Transcript for Vital Signs Telebriefing: Gaps in HIV Testing and Treatment Hinder Efforts to Stop New Infections
Tuesday, March 19, 2019
Please Note: This transcript is not edited and may contain errors.
Moderator: Welcome and thank you for standing by. At this time all participants are in listen only mode until the question and answer section of today’s conference. At that time, you may press star 1 on your phone to ask a question. I would like to inform all parties today’s conference is recorded. If you have any objections, you may disconnect at this time. I’d now like to turn the conference over to Kathy Harben. Thank you, you may begin.
Kathy Harben: Thank you, Dustin. And thank you all for joining us today for the release of a new CDC Vital Signs on the opening day of 2019 national HIV prevention conference. We are joined today by the U.S. Surgeon General, DR. Jerome M. Adams. Also joined by the CDC Director DR. Robert Redfield. The Director of CDC’s national center for HIV/aids, viral hepatitis, STDs, and TB prevention, DR. Jonathan Mermin. And also by the director of CDC’s division of HIV/aids, and TB prevention, DR. Eugene McCray. I will now turning it over to Surgeon General Adams for opening remarks.
Surgeon General, DR. Jerome M. Adams: Thanks everyone for joining us. And I want to start by saying HIV has cost America too much for too long. Since 1981, 700,000 Americans have lost their lives to HIV. And the sad reality is, if we accept the status quo, over the next decade another 400,000 Americans will become infected with this virus. But I’m here today to say that HHS leadership from many divisions decided not to accept the status quo. We came together to develop a bold but completely achievable plan to end the HIV epidemic in America. Why now? Well quite simply because we have the right data, the right tools, and we have the right leadership highlighted by a world renown HIV researcher as head of CDC to end the HIV epidemic in America. For example, anti-retro viral therapy, now on a one bill a day regime enables the vast majority of individuals living with HIV to live a normal life. And we now know that achieving an undetectable viral load, means that it’s virtually impossible to transmit the infection to a partner. We also have pre-exposure prophylactics one pill a day that can prevent the acquisition of HIV from an untreated partner up to 97%. With these medical tools, if we could identify everyone infected or at risk, we could theoretically end the epidemic today. But the fact is we don’t live in a theoretical world so this plan will fill the gap between the theoretical and practical. Secretary Azar was immediately supportive of this plan. He then shared the plan with the president and the president with no hesitation said I’m in. And thus in his state of the union adDress, President Trump told the American people, and I quote, “in recent years, we have made remarkable progress in the fight against HIV and aids. Scientific breakthroughs have brought a once distant Dream within reach. My budget will ask democrats and republicans to make the needed commitment to eliminate the HIV epidemic in the United States within ten years. ”
Now as you know the president has requested additional $291 million in new funding for fiscal year 2020 to begin this initiative. And we are all hopeful that congress will support the president’s request in this regard. We’ll also be kick starting the initiative with more than $30 million in fiscal year 19 minority HIV funds money which office of the assistant secretary for health has designated specifically to ensure that we built foundational teams and plans within communities before fiscal year 20 resources become a reality. So here we are. We have a direct, bold, but fully achievable plan to target the hardest hit communities with extra boots on the ground and resources to adDress the HIV epidemic. This will be a phased approach and it will begin immediately. You are going to hear this repeatedly throughout the conversation today and our talking points moving forward, but it is very important that you all hear this. 80% of HIV infections come from about 40% of people with HIV who did not know they have HIV or not in care. That’s why over the next five years, we will target the 48 highest burden counties in the united states, in addition to Washington D.C., San Juan, Puerto Rico, and several additional states, seven states, Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina because they have an especially heavy rural HIV burden. At the end of five years, we expect to have reduced new HIV infections in America by 75%. After year five, we will expand activities to include the next highest burdened jurisdictions. By the end of year ten, we fully expect to achieve a 90% overall increase in new HIV infections. At a high level we are going to execute four case strategies. Number one, we are going to diagnose all people with HIV as early as possible after infection. Number two, we are going to treat the infection rapidly and effectively to achieve sustained viral suppression. Number three, we’ll protect people at risk for HIV using proven intervention methods including pre-exposure prophylactic or PrEP, a medication that can prevent HIV infections. Number four, we will respond rapidly to detect and respond to growing HIV clusters and prevent new HIV infections. We don’t expect to do this alone.
We will end the HIV epidemic only by working together. This approach will leverage partnerships not only along HHS agencies but many other federal agencies. They will all have a role to play. In a decision, we’ll work with state and local health official, faith based partners and others to establish public private collaborations. The fact is this is going to a whole of society initiative. We have an unprecedented opportunity to end the HIV epidemic in America. And that’s why the time to act is now. I’d like to turn it over now to DR. Redfield CDC director.
Robert Redfield: thank you, DR. Adams. I have always believed in seeing the possible. And today’s Vital Signs report illustrates how a goal that once seemed impossible is now within our reach. I believe that with the right investment, in the right places, using the right strategies, when we return in ten years to the national HIV prevention conference, we will be talking about what we did all together to eliminate new HIV infections in the United States. Not what we could do. You heard about where we want to go. But let’s take a step back and look at where we are today. There is approximately 1.1 million people with HIV infection in our country. Today there are about 39,000 new infections each year. Of note, after five years of step wise decline, we’ve plateaued since 2013. This is because effective prevention and treatment options are not adequately reaching all who need them. The majority of new infections occur among gay and bisexual men with black and Latino gay and bisexual men bearing disproportionate number of those infections, especially of those between the ages of 25 and 34. HIV touches every corner of our country, mainly cities, but rural areas as well. With diagnosis rates currently highest in the south. And Indian country we are seeing significant increases in new HIV infection among gay and bisexual men. CDC is proud to be part of the fight to prevent HIV from the very beginning. And we will continue to play a critical role in this important new initiative. Our efforts will include working closely with other HHS agencies, as well as local, state, tribal and territorial governments to help ensure progress. We will listen to people living with HIV infection, the community members and leaders, and to our public health partners in the most effective jurisdictions that we can reach those greatest need. We will establish teams to eliminate HIV infection in high burden areas, and provide important operational support. These teams may vary based on the community’s needs. Key will be the full participation of the communities themselves, along with local health systems and public health leaders. We will also partner with HRSA and state and local health systems and agencies to increase the capacity to diagnose HIV infection in high burden areas. We’ll do this by implementing systems to increase routine HIV testing in clinical settings and reach more people with nonclinical testing options. We will support treatment that begins quickly. Ideally, at the time an infection is diagnosed. This includes scaling up support systems to ensure people will get the HIV care they need and stay in care. What more, we will connect HIV negative persons to needed prevention resources. We will work with HRSA and other partners to increase access to and use of PrEP for all people at risk. This includes increasing PrEP availability in community health centers, providing training of health care professionals, and conducting outreach for those at highest risk. In addition, we will work with local communities to ensure additional comprehensive prevention services, such as syringe service programs where appropriate. Finally, we will accelerate the deployment of effective cluster and detection and response systems to quickly identify and respond to concerning clusters of new HIV infection and stop their spread. DR. Adams previously mentioned four key strategies for the HIV elimination initiative. Diagnose. Treat. Protect. And respond. The data we are highlighting today underscores the tremendous impact on two of those strategies. Diagnose and treat. According to today’s report 80% of infections in 2016 were from people HIV infection who were unaware of their infection but who were aware and not receiving HIV care. This is a missed opportunity. If we increase access to testing and treatment for HIV infection, we can prevent a lion’s share of new infections in this country. Once people with HIV infection are diagnosed and taking anti-viral medication as prescribed, they can keep their viral levels in their body at very low levels undetectable. This is what we call viral suppression. Studies show that people with HIV who are virally suppressed not only live longer, healthier lives, but they also have effectively no risk of transmitting the virus to sexual partners. The bottom line is HIV treatment saves lives and prevents new infections. l believe that science that sits on the shelf has no value. Today’s Vital Signs data highlights my point. We have all the necessary tools to allow people with HIV to live longer, healthier lives, and to stop new infections. But those tools will not help people. Those tools will not help if people’s HIV infections are not diagnosed or if they are unable to benefit from treatment. We must take advantage of these tools and we must apply them now to eliminate new HIV infection. Please join me and embrace the possible. Together we can end the HIV epidemic once and for all and give rise to a HIV free generation. Now I turn it over to DR. Mermin for a closer look at today’s findings.
Jonathan Mermin: Thank you, DR. Redfield. As you heard this Vital Signs highlights the gap that are preventing us from stopping new HIV infections. And emphasizes the impact that HIV prevention resources could have if we expanded and improved HIV testing and treatment. The study itself is based on a mathematical model that Draws upon CDC’s HIV surveillance data about new diagnoses, risk behaviors of persons with HIV, along the continuum of care with infection to treatment, and viral suppression. HIV transmission rates were highest among people whose HIV was undiagnosed because they do not know their HIV status. This is followed by people whose HIV infection has been diagnosed but who weren’t receiving regular HIV care and treatment. On other end of the continuum, 50% of people with HIV are regularly taking HIV treatment and other studies indicate that people who are suppressed effectively have no risk of transmitting HIV as long as they stay virally suppressed. So the key to controlling HIV is helping those with HIV to control the virus. When we look at these new data describing where new infections are occurring, three things become clear. First, need to increase the proportion of people who are aware of their HIV infection. In the analysis, about 40% of new infections came from about 15% of people with HIV whose infections was undiagnosed. Second, it’s critical to help those with diagnosed HIV infection to get into and stay in care. In this analysis more than 40% of new infections came from people whose HIV was diagnosed but who were not receiving regular HIV care. Each and every person with HIV should be supported in getting the profound help and prevention benefits of treatment. For people with HIV knowing that treatment prevents transmission to sexual partners is seen as a major benefit of taking medicine. And one that could reduce feelings of stigma that could negatively effect the lives of people with HIV. Third, guidelines recommend that clinicians provide HIV treatment unless there is a medical contraindication. And it’s important that we help them take their medication as prescribed. About 20 percent of new infections came from people with HIV who were receiving care, but who were not virally suppressed, primarily because they are not prescribed treatment or face challenges to adhering to HIV treatment. Time spent working closely with patients who are having trouble paying for, picking up, or taking their daily medications is time well spent. Today we have the tools to end the HIV epidemic, but a tool is only useful if it’s in someone’s hand. This data emphasize why it’s vital to bring testing and treatment to people with HIV. We can empower them to take control of their lives and change the course of this epidemic. We will need to deliver these interventions and other proven tools like PrEP, condoms, and syringe service programs out to the individuals and communities where they are most needed, if we are to end the HIV epidemic in this country. Now I’d like to hand the phone over to DR. Eugene McCray director of CDC division of HIV for final remarks.
Eugene McCray: thank you, DR. Mermin. It has now been seven years since the landmark clinical trials showed early HIV treatment can Dramatically reduce the risk of transmission. Since that time, CDC has fundamentally reshaped our HIV prevention strategy. We have been pursuing what we call high impact prevention, which means using our available resources to make the greatest possible impact on HIV in the U.S. We save lives and save money by focusing the right interventions on the right people in the right places. We remain focused on making sure that every person with HIV in America receives a diagnosis, is connected to medical care, and receiving sustained HIV treatment, and that those at risk for HIV are provided with appropriate prevention services. I’d like to close with four main things people can do today to help eliminate HIV. First, everyone between the ages of 13 to 64 should get tested for HIV at least once in their lifetime. Those at higher risk should get tested at least annually. Getting tested for HIV is faster and easier than ever before. And when you take the test, you take control. Second, everyone who tests positive for HIV should seek medical care as soon as they find out they have HIV and take advantage of today’s treatment options. We want people to know that HIV treatment works. Successful treatment not only improves your health, it also helps protect your partners from infection. Third, support family and friends who have HIV. You will hear this time and time again, stigma is the enemy of public health. We all have a role to play in stopping HIV stigma. When we support people with HIV, we make it easier for them to live healthier lives. Fourth, there are a number of ways people can be empowered to protect themselves and their partners. People at risk for getting or transmitting HIV should consider all prevention tools, such as PrEP, condoms, and other support services that can make it easier to get in care and stay in care. The landscape for people with HIV has shifted Dramatically in recent years. The time is now to put our powerful tools into action. Thank you. And now I’ll turn it back over to our moderator.
Kathy Harben: thank you, DR. McCray, and thank you, Dustin, we are now ready for the question-and-answer period.
Moderator: thank you. We’ll now begin the question-and-answer session. If you’d like to ask a question, please press star 1 on your phone and record your name clearly. If you need to withDraw your question, please press star 2. Again, after the question please press star 1 for the question to come through. Please stand by. And our first question is from mike. Go ahead your line is open.
Mike Stobbe (Associated Press): Hi. Thank you for taking my question. DR. Redfield mentioned one of the things that would be done during this effort was that he would work with local communities to establish syringe service programs where appropriate. Could you all speak to that a little more? How many more needle exchange syringe service programs do you think are needed? And where are they needed? And i have a second question after that.
Jonathan Mermin: This is Jonathan Mermin. After two decades of decreasing new infections of HIV among people who inject Drugs, we have seen a leveling off over the past few years. And that’s also occurred with several clusters and outbreaks of HIV among people who inject Drugs. The largest that occurred was identified was several years ago in Scott County, Indiana, where over 200 people were rapidly infected with HIV. But we have seen other small outbreak clusters since that time. So bringing preventive services and treatment to people who inject Drugs is critical to the success of ending the HIV epidemic in the country. Right now, there are many states and local communities that have expanded syringe service programs in their areas, but it is clear that because we are still getting infections that they haven’t extended to all the places that need them. And that when they occur, they may not be reaching everyone who lives there who would benefit from accessing syringe service programs. One of the benefits of syringe service programs is not only they prevent transmission of HIV and hepatitis and bacteria that causes heart infections, but they also have been shown to triple the chance that a person will get into substance use treatment and stop using Drugs in the first place.
Mike Stobbe: Okay. But I’m sorry my question was, how many do you think need to it be added? And where?
Redfield: So I think this is DR. Redfield, ultimately with the initiative, each of the communities are going to be developing their own independent strategy where they feel these resources need to be applied. And i think so, obviously, we are trying to make sure we provide evidence based data and recommendations that say syringe programs work. But we’ll be working with each of the communities to see how they believe those services need to be augmented in their own communities. So i think there is no direct answer to your question right now, but each community of the 50 jurisdictions and then the seven states will be part of this initial initiative, you know, they are going to do their own critical analysis and plan as to how many new syringe service programs need to be integrated into their plan.
Mike Stobbe: Okay. Thank you. And my second question was, the number DR. Adams mentioned 290 million was part of the proposal. Some researchers said who achieve the goals you have outlined in ten years, it would be more in the order of 8 billion or even more. Do you mind speaking to that question that arose, how did you come up with 291 million? And do you mind speaking to the discrepancy between that amount? Is that amount going to keep rising each year? Or, no, you definitely say, why do you think 291 million is sufficient and not the multiple billions that have been estimated by others?
Redfield: well, i don’t think they are mutually exclusive. Clearly the 291 was the amount of resources that selectively the key agencies requested for 2020 budget. This is a multiyear initiative. It’s going to go on for, as we said, it’s a ten year initiative. I think all of us are confident that the resources that are required to accomplish this mission are in the long-term plan. What you’ve seen and what has been made available publicly is the resources required for the fy20 budget. And i think we are all confident that, as i said, those were the resources we requested, for 2020.
Kathy Harben: next question, please.
Moderator: our next question is from Shraddha Chakracher from Stat News. Go ahead your line is open.
Shraddha Chakracher: thanks for taking my question. I was wondering if you could give me some context on today’s numbers, 80% knew transmissions from 40%. Is this an increase? Decrease from previous years? Can you speak a little bit about that? Thank you.
Jonathan Mermin: sure. We have done this analysis once before. And what we have seen since then is that there is an increased proportion of people living with HIV that are virally suppressed. Therefore, the infections are coming from the other people, people earlier in the continuum of care. Even though we have increased proportion of people with HIV who know their status as having HIV, there is an increased proportion of infections coming from them because we have been able to move more people down the continuum. And the same thing, you know, affects other parts of that continuum of care. So essentially what we have seen is an increased proportion of people who are getting the treatment that they need, and increased need to expand testing and ensure that the people who have HIV and don’t know they have it are both diagnosed and linked to the service that is will prevent them from being sick and not allow them to transmit to others.
Kathy Harben: next question, please.
Moderator: our next question is from Kimberly Leonard from the Washington examiner. Go ahead your line is open.
Kimberly Leonard: yes, i was wondering if you can talk about many so of the reasons when people are given HIV diagnosis why they aren’t immediately given a prescription at that time. What do we know about that? Thank you.
McCray: so the factors are several. First, the guidelines regarding immediate treatment have really just been sort of established. So usually takes a little time for these guidelines to become adopted and widely implemented. I think the second reason is also, you know, even though the goal is to start people on treatment immediately, sometimes there are both financial and social barriers that make it challenging to get people to get access to the Drugs immediately. So communities are having to work to identify solutions so that they have Drugs that are readily available and people come in get on treatment immediately. So it’s going to take a little bit but we are hoping with this initiative we will work with communities to really develop a number of options that would be available to individuals who want to get on treatment immediately so that anyone who wants to get on treatment immediately and if they want to get on it, they should be able to get on it. But many of the challenges, as i mentioned earlier, are financial and social.
Kimberly Leonard: And who is speaking, please?
McCray: I’m sorry, I’m DR. McCray.
Kimberly Leonard: Thank you, DR. McCray.
Kathy Harben: Next question, please.
Moderator: our next question is from Donald McNeill from New York Times.” Go ahead your line is open.
Donald McNeill: Thank you. I’d like to take up the question of cost again which was touched on. Every HIV specialist I talk to says this is the way to fight the epidemic. This is the right plan. Everybody on test and treat. Everybody on PrEP. What you are talking about a million people who need to be put on treatment and a million people who need to be put on PrEP. And $291 million doesn’t begin to tickle the toes of the actual cost of doing that. You know, ART now up to $50,000 a year. And PrEP is now $20,000 a year. Even if you cut those prices in half, or by two thirds, you are still running into the billions of dollars. How does this, unless you plan to do something to cut the price of Drugs down to the generic level, how do you plan to actually get this plan done? How is it going to happen? Rather than just being noble declarations but no follow-through that makes it possible to do it?
Redfield: yeah, Bob Redfield here. My comment would be we are going to get this plan done.
Donald McNeill: How?
Redfield: Those of us that spent the last six, seven months putting it together, many of which you know, are very cognizant of the issues that you just raised. What you have in the public domain is FY 2020 request of the augment current budgets that all our agencies currently have. And i can just say that is a multi-year ten year initiative. It has been planned by individuals who know all the issues you just raised. And I’m confident that as the funding requirements are in the public domain over the next years ahead, you’ll see that there is a realistic strategy as the assistant secretary for health affairs has said, as i’ve said, this will accomplish this mission. It’s not at present time for us to release all the details that you are asking for, but i can only say that we understand this. We are building this on, you know, obviously significant structure for HIV programs that we have in this country. But that said, there is still going to be significant requirements, as you highlighted, but again.
Donald McNeill: Forgive me, why is it me highlighting them? It should be that you leaders should be confronting the cost question along with medical question.
Redfield: Your supposition is we haven’t highlighted them.
Donald McNeill: But I don’t hear it publicly in these discussions.
Redfield: It’s not in the public domain right now but I’m telling you we got the 291 we asked for this year. We have ten-year plan that we are confident we’ll have the resources to meet the mission.
Kathy Harben: okay. Next question, please.
Moderator: Our next question is from Steven Johnson from modern health care magazine. Go ahead, your line is open.
Steven Johnson: Hi. Thank you very much. I was wondering, within your plan, how do you plan to address the issue of the HIV workforce? I don’t see anything in terms of how any plans towards scaling up the health care workforce to meet the demands that are going to be needed.
Redfield: Well, that’s a critical question. And, again, what — this current initiative which i think we tried to say, it’s not a top down Driven initiative. The current initiative is to highlight these 50 jurisdictions in these seven states. And for those jurisdictions to then be able to articulate exactly where the gaps are. Clearly creating this HIV workforce is going to be fundamental. Both at the community level to get effective engagement of some of the hard to reach communities, whether it’s transgender persons, or different communities or iv Drug users, as well as the human clinical workforce that we’ll need to do this. Rather than be prescriptive and say this is the way the department of human services says every community needs to augment their HIV workforce, what we’ve said is fundamental to this is the creation of a HIV workforce that will be defined and developed by the individual communities. But, again, you are exactly right, that there needs to it be a workforce developed. We feel, though, unlike historical plans, that’s sort of put down through the system public health, fundamental to this workforce it needs to be something that is developed by the community before the community and in the community. The biggest gap for us right now is to get the community engaged. We are not going after the easy individuals to engage in care. People who have not engaged in care as of 2019, 2020 are definitely the harder to reach individuals. And so that community workforce, i can’t underscore how important that is going to be, a large part of it is going to be no traditional public health workforce, it’s going to be community workforce. But we are very cognizant of it. I think you’ll see each community begin to develop it on their terms. Our role is to help support that in terms of finances. We also have the capacity to augment this with public health individuals, if the local community wants augmentation.
Kathy Harben: Next, question, please.
Moderator: Our next question is from Ivan Couronne from AFP. Go ahead, your line is open.
Ivan Couronne: Thank you. Do you have more precise data on who takes PrEP today? How many people? And where? And what is your goal for PrEP extension in the next five years, for instance?
McCray: Yeah, we have some data we clearly know from the data that we have that PrEP uptake is not nearly what we want it to be. We estimate there is approximately 1.1 million people potentially eligible for PrEP in the U.S. majority of those men who have sex with men. And we know just 10% of those people that need PrEP are actually getting it. But there is some encouraging news, and that is a study was recently reported at the conference on viruses that looked at men who have sex with men in 20 cities and looked at PrEP awareness and PrEP uptake. And what we saw in that study was significant increase in PrEP uptake. And major increase in PrEP awareness. But the challenge when we look at the data more closely is that when you look at PrEP uptake primarily among white men who have sex with men. And we still see PrEP uptake lagging in Hispanic, Latino, and MSM and black MSM. So we still have a ways to go. We said lots of people need it. We have encouraging news and information that uptake is increasing. But we have a long, long way to go.
Ivan Couronne: Do you have a specific goal for this?
McCray: We want to get PrEP uptake up to 50% for eligible individuals.
Ivan Couronne: Thank you.
Kathy Harben: Next question.
Moderator: Our next question is from Leonard Bernstein from “Washington Post.” Go ahead your line is open.
Leonard Bernstein: Hi, this is for anyone. What’s the major barrier to getting a diagnosis? Do you put it more on folks who don’t get health care, in general, or are docs not asking the right questions of the right people? That would seem a simple blood test. And if there are so many people not getting it, sort of interested in why that is.
Jonathan Mermin: Well, two aspects to approaching HIV testing. One is making it easy. You know, it should be as simple as getting a cholesterol check but often it’s not. CDC has recommended that all Americans get a HIV test at least once in their lifetime since 2006. And the way to do that is have it routinely conducted in the clinical setting. And yet a lot of people, in fact, about 80% of people newly diagnosed with HIV have said they went to the health care system sometime in the past year or two, but were not actually tested for HIV. So that’s a gap in our system. The other is people who are at higher risk for HIV where we recommend they get tested at least once a year, sometimes more frequently. And for those it’s empowering people to make getting the HIV test easy. Some of it is going to clinics and having their physician know that they should be getting the test at a routine time. And the other is making the tests themselves both better, more accurate, and also more easily available. And cdc just completed a study and presented at the conference that DR. McCray mentioned where we actually mailed people HIV tests over the internet and found very high accurate testing in their home and that they actually not only did they use the tests over the following year, but also shared those tests and reported that a fairly large number of their friends and partners also got tested. And in the end, more people were diagnosed with HIV because we empowered people with the ability to test themselves.
Redfield: so there really are the two things that DR. Mermin said. Unfortunately in the clinical setting there has been a, if you will, diagnostic complacency. And as illustrated by the number of individuals that have actually seen physicians or nurse practitioners or health establishments in the year prior to their diagnosis. As you mention, 70 or 80%. The other that he illustrates which is so important is to be open for innovation for diagnostics be done in what we would call nontraditional clinical settings. If we continue to do everything that we’ve always done, and expect different results, then i think we’ll get what we’ve always gotten. So i do think those are the two is looking at nontraditional, nonclinical settings to facilitate diagnostics. And to really adDress now once again in the medical community that there is an important public health role that they play in helping us establish an early diagnosis for HIV for all individuals that are HIV infected, not just for their own health, but, obviously, to allow them to become virally suppressed so they are no longer giving it to others. It is shocking in 2018, 2019, 2020, we still have, 15% of individuals living with HIV infection in our nation are undiagnosed.
>> thank you.
Kathy Harben: Next question, please.
Moderator: We show no further questions at this time.
Kathy Harben: okay. All right. Thank you everyone for joining us. Many thanks to the surgeon general, DR. Redfield, DR. Mermin, and DR. Mccray. If you have follow up questions or other questions, you can call us at 404-639-3286. Or email us at, media @cdc.gov. Thanks very much. That’s the end of this call.
Moderator: that concludes the conference. Thank you for participating. You may disconnect at this time.
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