Theodoros F. Katsivas, M.D., M.A.S., of UC San Diego Owen Clinic, presents "San Diego Primary Care Providers' Attitudes to HIV and HIV Testing" at AIDS Clinical Rounds
Kathleen Brady of the PDPH presented the annual report on the HIV epidemic in Philadelphia at the February 2017 meeting of the Philadelphia Ryan White Part A Planning Council.
Alex Shirreffs, the HIV/HCV Project Coordinator at the Philadelphia Department of Public Health, presented on Hepatitis C and HIV co-infection at the April 2017 meeting of the Positive Committee.
Theodoros F. Katsivas, M.D., M.A.S., of UC San Diego Owen Clinic, presents "San Diego Primary Care Providers' Attitudes to HIV and HIV Testing" at AIDS Clinical Rounds
Kathleen Brady of the PDPH presented the annual report on the HIV epidemic in Philadelphia at the February 2017 meeting of the Philadelphia Ryan White Part A Planning Council.
Alex Shirreffs, the HIV/HCV Project Coordinator at the Philadelphia Department of Public Health, presented on Hepatitis C and HIV co-infection at the April 2017 meeting of the Positive Committee.
Dr. Kathleen Brady of the AIDS Activities Coordinating Office presented this epidemiologic update to the Philadelphia EMA HIV Integrated Planning Council on February 9, 2018.
Michael Tang, MD
Infectious Disease Fellow
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California, San Diego
Global Medical Cures™ | HIV TESTING IN USA
DISCLAIMER-
Global Medical Cures™ does not offer any medical advice, diagnosis, treatment or recommendations. Only your healthcare provider/physician can offer you information and recommendations for you to decide about your healthcare choices.
This workshop is designed to talk about the impact of STDs on youth under the age of 25. This workshop will discuss the importance of sexual health screenings, partner management, and current data around STD morbidity rates. We will also talk about current STD clinical recommendations for the treatment of gonorrhea, chlamydia, and syphilis. Participants will engage in an interactive activity where they will sharpen their skills on effective partner management strategies.
Summary of findings from qualitative study that examined circumstances prompting HIV testing among trans women in Indiana. This presentation was delivered at the Association of Nurses in AIDS Care Conference in Atlanta, GA in November 2016. The paper, HIV testing and entry to care among trans women in Indiana was published in the Journal of the Association of Nurses in AIDS Care: http://dx.doi.org/10.1016/j.jana.2017.05.003
Dr. Kathleen Brady of the AIDS Activities Coordinating Office discussed three cycles of the National HIV Behavioral Surveillance in Philadelphia, including cycles with men who have sex with men (MSM), high-risk heterosexuals, and injection drug users. This presentation took place at the Philadelphia EMA HIV Integrated Planning Council meeting on Thursday, January 11, 2018.
Improvement Story session at the 2013 Saskatchewan Health Care Quality Summit. For more information about the summit, visit www.qualitysummit.ca. Follow @QualitySummit on Twitter.
Better Care
Germain Bukassa Kazadi
Shaun Staunton (Tascahrd) reports on a Qld study of HIV nurses and recommends that HIV nurses could play a greater role in HIV health promotion and prevention. This presentation was given at the AFAO/NAPWA Gay Men's HIV Health Promotion Conference in May 2012.
SBIRT and SAMHSA's 8 Strategic Initiativessideponytail
Slides from a webinar held by the National SBIRT ATTC. Video is on TheIRETAChannel on Youtube: http://www.youtube.com/watch?v=f6NrKuGlGRs&feature=share&list=PLiML4AFpuB72LBaPShcu2yQv_WpsGY9a9
Hi52Hlth: Using Mobile Technology to Access Healthcare for TeensYTH
Hi52Hlth is a mobile application (app) created to engage adolescents and young adults in the search for resources in the Houston area. The app allows the user to search for locations of clinics and community organizations with directions, articles and videos on HIV/AIDS, ability to ask questions directly to health avatars ("Tiff" and "Ty"), PEP (Post-Exposure Prophylaxis) and PrEP (Pre-Exposure Prophylaxis) information, and a frequently asked questions section.
Join us as we discuss best practices for integrating HIV prevention (e.g. HIV testing, PrEP and linkage to care) into primary care within the context of enhancing clinical workforce development.
Panelists:
• Marwan Haddad, MD, MPH, AAHIVS, Medical Director, Center for Key Populations, Community Health Center, Inc.
• Jeannie McIntosh, APRN, FNP-C, AAHIVS, Family Nurse Practitioner, Center for Key Populations, Community Health Center, Inc.
HIV Nursing and Home & Community Care Conference griehl
This joint presentation by Susann Nasewich and Greg Riehl will describe HIV Nursing as it relates to pre and post test counseling, and what is important to know for home and community care nurses and aides.
Dr. Kathleen Brady of the AIDS Activities Coordinating Office presented this epidemiologic update to the Philadelphia EMA HIV Integrated Planning Council on February 9, 2018.
Michael Tang, MD
Infectious Disease Fellow
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California, San Diego
Global Medical Cures™ | HIV TESTING IN USA
DISCLAIMER-
Global Medical Cures™ does not offer any medical advice, diagnosis, treatment or recommendations. Only your healthcare provider/physician can offer you information and recommendations for you to decide about your healthcare choices.
This workshop is designed to talk about the impact of STDs on youth under the age of 25. This workshop will discuss the importance of sexual health screenings, partner management, and current data around STD morbidity rates. We will also talk about current STD clinical recommendations for the treatment of gonorrhea, chlamydia, and syphilis. Participants will engage in an interactive activity where they will sharpen their skills on effective partner management strategies.
Summary of findings from qualitative study that examined circumstances prompting HIV testing among trans women in Indiana. This presentation was delivered at the Association of Nurses in AIDS Care Conference in Atlanta, GA in November 2016. The paper, HIV testing and entry to care among trans women in Indiana was published in the Journal of the Association of Nurses in AIDS Care: http://dx.doi.org/10.1016/j.jana.2017.05.003
Dr. Kathleen Brady of the AIDS Activities Coordinating Office discussed three cycles of the National HIV Behavioral Surveillance in Philadelphia, including cycles with men who have sex with men (MSM), high-risk heterosexuals, and injection drug users. This presentation took place at the Philadelphia EMA HIV Integrated Planning Council meeting on Thursday, January 11, 2018.
Improvement Story session at the 2013 Saskatchewan Health Care Quality Summit. For more information about the summit, visit www.qualitysummit.ca. Follow @QualitySummit on Twitter.
Better Care
Germain Bukassa Kazadi
Shaun Staunton (Tascahrd) reports on a Qld study of HIV nurses and recommends that HIV nurses could play a greater role in HIV health promotion and prevention. This presentation was given at the AFAO/NAPWA Gay Men's HIV Health Promotion Conference in May 2012.
SBIRT and SAMHSA's 8 Strategic Initiativessideponytail
Slides from a webinar held by the National SBIRT ATTC. Video is on TheIRETAChannel on Youtube: http://www.youtube.com/watch?v=f6NrKuGlGRs&feature=share&list=PLiML4AFpuB72LBaPShcu2yQv_WpsGY9a9
Hi52Hlth: Using Mobile Technology to Access Healthcare for TeensYTH
Hi52Hlth is a mobile application (app) created to engage adolescents and young adults in the search for resources in the Houston area. The app allows the user to search for locations of clinics and community organizations with directions, articles and videos on HIV/AIDS, ability to ask questions directly to health avatars ("Tiff" and "Ty"), PEP (Post-Exposure Prophylaxis) and PrEP (Pre-Exposure Prophylaxis) information, and a frequently asked questions section.
Join us as we discuss best practices for integrating HIV prevention (e.g. HIV testing, PrEP and linkage to care) into primary care within the context of enhancing clinical workforce development.
Panelists:
• Marwan Haddad, MD, MPH, AAHIVS, Medical Director, Center for Key Populations, Community Health Center, Inc.
• Jeannie McIntosh, APRN, FNP-C, AAHIVS, Family Nurse Practitioner, Center for Key Populations, Community Health Center, Inc.
HIV Nursing and Home & Community Care Conference griehl
This joint presentation by Susann Nasewich and Greg Riehl will describe HIV Nursing as it relates to pre and post test counseling, and what is important to know for home and community care nurses and aides.
Representatives from the Philadelphia Department of Public Health (PDPH) presented an update on their strategic plan for sexual health at the February 2015 meeting of the Philadelphia Ryan White Part A Planning Council.
C-YA! Philadelphia EMA's Plan to Connect our Co-infected Community to a Cure ...Office of HIV Planning
Alex Shirreffs of the Philadelphia Department of Public Health provided this overview of the Philadelphia area's plan to end HIV and Hepatitis C coinfections to the HIV Integrated Planning Council on May 10, 2018.
Iowa TelePrEP: Delivering PrEP through Telemedicine and Public Health Partner...YTH
Telemedicine is a collection of means or methods for enhancing health care, public health and health education delivery and support using telecommunications technologies. With more than 95% of adults, and 100% of young adults between the age of 18-29 owning a cell phone in the United States, a technology-based health intervention can be available to hard-to-reach populations or underserved areas.
Panelists will engage a rich dialogue and showcase innovative and effective ways to create prevention programs for HIV and STDs using the potential telehealth can offer, specifically with linking young people to HIV pre-exposure prophylaxis, or PrEP. This plenary brings together leaders in the field of HIV prevention, research and policy along with private organizations and companies that are currently active on the field of biomedical prevention.
Iowa TelePrEP: Delivering PrEP through Telemedicine and Public Health Partner...YTH
Telemedicine is a collection of means or methods for enhancing health care, public health and health education delivery and support using telecommunications technologies. With more than 95% of adults, and 100% of young adults between the age of 18-29 owning a cell phone in the United States, a technology-based health intervention can be available to hard-to-reach populations or underserved areas.
Panelists will engage a rich dialogue and showcase innovative and effective ways to create prevention programs for HIV and STDs using the potential telehealth can offer, specifically with linking young people to HIV pre-exposure prophylaxis, or PrEP. This plenary brings together leaders in the field of HIV prevention, research and policy along with private organizations and companies that are currently active on the field of biomedical prevention.
Do One Thing Youth Engagement in an HIV Media, Testing and Treatment Health C...YTH
Youth engagement in an HIV/ HCV media, testing and treatment campaign in Philadelphia. Health communications include social media, website, Twitter feed, Facebook, yard signs, posters billboards, and other promotional items. What is an HIV test? Normalizing HIV testing
Philadelphia Department of Public Health HIV Prevention ActivitiesOffice of HIV Planning
Coleman Terrell of the Philadelphia Department of Public Health presented on the PDPH's HIV Prevention Activities at the Philadelphia HIV Prevention Planning Group's December 2014 meeting.
Dr. Kathleen Brady's presentation on PrEP (pre-exposure prophylaxis) for HIV, as given to the Philadelphia HIV Prevention Planning Group (HPG) on March 25, 2015.
Behavioral Health Navigator Presentation by Emerson Evans 12-12-13Office of HIV Planning
Emerson Evans (AACO) presented on a SAMHSA-funded behavioral health navigator program on 12-12-13. This program in Philadelphia was discussed with the Philadelphia EMA Ryan White Part A Planning Council.
Dr. Kathleen Brady (AACO)'s annual epidemiological update. This presentation was given to the Philadelphia EMA Ryan White Planning Council on Thursday, February 20, 2014.
Evelyn Torres and Sebastian Branca's update on AACO's Client Services Unit (CSU), Housing Services Program (HSP), and Quality Improvement (QI) programs
Dr. Sarah Wood and Kimberley Desir's presentation to the RWPC's Positive Committee on Children's Hospital of Philadelphia's PrEP program, Project PrEPare, from April 2013.
Consultant Matthew McClain presented these guidelines and suggestions for updates to the Prevention Planning Group (PPG), based on earlier suggestions from the body.
AACO's Annual Client Services Unit, Housing, and Quality Management PresentationOffice of HIV Planning
Evelyn Torres and Sebastian Branca presented on Philadelphia's AIDS Activities Coordinating Office's Client Services Unit, Housing Services Program, and Quality Management program at the February 6, 2013 meeting of the Needs Assessment Committee of the Philadelphia EMA Ryan White Planning Council.
Nicole Johns of the Office of HIV Planning presented this updated version of the very popular "Where We Live Matters" to the Positive Committee on January 14, 2013.
Dr. Kathleen Brady of Philadelphia's AIDS Activities Coordinating Office (AACO) gave this presentation at the January 9, 2013 Comprehensive Planning Committee meeting.
Reaching the goals of the National HIV/AIDS Strategy. This presentation was originally conducted at the Office of HIV Planning's Community Empowerment Workshop held at St. Luke's Church on October 16, 2012.
Planning in a time of uncertainty and change
This presentation was originally conducted at the Office of HIV Planning's Community Empowerment Workshop held at St. Luke's Church on October 16, 2012.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
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ASA GUIDELINE
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
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The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
1. Stacey B. Trooskin, MD PhD
Assistant Professor
Drexel University College of Medicine
Using Community-Engaged Research toUsing Community-Engaged Research to
Address Racial and GeographicAddress Racial and Geographic
Disparities in HIV and HCV InfectionDisparities in HIV and HCV Infection
2. Racial Disparities in HIV InfectionRacial Disparities in HIV Infection
• African Americans represent 14% of the
population and 45% of HIV infections
• African Americans are more likely to present
later in the course of their infection and have
higher rates of AIDS-related mortality
• Traditional behavioral risk factors don’t explain
disparities
– More limited access to HIV testing, lower insurance
rates
– Structural and social factors
– Complex sexual networks
3. Geographic DisparitiesGeographic Disparities
• In many urban areas, a few
neighborhoods account for a
large share of HIV infections
• HIV infections cluster
• Some neighborhoods have
HIV infection rates similar to
sub-Saharan Africa
• Maps tell us where to focus
intensive prevention and
treatment efforts Source: AIDSVu
4. • Philadelphia has infection rates 5 times the national average
• Heterosexual epidemic
• Zipcode 19143 (in Southwest Philadelphia) is the second most
populous zipcode in the city (60,000 people)
– 86% African American, 30% people < poverty line
• Zipcode 19143 has the 2nd
highest number of people living
with HIV/AIDS (1,014 individuals in 2010)
– Approximately 1.8% seropositivity
• Rates of Hepatitis C (HCV) in 19143 unknown, but likely high
• 19143 has few medical and health resources
HIV & HCV in SouthwestHIV & HCV in Southwest
PhiladelphiaPhiladelphia
5. Rates of Persons Living with HIV/AIDS by Zip
Code and Census Tract, 2009
Source: AIDSVu
6. Do One Thing OverviewDo One Thing Overview
• Southwest Philadelphia, PA is a medically underserved area with high
rates of HIV and HCV infection & few HIV and HCV testing & treatment
services
• Do One Thing is a testing, linkage to care and treatment campaign that
stimulates demand for and provides HIV and HCV testing and treatment
across an entire zipcode
• Do One Thing includes:
• A large-scale social marketing and media campaign
• Community outreach and mobilization
• Partnerships with business, community organizations, and faith institutions
• A partnership with a federally qualified health center in Southwest
Philadelphia to routinely offer HIV testing to all patients over age 13
• Rapid HIV and HCV testing in a mobile unit, door-to-door testing in 4 census
tracts
• Community service and volunteerism
• Monitoring and evaluation
9. Social Marketing CampaignSocial Marketing Campaign
• Website: 1nething.com
• Texting service
• Yard signs, door knockers, door to door
outreach
• Palm cards
• Street outreach
• Twitter feed with map of mobile
unit of of mobile unit
locations
12. Routine HIV Testing at theRoutine HIV Testing at the
Health Annex, a FQHCHealth Annex, a FQHC
13. Victories and Challenges withVictories and Challenges with
Routine Testing in Clinical SettingRoutine Testing in Clinical Setting
Clinical Challenges and Lessons learned
• Policy Change: Leadership is most important factor
• Integrated Model: Know your patient flow and model
– NP clinical model with MAs testing model
• EMR Enhancement
• Staff and Provider Training
• Financial incentives
14. Victories and Challenges withVictories and Challenges with
Routine Testing in Clinical SettingRoutine Testing in Clinical Setting
Clinical Challenges and Lessons learned
• Offer rate has plateaued at 70%
– Next step: incentivize acceptance rate
improvements
• High decline rate: most commonly cited reasons
are “recently tested” and “wasn’t expecting an
HIV test”
• Behavioral risk profiles: most new positives have
“no identified risk;” most are young, African
American women
• Lower seropositivity than expected: 0.4%
• 95% linkage and retention in care rate; has been
sustained over time
18. Demographic Percentage
Gender Female 45%
Male 54.4%
Transgender .6%
Race African American 90%
African 3%
Other 7%
Education Less than high school 20%
High School 50%
Some college/AA 21%
4 year college 8%
Household Income <$10,000/yr 43%
$10,000-15,000/yr 15%
$15,000-20,000/yr 12%
>$20,000/yr 30%
Employment Unemployed 37%
Part-time 15%
Disabled 11%
Full-time 31%
Other 6%
Demographi
c
Percentage
Health Insurance
Status
None 37%
Medicaid 36%
Private 18%
Other (Medicare,
Veterans, etc)
9%
Sexual Orientation
(self-report)
Heterosexual 89%
Gay/Lesbian 6%
Bisexual 5%
19. Risk Behavior Percentage
Multiple sexual partners 22%
Believe partner has multiple sexual
partners
24%
Ever injected drugs 6.7%
Ever used crack or cocaine Cocaine 15%
Crack 14%
Tattoos 49%
If tattooed, received tattoo at
tattoo
party
24%
Ever tested for HIV? 85%
Ever tested for HCV? 36%
Reported venue for testing for HCV Doctor’s Office 56%
Reported reason for testing for HCV Participant asked for the test 41%
Doctor Recommended 33%
Other 26%
20. Clinical and Non-ClinicalClinical and Non-Clinical
HIV Testing TrendsHIV Testing Trends
• Clinical Settings
– Tested 2,100 people for HIV in clinical settings
– Health Annex (FQHC) seropositivity: 0.4%
– Greatest challenge: 55% decline rate
• Non Clinical Settings
– Tested 900 people for HIV in non-clinical settings
• 1.3% HIV seropositivity
– Tested 350 people for HCV in non-clinical settings since December
2012
• 4.8% HCV seropositivity
21. Linkage to Care Protocol
OraQuick® rapid HCV
antibody test reactive
OraQuick® rapid HCV
antibody test reactive
Confirmatory test is
positive
Confirmatory test is
negative x 2
D1T staff notifies
patient and provides
counseling
D1T staff notifies
patient : counseling +
insurance status
Insured with a
primary care provider
Referral
Insured with no known
primary care provider
PCP visit followed by
referral
Uninsured with no
primary care provider
Social worker works w/
clients to gain
insurance + then refers
OraQuick® rapid HIV
antibody test reactive
D1T staff immediately
links patient to HIV
care within 24-48 hrs
If
uninsur-
able,
refer to
health
center
Repeat test Blood
draw for confirmatory
Western blot
Repeat test Blood
draw for confirmatory
HCV PCR quant
Repeat test Blood
draw for confirmatory
HCV PCR quant
22. Preliminary linkage to HIV carePreliminary linkage to HIV care
trends: Non-clinical Testingtrends: Non-clinical Testing
12 People Tested Preliminary Positive
10 confirmed
positives
2 discordant
confirmatory results
8 known positives 2 new diagnoses
4 currently in care
1 LTFU
6 being linked to
care
1 awaiting
viral load
results
23. Demographic characteristics of HIV-positiveDemographic characteristics of HIV-positive
patients in non-clinical settingpatients in non-clinical setting
• Average age HIV+ = 44 years old
• African American
• Transmission risk factors: MSM (2),
Heterosexual (5), no identified risks (5)
• 2 co-infected with HCV
24. Preliminary Linkage to Care Trends forPreliminary Linkage to Care Trends for
Non-clinical Testing: HCVNon-clinical Testing: HCV
17 People Tested Preliminary Positive
13 chronically infected 2 cleared virus
10 previously known 3 new diagnoses
1 currently in care 2 in process of
linkage
10 linked to care
outreach services
2 uninsured 10 have insurance
2 with insurance
pending
6 referrals
pending
4
awaiting
referrals
2 awaiting results
25. • Average age is 52
• One third are NOT in baby boomer birth cohort
• Mode of transmission: no identified risk (7),
IDU/cocaine use (7), Heterosexual (1)
• 2 co-infected with HIV
• Tattooing in unregulated environments
Demographic Trends of HCV positiveDemographic Trends of HCV positive
Patients in non-clinical SettingPatients in non-clinical Setting
26. • Continuing Quality Improvement (CQI) is critical
• Many are known HIV and HCV positive and not in care
• Comprehensive campaign is a way to raise awareness,
fight stigma and re-engage patients in care
• Biggest challenge in non-clinical setting: retaining HIV
patients in care
• Biggest HCV challenge: payment and linkage
– insurance and referrals for HCV care
Lessons Learned and ImplicationsLessons Learned and Implications
27. • Biggest challenge in clinical setting: high decline rate
• 74% of patients testing for HIV at clinic were women; men
more frequently decline HIV testing in clinical setting
• More new diagnoses in clinical settings than non-clinical
settings
• Offering HIV and HCV testing together may enhance testing
rates
• Street and door to door outreach is effective, especially for
reaching youth and men
• High HCV seropositivity rate; few clients are in care
• Volunteers reduce staff costs and enhance sustainability
Surprising FindingsSurprising Findings
28. WhatWhat is next?is next?
• Enhancing routine testing at FQHC
– Boost our offer rate and reduce our decline rate
• Develop a complete neighborhood-based diagnosis,
treatment and care cascade
• GIS mapping of hotspots for HIV and HCV
• Trial comparing control and treatment neighborhoods
• Cost-effectiveness study
• Complete program evaluation, including improvements
from baseline
• Mapping transmission using HIV sequences at
neighborhood level
29. • Principal Investigator
Amy Nunn, ScD
Brown University
• Gladys Thomas, Project Director
• Gilead Sciences
• Health Annex partners
• 80 Volunteers
• The Southwest Philadelphia community
AcknowledgementsAcknowledgements
Editor's Notes
N=900
HIV confirmatory Western blot HCV confirmatory PCR quant Assist client, go to appts, follow up Uninsured still a big challenge. Tried to overcome by creating avenue for individuals to receive insurance. Safety net of health center if uninsurable