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LOS ANGELES COUNTY COMMISSION ON HIV INTEGRATED PLANNING Developing a Single Planning Approach to LOS ANGELES COUNTY COMMISSION ON HIV INTEGRATED PLANNING Developing a Single Planning Approach to HIV Prevention, Care and Treatment in Los Angeles County Unification of LA County’s Two HIV Planning Bodies Michael Green, Ph. D Chief of Planning Division of HIV and STD Programs (DHSP) Department of Public Health, County of Los Angeles Craig A. Vincent-Jones, MHA Executive Director Los Angeles County Commission on HIV November 21, 2013 SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

PRESENTATION OVERVIEW I. Los Angeles County EMA II. Impetus for Integrated Planning III. Process PRESENTATION OVERVIEW I. Los Angeles County EMA II. Impetus for Integrated Planning III. Process for Integrated Planning IV. The New Configuration V. SLIDE Lessons Learned LOS ANGELES COUNTY COMMISSION ON HIV

I. LOS ANGELES COUNTY EMA Description LOS ANGELES COUNTY Most populous county in US. I. LOS ANGELES COUNTY EMA Description LOS ANGELES COUNTY Most populous county in US. Greater population than 42 individual states. 88 incorporated cities and many unincorporated areas. One of the most racially/ ethnically diverse areas in the US. Urban, suburban and rural areas. Divided by the San Gabriel and Santa Monica mountain ranges. SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

I. LOS ANGELES COUNTY EMA 2013 Estimated Number of Persons Living with HIV and I. LOS ANGELES COUNTY EMA 2013 Estimated Number of Persons Living with HIV and AIDS in LA County (1) (2) SLIDE (3) Estimate that 18. 1% of HIV+ in LA County are unaware of their infection; modified from CDC estimate. Of 4, 853 notifications pending investigation, estimate half of 2, 400 who have detectable VL or confirmatory test to be unduplicated cases. Of 4, 200 notifications pending investigation, estimate about 2, 000 who have detectable VL or confirmatory test to be unduplicated cases. LOS ANGELES COUNTY COMMISSION ON HIV

I. LOS ANGELES COUNTY EMA Division of HIV and STD Programs (DHSP) Integration § I. LOS ANGELES COUNTY EMA Division of HIV and STD Programs (DHSP) Integration § Announced February 2011 § Organizationally realigned the former HIV Epidemiology Program, Office of AIDS Programs and Policy and STD Prevention and Control § Efficiency and evidence-based driven § Largest fully integrated local health department § Controls all HIV and STD health department programming SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

I. LOS ANGELES COUNTY EMA DHSP Projects and Programs § HIV and STD Prevention I. LOS ANGELES COUNTY EMA DHSP Projects and Programs § HIV and STD Prevention and Control § HIV Testing Services q Targeted, Routine, Social Network, Mobile Unit-Based § STD Screening and Treatment Support q Public Sector/Private Sector § HIV Care and Treatment Services § Integrated Behavioral Health in Primary Care Settings § Navigation, Linkage, Retention Initiatives § Geographic-specific STD Control Effort SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

I. § § § § LOS ANGELES COUNTY EMA DHSP Projects and Programs (cont. I. § § § § LOS ANGELES COUNTY EMA DHSP Projects and Programs (cont. ) Syndemic Planning and Geospatial Analysis Use of Surveillance Data/Data Matching/Data Sharing Public Health Investigation and Use of Community Embedded Disease Intervention Specialists Biomedical Interventions (PEP) Integrated TLC+, Pr. EP and Social Network Testing Housing Services Coordination with HOPWA Medical Care Coordination Integrated Community Planning SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

I. § LOS ANGELES COUNTY EMA Sharing Data to Improve Planning Evaluate HIV/STD surveillance, I. § LOS ANGELES COUNTY EMA Sharing Data to Improve Planning Evaluate HIV/STD surveillance, program, and other data to identify areas for programmatic focus, inform planning processes, and implementation strategies by: q q q SLIDE Matching HIV/STD surveillance and program data to evaluate testing, linkage, retention, and viral load suppression across the spectrum of engagement in care, Use of HIV/STD surveillance data to identify geographic areas and populations most impacted by HIV/STD syndemics, Improve accuracy and efficiency of data collection and facilitate useful reporting. LOS ANGELES COUNTY COMMISSION ON HIV

II. IMPETUS for INTEGRATED PLANNING Change is Hard “It’s going to be messy. Whether II. IMPETUS for INTEGRATED PLANNING Change is Hard “It’s going to be messy. Whether you support it, or whether you oppose it. . . it’s going to be messy. ” q David Brooks, political pundit, on health care reform “It’s going to be messy. It’s going to be politically contentious. But it—in the end—it’s going to happen. ” q EJ Robinson, political pundit, in response to David Brooks Accepting that transformational change of any type is difficult—it creates anxiety and disquiet (even among those who support it), and will be full of unexpected events and turns—before you begin. . . is key to a process that, eventually, finds its way to the desired result. SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

II. IMPETUS for INTEGRATED PLANNING External Factors n Improved planning and coordination of services II. IMPETUS for INTEGRATED PLANNING External Factors n Improved planning and coordination of services and resources— q q q n National HIV/AIDS Strategy (NHAS) Treatment Cascade (national “Continuum of Care”) Early Identification of Individuals with HIV/AIDS (EIIHA) Testing, Linkage to Care, Treatment Plus (TLC+) Enhanced Comprehensive/HIV Prevention Planning (ECHPP) Emergence of disparities/inequities/social determinants as a key Commission focus and priority SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

II. IMPETUS for INTEGRATED PLANNING Internal Factors n Implementation of the Affordable Care Act II. IMPETUS for INTEGRATED PLANNING Internal Factors n Implementation of the Affordable Care Act (ACA): q q Need to improve service delivery efficiency and reduce duplication of effort Prospects of additional savings and resources n Need to generate more enthusiasm/momentum for HIV prevention planning after CDC changes n Consistent with the Commission’s strategic plan n Possible reductions in federal and state Ryan White/federal appropriations and other resources SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

II. IMPETUS for INTEGRATED PLANNING Numerous Earlier Efforts to Integrate 1) Commission and PPC II. IMPETUS for INTEGRATED PLANNING Numerous Earlier Efforts to Integrate 1) Commission and PPC attempted merger in 2002: q q Commission approved it; PPC opposed it—unanimously PPC was concerned that care/treatment focus would shift attention away from prevention, Commission’s relationship with DHSP concerned PPC, The planning body votes created hard feelings/ resentments for a decade. 2) Quarterly joint Co-Chair meetings not successful. 3) Joint Public Policy (JPP) Committee formed, 2008: q q SLIDE Three separate attempts to integrate policy work, Both bodies’ single policy unit for five years. LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Milestones on the Path to Unification 2009 2010 Joint III. PROCESS for INTEGRATED PLANNING Milestones on the Path to Unification 2009 2010 Joint Commission/ PPC Integration Task Force formed. Joint meetings to explore additional coordination/ collaboration. SLIDE 2011 Task Force adopts TLC+ framework as integration strategy. 2012 LA County Commission/ Comprehensive PPC becomes a HIV Plan 2012 - single, integrated 2017 created. planning body (unification). LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Change Leaders In 2009, Commission and PPC formed a III. PROCESS for INTEGRATED PLANNING Change Leaders In 2009, Commission and PPC formed a joint “Integration Task Force” to improve collaboration and exchange between the two planning bodies— q q The first year was spent educating members about the full range of LA County’s HIV services and activities—and defining terminology acceptable to both groups; Began integrating care/prevention services/interventions into a TLC+ framework; ECHPP eventually became the predominant strategic prevention approach. Task Force recommended, and Commission/PPC agreed —to develop an integrated Comprehensive HIV Plan. SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Catalysts for Change Transformation depends on “change leaders” capable III. PROCESS for INTEGRATED PLANNING Catalysts for Change Transformation depends on “change leaders” capable of ascertaining when timing and momentum are right for change (“catalysts for change”): q q SLIDE Following International AIDS Conference (IAC), where “treatment as prevention” was predominant; Improved relations between two planning bodies due to joint development of Comprehensive HIV Plan; Diminished enthusiasm for HIV prevention planning due to limited role in CDC’s new HIV Planning Guidance; In preparation for ACA roll-out, HIV service delivery will be re-organized/re-structured on a broader scale. LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Comprehensive HIV Planning (CHP) Task Force Integration Task Force III. PROCESS for INTEGRATED PLANNING Comprehensive HIV Planning (CHP) Task Force Integration Task Force becomes Comprehensive HIV Plan (CHP) Task Force, to oversee Plan development. Force Final Los Angeles County Comprehensive HIV Plan 2013 – 2017 submitted to HRSA and CDC, 3/2013: q q q SLIDE Links HIV prevention, care and treatment services to NHAS goals, treatment cascade, and ACA; Local continuum of care consistent with local/national priorities; addresses disparities/health inequities; Goals/objectives to be monitored/updated annually. LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Framework and Parameters FRAMEWORK: The term “unification” was selected III. PROCESS for INTEGRATED PLANNING Framework and Parameters FRAMEWORK: The term “unification” was selected FRAMEWORK carefully—to represent a union of interests, rather than one interest consuming or absorbing the other. TIMELINE: Commission and PPC agreed to complete TIMELINE the process in six months—by July 2013—because: n n n SLIDE procrastination weakens stakeholder resolve/enthusiasm; the HIV planning body could not devote more time to unification with ACA implementation advancing so rapidly; unification needed a sense of urgency to generate a timely County response (from other, necessary departments). LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Building Community Consensus Following successful development of the CHP, III. PROCESS for INTEGRATED PLANNING Building Community Consensus Following successful development of the CHP, the Commission agreed (unanimous) to “merge” in Spring 2012; PPC agrees (unanimous) in September 2012: q q q Two (2) co-chairs from the Commission/and 2 from the PPC; Merger is formally renamed a “unification”; and CHP Task Force agrees to an expedited timeline. LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Anticipated Challenges CHP Task Force anticipated the following challenges: III. PROCESS for INTEGRATED PLANNING Anticipated Challenges CHP Task Force anticipated the following challenges: q q q SLIDE Generating/maintaining stakeholder support/enthusiasm; A continuing, relevant role for HIV community health planning after implementation of the ACA; Integrating HIV care and prevention perspectives into a single, jurisdictional HIV response; Presenting HIV care and prevention in a balanced manner that gives both perspectives sufficient consideration; Synchronizing planning, priorities, allocations and standards of HIV care and prevention; Effectively blending two distinct organizational cultures. LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Changing Organizational Culture Los Angeles County Commission on HIV III. PROCESS for INTEGRATED PLANNING Changing Organizational Culture Los Angeles County Commission on HIV Ø Ø Ø Ø Outcome Authority Consumer Decision/Action Committee-driven 35 -45 members Reports to BOS > Audience SLIDE PLANNING BODY Planning Body CULTURAL Cultural CHARACTERISTIC Characteristic Prevention Planning Committee (PPC) Meeting Type Ø County Role Ø Membership Ø Meeting Purpose Ø Work Origins Ø Ave. #/Members Ø Reports To Ø Community Interest Ø Process Advisory Planner Inform/Dialogue Hybrid 15 -25 members Reported to DHSP < Audience LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Strategies for Effective Forward Progress STRATEGY #1: No “sacred III. PROCESS for INTEGRATED PLANNING Strategies for Effective Forward Progress STRATEGY #1: No “sacred cows” nor “untouchable” issues— #1 everything could be on the table. STRATEGY #2: Stick to key organizational issues—structure, #2 membership—leave the rest for new planning group. STRATEGY #3: Guard against issues that distract unification #3 from its purpose—don’t get caught “in the weeds. ” STRATEGY #4: Dismantle the care/prevention “siloes” by blending the two distinct planning body cultures. SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Stakeholders: Administrative Mechanism Organization LA County Board of Supervisors III. PROCESS for INTEGRATED PLANNING Stakeholders: Administrative Mechanism Organization LA County Board of Supervisors [Chief Elected Official (CEO), per Ryan White (RW)] LA County Chief Executive Officer (CEO) Executive Office of BOS Department of Public Health Commission on HIV Division of HIV/STD Programs (RW Grantee) (RW Planning Council and HIV Planning Group) Consumers SLIDE Providers (RW Administrative Agency) Other Stakeholders LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING County Code 3. 29 (Ordinance) COMMISSION ON HIV: • III. PROCESS for INTEGRATED PLANNING County Code 3. 29 (Ordinance) COMMISSION ON HIV: • Ryan White Part A Planning Council; • Primary community advisory mechanism on HIV-related matters to the Los Angeles County Board of Supervisors (BOS); • HUD HOPWA SPNS grantee; • Additional roles due to unification (e. g. , HPG). CODE 3. 29: 3. 29 • Code 3. 29, legal authority empowers Commission; • Summarizes Commission role(s), membership, responsibilities, etc. ; • Changes to Commission must be approved by BOS and chaptered in Code; • Unification began with the Ordinance. chartered County commission with multiple roles. LA County Charter Code Title 3—Chapter 29, governing Commission, also known as the Ordinance. SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Technical Assistance (TA) Consultant 1) During Fall 2012, the III. PROCESS for INTEGRATED PLANNING Technical Assistance (TA) Consultant 1) During Fall 2012, the CHP Task Force recommended hiring a consul 2012 tant to 1) facilitate unification planning, and 2) who had sufficient RWPA/CDC expertise to ensure that federal guidance/expectations would be reliably represented and properly addressed in unification. 2) The Task Force felt that using an outside facilitator was beneficial in a number of ways: it would enhance more orderly decision-making, and could mitigate the impact of unexpected surprises or results. 3) As a non-conflicted, third-party facilitator, the consultant would also be better equipped to identify and confront subjective bias or unresolved conflict if it emerged, and to maintain greater objectivity. 4) In 12/2012, HRSA approved LA County’s request for Technical Assis 12/2012 tance (TA) and assigned Emily Gantz Mc. Kay to serve as the consultant for the unification. Ms. Gantz Mc. Kay began her work 1/2013 SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Unification Timeline: 1. 2. 3. 3. 4. 5. 6. III. PROCESS for INTEGRATED PLANNING Unification Timeline: 1. 2. 3. 3. 4. 5. 6. 7. 8. 9. 10. 11. SLIDE CHP Task Force and TA revise Commission Ordinance/By-Laws February 2013 Revised By-Laws submitted to Commission/project officers March 2013 Commission/PPC approve plan for transitional Open Nomi. March 2013 nations process to recruit/select new members Membership application, evaluation/scoring materials revised April 2013 Membership applications due April 2013 Membership interviews May 2013 Commission/PPC nominates members to BOS May 2013 Commission/PPC approve revised By-Laws May 2013 BOS appoints new members at two separate meetings June 2013 New membership seated at new Commission’s inaugural meeting/ July 2013 Ordinance approved by BOS June 2013 Ordinance authorizing new Commission enacted/membership July 2013 LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Fundamental Membership Decisions MEMBERSHIP: The formation of a unified III. PROCESS for INTEGRATED PLANNING Fundamental Membership Decisions MEMBERSHIP: The formation of a unified planning MEMBERSHIP body requires a new membership, and is enacted when the new members are installed: n n n SLIDE a limited number of membership seats would be added (Board of Supervisors concern); equal attention to RWPA and CDC guidance—even though RWPA “requires” and CDC only “recommends” specifics; anyone wishing to serve on the new planning body must (re-)apply— regardless of a candidate’s current planning body member status or participation on the Task Force. LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Transitional Open Nominations Process Membership Work Group: Task Force III. PROCESS for INTEGRATED PLANNING Transitional Open Nominations Process Membership Work Group: Task Force assigned membership nomination responsibilities to work group. SLIDE • Work group developed a “Transitional Open Nominations” process to expedite the approved membership nominations process; • Shortened 20 -page membership application to 6 page applicant/ demographic summary; • The “interview” became the core component of applicant evaluation; • Revised the evaluation/scoring tools accordingly— all membership evaluation/nominations materials were public documents; • All applications due two weeks after revised membership application submitted to Commission/PPC for review/approval; • All membership applicants required to submit applications; • All applicants, except institutional representatives, were interviewed. LOS ANGELES COUNTY COMMISSION ON HIV

III. PROCESS for INTEGRATED PLANNING Membership Results Transitional Open Nominations Process Results: 46 members III. PROCESS for INTEGRATED PLANNING Membership Results Transitional Open Nominations Process Results: 46 members and 15 alternates appointed by the BOS—leaving only five (5) seats vacant. n n Complies with “reflectiveness”/ “representation” requirements from RWPA, and CDC’s Parity, Inclusion and Representation (PIR) recommendations; Three types of members on the new Commission: returning Commission members, returning PPC members, and new members —representing educational/ orientation challenges. SLIDE Membership: 79 applications submitted by first deadline. Interest in joining the new Commission far exceeded the projected response, in part due to (as expressed by applicants): n n n Unification generated community enthusiasm; HIV stakeholders got involved due to changes; Applicants felt it was a new organization; It was an opportunity to bring new issues; Applicants excited about the new direction. Still Unresolved: defining “HIV prevention” consumer organizationally. LOS ANGELES COUNTY COMMISSION ON HIV

IV. NEW CONFIGURATION Timing of Decisions/Actions It was necessary to make decisions concerning organization, IV. NEW CONFIGURATION Timing of Decisions/Actions It was necessary to make decisions concerning organization, structure and authority prior to unification--all other decisions were left for the Commission to make after unification. Pre-Unification Post-Unification Structure (e. g. , roles/authority) Policy (e. g. , rev. conflict-of-interest) Organization (e. g. , committees) Procedural (e. g. , allocations) Membership Training Responsibilities Scope/Span (e. g. , STDs) Staffing/Support Budgeting SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

IV. NEW CONFIGURATION Committee/Organization Structure Committee/caucus structure remained Transgender mostly unchanged. Caucus Functional organization IV. NEW CONFIGURATION Committee/Organization Structure Committee/caucus structure remained Transgender mostly unchanged. Caucus Functional organization around the type of work, rather than topic or content. Each committee deals with care and prevention issues equally, not in “service siloes. ” Operations Committee Ø Ø Ø Membership Assess. Admin. Mech. Policies/Procedures Public Awareness Comprehensive Training Program SLIDE Consumer Caucus Latino Caucus Community Engagement Task Force Planning, Priorities and Allocations (PP&A) Committee Ø Ø Ø Comp. HIV Plan Priorities/Allocations Needs Assessment Expenditure Review Directives, Program Models, Services Los Angeles County Commission on HIV Executive Committee Public Policy Committee Ø Ø Ø Legislation Budgets/Funding Regulatory Affairs Benefits Intergovernmental Affairs/Interaction Standards and Best Practices (SBP) Committee Ø Ø Ø HIV Continuum Standards of Care Best Practices Key Populations Determinants, Barriers, Access LOS ANGELES COUNTY COMMISSION ON HIV

IV. NEW CONFIGURATION Immediate Post-Unification Work Integrating two HIV planning groups. . . only IV. NEW CONFIGURATION Immediate Post-Unification Work Integrating two HIV planning groups. . . only the first step! LEADERSHIP How do you ensure a leadership team that reflects integrations and is balanced? COMMITTEES ORIENTATION What role do committees have and how will they change in the new structure? How can you get everyone on the same page and with similar levels of knowledge? WORK PLANNING POLICIES/ PROCEDURES MEETINGS How will the work schedule and its timing change and how will the work get addressed/ done? What policies/procedures are important now, need to be revised, and how? Still much work left to do before Commission can claim full HIV planning integration. . . SLIDE How does organizational culture get addressed through public meetings? and, . . . some work goes on— indifferent to the time-consuming nature of integration! LOS ANGELES COUNTY COMMISSION ON HIV

V. LESSONS LEARNED Enacting the New Commission § § § § SLIDE Much of V. LESSONS LEARNED Enacting the New Commission § § § § SLIDE Much of the work occurs afterwards Stakeholder investment/buy-in Support of the grantee/CEO Right/opportune timing “Consumer” definitions Jurisdictional similarities Aggressive timeline Creating enthusiasm and momentum LOS ANGELES COUNTY COMMISSION ON HIV

V. LESSONS LEARNED Five Things Wish We Had Known Entering the Process Issue #1: V. LESSONS LEARNED Five Things Wish We Had Known Entering the Process Issue #1: How do we define “HIV-negative or prevention consumer” [vs. #1 “unaffiliated (HIV-positive) consumer” from HRSA]? Issue #2: How do we integrate very different “cultures” of the former #2 Commission and former PPC? Issue #3: What is the meaning of “integration” in an organizational #3 setting (vs. used as a programmatic reference)? For example, what are the indicators that an organization has successfully integrated, vs. successfully collaborated or partnered? Issue #4: How do we allocate funds for prevention activities that have #4 already been determined? Issue #5: What are the decisions that must be made before two planning #5 groups can integrate (vs. what decisions can be left to the planning body to make after it has integrated)? SLIDE LOS ANGELES COUNTY COMMISSION ON HIV

V. LESSONS LEARNED Leading Change: Why Transformation Efforts Fail by John K. Potter EIGHT V. LESSONS LEARNED Leading Change: Why Transformation Efforts Fail by John K. Potter EIGHT WAYS TO PREPARE 8 WAYS FOR A SUCCESSFUL TRANSFORMATION How LA Did It #1 Establish a Great Enough Sense of Urgency Expedited Timeline, membership process #2 Create a Powerful Enough Guiding Coalition CHP Task Force was established/successful #3 Have a Vision The vision was key foundation of CHPlan #4 Communicate the Vision by a Factor of Ten Each agenda included topic and work #5 Remove Obstacles to the New Vision Took on harder tasks first to build momentum #6 Plan for and Create Short-Term Wins Another benchmark approved at each mtg. #7 Don’t Declare Victory Too Soon We haven’t! Expect it LOS ANGELES COUNTY may take 2 yrs to assess COMMISSION ON HIV This will take time as SLIDE #8 Anchor the Changes in the Organizational Culture

CONTACTS for Further Information LOS ANGELES COUNTY EMA GRANTEE/ADMINISTRATIVE AGENCY PLANNING COUNCIL Michael Green, CONTACTS for Further Information LOS ANGELES COUNTY EMA GRANTEE/ADMINISTRATIVE AGENCY PLANNING COUNCIL Michael Green, Ph. D Craig Vincent-Jones, MHA Chief of Planning Executive Director Division of HIV/STD Programs Los Angeles County Commission on HIV 600 Commonwealth, 10 th Floor 3530 Wilshire Blvd. , Ste. 1140 Los Angeles, CA 90005 Los Angeles, CA 90010 213. 351. 8002 213. 738. 2816 [email protected] lacounty. gov [email protected] org SLIDE LOS ANGELES COUNTY COMMISSION ON HIV