE STATE’S TERRITORIALS, LOCAL HEALTH
DEPARTMENTS. WE WERE OBVIOUSLY IN THE FIELD
WITH THESE INTERVAL JURISDICTIONS THEY WILL HAVE TO
TRY TO UNDERSTAND WITHIN THEMSELVES EXACTLY HOW THEY WANT
TO LEAD THEIR RESPONSE, OKAY? BUT WE WILL BE THERE IN THOSE
DISCUSSIONS BECAUSE THE INTENT AS EUGENE AND OTHERS HAVE SHOWN
IS WE’RE TRYING TO END AN OUTBREAK THAT’S HRARPLGLY IN MEN
WHO HAVE SEX WITH MEN BOTH AFRICAN AMERICAN AND LATINO, AND
LARGELY BETWEEN 25-35 YEARS OF AGE.
SO OBVIOUSLY THAT GROUP’S GOT TO BE FULLY ENGAGED IN IT.
WE’RE TRYING TO END AN OUTBREAK THAT IS NEGATIVELY IMPACTED BY
THE OPIOID AND DRUG USE EPIDEMIC SO THEY HAVE TO BE.
SO WE WILL BE THERE AS THOSE PLANS GET TO GO.
WE DO, YOU KNOW WE DON’T JUST SORT OF HAND THE RESOURCES AND
SAY JUST YOU KNOW TELL US IN A YEAR HOW YOU DID IT, THERE WILL
BE A PROCESS. BUT IT’S NOT GOING TO BE–YOU
KNOW A LOT OF THESE JURISDICTIONS WHERE THE
RESOURCES GO TO THE STATE AND THEY NEVER GET DOWN TO THE
PROJECT. THIS IS A–IT’S NOT GOING TO
INFLUENCE THE ALMOST $800 MILLION FOR EXAMPLE, THE
CDC CURRENTLY HAS FOR OUR HELP TO STATE AND TERRITORIALS AND
OUR OWN, 80% OF THE THAT MONEY GOES OUT IT WILL NOT BE PART OF
THAT MONEY. THAT’S OUT.
THIS IS A NEW INITIATIVE, NEW RESOURCES, BUT I THINK WE WILL
LEARN A LOT ALONG THE WAY, YOU ARE NOT FAR FROM US.
WE WOULD LOVE TO HAVE YOU COME AND, YOU KNOW YOU’RE NOT FAR
FROM US, YOU WILL SEE IT, WE WILL WORK WITH THE GOVERNOR AND
THE STATE HEALTH DEPARTMENT AND THE FOUR JURISDICTIONS, WE HAVE
A MEETING COMING UP AND WE WILL BROWEDDEN THIS BECAUSE WE WILL
GET A LOT OF EXPERIENCE JUMP STARTING THIS BY SEEING HOW WE
GET THE FORCED JURISDICTIONS IN THE ATLANTA AREA AND I’M SURE WE
WILL LEARN A LOT AS WE ALL GET ENGAGED IN THAT AND BUT THIS IS
REALLY THE ADMIRAL SAID IT THE CLEAREST, THIS IS BY THE
COMMUNITY, FOR THE COMMUNITY AND IN THE COMMUNITY EMPLOY THE ONLY
TECHNOLOGY TRANSFER THAT’S GOING TO HARM US IS IF THE COMMUNITY
CHOOSES NOT TO ENGAGE. I SKWROUFT GOT BACK FROM THE
EBOLA OUTBREAK IN THE DRC, AND LET ME TELL YOU THE FACT THAT
THE COMMUNITY IS NOT ENGAGED IS HARMING THE OUTBREAK RESPONSE.
SO WE HAVE TO GET THE COMMUNITY ENGAGED.
WE SPENT A LOT OF ENERGY IN ENGAGING COMMUNITY LEADERS
ALREADY AT A NATIONAL LEVEL. BUT WE NEED NEED THE LOCAL
COMMUNITY ENGAGED AND THE OTHER THING WE NEED AND I’VE SAID THIS
BEFORE, PROBABLY ONE OF THE MOST IMPORTANT TEACHERS BEBEYOND THAT
TO REFINE THIS OUTBREAK AS TONY SAID, WE WILL HAVE A TEN YEAR
PROGRAM AND IT’S NOT GOING TO GET EVERYTHING RIGHT, THE MOST
IMPORTANT TEACHERS ARE ACTUALLY THE INDIVIDUALS THAT GET
INFECTED IN THE FIRST TWO YEARS SO THEY CAN TRUST US ENOUGH TO
BE PART OF THE TEAM TO HELP TEACH US WHAT DIDN’T WORK.
WHY DIDN’T IT WORK FOR THEM? AM I LIKELY TO BE THE PERSON
THAT WILL ENGAGE THEIR TRUST TO DO THAT?
PROBABLY NOT, SO THE COMMUNITY IS SO IMPORTANT IN GETTING THEIR
ENGAGEMENT. SO ONE OF THE–I’M VERY
CONFIDENT IN MY INTERACTIONS WITH COMMUNITY LEADERS THAT THE
COMMUNITY WILL ENGAGE BUT I JUST WANT TO UNDERSTAND, THEY REALLY
ARE ONE OF THE MOST IMPORTANT CRITERIA FOR WHETHER THIS WILL
WORK.>>IT’S THREE–IT’S A BIT PASSED
THREE 15:00 WHEN WE SAID WE WOULD TAKE A BREAK DO OUR
FEDERAL LEADERS HAVE FIVE OR TEN MINUTES THAT WE COULD TAKE A FEW
MORE QUESTIONS?>>SURE.
>>GREAT.>>ALL RIGHT.
THANK YOU NEXT QUESTION, JOHN SAPERO?
>>SO I’M WONDERING TWO THINGS VERY BRIEFLY, ONE IT’S GREAT TO
SIT HERE AND HEAR YOU SPEAK WITH SUCH PASSION AND COMMITTED TO
AND TO BE AGGRESSIVE ABOUT THAT PASSION BECAUSE I THINK THAT WE
HAVE FELT THAT IN THE COMMUNITY FOR A LONG TIME AND I LOVE
SEEING THAT DEMONSTRATED BACK TO US.
MY CONCERN IS JUST SOMETHING THAT YOU WERE DISCUSSING AND
THAT IS COMMUNITY VERY OFTEN IS HIGHLY MOTIVATED, HIGHLY
AGGRESSIVE AROUND DOING GREAT WORK AND ENDING OUR EPIDEMIC BUT
AT TIMES IN RURAL AREAS PERHAPS OUR PEERS TALK ABOUT IT IN THE
SOUTH WHERE WE HAVE CITY, ENTITIES THAT ARE RESISTANT TO
TALKING ABOUT HIV, PROMOTING HIV IN MEDIA, SOCIAL MARKETING, WHAT
HAVE YOU, SUPPORTING PREP AND WHAT HAVE YOU AND THAT CAN OCCUR
AT THE CITY LEVEL, COUNTY LEVEL, STATE LEVEL, WHAT HAVE YOU AND
HOW CAN YOUR–AGGRESSION, BEING AGGRESSIVE ABOUT IT TRANSLATE
INTO ACTUALLY HAVING THE COMMITMENT TO DO THE WORK AND
THE WORK IS THE WAY YOU FEEL IT NEEDS TO BE DONE.
HOW PRESCRIPTIVE CAN YOU BE IN THAT AS WE MOVE FORWARD.
>>SO THIS WILL BE IMPORTANT, PEOPLE HEARD ME SAY THIS IN MIKE
STONE AND I THINK HE KNEW I FELT THIS WAY MY WHOLE LIFE AND IN MY
OWN LIFE, I KEEP TELLING HIM, STIGMA IS THE ENEMY IN PUBLIC
HEALTH IT’S STILL IN TRANSGENDER PERSONS COMMUNITY, IT’S STILL IN
AFRICAN AMERICANS WHO HAVE SEX WITH MEN IN THE SOUTH AND LATINO
AND MEN WHO HAVE SEX WITH MEN. IT’S NOTHING COMCOMPARED TO THE
STIGMA WITH THE OPIOID EPIDEMIC AND ONE OF MY SIX CHILDREN
ALMOST DIED FROM COCAINE COUPLED WITH FENTYNL, BUT I HAD NO
CONCEPT OF ALL THE SUBTLE STIGMATIZATION THAT OCCURS.
SO I THINK ONE THING THAT ALL OF US WILL COMMIT OURSELVES TO IS
BEING LEADERS, BEING IN THE COMMUNITY.
TELL BE A LIFT. WE HAVE TO EDUCATE THE FAITH
COMMUNITY. YOU KNOW THE ADMIRAL’S TILES
THEY HAVE A CRITICAL ROLE TO PLAY.
SO GO DOES THE MEDIA. SO I THINK MORE AND MORE TO
REENFORCE THAT THAT LEADERSHIP, THE ADMIRAL WILL TALK ABOUT IT
PARTICULARLY IN THE INDIAN POPULATION AND YOU KNOW, THAT
BASICALLY, STIGMA IS A BIG DEAL AND IN THESE RURAL AREAS WE KNOW
IT THAT’S WHY WE INCLUDED SEVEN RURAL STATES BECAUSE WE KNOW
THAT’S A HEAVY LIFT BECAUSE YOU ARE GOING INTO A COMMUNITY THAT
MAY HAVE TWO OR THREE PEOPLE WITH HIV INFECTION AND THEY MAY
NOT EVEN BE COMFORTABLE GETTING THEIR MEDICATION IN THEIR OWN
CITY SO THEY GO TO SOME OTHER CITY, YOU KNOW.
I, WOOED MANY YEARS AGO, I’VE SEEN THIS, YOU KNOW IN
SITUATIONS WHERE PEOPLE WILL GO FROM ONE CITY TO ANOTHER TO GET
THEIR CARE.>>SO IF I COULD JUST, I’M NOT
REALLY SPEAKING SO MUCH FOR STIGMA IN THE COMMUNITY, I WOULD
CALL IT ORGANIZATIONAL STIGMA–[SPEAKING AT ONCE
]–THAT ACTUALLY RECEIVE OUR FUNDING AND THEIR RESISTANCE TO
MAXIMIZE ITS POTENTIAL IN THE COMMUNITY!
>>OKAY.>>I KNOW WHAT YOU’RE TALKING
ABOUT, AND AND TO SAY NO PROBLEM, WE WILL TAKE CARE OF
THAT IS BEING MISLEADING AND GLIB AND THAT’S WAWE DON’T WANT
TO BE. BUT ONE OF THE THINGS MIGHT
ADDRESS AT LEAST IN PART, IT WILL NOT SOLVE THE ISSUE YOU’RE
BRINGING UP IS TO HAVE THE WORK, THE HEALTH WORKFORCE THAT WE’RE
TALKING ABOUT AND AS MUCH OF THE COMMUNITY PEOPLE TO BE PROACTIVE
TO GET OUT INTO THE COMMUNITY AND SEEK OUT AS OPPOSED TO
SAYING OKAY, YOU WILL BE AMENABLE TO ACCEPTING PEOPLE WHO
WILL BE COMING IN FOR PREP OR COMING IN FOR TREATMENT, IT’S
MORE OF A PROACTIVELY GOING OUT AND I KNOW IT’S MUCH MORE
DIFFICULT IN RURAL AREAS BUT THE KINDS OF THINGS THAT WERE DONE
IN SAN FRANCISCO THAT WAS DONE IN NEW YORK AND THAT WE DID IN
WASHINGTON D. C., YOU WOULD BE SURPRISED WHEN YOU GO OUT AND
START PROACTIVELY GOING AFTER AND BRINGING PEOPLE INTO THE
SYSTEM THAT ALL OF A SUDDEN, THE PEOPLE WHO ARE ESSENTIALLY EVEN
NEUTRAL OR RESISTANT TO IT KIND OF PLAY ON AND DO IT.
THAT’S WHAT HAPPENED IN D. C. I MEAN IN D. C. NOTHING WAS
HAPPENING. NOBODY WAS DOING ANYTHING UNTIL
WE ACTUALLY PARTNERED WITH THE DEPARTMENT OF HEALTH.
WE PARTNERED WITH THE C-FAR AND WE WENT OUT INTO THE COMMUNITY
AND THEN ALL OF A SUDDEN THINGS STARTED TO HAPPEN.
NOW I WILL NONAPOPTOTIC THE GUARANTEE THAT IT WILL HAPPEN
ALL ACROSS THE MAP, BUT I THINK IT’S GOING TO HAPPEN IN SOME
PLACES.>>GREAT.
THANK YOU.>>AND I WILL SAY AND THIS IS
PARTIALLY MY ROLE IS WE WANT TO WORK TOGETHER, YOU KNOW FEDERAL,
STATE, COMMUNITY, BUT, THIS IS REALLY GOING TO BE MANAGED AS AN
INITIATIVE AND AS A PROGRAM. WITH REAL METRICS AND REAL
ACCOUNTABILITY BUT IT DOESN’T MEAN PUNITIVE ACCOUNTABILITY BUT
IF WE’RE FOCUS ON THE DOING WHAT WE ARE SUPPOSED TO BE DOING, WE
NEED TO FIGURE OUT WHAT OUR PART IS, AND OUR ROLE AT THE ASH IS
TO BE AN ORGANIZER AND MAKE SURE THAT EVERYONE’S WORKING WELL
TOGETHER AND WE’RE,A CHIEFING WHAT WE NEED TO,A CHIEF AND
THAT’S OUR COMMITMENT IN THIS WORKING GROUP TO BE GRANULAR AND
UNDERSTAND THAT THIS MONEY, PRECIOUS MONEY IN BUDGET TIMES
WHERE THINGS ARE BEING CULT ALL OVER THE PLACE, REALLY PRECIOUS
MONEY GETS SPENT IN THE MOST EFFECTIVE WAY WE CAN DO IT.
THIS HAS BEEN THERE FOR 30 YEARS NOW SUPPORTING THE
PATIENTS AND THEY HAVE BEEN DEVELOPED DIFFERENT MODELS
REGARDING REACHING OUT TO THE COMMUNITY AND I WILL ASK MY
COLLEAGUE THERE WHO’S LEADING THE RYAN WHITE PROGRAM TO
COMMENT ABOUT HOW HRSA AND RYAN WHITE IS DOING.
>>I THINK GETTING BACK TO ISSUES AROUND PLANNING THAT FOR
THE CITY AND COUNTIES THAT WE’RE TARGETING IF I GET THIS IN THE
ONE TEXT, THAT HIV ARE REQUIRED TO BE ON BY LAW AND IT STAYS
WHAT TYPE OF PEOPLE YOU NEED TO GET ON THERE SO WE HAVE GOOD
DIVERSITY THERE FOR THE PLANNING AND THAT’S ONE TECHNOLOGY
TRANSFER WE DO TO REDUCE STIGMA AND AS WELL AS PEOPLE LIVING
THROUGHOUT THE CLINICAL PROGRAMS AND QUALITY IMPROVEMENT AND ALL
THAT. SO DEFINITELY SOMETHING WE WILL
CONTINUE TO WORK ON, OBVIOUSLY STIGMA IS STILL HUGE, I SEE IT
IN MY OWN PRACTICE IN BALTIMORE WHERE PEOPLE EAT OFF OF PAPER
PLATES IN A COMMUNITY THAT HAD THIS FOR MANY, MANY YEAR AND WE
NEED THAT BROAD ENGAGEMENT AND WE HAVE STARTED WORKING CLOSELY
WITH CDC TO FIGURE OUT HOW THAT WILL WORK TOGETHER AND SOME OF
THAT COMMUNITY BASED EDUCATION CAMPAIGNS OR SOMETHING ARE
BETTER EXPERTISE THAN WE DO AND CERTAINLY IN DIFFERENT
DIFFERENTS IN NEW YORK IS A GREAT EXAMPLE WHERE THEY’VE
REACHED IN AND TRY TO ADDRESS STIGMA AND MESSAGING AROUND
THESE ISSUES. THEY’VE HAD GREAT SUCCESS AND WE
WILL LEARN FROM THAT AS WELL.>>I THINK WE CAN–ONE MORE
QUESTION BEFORE BREAK AND THEN WE DO HAVE OUR LIAISONS FROM THE
AGENCIES WHO WILL BE WITH US, I BELIEVE FOR THE FURTHER
DISCUSSION.>>GREAT.
THE LAST QUESTION WILL BE GO TO ROBERT.
>>THANK YOU.>>THIS IS A MAGNIFICENT MODEL,
WHOLE OF SOCIETY, INITIATIVE, THE PLANNING HAS PIONEERED IN
BURKELY IN PUBLISHING HEALTH, I WAS REMEMBERING WHAT A GREAT
SUCCESS AND WHAT A GREAT OPPORTUNITY IT IS AND PIONEERS
HERE, I REMEMBER IN 1981 [INDISCERNIBLE] MR. FAUCI,A
LEWDED TO HOW FAR WE’VE COME, THE PROBLEM IN AMERICA, IT’S NOT
IN ISOLATION, I HAVE LECTURED NOW, ON AIDS, AIDS RELATED
TOPICS IN MORE THAN 30 COUNTRIES AROUND THE WORLD, I WOULD LIKE
TO KNOW WHAT WE’RE DOING NOW TO INTEGRATE THE GLOBAL APPROACH TO
FIGHTING AIDS WHICH IS I THINK ESSENTIAL FOR US TO WIN IT AT
HOME, TOO, THANK YOU.>>SO RIGHT NOW THERE’S NOT AN
INTEGRATION PART OF THIS PARTICULAR PLAN SO QUESTIONS
AROSE WHEN WE FIRST STARTED TALKING ABOUT THIS, WOULD THIS
MEAN LESS OF A COMMITMENT FROM THE STANDPOINT OF EVERYTHING
FROM RESEARCH TO IMPLEMENTATION IN THE INTERNATIONAL PROGRAMS WE
HAVE AND THE ANSWER IS NO, SO IT ISN’T AS IF WE’RE SWITCHING
INTEREST FROM INTERNATIONAL TO HERE, BUT WE DO HAVE TARGETED
TYPES OF APPROACHES THAT ARE SO DIFFERENT FOR DIFFERENT
COUNTRIES, SOUTH AFFRIC AYOU KNOW ISSUES THE EAST CAPE VERSUS
THE WEST CAPE ARE DIFFERENT, DIFFERENCES IN KENYA, DIFFERENTS
IN ROUGH ATOM WANDA, SO I’M NOT SURE WHAT YOU MEAN BY
INTERNATIONAL CLASSIFICATIONIATION, TO THE
EXTENT THAT WE REALIZE THAT ONE SIZE DOES NOT FIT ALL THAT WE’VE
INTEGRATED THE PLAN. SO THIS PARTICULAR PLAN THAT WE
HAVE RIGHT NOW IS FUNDAMENTALLY BASED ON THAT WE HAVE IN THIS
COUNTRY A DIFFERENT KIND OF AN OUTBREAK THAN YOU HAVE IN OTHER
COUNTRIES THAT ARE–THE ONES THAT ARE DRIVING THE PANDEMIC
FROM A GLOBAL STANDPOINT. THIS IS A VERY RESTRICTED
EPIDEMIC IN THE UNITED STATES. IT’S NOT A GENERALIZED EPIDEMIC.
SO DOING IT THE WAY WE’RE DOING IT RIGHT NOW, EVEN THOUGH
CLEARLY IN SOME OF THE DEVELOPING COUNTRIES, THEY ARE
TARGETING HIGH RISK POPULATIONS, I MEAN WHEN YOU TALK ABOUT WHERE
YOU ARE IN KENYA AROUND THE LAKE AREA, WHERE YOU ARE IN ROWANDA
WHERE YOU ARE THERE, BUT TO SAY WE HAVE AN INTEGRATED PLAN, WAIT
FRANKLY IT’S NOT INTEGRATED. IT IS ONE THAT IS FUNDAMENTALLY
LOOKING AT A GEOGRAPHIC AND DEMOGRAPHIC HOT SPOT IN THE
UNITED STATES AND THAT’S WHAT THIS PLAN IS.
>>MY COMMENT WAS STIMULATED IN PART BY DR. REDFIELD’S RETURN, I
GUESS FROM THE DRC, THE FORMER BELGIAN CONGO AND HOW MANY–I
MEAN WE DO GET A FEW PEOPLE WHO IMMIGRATED FROM COUNTRIES WHERE
THERE ARE PROBLEMS AND IT’S GOOD TO KNOW I GUESS FOR THE PUBLIC
TO KNOW THAT IN FACT OUR EPIDEMIC IS CONFINED TO THIS–TO
MORE LOCALIZED SITUATIONS. BUT I DO THINK WE NEED TO
APPRECIATE THE GREAT EFFORTS BEING DONE BY YOU
INTERNATIONALLY AS WELL. IT’S VERY IMPORTANT.
>>I’M NOT ON THE PANEL, BUT I THINK CAN COMMENT ON YOUR POINT.
IN ALABAMA WE’RE TAKING A LOT OF LESSONS WE LEARNED AND HELPING
TO ADDRESS THE EPIDEMIC AND IN THIS SAY ZAPBIA, SOUTH AFFRIC
AOTHER PLACES, THINGS THAT WORK, QUALITATIVE RESEARCH,
INTERVENTIONS ON A LOCAL LEVEL AND TAKING THE BEST PRACTICES
AND APPLYING IT LOCAL EVEN THOUGH THE EPIDEMIC IS
DIFFERENT. THAT’S THE BEAUTY OF THIS, IS
THAT THE CUMULATIVE EXPERIENCE I THINK WILL MAKE THE DIFFERENCE.
>>MIKE, ALSO JUST I THINK THE ADMIRAL ALLUDED TO THIS–BOB, ALLUDED TO THIS, SO WHEN WE WERE PUTTING TOGETHER THE PEP FAR
PROGRAM WHEN I WENT TO AFRICA TO PUT TOGETHER HOW WE COULD DO
THIS, IT WAS NOW SEEMINGLY SO SIMILAR TO WHAT WE SAID HERE, WE
SAID LET’S TAKE OUT THE COUNTRY WHERE IS WE SAID WE COULD GET
50% OF THE INFECTIONS GLOBALLY WE WE WERE LOOKINGA THE
DIFFERENT COUNTRIES AND WE SAID THIS ONE IS OUT, THIS ONE’S OUT
AND WE GOT A GROUP OF COUNTRIES, THE FIRST 14 COUNTRIES WE DECIDE
TO MAKE THE PEP FAR PROGRAM WERE SO SIMILAR FROM A STRATEGIC
STANDPOINT. WE LOOKEDDA THE THIS MAP HERE
AND WE SAID YOU HAVE 48 COUNTIES PLUS THE DISTRICT PLUS SAN JUAN,
RURAL STATES THAT’S MORE THAN 50% OF THE POPULATION OF THE
CASES OF HIV. WE DID THE SAME THING WITH PEP
FAR. WE LOOKEDDA THE MAP AND SAID
GIVEN THE RESOURCES WE HAVE HOW COULD WE GET AT LEAST 50% OF THE
POPULATION AND THAT IS HOW WE GOT THOSE 14 ORIGINAL COUNTRIES
SO WE LEARNED A LESSON BACK AND FORTH.
>>THANK YOU.>>JUST FOR EVERYONE, I THINK
THE ADMIRAL SAID THIS, THE INTENT IS OBVIOUSLY TO ADDRESS
THE HIV EPIDEMIC IN ALL THE COUNTIES.
BUT I WILL TELL YOU AS SOMEBODY WHO’S BEEN A BIG ADVOCATE IS
PUTTING THE TOOLS TOGETHER IS TONY AND THE OTHERS OVER THE
YORES IS YOU HAVE TO SHOW THE POSSIBLE.
WE WANT TO MAKE SURE THAT BY TARPGETING THESE 50 COUNTIES,
THEN AND WORKING TOWARDS THIS GOAL, THAT WE CAN BEBIN TO
ILLUSTRATE VERY CLEARLY THAT WE CAN MEET OUR TARGETS
COLLECTIVELY ALTOGETHER, AND SEE THAT 75% REDUCTION IN FIVE
YEARS, THAT’S A BOLD–TAKEN–THEY’S A BOLD GOAL.
BUT IF WE TRIED TO BE MORE DIFFUSIVE IN THE BEGINNING, I
DON’T THINK WE WOULD BE ABLE TO GALVANIZE THE RESOURCES THAT ARE
REQUIRED FOR YEAR, TWO, THREE, FOUR, FIVE.
WE WERE LUKEY TO HAVE THE EXAMPLES–LUKEY TO HAVE THE
EXAMPLES THAT JOHN DID IN WASHINGTON, EXAMPLES OF TONE
NEUROECTODERMAL WASHINGTON D. C. TO SHOW THESE COMMUNITIES IN
SAN FRANCISCO, THESE COMMUNITIES WERE ACCOMPLISHING THIS SO THAT
YOU HAD, YOU KNOW YOU HAD A NUMBER OF COMMUNITIES THAT HAD
DEMONSTRATED IT’S NOT HYPOTHETICAL, IT’S POSSIBLE.
AND SO, REALLY I JUST WANT PEOPLE TO REALIZE THAT SOME
PEOPLE WONDER, YOU KNOW WHY AREN’T WE DOING IT FOR THE WHOLE
COUNTRY. WELL WE’RE TRYING TO TARGET THE
50% AND SHOW A SIGNIFICANT IMPACT SO THAT WE CAN COMPLETE
THE RESOURCES REQUIRED THROUGHOUT THE NATION.
>>I WANT TO THANK YOU ALL FOR YOUR TIME AND YOUR LEADERSHIP.
DR., WE’VE HEARD YOUR CHARGE TO US TO GIVE INPUT AND
RECOMMENDATIONS ON HOW TO REACH THOSE WHO NEED PREVENTION AND
TREATMENT, HOW TO ENGAGE COMMUNITIES, THIS WHOLE SOCIETY
EFFORT AND ADDITIONAL MEMBERSHIP ON PACHA.
WE WILL BEGIN WORKING ON THAT IN ABOUT 15 MINUTES FROM NOW, WE
WILL HAVE AN OPPORTUNITY TO CONTINUE TO I THINK THE
QUESTIONS AS WELL WITH THE FEDERAL REASONS HERE.
SO WE WILL TAKE A 15 MINUTE BREAK HERE AND RETURN.
THANK YOU.

USC-BUGS 2017: Symphony of Sight

USC-BUGS 2017: Symphony of Sight


The human eye can only see so much. But that hasn’t stopped us from observing
the strange and complex universe that surrounds us. Over time, we’ve looked at the big,
and the small. Now, we must find a way to see the whole. Throughout history, scientists have tried
to solve the puzzles of the universe by focusing on one piece at a time, in hopes of understanding
the comprehensive whole. If we think in terms of music, this method
is similar to recording several instruments separately. But, what if instead we could capture the
harmony of each instrument, as if it were a live performance? This is what scientists are now trying to
do with living organisms and a recent discovery has made the path to this approach a great deal clearer. Which brings us to … the Hyper Spectral Phasor. Scientists at USC’s Fraser Lab are utilizing
this new tool to visualize the complex internal structures of zebrafish. The technology interprets naturally emitted wavelengths and then paints a color map onto a real-time video of the model. This means, that we can push beyond the capabilities of the human eye, and capture the infinitesimally small differences in color. The scientists in the lab have already begun to consider how this tool can benefit surgical practices, disease diagnostics, and food and health services. But this discovery has also opened the door to something deeper. An opportunity to discover a missing piece from our past. For most of history, this palmist existed
as a simple prayer book. That is, until one day, a scholar noticed
traces of a text hidden beneath the surface. It was a glimpse of several treatises by the Greek mathematician Archimedes. For years, scholars tried to piece together
the remnants of the writings, but ancient scribes had damaged most of the original manuscript. It wasn’t until recently that the Hyper Spectral Phasor fully revealed them. Our history, just like our universe is laden
with mysteries. Mysteries that will continue to confound us, but with discoveries like the Hyper Spectral Phasor, we can begin to look at these mysteries
from a new perspective, a more holistic perspective. One that could offer us answers that we didn’t even
know were waiting to be discovered. {music}

Inside China’s Edible Insect Industry (Part 2)

Inside China’s Edible Insect Industry (Part 2)


Hey! This is Mat from Vice’s Brooklin office, We’re picking up where we left off, with Vice’s China story on the culture of insect eating This is
Inside China’s Edible Insect Industry (Part 2) Hey! It’s Josh.
We’re in the Yangzhou’s country side, and I’m about to pick some bugs
to eat for dinner. Originally known for destroying soybean plants, the “doudan” is a pest that transformed into
a seasonal delicacy, like lobster. I went to meet with Lu Jun,
an entrepreneur, and a “doudan” lover, who started the bug farm to meet the local demands. So this is a doudan.
The entire green house is full of them. This one’s probably 30 days old.
Pretty soon you’ll be able to eat it. 55 of these cost about $50. I’m not really freaked out by it.
That looks like a nice, healthy green color. They eat pesticide free soybeans. This look like a 2 or 3 bite doudan to me. You can swallow it hole,
but who wants to do that? You’re suppose to savor it. Xia Zhenqiang is the business partner and
researcher behind doudan enterprise. He studied doudan for 10 years
at his lab at the School of Engineering. I asked Mr. Xia to take me to his moth breeding compound, so I can see his special techniques in action. It’s definetly a little gross. All of these doudan, basically got some
kind of weird fungal infection, or problem. And so result is that, they become like weird
brightly colored orange funguses, or turn totally white and slimy. Jun Lu invited me to a
doudan feast at a local restaurant. It turns out that cooking doudan is
as labor intensive as breeding them. It’s actually a little bit nasty because you’re basically crushing this creature from tale to nose. Bug comes on, guts come out. It looks like the consistency of an egg drop soup,
or something. I think I liked the look of them a little bit better
when they were whole. Now there’s like all this bug pulp,
in the parking lot, outside the restaurant, and some measly white flesh in this basin next to her. Unlike the insects I ate in Yunnan, which were
pretty much deep-fried and served whole, the doudan were presented in a way that was
a little bit different from how they looked in the field. Let’s try it. It doesn’t taste super strongly of anything actually. It’s just very soft, kinda slightly chewy taste. Let’s try some more. So it’s the start of doudan season now, and that’s when doudan are the most expensive. So this plate is around 2.000 yuan,
about 300 US dollars. So it’s not to be wasted. The most disgusting insect I can think of is the cockroach. It was with a mixture of dread and morbid curiosity, that I had to visit Xiao Pin’s cockroach farm,
in the middle of nowhere, in Hunan. It’s actually really nice out here, but than there’s like this gray concrete bunker
filled with cockroaches. There aren’t any cockroaches roaming around here.
Just smells like a bit musky. This is getting a bit nasty. Aw, it just reeks. It’s super warm. And there’s just bugs everywhere. They just crawling everywhere. It’s really warm and hot. So it’s like pure protein albino cockroach,
that just shed all of his skin. So like 250, more than 250 kilos of cockroaches in here. We’re in a room full of almost
$10.000 worth of cockroaches. Hey! It’s Josh, and we’re harvesting cockroaches in Hunan, to make into powder. Usually Xiao would drown the cockroaches in boiling water, but power was out in the village, so we had to use cold water and a wok. After collecting cockroaches, we set off to
Xiao Pin’s family home to cook them. It’s about seeing the world,
and trying foods you never tried before. But this like garbage. It’s really like a hot garbage smell. It smells like New York city sidewalk to me. Dig in !
LOS I just like really don’t want to eat… this. Oh God, I really don’t want to. This is Josh, this is a cockroach, this is the cockroach farmer, and I guess I’ll try one that he raised. It just taste like the smell of cockroaches. Yeah… Xiao Pin’s cockroaches are mainly used
for Chinese medicine. He grinds them up into powder form
to ship to customers from the village. I asked his neighbors if they knew
what kind of powder it was. No one really seemed to enjoy the smell. Even though I still find cockroaches repulsive, I was still interested to see how other bugs
could improve our lives in the big city. Jiangsu’s reputation as a start up paradise
is empowering a tech from, that wants to create insects based
protein for a sustainable future. I went to meet Chaterina Unger,
the co-founder of “Living Hive” , a sustainable self contained solution for
growing meal worms in your own kitchen. Hi! Nice to meet you!
Nice to meet you! So this is the hive !?
Yeah, this is the hive. It starts with the beetles in the top. It’s where they have fun,
they hang out, they lay their eggs. The eggs are than hatched into baby meal worms, and out of these baby meal worms,
the big meal worms develop, so that’s already close to the end size. You feed each tray,
so in each tray is one week of development, which means in the first one there’s
week one of meal worms, week 2 , week 3, and so on. So you feed each tray, you’ve also feed the beetles. Once they are mature enough,
than they go into the harvest area. So you activate the harvest area. It looks like this At this moment of time the meal worms already
matured partially into the pupae. Looks like this. It’s kind of the cocoon. This you put back into the top to restart the life cycle, and the rest of them, all go through to the second stage, and only the good ones will crawl across a ramp, and fall into the harvest area. When you harvest it looks like this. So how long will it take to basically
fill this with meal worms? Like we see here. The life cycle is about seven weeks. Once you have the cycle full going,
you can harvest every week, continuously. For being a hard work company we found that infra-structuring “?” is just ideal for us to do prototyping very fast. Here, you order something,
and than the next day it arrives at your office. So prototyping and testing
ideas quickly is very easy here. I was looking into industrial scale meat production, production of animal protein. This led me to all different kinds of things. I looked into micro algae, into lab grown meat, I looked into all different kind of processes, and insects were just one of it. So it was just interesting to work as a food source, and it made the most sense
from the sustainability stand point. Where do you see insect eating going, say… 30 or 50 years from now? It is a future food in some ways,
but it’s also a food from the past. Here in China, in Africa, in South America, people eat them already. For the next 20, 30 years
I think is just going to become very normal. You know, insect protein powder, next to other protein powder, or next to the flour in a bakery, or area in a supermarket. And people will acknowledge it as such. Chaterina invited me to a meal worm brunch
she was hosting with some friends. It was interesting to taste how virtually indistinguishable the meal worms were from normal ingredients. OK, so this is cush-cush salad with
rosted meal worms, and Feta, and olives. OK, and these are white bean meal worms patties. Great! It’s really really good. It tastes like… Latka “?” I was “?” for a long time, when I lived in China, and we used to eat a lot of that,
like soy based meat, stuff like that. and it’s really… not particularly healthy in the digest col. – So, you’re one of the engineers for the “Living Hive” project?
– Yes. Was it engineering, plus insect interest,
that you had before, or primarily engineering? My background is aerospace engineering, and I’m really interested in… going to Mars, and all of these things. One of the things that really strike me is that, a lot of proteins and nutrients in a very small package. When you’re launching into space, that is something that you have to really consider, right? That’s something that really made me
very interested about that project. A big percentage of our customers are man. I’m not sure exactly why.
Maybe they’re just more interested in new technology. I’m not sure. We said, OK, we have to design for…
for their… for whoever they live with, really, that they are fine with it. Whoever is like:
You’re not raising bugs in my apartment! Yeah. Living in densely packed cities it’s clear that having a smaller footprint can lead to a more sustainable future. Right now, insect eating in China and around the world, has yet to be accepted on a completely wide spread level. It feels like it’s still in a faze to being a food trend, like wheatgrass, quinoa or goji berries. But there is a pretty clear irony that the
people who are eating insects in China, are either from the poorest side of society, or those who have
the financial means to enjoy it as a novelty.

Insect Lore’s Butterfly Feeder

Insect Lore’s Butterfly Feeder


Butterfly Feeder. Fill it like a
hummingbird feeder. With this colorful butterfly feeder,
butterflies on the go can get the same sweet treatment as their hummingbird
friends. Mix together some nectar. Easy recipe
included. Pour it into the feeder’s reservoir, hang
your feeder from a limb, or set it on a flat surface and wait for
wild butterflies to arrive to drink from the colorful flowery wicks. Entomologist approved, this beautiful
feeder will provide hours of enjoyment for the whole
family. Ages 4 and up.