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20MHT Classic: Adding PrEP injectables to fight against HIV · 20-Minute Health Talk

0:00
Today is World AIDS Day,
0:02
a day of awareness started in
0:03
1988 by the World Health
0:05
Organization and the United
0:07
Nations to drive action and
0:08
reduce stigma around the deadly
0:10
autoimmune disease.
0:11
The first treatment for HIV came
0:13
in 1987, known as AZT.
0:15
As more treatments hit the
0:17
market in the ensuing decades,
0:18
what had been a death sentence
0:20
became a condition well managed
0:21
with daily medications. Today,
0:23
preexposure profile laxis,
0:25
better known as Prep,
0:26
is the standard of care and is
0:28
recommended for anyone
0:29
at risk for HIV.
0:30
Originally available only
0:32
as a daily pill,
0:33
the FDA approved an injectable
0:34
form of Prep in late 2021,
0:36
adding yet another tool in the
0:38
fight against HIV and AIDS.
0:40
Our colleague David Reich
0:41
hale sat down with Dr.
0:43
David Rosenthal from Northwell
0:44
Health, dr. Daskalakis, MD, director of the Division of HIV/AIDS Prevention
0:47
for the Centers for Disease Control and Prevention (CDC) and Dr.
0:49
Dr. Charles Gonzalez with the New
0:50
York State Department of Health.
0:56
Welcome back to 20 minutes health talk.
0:59
I'm David Reich Hale.
1:00
This is part two of our conversation with Dr.
1:03
David Rosenthal of Northwell Health
1:06
Demetre Daskalakis, MD, from the CDC and
1:09
Dr. Charles Gonzalez from the New
1:10
York State Department of Health.
1:12
In this episode,
1:13
we cover the benefits and
1:15
implementation of the recently
1:17
approved Prep injectables.
1:21
Dr. Rosenthalk. What is prep?
1:23
And how significant are these
1:25
new injectables in the effort to
1:26
end the HIV epidemic? Great.
1:29
So Prep has been around for
1:30
about ten years now.
1:31
It's a biobehavioral intervention,
1:33
which means it's both medication
1:35
as well as being contact and
1:38
working with a healthcare
1:39
provider to decrease your risk
1:41
for transmission of HIV.
1:42
So we used to call Prep one pill
1:44
once a day to prevent HIV,
1:46
but in December,
1:47
we actually had a new injectable
1:48
medication which was released
1:49
that allowed us to be able to
1:50
get an injection every two
1:52
months once you get through
1:53
the startup period.
1:54
And that helps you be able to
1:55
prevent yourself from getting
1:56
HIV to decrease your risk.
1:58
Sort of like some people are
2:00
interested in birth control
2:01
to prevent pregnancy.
2:02
Prep is a preventative modality
2:04
that helps you prevent
2:05
yourself getting HIV.
2:06
You said it's every two months.
2:07
Right.
2:08
So the injectable right now is
2:09
actually the way it's dosed is
2:11
it's once and then it's
2:12
another month.
2:13
So it's two months in a row,
2:14
and then it's every other month
2:15
is what the current guidance is
2:17
for that injectable medication.
2:18
And how long has this been,
2:20
you said in market,
2:21
it's only been since the end
2:22
of last year. Right.
2:23
So it's brand new.
2:24
So it came out basically with
2:26
FDA approval in December,
2:28
and Dr.
2:29
Deskalakis' group actually was
2:30
able to kind of put together
2:31
some guidelines in anticipation
2:32
of that coming out with some new
2:34
guidelines in 2021 that I'm sure
2:36
he can tell us about kind of the
2:37
importance of being able to use
2:38
the injectable prep as part of
2:40
the changing the direction of
2:42
prep and how we see that.
2:43
Dr. Daskalakis.
2:45
Great. Thank you. No, so really,
2:48
we've heard what this adds it is
2:51
really about know there are
2:53
people who are interested in not
2:56
having HIV medicines around
2:58
their home and I think that for
2:59
some people this could mean a
3:01
really important innovation that
3:03
makes them more comfortable
3:04
engaging with HIV prevention.
3:07
And I really agree and the sort
3:09
of spectrum of interventions
3:12
that come along with Prep,
3:13
whether that's testing
3:15
or other counseling,
3:16
harm reduction and other
3:18
services that are critical to
3:20
preventing HIV as well
3:21
as other infections,
3:22
I think that one of the
3:23
challenges for injectable Prep
3:26
is that its implementation
3:29
is complex.
3:30
So I think we're hearing from
3:32
frontline providers that really
3:34
working this new injectable into
3:38
the flow of what they do every
3:40
day can be challenging
3:42
and also complex.
3:44
But I think that not dissimilar
3:46
from other Prep interventions
3:48
in the past.
3:49
There is definitely a lead in
3:50
period. Speaking of that,
3:52
this drug also has an
3:54
interesting complexity which is
3:56
that there's a long tail.
3:58
And what I mean by that is
4:00
when you stop the drug,
4:01
it requires some additional pre
4:04
exposure Prophylaxis strategy
4:06
for about a year after.
4:08
So though it,
4:09
I think is really wonderful from
4:11
the perspective of giving people
4:12
options who are interested in
4:15
not having HIV medicines in
4:16
their home or around or don't
4:18
want the burden of taking a pill
4:20
once a day. Or for that matter,
4:21
for some populations, gay,
4:23
bisexual and other men who have
4:24
sex with men and transgender
4:26
women and others take on demand
4:29
preexposure prophylaxis.
4:30
So that two,
4:30
one one strategy that is not
4:33
technically recommended
4:35
above daily prep,
4:36
but is an option that's provided
4:37
in our new guidance or
4:38
guidelines that came
4:39
out just recently.
4:40
So that tail is actually a big
4:42
deal because people potentially
4:45
will have drug levels in their
4:46
bodies for up to a year after
4:49
they stop the injection.
4:50
So it's really important to have
4:51
a really good conversation with
4:53
patients so they know what
4:55
they're getting themselves into.
4:56
Though again,
4:57
I think that it has a really
4:58
important role for lots of
5:00
people given the addition
5:01
of a choice.
5:02
So I think the implementation
5:04
challenges you talked about
5:05
are really important.
5:05
One of the ones that I know I've
5:07
seen is that there's a huge need
5:09
for young adults or people that
5:10
are younger that don't
5:12
necessarily take any
5:12
other medications.
5:13
And so starting a daily prep
5:15
medication was very challenging
5:16
for them for medication
5:17
adherence purposes.
5:18
So one of the real advantages of
5:20
this medication is that you can
5:21
get your injection in the
5:22
doctor's office on
5:23
a regular basis.
5:24
But the challenge that we're
5:25
meeting with them is that those
5:27
patients want to start prep
5:28
fast. And unfortunately,
5:29
the implementation challenges
5:31
we're having is that currently
5:32
we need to order the medication,
5:34
wait for it to be delivered,
5:35
wait for that to happen,
5:36
do an authorization,
5:37
and that takes time.
5:38
And so that's the biggest
5:39
challenge that we've really had,
5:40
at least in my hands for getting
5:43
prep with Cabotegravir
5:45
injectable into the hands of
5:46
younger patients specifically.
5:48
And can any of you talk a little
5:50
bit about how we got
5:52
to this point?
5:54
There have been two large HIV
5:57
prevention trials in the order
5:59
of hundreds of people who have
6:00
been on the intervention.
6:01
There's one that they're
6:03
continuing as an open label
6:04
extension as well throughout
6:06
the world.
6:07
So it's a fair amount of folks
6:09
that have gone through
6:09
the intervention.
6:10
And the studies are remarkable
6:12
in that when you look at the
6:14
just effectiveness of
6:16
the injectable,
6:17
probably because of the lack
6:19
of issue around adherence,
6:21
it looks like it's better
6:22
than oral prep.
6:23
That doesn't mean that actually
6:24
oral prep is probably worse if
6:26
used close to perfectly.
6:29
But perfection is easier when
6:31
you don't have to take a pill
6:32
a day. So that's, I think,
6:34
where the injectable
6:35
is really exciting.
6:37
I'll also add there's a lot
6:39
coming through the pipeline
6:42
and I will say,
6:43
and I think it's fair to say
6:45
only some of them will look
6:47
demedicalized because many of
6:49
them are going to be long acting
6:52
potentially injectable
6:53
or implants.
6:54
Some of them could be an
6:56
implant once a year,
6:57
which means that there's an
6:58
opportunity to sort of loosen up
7:02
some of the medical
7:04
interventions.
7:05
And one thing I think that's
7:06
also important, right,
7:06
is that there's differences.
7:08
So just because the injectables
7:09
work really well for some people
7:11
does not mean that the oral
7:13
daily medications are
7:14
necessarily inferior
7:15
for some people.
7:16
A lot of people find it very
7:18
easy to take a pill once a day.
7:20
They find it very effective to
7:22
be able to have control over
7:23
that on their own and to be
7:24
able to kind of take that
7:25
intervention on their own.
7:26
And so I think that
7:27
the key option,
7:28
which I think both
7:28
of you mentioned,
7:29
is that different strokes are
7:30
different folks, right?
7:31
So different people are allowed
7:33
to pick the option that's going
7:34
to work best for them.
7:35
And this is just talking about
7:36
possibilities and options about
7:37
ways we can get interventions
7:39
into the hands of more
7:40
people that need it.
7:42
Exactly so.
7:44
And it's not as if oral prep
7:48
is a second hand here.
7:51
There is no evidence that one is
7:54
more potent than the other or it
7:57
just matches to adherence.
7:59
And the more we can tailor
8:01
prevention to one's lifestyle,
8:03
the easier it will be for its
8:06
acceptance and for
8:08
its general use.
8:11
And there's no reason why you
8:13
can't switch back and forth what
8:15
works for periods of time,
8:16
right?
8:17
The other thing is the question
8:18
of adherence,
8:19
how this fits into lifestyles
8:22
perfectly.
8:23
Injectable works fantastic for a
8:26
long haul trucker, for example.
8:28
Anyone who changes time zones,
8:30
an airline steward,
8:32
any of those things.
8:33
These things are marvelous.
8:36
You.
8:42
There are still about 38,000
8:44
new HIV cases each year.
8:47
What other strategies are in
8:48
place to reduce these numbers?
8:50
Now, of course,
8:50
they're nowhere near where they
8:52
were during the peak of
8:53
the HIV AIDS Cris. Dr.
8:56
Doscalakis give us the national
8:58
view on this.
8:59
Yeah,
9:01
I think that we've seen it.
9:02
There's been about an 8%
9:04
decrease between 2025 years
9:07
before, so that's good.
9:09
But to accelerate that decrease,
9:11
it's really not just
9:13
all about prep.
9:14
It's really about the sort of
9:16
full toolkit that we have
9:19
for HIV prevention.
9:20
And so that spans the Gamut from
9:23
testing because that really is
9:26
the key that unlocks the door to
9:28
so many wonderful status neutral
9:30
strategies that are good for
9:32
people regardless of
9:32
their HIV status.
9:33
And so that means prep for
9:35
people who could benefit from it
9:36
and actually just engagement
9:38
in prevention,
9:38
even if they don't go on prep to
9:40
make sure that that conversation
9:41
continues in an assessment and
9:43
reassessment and then
9:44
also you equals you.
9:45
So from the perspective that
9:46
treatment is in fact prevention,
9:49
I think that that's all a part
9:52
of it. So we have work to do,
9:53
not only in prep.
9:55
So about 23% to 24% of people
9:57
with indications for prep are on
9:59
it in the United States based
10:00
on our estimates.
10:01
And our viral suppression rate
10:03
is a little bit under 65%.
10:05
And so there is work to do.
10:07
And I think when you put all
10:09
of these things together,
10:10
what happens is you hit a sweet
10:12
spot and potentially you get to
10:14
drive infections down faster.
10:15
And so places with very high
10:17
viral suppression as well as
10:19
good prep uptake tend
10:20
to do really well.
10:21
And so we could even
10:22
leave the US.
10:23
For a moment and talk
10:24
about London.
10:25
They're fascinating with a high
10:27
viral suppression rates,
10:28
like in the really high prep
10:30
uptake in some of their
10:32
key populations.
10:33
And the effect is really like
10:35
it's potentiating to decrease
10:37
infections more rapidly.
10:38
And so when you look
10:40
at the country,
10:41
that means a lot of work to do
10:43
in the south and some of what
10:44
that has to do with know health
10:47
care access and stigma,
10:48
along with a lot of
10:49
other complexity.
10:51
Not to say that there's not
10:52
work to do in New York,
10:53
but I think that there's some
10:54
really good things and good
10:55
models of how when you get
10:56
to that sweet spot,
10:57
you're able to drive infections
10:59
down even faster. So, Demetri,
11:01
I want to pick up on a couple of
11:02
those themes and I think Charles
11:03
will then can talk about the New
11:04
York experience with that.
11:06
But what you talked about was
11:07
the concept of really status
11:08
neutral HIV prevention.
11:10
And what that means is starting
11:12
the whole concept of
11:13
this with a test.
11:14
So by offering HIV testing,
11:16
by offering STI testing,
11:17
by opening the conversation from
11:19
every healthcare provider at
11:21
every point of access we can,
11:22
by giving people the test,
11:24
then we're able to let people
11:25
know what's going on.
11:26
So I always tell patients that
11:27
knowledge is power and the test
11:28
is giving them that knowledge.
11:30
Then if the test is negative,
11:31
then we're able to take people
11:33
towards a prevention modality.
11:34
How can we prevent you
11:35
from getting HIV?
11:36
How can we prevent you from
11:38
getting another STI?
11:39
Is that frequent testing?
11:40
Is that a prevention modality?
11:42
Is it condoms?
11:42
Is it knowing more about
11:44
your partners,
11:45
whatever choices you're making?
11:46
And if your status is positive,
11:48
then how can we take you from
11:49
being positive to being virally
11:51
suppressed like you were
11:52
talking about?
11:52
So really breaking down
11:53
that cascade,
11:54
starting with this status
11:55
neutral prevention.
11:56
But the key concept that lids to
11:58
the top of that is in order to
11:59
do the status neutral approach,
12:01
we have to have providers that
12:02
are offering that testing to
12:04
everyone that is opening
12:05
the door all the time.
12:07
And I think one of the
12:07
challenges we have with Prep
12:09
is people say, oh,
12:09
Prep so complicated,
12:10
it's so difficult.
12:11
And I want to remind people,
12:13
especially primary
12:13
care providers,
12:14
that Prep is one pill once a
12:16
day. In its simplest form,
12:17
it is as easy as prescribing a
12:20
blood pressure medication or an
12:21
asthma medication or a
12:22
diabetes medication.
12:24
The labs you get to see your
12:25
patients four times a year.
12:26
It's a very straightforward
12:27
modality that not only needs to
12:29
be provided by people that have
12:31
experience in the HIV and
12:33
AIDS in the ID world,
12:34
but really by primary care
12:36
providers to really make
12:37
a big difference.
12:37
Because by having more of those
12:38
people out there to do it,
12:40
then we're going to make
12:40
a big difference.
12:42
And it's hard to get folks to
12:44
discuss these things in terms of
12:46
risk because immediately the
12:49
barriers go up and the feeling
12:53
that folks are being targeted
12:55
because of their race
12:57
or their behavior.
12:58
And one of the things that the
13:01
beautiful things that Dr.
13:02
Duskalakis did when he was in
13:03
New York was to develop the sort
13:05
of status neutral as
13:07
you're mentioning,
13:07
you come in and you get an HIV
13:09
test and then the discussions
13:11
begin.
13:12
It's incredibly helpful way of
13:15
opening up the discussion
13:17
in a non judgmental way,
13:19
if it's standard,
13:20
and that's the only way to
13:22
proceed. Well, Dr. Gonzalez,
13:24
and you just touched on health
13:26
equity because it underlies all
13:27
of the topics we are talking
13:28
about today,
13:29
and its importance was outlined.
13:31
And there was an annual Call to
13:33
Action letter issued by the New
13:35
York State's Department
13:36
of Health,
13:37
and it named DOH's number one
13:39
priority as taking decisive
13:41
action to address persistent
13:44
disparities in new HIV diagnosis
13:46
and HIV viral suppression rates
13:48
for black New Yorkers.
13:49
Can you talk a little
13:50
bit about this?
13:52
Well,
13:55
actually,
13:56
I can talk a lot about this.
13:57
Okay.
13:58
But one of the things is
14:00
whether we talk about institute
14:03
for Healthcare Improvements
14:05
White Paper 216 we have to
14:08
acknowledge that health
14:09
organizations alone do not have
14:11
the power to affect multiple
14:14
determinants of health,
14:15
but they do have a
14:16
responsibility to address those
14:19
health inequities directly
14:21
during clinical interactions and
14:23
in order to improve patients
14:25
health and quality
14:26
of life with us.
14:28
What we've done is try to
14:33
hone down as much as
14:35
possible on data
14:39
as opposed to misperceptions.
14:41
All right,
14:42
we know that communities that
14:44
are marginalized or living in
14:47
marginalized conditions and we
14:48
use the word marginalized
14:50
conditions all you have to do is
14:53
think of COVID are those social,
14:55
political and economic
14:56
conditions contributing
14:58
to health itself?
14:59
And health care inequities the
15:02
term we use is to resist
15:04
that tendency to define
15:06
marginalization as a
15:07
characteristic of individuals or
15:09
groups rather than conditions in
15:12
which they live. For example,
15:14
mental health issues such
15:17
as anxiety, depression,
15:18
substance use along with the
15:20
experience of trauma,
15:21
whether it's interpersonal
15:23
community or partner violence
15:25
are more prevalent in
15:26
populations experience
15:27
socioeconomic disadvantage.
15:30
Another example would be like
15:32
in New York's, Manhattan,
15:34
Upper East Side,
15:34
there's eleven year median
15:36
life expectancy,
15:38
expectancy rather difference
15:39
between those folks
15:41
and those living
15:42
in Brooklyn's brownsville and
15:45
these things are quite
15:46
extraordinary.
15:47
What we have found is that
15:50
working with community
15:52
based organizations,
15:53
folks that know their community
15:56
are the best means by which
15:59
messaging both whether it be
16:01
COVID or prep are
16:04
the best means.
16:06
It's not that healthcare
16:07
providers are not trusted,
16:09
but the community needs to be to
16:11
understand that or expect and
16:15
should demand that we are
16:17
responsible to the community for
16:20
health and their population.
16:22
And we've done this in certain
16:24
communities by targeting
16:27
not the individuals,
16:28
but the community based
16:30
organizations to network as best
16:32
as possible with healthcare
16:35
providers to be trusted
16:38
community
16:40
messengers as well as advocates
16:43
for the community to access.
16:46
Such things as contraception,
16:50
prep post exposure prophylaxis,
16:54
or to deal with chronic diseases
16:56
such as diabetes,
16:57
which are rampant in folks with
17:00
lower socioeconomics.
17:02
And
17:05
it's trying to get both the
17:09
community based organizations
17:10
and the healthcare organizations
17:12
to work effectively together
17:14
and not in isolation.
17:16
And with that really I think
17:18
that one of the things that
17:19
we've noticed is that we're
17:21
seeing increased numbers of
17:24
we're seeing the individuals who
17:26
are acquiring HIV that are newly
17:27
diagnosed with HIV that are
17:29
unfortunately coming
17:30
approximately two thirds from
17:31
communities of color.
17:32
And we're seeing unfortunately
17:34
the uptake of prep to be much,
17:35
much smaller in those exact
17:37
same communities.
17:38
So we still have work to do,
17:39
I think,
17:39
both in the state as
17:40
well as nationally.
17:42
Kind of talking about ways that
17:43
we can help write the prevention
17:45
modalities to make sure that
17:46
we're really targeting them,
17:47
not just to people that
17:48
want to get them,
17:49
but to people that need them.
17:50
To the highest population that
17:52
are currently acquiring HIV.
17:54
And I think part of the reason
17:55
that we're having challenges
17:56
with that is often stigma both
17:59
within the communities and also
18:00
within the providers that help
18:01
care for those communities.
18:03
And so I think that those are
18:04
really big challenges that
18:05
we need to look at.
18:06
And I think one of the
18:07
things Dr. Escalakis,
18:08
when you were in New York City
18:09
that you really kind of are a
18:10
very early adopter of was the U
18:12
equals u message or undetectable
18:14
equals untransmittable signing
18:15
onto the Prevention
18:16
Access campaign.
18:17
And I think that it's very
18:19
exciting that we're able to kind
18:20
of take a look and see where the
18:21
science is and where there is
18:22
and be able to take that science
18:24
and focus on the science
18:25
rather than the stigma,
18:27
which is the message
18:27
for prevention.
18:28
Ashleys campaign and how do we
18:29
take that which we did for those
18:31
that are living with HIV using
18:33
a status neutral approach?
18:34
How do we kind of maneuver that
18:35
into the HIV prevention world?
18:37
Now,
18:38
Dr. Daskalakis,
18:39
from your time in New York City,
18:41
you were integral in designing
18:43
and leading many HIV and STD
18:45
programs. That includes and Dr.
18:47
Rosenthal just mentioned this
18:49
the U equals you campaign.
18:51
Can you share more details?
18:53
U Equals You is an incentive
18:56
to people living with HIV.
18:57
And I know my personal
18:59
experience providing care for
19:00
folks footnote I'm about to
19:01
start doing in Atlanta too,
19:03
after a little pause.
19:04
But is that there's something
19:06
liberating to people that
19:09
they're not someone who could
19:10
transmit HIV and it makes people
19:14
feel like they are attractive,
19:16
that they're desirable and
19:19
that there's less burden.
19:21
What do we need to do to have
19:23
that same conversation
19:24
in prevention?
19:25
How do you generate not only
19:28
interest in prevention
19:29
but demand?
19:30
And it tends to be what's
19:32
good for me about this.
19:34
And so I think that we need
19:35
to do a better job.
19:36
And I think at CDC we're working
19:37
on it and I think have done
19:38
made some strides,
19:39
but more to come of really how
19:42
can we generate demand
19:44
for people?
19:44
And what does it mean to sort of
19:46
make this not just something
19:48
that is about ending
19:49
an epidemic,
19:50
but about making my life better
19:53
in the prevention space as well?
19:54
And I think that though I love
19:56
talking about ending epidemics
19:57
because I think it's feasible,
19:58
even though we don't have
19:59
a cure or a vaccine,
20:02
I think that sort of taking it
20:04
back down to that behavioral
20:05
piece of like,
20:07
what do people really want
20:08
out of prevention?
20:09
And how do you better make it
20:12
something that is desirable
20:14
rather than something that's
20:15
imposed upon them as an
20:16
intervention because they're in
20:18
a community that is somehow
20:19
stigmatized as potentially not
20:21
transmitters of HIV but
20:23
acquirers of HIV.
20:25
So that second side of that coin
20:27
is fascinating and that I think
20:29
needs a lot of conversation.
20:31
Some of it has to do with where
20:32
you're putting the services.
20:33
And so I think that efforts to
20:35
put services near sexual health
20:37
environments is really important
20:38
because then it becomes a
20:39
part of other services.
20:40
You need work to try to
20:42
embed prevention,
20:43
status neutral prevention in
20:45
transgender health environments,
20:47
in women's health environments,
20:48
in drug user health
20:49
environments,
20:50
really sort of go to the point
20:52
that this is another part of
20:54
what you would do for your
20:55
health as something that's
20:56
desirable rather than
20:58
imposed on you.
20:59
I'm not sure if you can see me,
21:00
but I'm giving you
21:01
snaps right now.
21:01
I think that's exactly where we
21:02
need to be. I can feel the snap.
21:04
There you go. That sounds great.
21:07
I think that's exactly
21:08
where we need to be,
21:09
and I think that that's
21:09
so important.
21:10
I take care of a number of
21:12
patients that are from
21:13
communities of color,
21:14
that are trans individuals that
21:16
are living in the city that
21:17
really do need kind of those
21:18
comprehensive health
21:19
care services.
21:20
They need primary care.
21:21
They need HIV prevention.
21:22
They need hormonal care.
21:23
They need to make sure that
21:24
we're providing all of the sort
21:25
of resources they need kind
21:26
of wrapped up together.
21:27
And we are fortunate being in
21:29
New York because we have
21:30
programs that help uninsured
21:31
individuals and people that
21:32
aren't documented,
21:33
like some of the ADAP and prep
21:35
app programs that exist here due
21:37
to the resources that Charles
21:38
and the New York State
21:39
Department of Health
21:39
have put together.
21:40
But I think that we still need
21:43
to make sure that we can create
21:44
more settings where people can
21:45
get that kind of care,
21:46
where they can get that complete
21:47
holistic care to take care of
21:48
them as individuals in a sex
21:50
positive environment where
21:51
they're positive,
21:51
where they're happy,
21:52
where they can make sure that
21:54
they can express themselves in
21:55
ways that are going to be okay.
21:57
Because just because people are
21:58
having what the medical
21:59
community may consider, quote,
22:01
unquote,
22:01
I'm giving air quotes right
22:02
now high risk sex doesn't
22:04
necessarily mean that what that
22:05
is is that we really are having
22:07
risk that needs to be done in
22:08
a way that's different.
22:09
We need to make sure that those
22:10
individuals are getting the best
22:11
kind of health care and the best
22:13
kind of preventative care around
22:14
the world that we can offer.
22:16
Well, Dr. Rosenthal, Dr.
22:17
Doscalakis, and Dr. Gonzalez,
22:20
this was extremely insightful
22:21
and I think our audience would
22:23
be very thankful for it.
22:25
So I appreciate all of you
22:27
joining us on 20 Minutes Health
22:30
Talk. And to you, the listener,
22:32
thanks for tuning in.
22:33
I'm David Rice.
22:34
Have a great day.
22:40
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