Jurisdictional Approach to Curing Hepatitis C within the Ryan White - - PowerPoint PPT Presentation

Jurisdictional Approach to Curing Hepatitis C within the Ryan White HIV/AIDS Program (RWHAP)

Highlights, tips and tools webinar

January 22, 2020

Sara Woody Public Health Analyst Office of Training and Capacity Development (OTCD), Special Projects of National Significance (SPNS) HIV/AIDS Bureau (HAB)

Agenda

• HIV/AIDS Bureau (HAB) Vision and Mission
• Introductions
• Presentations
• Question and Answer

2

HIV/AIDS Bureau Vision and Mission

Vision

Optimal HIV/AIDS care and treatment for all

Mission

Provide leadership and resources to assure access to and retention in high quality, integrated care, and treatment services for vulnerable people living with HIV and their families

3

Introductions

• Today’s Presenters
• Dana Higgins, Dept. of Public Health, City of Philadelphia, PA
• DeLita Rose-Daniels, City of Hartford, Health & Human Services Department
• Nirah Johnson, NYC Health Department
• Courtney Gidengil, RAND Corporation
• Dan Czajka, Debbie Isenberg, Phil Melemed, NASTAD
• HRSA Project Officers
• Marean Duarte, Philadelphia Part A Project Officer
• Durkia Hudson, Hartford Part A Project Officer
• Sera Morgan, NYC Part A Project Officer
• Travis Brookes, NASTAD and North Carolina Part B Project Officer
• Sara Woody, RAND Corp. Project Officer

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Saying C YA to Hep C in Philly

How Close Did We Get to Ending Hep C in PLWH & What Will it Take to Get There?

Dana Higgins, MPH Danica Kuncio, MPH

Jurisdictional Approach to Curing HCV Among HIV/HCV Co-Infected People of Color

• 3-year HRSA/SPNS cooperative agreement; September 2016 – September 2019
• C Who is Co-Infected

Data & Evaluation

• Cross train staff on HCV

Training & Capacity Building

• Connect PLWH to Cure

Re-Engagement in Care

• Continuity & Sustainability

Service Integration

E L I M I N A T I O N

C Ya: Philly’s Plan to End HCV in PLWH

Snapshot of Philadelphia EMA*

HIV

• 19,199 people living with HIV
• Ryan White Part A supports network of services
• 21 adult HIV care & 23 adult case management providers

Hepatitis C (HCV)

• Over 55,000 people living with HCV
• Limited funding for viral hepatitis services
• Hep C Allies of Philadelphia (HepCAP) Coalition

HIV/HCV Co-Infection

• Estimated 3,086 co-infected PLWH at start of C Ya in 2016

* Disease data limited to Philadelphia County due to surveillance limitations in surrounding EMA counties HepCAP Town Hall in North Philadelphia

C YA Activity: Data-Driven Quality Improvement

Challenge: HRSA’s one-time HCV screening measure gives limited snapshot of HCV in PLWH Solution: Set a new 2017 QI measure to drive improvements to RNA test outcomes

Ongoing feedback via quarterly reports Review care sites’ protocols to see where best practices were/were not applied Low performing sites do a root cause analysis for barriers C Ya team provided feedback to help sites improve outcomes Describe HCV testing process Is PHL11 performance below 90%?

C Ya Interventions: Increased HCV Testing and Treatment Capacity

All 21 RW adult care sites in the EMA have at least 1 HCV treater onsite

• Increased HCV treatment capacity in the Philadelphia EMA from 14 sites in 2016 and trained 89

providers

HCV reflex testing (HCV antibody with reflex testing to HCV RNA) availability results in better viral load completion among Ab+ patients

• C Ya activities encouraged all 21 RW care sites to standardize HCV reflex testing
• 2016: 9 sites (43%)  2019: 19 sites (90%)

Identify Coinfected PLWH who are Out of HIV Care

• Leverage existing data-to-care infrastructure to relink PLWH to care Use DIS
• Incorporate HCV care into HIV care plan
• Increase in RNA testing for PLWH with a positive HCV antibody test result
• 1 year after implementation, 19 RW care sites reported PHL11 performance greater than 90%

HCV Care Continuum is Improving

PLWH & HCV Diagnosis

2,813

82% 70% 28%

2,813

93% 77% 52%

3,238

90% 73% 55%

0% 20% 40% 60% 80% 100%

HCV AB Positive Confirmatory RNA Test HCV RNA Positive HCV Resolved 38% of HCV RNA+ PLWH cured 67% of HCV RNA+ PLWH cured 60% of HCV RNA+ PLWH cured Baseline (Dec 31, 2016) Sept 30, 2019 Sept 30, 2019 (Includes new HIV/HCV diagnosis)

Source: Philadelphia Department of Public Health, AIDS Activities Coordinating Office & Viral Hepatitis Program

Confirmatory HCV RNA Testing Is Improving

Data Snapshot: Individuals In HIV Care and Out of HIV Care

90% 81% 73%

95% 88% 80%

0% 20% 40% 60% 80% 100%

Ryan White Non-Ryan White Out of Care

% Receiving HCV RNA Testing

2016 2019

(Non- RWHAP) (RWHAP

Source: Philadelphia Department of Public Health, AIDS Activities Coordinating Office & Viral Hepatitis Program

In HIV Care: For those virally suppressed, having at least 1 viral load or CD4 performed in the previous 365 days. For those not virally suppressed, having at least 2 viral load or CD4’s performed in the previous 365 days.

P<.0001 P<.0001 P<.0001

1,776 742 391 1,474 270 613

HCV Cure Access Is Improving

Data Snapshot: PLWH/HCV RNA+ In HIV Care and Out of HIV Care who Cured their HCV

47% 41% 16%

72% 56% 24%

0% 20% 40% 60% 80% 100%

Ryan White Non-Ryan White Out of Care

% HCV Cured 2016 2019

Source: Philadelphia Department of Public Health, AIDS Activities Coordinating Office & Viral Hepatitis Program

In HIV Care: For those virally suppressed, having at least 1 viral load

• r CD4 performed in

the previous 365

• days. For those not

virally suppressed, having at least 2 viral load or CD4’s performed in the previous 365 days.

P<.0001 P<.0001 P<.0001

587 1,025 93 170 87 148

(RWHAP) (Non-RWHAP)

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Key Successes

• C Ya improved diagnosis and treatment of HCV in PLWH
• 95% of HCV AB+ patients in the RW care system received confirmatory HCV RNA testing
• 75% of HCV RNA+ patients in care in the RW care system were cured of their HCV

HCV surveillance data is critical

• Ability to assess scope of co-infection necessary to monitor progress towards micro-

elimination

Providers are open to integrating HCV into their practices

• RW providers supported each other in building HCV capacity in our jurisdiction

HRSA should continue to invest in HCV elimination – it is a feasible goal!

• 12 of 21 RW HIV care sites are housed in community health centers or FQHC systems
• Integrating HCV in Philadelphia has ripple effect benefitting high-need communities

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Sustainability

Philadelphia’s Sustainability Wish List for HRSA:

• Promote reflex HCV testing as tool to improve HCV diagnosis
• Recommend that all HIV care sites offer incorporate HCV treatment
• Provide resources to encourage ongoing service integration of intersecting

health issues

• Our patients do not live in siloes so services to improve their care outcomes shouldn’t

either!

• Identify strategies to address drug user health and collaborate with other program areas:

HEP, STD, Opioids, etc.

THANK YOU!

Philadelphia Department of Public Health

Viral Hepatitis Team AIDS Activities Coordinating Office C Ya & Data-to-Care Teams

Community Partners

HepCAP & the C Change Team MidAtlantic AETC Philadelphia Performance Site at Health Federation Philly’s HIV Service Providers Philadelphians living with HIV & Hep C

National Partners

HRSA Bureau of HIV/AIDS RAND

Project A t ACCE CCESS SS Ach chievi ving Comprehensive C Coverage E Early, Systematically, a and Sustainably Data t a to Car Care e

The Hartford TGA

• Hartford, Middlesex and Tolland County
• 16 Ryan White Part A Service Sites
• 7 Hep- C Service Sites
• 13 HRSA Defined Service categories
• 3652 HIV positive individuals in the TGA
• 631 Coinfected individuals in the TGA

HIV/ HCV CAREWare Screening Cured Retained Link Dependable Variable Hep C Free Community

Added ed HCV HCV Perfor

• rmance

e Measures es

12 S 12 Service C Charges f for track cking HCV c care a and

• utcom
• mes
• HIV/HCV Patient Education
• HIV/HCV Treatment Initiated
• HIV/HCV Adherence Assessment
• HIV/HCV Adherence Support
• HIV/HCV Adherence Advocacy
• HIV/HCV Case Conference
• HIV/HCV Referral to Supportive Service
• HIV/HCV ID Service Face to Face
• HIV/HCV Treated Complete
• HIV/HCV Post Treatment Follow up 1
• HIV/HCV Post Treatment Follow up 2
• HIV/HCV Self Resolved without Treatment

Provider Navigator Nurse Care Team Cure

Thank you

Hartford CT TGA Project ACCESS DeLita Rose-Daniels rosed003@Hartford.gov

Project SUCCEED

A Health Department Intervention to Eliminate Hepatitis C in People Living with HIV in NYC

NYC Health Department Viral Hepatitis Program | HIV Care & Treatment Program

Hepatitis C (HCV) in People Living with HIV (PLWH), NYC 2015

100% 79% 58% 27% 13% Reported with HCV RNA positive ever Evaluated for treatment Initiated treatment Cured

15% of 81,664 PLWH ever had HCV HIV/HCV coinfection HIV monoinfection HCV Care Continuum for HIV/HCV Co-infected Individuals, NYC 2015

NYC HIV/HCV Clinical Care Environment

• Excellent health insurance access for PLWH
• Few HCV medication coverage restrictions
• Few clinical prescriber restrictions
• Many experts in HIV/HCV care
• Robust HIV and HCV surveillance systems

Project SUCCEED Model

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Provider Education & Training Clinical Practice Facilitation Telephone Outreach & Linkage to Care Analysis of Co-Infected Population through matching of HIV and HCV surveillance data

Project SUCCED Cohort and Preliminary Outcomes

Preliminary Outcomes as of January 202O *To account for out-migration and deaths, the number of individuals considered to be diagnosed and living in NYC has been restricted to people who had at least one HCV or HIV lab test reported since 2014 and weren’t known to have died prior to 2017.

**Result at the time of their last test, as of November 30, 2019.

85,890 HIV-diagnosed

people

as of December 2016*

88,710 HCV-diagnosed

people

as of December 2016*

11,536

ever infected with HIV

and HCV

4,200

HIV/HCV RNA positive as of 2017

2,985

HIV/HCV RNA Status as of 2019

1593 (53%)

RNA negative**

1392 (47%)

RNA positive**

1,215 Excluded Deceased, out of jurisdiction, HCV or HIV uninfected, already treated for HCV, without a HCV RNA lab report after 2014, VA patients

Case Investigation

• Low threshold intervention to:
• Increase awareness of latest

HCV screening treatment guidance for PLWH

• Connect HIV providers to HCV

care coordination resources

• Key messages:

1. Test all PLWH for HCV at intake to care 2. Retest people at risk annually 3. Treat all coinfected patients

Provider Guidance

Provider Education & Training Curriculum

Training Format

HCV Patient Navigation Full day In-person HCV Medication Coverage and Prior Authorization 2-hour Live Webinar or In-Person HCV Basics Presentation for communities at risk 1 hour In Person HCV Clinical Care and Treatment 9 CME/CNE/CEU Live Webinar HCV Treatment in People who Use Drugs 2 CME/CNE/CEU Live Webinar or In-Person Live Preceptorship in a Liver Clinic 4 CME/CNE

Communities of Practice and Learning

• NYC Hep C Task Force – quarterly coalition meetings
• HIV/HCV Treatment Access Committee – quarterly meetings to

convene Project SUCCEED intervention partners

• HCV Elimination in PLWH Symposiums to discuss micro-

elimination goals, objectives, activities and progress Attended by representatives from health care facilities and community organizations serving high-burden populations See meeting invitation, notes and newsletter archive here.

Clinical Practice Facilitation Tools

Formal agreements with highest burden facilities participated in a one-year project:

• Electronic Health Record data review tool to assess screening and treatment rates
• HCV quality improvement project guidance and support

HIV/HCV Dashboard

Facility-specific surveillance based dashboards, emailed to HIV health care facilities, showing:

• Proportion of PLWH

established in HIV care at the facility who ever tested HCV RNA positive who had been treated for HCV

Mock Dashboard

HIV/HCV Patient Lists

Surveillance-based HIV/HCV RNA+ patient lists to support providers to:

• Review and promote

HCV treatment

• Report patient

disposition back to the Health Department

HIV Undetectable, Hep C Cured!

Nirah Johnson, LCSW Viral Hepatitis Program | NYC Health Department njohnso2@health.nyc.gov

This initiative is funded through the U.S. Department of Health and Human Services (HHS) Secretary’s Minority AIDS Initiative Funding (SMAIF) and administered through the Health Resources and Services Administration (HRSA)’s HIV/AIDS Bureau (HAB) through the Special Projects of National Significance (SPNS) Program (Grant number U90HA30517). This information and its conclusions are those of the authors and should not be construed as the official position or policy of HRSA or the U.S. Government. Responsibility for the content of this report rests solely with the named authors.

New York City Health Department Project SUCCEED Team

HIV Care & Treatment

• Amber Casey, Deputy Director
• Katherine Penrose, Senior Research Analyst
• Kizzi Belfon, Surveillance & Evaluation Analyst
• Graham Harriman, Director

HRSA

• Sera Morgan, New York EMA’s HRSA Project Officer

Viral Hepatitis

• Alexis Brenes, Health Care Access Specialists
• Farma Pene, Health Care Access Specialists
• Natalie Octave, HIV/HCV Project Coordinator
• MaNtsetse Kgama, HIV/HCV Project Manager
• Jessie Schwartz, Clinical Coordinator
• Kelly Huang, Surveillance & Evaluation Analyst
• Nirah Johnson, Director of Capacity Building
• Angelica Bocour, Director of Surveillance
• Ann Winters, Medical Director

This initiative is funded through the U.S. Department of Health and Human Services (HHS) Secretary’s Minority AIDS Initiative Funding (SMAIF) and administered through the Health Resources and Services Administration (HRSA)’s HIV/AIDS Bureau (HAB) through the Special Projects of National Significance (SPNS) Program (Grant number U90HA30517). This information and its conclusions are those of the authors and should not be construed as the official position or policy of HRSA or the U.S. Government. Responsibility for the content of this report rests solely with the named authors.

Title

Evaluation and Technical Assistance Center (ETAC) Findings: Provider Knowledge

January 22, 2020 RAND Corporation Courtney Gidengil, MD MPH

Findings are preliminary and have not been peer reviewed; please do not cite.

Multisite Evaluation Data Sources

Implementation Plans/Logs

Focus Groups

(Patients / Providers)

Knowledge Assessments

(Patients /Providers)

Client Data

HIV/HCV Care Continuum

Evaluation Questions

• 1. What activities did the jurisdictions engage in to change system-

level barriers and provider and patient behaviors regarding the HCV care continuum among people coinfected with HIV and HCV?

• 2. How have HIV providers’ HIV/HCV co-infection knowledge

and behaviors changed as a result of the project?

• 3. How have HCV knowledge and behaviors changed among

people with HIV as a result of the project?

• 4. What impact has the project had on HCV care continuum
• utcomes among people coinfected with HIV and HCV?

Clinical and Non-Clinical Provider Focus Groups

• Conducted in seven jurisdictions
• NYC, Philadelphia, Hartford, Baton Rouge and New Orleans, Raleigh /

Durham, Connecticut (excluding Hartford), and Southwest Texas

• Recruited through clinics, email lists, word of mouth, meeting

announcements, and in-person at provider events

• Baseline: 91 clinical providers and 96 non-clinical providers (n=187)
• Follow-up: 54 clinical providers and 36 non-clinical providers at follow-up (n=90)
• Used focus group guide with questions on barriers to screening

and treatment, and training

• Example: “What are some of the challenges you have encountered (or expect

to encounter) when performing HCV screening for people living with HIV?.”

• Preliminary analyses conducted on portion of the data

Providers Perceived Improvements from Trainings and Communities of Practice and Learning

• “We weren’t doing Hep C testing at all until this project
• happened. Once this project was introduced to us and we got

certified, we started doing the testing.” (Nonmedical Provider)

• “We were always doing case conferences, but it’s making them a

more regular part of the treatment experience, both with the client and without. I think having those regular meetings, altogether with the care team throughout the treatment process to identify what new barriers have occurred, how has it going working with the previous barriers, that’s been a piece of [PROGRAM] for us.” (Medical Provider)

Providers Continued to have Concerns about Patient Readiness for HCV Treatment

• “They're still denying people if they have positive drug screens, if

they test positive, not just for opiates, but cocaine, which has nothing to do with anything. They should still be able to get treatment.” (Non-Medical Provider)

• “If a client is not coming virally suppressed because they’re not

taking their HIV med, why would we prescribe them treatment for Hep C if we’re uncertain of that compliance?” (Non-Medical Provider Group)

Provider Knowledge Assessment (Pre-Implementation)

• 701 HIV providers across 7 RWHAP jurisdictions responded to

a cross-sectional survey

• 434 included in analysis of knowledge score by provider type
• 376 included in multivariate model
• 17-item HIV/HCV coinfection knowledge assessment (Year 1)
• Developed using information from the American Association for the

Study of Liver Diseases and the peer-reviewed literature

• Multivariate linear regression predicting knowledge score
• Calculated by dividing # correct responses by # total items
• Preliminary analyses conducted on portion of the data
• Post-implementation results not yet available

Average Provider Knowledge Score (Pre-Implementation)

Domain Overall Percent Correct MD NP/PA MCM Other clinical staff P- value Knowledge score 65%* 80% 73% 52% 47% <0.001 HCV treatment regimen questions 77% 90% 84% 61% 63% <0.001 SUD/mental health questions 51% 69% 57% 39% 27% <0.001 Socio-economic barriers questions 62% 74% 72% 52% 42% <0.001

* Score is % correct

Items answered incorrectly (Correct answers are Disagree or Strongly Disagree) % Incorrect

• r Missing

Depression is as prevalent among HIV/HCV-coinfected patients as in the general population 68% It is recommended that substance users have a period of abstinence from alcohol and illicit drugs for at least 6 months before beginning HCV treatment 61% HCV treatment is too expensive for most patients 53% People who use illicit drugs are unlikely to be adherent to HCV medication regimens. 42%

Gaps in Provider Knowledge (Pre-Implementation)

Predictors of Provider Knowledge (Pre-Implementation)

Multivariate regression of provider attributes associated with knowledge score (N=376) β p-value Provider type MD ref

• NP/PA
• 6.7

0.0042** MCM

• 23.8

<0.001** Other clinical staff

• 25.8

<0.001** Years treating HIV 0.05 0.57 RWHAP provider 1.6 0.53 Number of people with HIV in caseload 0.008 0.009** Notes: (1) Analysis adjusted for site; (2) * Significant at p < .05 ** Significant at p < .01

Predictors of Provider Knowledge (Pre-Implementation)

Multivariate regression of provider attributes associated with knowledge score (N=376) β p-value % people with HIV caseload screened for HCV 0% ref

• 1 - 74%

1.7 0.67 75 - 100% 6.2 0.15 % HIV/HCV patients treated/referred 0% ref

• 1-49%

6.3 0.07 50-100% 9.8 0.009** Any people with HIV in caseload with psychiatric disorder

• 0.2

0.98 Any people with HIV in caseload with SUD 2.3 0.67 Notes: (1) Analysis adjusted for site; (2) * Significant at p < .05 ** Significant at p < .01

Summary

Provider Focus Groups

• Providers perceived training and CPL to be useful
• Concerns and misconceptions about readiness remained

Provider Knowledge Assessment (Pre-Implementation)

• MDs followed by NP/PAs performed strongest across all items and domains
• Important knowledge gaps across all provider types in areas of substance use

and mental health issues as well as socio-economic barriers

• Gaps between provider types was smallest for socio-economic barriers, but still

significant

• Interventions to improve knowledge and support treatment should consider:
• Tailoring to provider type (MD/NP/PAs versus others)
• Including education around treatment of those with substance use and mental health

issues, and addressing socio-economic barriers

Thank you!

Jurisdictional Approach to Curing Hepatitis C Among HIV/HCV Co-infected People of Color

Debbi bie I e Isenber nberg

Evaluation & Technical Assistance Consultant

Dan an Cz Czajk ajka

Manager, Health Care Access & Hepatitis

Phi hil Mel elem emed

CAREWare Consultant

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• SMAIF funded Special Project of National Significance (SPNS)
• Three-year project (September 30, 2016 – September 29, 2019)
• Currently in a no-cost extension period until March 31, 2020
• Goals
• Cure HCV among co-infected PLWH, focusing on people of color
• Establish a sustainable HCV care cascade
• NASTAD serves as the State Health Departments Coordinating Center
• Assisted with the participation of Louisiana and North Carolina

Background

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Gaps at Every Level

System Provider

• HCV treatment cost
• Provision of HCV

treatment under Medicaid

• Case ascertainment

(existing coinfection among PLWH)

Patient

• Treatment guideline

confusion

• Attitudes/ stigma

towards social and behavioral determinants of health

• Accessing HCV services

and health in general, especially substance use disorder

• Knowledge of HCV

symptoms and treatment

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• 3 Clinics Participated
• 2 in New Orleans, 1 in Baton Rouge
• Federally Qualified Health Centers
• Health Models Coordinators (HMCs)
• Housed at participating clinics
• Received HIV/HCV co-infection training
• Responsible for reporting activities and administering patient assessment
• 90-90-80 Goals
• 90% of clinics’ HIV+ clients provided annual opt-out screening
• 90% HIV/HCV co-infected clients linked to HCV care
• 80% HIV/HCV co-infected clients completed HCV treatment

Louisiana Structure

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• Patient Education
• Interactive one-on-one sessions once every 6 months
• Conducted patient-focused HCV awareness campaign
• Shared HCV resources and educational materials
• Retention/Linkage to Care Support
• Contacted out of care clients
• Maintained contact with clients in care
• Worked to address social determinants of health (insurance, housing, etc.)
• Assisted with scheduling and connecting clients to community resources
• Provided HCV treatment adherence support to co-infected clients

Health Models Coordinator Activities

58

• HMCs prioritize HCV cure for clients and providers
• System- and provider-level barriers limit achievement of cure
• Success is not always quantitatively measured

Lessons Learned

59

• 2 participating clinics
• Raleigh/Durham and surrounding counties catchment area
• Part of university health systems
• Co-infection Bridge Counselors
• Housed at participating clinics
• Support re-engagement, linkage to care, and treatment
• Enter activities in CAREWare
• North Carolina CAREWare team
• Regional Quality Council (RQC)
• Leveraging CAREWare for tracking progress and reporting

North Carolina Structure

60

• Goal: Expand CAREWare use for HCV

screening and treatment

• Meet data collection needs for project
• Provide foundation for statewide

expansion and use

• CAREWare documentation
• Performance measure development
• Enhanced data importing
• Identification of implementation steps for

expanded use

CAREWare Activities

Lessons Learned-Overall

• Capturing data is one piece of a coordinated effort to improve HCV

screening and treatment among people with HIV

• Current policy, practice and EHR data entry/important are essential

components

• Important to consider how CAREWare is being used when determining

level of customization for new data entry

• Need to outline desired custom reports/performance measures before

implementing changes to ensure that reporting needs are met

• Capturing HCV data in CAREWare can provide important information

about co-infection, screening activities and treatment needs

• Enhance HCV surveillance activities/Data to Care
• Inform QI activities for HCV screening and treatment

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Lessons Learned-CAREWare

• Labs
• Inconsistent fields used for HCVab and RNA can make it difficult to

use performance measures

• SVR12 not good measure because requires clinical interpretation in
• rder to enter
• Medications
• Non-ARV medications don’t allow entry for treatment reason (ie

HCV) so can be more challenging to find/enter HCV meds

• May be easier to create custom tab for treatment rather than

capturing medication but even this has challenges

• Difficult to report the absence of something (no HCV meds)

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Lessons Learned-Electronic Health Records

• Labs
• Integrating HCV screening as part of annual labs increases

completion rather than having clinician determine/remember to

• rder
• Risk is often not captured in a structured field in an EHR which can

make it difficult to know when risk-based screening is due

• Reflex testing is not necessarily the standard
• RNA Tests post treatment (for SVR 12) may not be drawn/well

documented

• Medications
• Start date reflects date prescribed, not date client started taking

medication

• Medication lists are not always reconciled in EHR, which can make

abstracting information challenging

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• Dan Czajka - dczajka@nastad.org
• Debbie Isenberg – isenbergconsulting@gmail.com

Questions

Q&A: Your Questions are Welcome!

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Archive

• The slides from today’s webinar will be posted to the TargetHIV website within

ten business days.

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HAB TargetHIV Website https://targethiv.org/calendar/webinar- and-call-archives

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