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Conversations with CEI
All Episodes (19)
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2. How Can We Destigmatize HIV and Pregnancy?
Preventing perinatal HIV transmission is an important strategy for eliminating HIV. Historically, rates of perinatal HIV transmission were 25-40% without interventions, but advances in HIV research, prevention, and treatment have made it possible to reduce that risk to less than 1%. Despite this progress, many myths and misconceptions about HIV and pregnancy remain. In this episode, Dr. Antonio E. Urbina, Medical Director of CEI’s HIV Primary Care and Prevention Center of Excellence, speaks with Dr. Andrés Ramírez Zamudio, Assistant Professor in the Department of Obstetrics, Gynecology and Reproductive Sciences and Department of Medicine, Division of Infectious Diseases, at the Icahn School of Medicine at Mount Sinai. Drs. Urbina and Ramírez Zamudio discuss strategies for preventing perinatal HIV transmission more broadly. As well, they unpack some of the common myths and misconceptions to help destigmatize HIV in pregnancy.
- CEI line for NYS providers: 866-637-2342 (press 2 for questions about perinatal HIV transmission)
- National hotline: (888) 448-8765
- The Well Project: https://www.thewellproject.org/
- International Workshop on HIV and Women: https://virology.eventsair.com/international-workshop-on-hiv-women-2023/registration/Site/Register
- Infectious Diseases Society for Obstetrics and Gynecology (IDSOG): https://www.idsog.org/
- NYS Perinatal HIV Care Guidelines: https://www.hivguidelines.org/perinatal-hiv-care/
Dec 08,2022 27:45 -
3. Taking the Next Step: Providing Proactive Reproductive Health Care in Your Clinical Setting
Reproductive healthcare is a critical part of healthcare overall. Yet components of this care, including abortion, are becoming more and more inaccessible to certain parts of the population, worsened by the overturning of Roe vs. Wade. The implications of this decision on access to care, marginalization and inequity are already being seen and causing substantial concern within the medical community.
In this episode, Dr. Erica Bostick chats with Dr. Rachael Phelps, a nationally recognized family planning expert, about the impact of this decision on New York State clinicians and patients. Dr. Phelps offers her expertise and insights into what encompasses reproductive healthcare, and how clinicians can “take the next step” in offering comprehensive, preventative reproductive health services to patients of all ages.
- CDC Medical Eligibility Criteria website: https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html
- CDC Medical Eligibility Criteria, PDF Chart: https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf
- CDC Selected Practice Recommendations website: https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html
- CDC MEC & SPR App: https://www.cdc.gov/reproductivehealth/contraception/contraception-app.html
- bedsider.org
- Society of Family Planning: https://societyfp.org/
- https://abortionpillcme.teachtraining.org/
- The Turnaway Study: https://www.ansirh.org/research/ongoing/turnaway-study
- Hey Jane Medical Abortion in NY https://www.heyjane.co/home-b
- Plan C Abortion Resource https://www.plancpills.org/
Nov 10,2022 38:41 -
4. Universal Hepatitis C Screening among Pregnant Persons: The Time is Now
Hepatitis C is the most commonly reported blood-borne infection in the US, responsible for more deaths than all 60 reportable infectious diseases combined. Once most prevalent among “Baby Boomers” or those born between 1945 and 1965, the current hepatitis C burden disproportionately affects young adults who inject drugs, including women of childbearing age. Because of this epidemiological shift, perinatal transmission – which happens when a pregnant person living with hepatitis C passes it to their baby either within the uterus or during labor – is also on the rise. Approximately 6% of infants born to people with hepatitis C will become infected.
Given the increased prevalence of hepatitis C among women of childbearing age, more people with hepatitis C will become pregnant and for many of them, obstetric care will be their primary encounter with the health system. Hepatitis C screening during pregnancy presents an opportunity for early identification as well as dialogue between pregnant people and their clinicians about transmission and risk. In a sense, pregnancy presents an ideal opportunity to diagnose hepatitis C among pregnant people, link them to care and refer them to treatment. Tackling hepatitis C among women, and during pregnancy in particular, is critical to achieving the New York State Hepatitis C Elimination Plan’s goal to eliminate hepatitis C as a public health problem in the state by 2030.
Resources
- New York State Department of Health AIDS Institute guideline for treatment of chronic HCV with direct-acting antivirals, Pregnancy and HCV: https://www.hivguidelines.org/hepatitis-care/treatment-with-daa/#tab_4
- New York State Department of Health AIDS Institute guideline for substance use disorder treatment in pregnant adults: https://www.hivguidelines.org/substance-use/sud-treatment-pregnancy/
- The American College of Obstetricians and Gynecologists Routine Hepatitis C Virus Screening in Pregnant Individuals Practice Advisory: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2021/05/routine-hepatitis-c-virus-screening-in-pregnant-individuals
- Godar, E.A., & Jhaveri, R. (2021). A survey of practices in the United States regarding hepatitis C screening in pregnant women. Clin Ther, 43(3):780-784. doi: 10.1016/j.clinthera.2021.01.016
- Kushner, T., Chappell, C.A., & Kim, A.Y. (2019). Testing for hepatitis C in pregnancy: the time has come for routine rather than risk-based. Curr Hepatol Rep,18(2):206-215. doi: 10.1007/s11901-019-00468-y
- Kushner, T. & Reau, N. (2021). Changing epidemiology, implications, and recommendations for hepatitis C in women of childbearing age and during pregnancy. Jour of Hepatol, 74(3):734-741. doi: 10.1016/j.jhep.2020.11.027
- Ly, K.N., Jiles, R.B., Teshale, E.H., Foster, M.A., Pesano, R.L., & Holmberg, S.D. (2017). Virus infection among reproductive-aged women and children in the United States, 2006-2014. Ann Intern Med, 166(11):775-782. doi: 10.7326/M16-2350
Oct 11,2022 27:48 -
5. Some Basics About HIV-Hepatitis B Co-Infection
HIV and Hepatitis B share similar routes of transmission. In United States, a large cohort study of patients with HIV showed that over 10 % of men who had sex with men, over 8% of those who injected drugs and over 5% of heterosexual individuals with risk factors tested positive for HBsAg or detectable HBV DNA. Because of the shared transmission routes, there is an increased risk of HIV and HBV co-infection. Despite the advancement of ART, that has a very efficient suppression rate of the HIV and HBV replication, morbidity and mortality rates are still higher in patients with HIV-HBV co-infection. In this episode, Dr. Steven Fine, an infectious disease specialist affiliated with the University of Rochester and Anthony Jordan Health Center, speaks about the management of Hepatitis B in patients with HIV.
- CEI Trainings: https://ceitraining.org/courses/
- Prevention and Management of Hepatitis B Virus Infection in Adults With HIV: https://www.hivguidelines.org/hiv-care/hbv-hiv/#tab_0
- Hepatitis B Virus/HIV Coinfection: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/hepatitis-b-virushiv-coinfection
- People Coinfected with HIV and Viral Hepatitis: https://www.cdc.gov/hepatitis/populations/hiv.htm
- Request a free training: https://www.surveymonkey.com/r/HCVDUH_Trainings
- Dr. Steven Mark Fine
Sep 15,2022 30:03 -
6. Where are we with an HIV vaccine and cure?
Despite the existence of medications that can control HIV and even reduce viral transmission, HIV is still a leading cause of death and a health threat to millions worldwide. The goal of this episode is to highlight where we are in the development of an HIV vaccine and cure which will improve the health and well-being of millions of people worldwide.
AIDS Vaccine Advocacy Coalition: https://www.avac.org/
Antibody therapy controls HIV for months in new clinical trial at The Rockefeller University: https://www.rockefeller.edu/news/32186-antibody-therapy-controls-hiv-for-months-in-new-clinical-trial/#:~:text=Now%2C%20findings%20from%20a%20clinical,conventional%20antiretroviral%20drugs%20cannot%20do.
AIDS Vaccine Advocacy Coalition (AVAC)
Aug 11,2022 45:55 -
7. Check Yourself! Bringing STI Home Testing to Your Patients
The COVID-19 pandemic substantially impacted the capacity of sexual health clinics across the nation. It also provided insight into the availability and demand for at-home health testing.
The National Coalition of STD Directors (NCSD) and LetsGetChecked, a virtual care company and commercial lab, have partnered on the Check Yourself initiative –the first ever STI home testing solution that was developed by, for, and in partnership with public health departments. Check Yourself was designed to expand capacity for self-collected STI testing within state and local health departments.
In this episode, Dr. Daniela DiMarco chats with Jennifer Mahn, Director of Clinical and Sexual Health at NCSD, and RJ Asplund, Vice President of Business Development at LGC Labs, about the Check Yourself partnership and how NYS clinicians can participate.
www.NCSDDC.org/Check-Yourself [email protected]Jennifer Mahn Profile at NCSDDC.orgRyan (RJ) Asplund LinkedInDr. Daniela DiMarco ProfileCEI TrainingCEI on LinkedInCEI on TwitterCEI on InstagramCEI on FacebookCEI on YouTube
Jul 14,2022 35:14 -
8. There is Love in the Overdose Prevention Center
The number of drug overdose deaths in the US more than quadrupled between 2000 and 2019, and opioid overdose was declared a national public health emergency in 2017. Nationally, overdose deaths were the highest on record in 2020 with over 91,000 drug-involved overdose deaths and over 68,000 opioid-involved overdose deaths reported. New York State is no exception to the trend –drug-involved overdose deaths increased by 37% between 2019 and 2020, and overdose deaths involving any opioid increased by 44% during the same period for an average of nearly 12 deaths every day.
In response to the growing crisis, New York State convened a Heroin and Opioid Task Force in May 2016and on November 30th, 2021 New York became the first US city to open officially authorized Overdose Prevention Centers. Overdose Prevention Centers are an evidence-based approach to preventing overdose deaths adopted by countries around the world, however they remain unsanctioned in the US. They offer supervised, hygienic spaces for people who use drugs to do so safely, and provide a connection to health promoting services, such as harm reduction, medical care, mental health therapy, drug treatment and social supports. In addition, Overdose Prevention Centers improve individual and community health, increase public safety and reduce the social consequences of drug use.
Opponents view the Centers as magnets for drug use, however the New York State Department of Health announced that in their first three months of operation, the Centers were used more than 9,500times and staff on-site averted more than 150overdoses to prevent injury and death.
New York Harm Reduction Educators: https://nyhre.org/ Washington Heights CORNER Project: https://www.facebook.com/WashingtonHeightsCORNERProject/ February 2022 NYSDOH Epi Data Brief: Basic Needs among People who Use Opioids in NewYork City during the COVID-19 Pandemic https://www1.nyc.gov/assets/doh/downloads/pdf/epi/databrief131.pdf NYSDOH New York State County Opioid Quarterly Report (April 2022): https://health.ny.gov/statistics/opioid/data/pdf/nys_apr22.pdf Levengood, T.W., Yoon, G.H., Davoust, M.J., Ogden, S.N., Marshall, B.D.L., Cahill, S.R., & Bazzi, A.R. (2021). Supervised injection facilities as harm reduction: a systematic review. Am J Prev Med,61(5):738-749. doi: 10.1016/j.amere.2021.04.17 Kral, A.H., Lambdin, B.H., Wenger, L.D., & Davidson, P.J.(2020). Evaluation of an unsanctioned safe consumption site in the United States. N Engl J Med,383:589-590. doi: 10.1056/NEJMc2015435
Jun 09,2022 01:06:01 -
9. Exciting Injectable PrEP for HIV; No More Pills!
Access to PrEP is a pillar of the NYSDOH End the Epidemic initiative, that emphasizes the safety and effectiveness of PrEP as a method to prevent HIV infection. However, structural and individual barriers may result in PrEP being underutilized, particularly by the populations at the highest risk of acquiring HIV. In this episode, Dr. Steven Fine, an infectious disease specialist affiliated with the University of Rochester and Anthony Jordan Health Center, speaks about the injectable option for PrEP, as a suitable choice for those who would prefer an alternative to preventative daily oral therapy.
https://www.hivguidelines.org/antiretroviral-therapy/art-injectable/https://www.hivguidelines.org/prep-for-prevention/https://www.health.ny.gov/diseases/aids/general/prep/prep_index.htmhttps://www.health.ny.gov/diseases/aids/ending_the_epidemic/index.htmhttps://ceitraining.org/courses/https://ceitraining.org/request/PrEP GuidelinesCEI TrainingEnding the EpidemicNYS Ending the EpidemicDr. Steven Mark Fine
May 12,2022 29:28 -
10. Where Are We Now With HIV and COVID-19
As we enter year three of the COVID-19 pandemic, we would like to review the latest updates about HIV and COVID-19.
In the first segment we will speak with Dr. Robert Fullilove, EdD, about the social and historical factors which have led to racial health disparities for HIV and COVID-19. In the second segment we will speak with Dr. Keith Sigel, MD, PhD, MPH, who will unpack the latest research and data about COVID-19 outcomes for Persons Living with HIV (PLWH). The goal of this episode will be to provide information for providers about how to understand and meet their patients’ needs in relation to HIV and COVID-19.
Part 1: Robert Fullilove, EdD,
- Robert Fullilove Columbia University Mailman School of Public Health https://www.publichealth.columbia.edu/people/our-faculty/ref5
- Burns, D Learning for Our Common Health Association of American Colleges and Universities Washington, DC 109-119 1999
- Golembeski C, Fullilove R Criminal (in)justice in the City and Its Associated Health Consequences. American Journal of Public Health 95 1701-6 2005
- Green LL, Fullilove MT, Fullilove, RE. Remembering the Lizard: Reconstructing Sexuality in the Rooms of Narcotics Anonymous. Journal of Sex Research 42 28-34 2005
- Fullilove RE HIV Prevention in the African American Community: Why Isn't Anybody Talking about the Elephant in the Room? AIDScience 1 1-7 2001
- Fullilove MT and Fullilove RE What's housing got to do with it? American Journal of Public Health 90 183-4 2000
- Fullilove RE, Green LL, Fullilove MT The Family to Family Program: A Structural Intervention with Implications for the Prevention of HIV/AIDS and Other Community Epidemics. AIDS. Vol 14 (1S) 2000.63-67 14(1S) 63-67 2000
- Levine RS, Foster JE, Fullilove RE et al. Black-White Inequalities in Mortality and Life Expectancy, 1993-1999 :Implications for Healthy People 2010. Public Health Reports 116 474-83 2001
- Malebranch DJ, Peterson JL, Fullilove RE, Stackhouse RW. Race and Sexual Identity: Perceptions about Medical Culture and Healthcare among Black Men Who Have Sex with Men. Journal of the National Medical Association 96 97-107 2004
Part 2: Keith Sigel, MD, PhD, MPH
- Braunstein, S. L., Lazar, R., Wahnich, A., Daskalakis, D. C., & Blackstock, O. J. (2021). Coronavirus disease 2019 (COVID-19) infection among people with human immunodeficiency virus in new york city: a population-level analysis of linked surveillance data. Clinical Infectious Diseases, 72(12), e1021-e1029.
- Centers of Disease Control and Prevention. (2021) COVID-19 and HIV. https://www.cdc.gov/hiv/covid-19/index.html
- Cooper, T. J., Woodward, B. L., Alom, S., & Harky, A. (2020). Coronavirus disease 2019 (COVID‐19) outcomes in HIV/AIDS patients: a systematic review. HIV medicine, 21(9), 567-577.
- Garret, N., Tapley, A., Andriesen, J., Seocharan, I., Fisher, L. H., Bunts, L., ... & Corey, L. (2021). High rate of asymptomatic carriage associated with variant strain Omicron. MedRxiv.
- Sigel, K., Swartz, T., Golden, E., Paranjpe, I., Somani, S., Richter, F., ... & Glicksberg, B. S. (2020). Covid-19 and people with HIV infection: outcomes for hospitalized patients in New York City. Clinical Infectious Diseases.
- Verity, R., Okell, L. C., Dorigatti, I., Winskill, P., Whittaker, C., Imai, N., ... & Ferguson, N. M. (2020). Estimates of the severity of coronavirus disease 2019: a model-based analysis. The Lancet infectious diseases, 20(6), 669-677.
Apr 14,2022 50:23 -
11. Behind the Scenes: A Look at the 2021 CDC STI Treatment Guidelines
In July 2021, the Centers for Disease Control and Prevention released new evidence-based guidelines for the prevention, diagnosis, and treatment of sexually transmitted infections. This is the first new issue since 2015. Listen to this episode for a discussion about how the guidelines are developed and some of the most important changes in the field.
2021 CDC STI Treatment Guidelines: https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020: https://www.cdc.gov/mmwr/volumes/68/rr/rr6805a1.htm?s_cid=rr6805a1_w National Network of STD Clinical Prevention Training Centers: https://www.stdccn.org/render/PublicVisit www.ceitraining.org for the toll-free number for NYS clinicians to discuss HIV, PEP, PrEP, HCV, Drug User Health, and STI management with a specialist.
Mar 10,2022 35:59 -
12. One Step Closer: Introducing the New York State Hepatitis C Elimination Plan
Hepatitis C is a major public health issue responsible for more deaths in the US than all 60 reportable infectious diseases combined, including HIV and tuberculosis. It infects about 25,000 people each year, most of whom don’tknow they are infected and are at risk for developing chronic infection. In New York State alone, over 6,000cases of hepatitis C were reported in 2019.
On November 17, 2021 the New York State Department of Health released the New York State Hepatitis C Elimination Plan which outlines five key principles, including: (1) Prevention; (2) Access to Care and Treatment; (3) Testing and Linkage to Care; (4) Surveillance, Data and Metrics; and (5) Social Determinants of Health. The Plan further defines priority populations and settings to ensure those most at risk are placed at the front and center of elimination efforts to help achieve World Health Organization targets of reducing new chronic infections by 90% and mortality by 65% by 2030.
New York State Hepatitis C Elimination PlanNew York State Hepatitis C Guidelines and RecommendationsNew York State Hepatitis C DashboardWorld Health Organization Hepatitis InformationTreatment Action GroupHep ElimiNATION InitiativeVOCAL New YorkAnnette Gaudino LinkedInChristine Kerr, MD LinkedInLauren Walker LinkedInCEI on LinkedInCEI on TwitterCEI on InstagramCEI on FacebookCEI on YouTube
Feb 10,2022 25:29 -
13. Simplified HCV Treatment for treatment naive patients: Anyone can do it!
According to the updated HCV guidelines, initial treatment of HCV infection includes patients with chronic hepatitis C who have not been previously treated with interferon, peginterferon, ribavirin, or any HCV direct-acting antiviral (DAA) agent, whether investigational, or US Food and Drug Administration (FDA) approved. However, the simplification of the treatment regimen for HCV may expand the number of healthcare professionals who prescribe antiviral therapy and increase the number of persons treated. In this episode, Dr. Steven Fine, an infectious disease specialist affiliated with the University of Rochester and Anthony Jordan Health Center, speaks about simplified HCV treatment for treatment naïve patients.
HCV Guidelines: hcvguidelines.orghttps://www.hivguidelines.org/hepatitis-care/treatment-with-daa/recommended-regimens-adults/https://www.hcvguidelines.org/Treatment-Naivehttps://ceitraining.org/courses/https://ceitraining.org/resources/hcv/https://www.health.ny.gov/publications/1806.pdf
https://www.health.ny.gov/diseases/communicable/hepatitis/hepatitis_c/providers/testing_law.htm
Jan 13,2022 24:38 -
14. The Intersection of Drug User Health and Infectious Diseases
Join us for the fifth and final episode of Any Positive Change, a Drug User Health Podcast. Dr. Margie Urban from the University of Rochester and the Clinical Education Initiative’s Sexual Health Center of Excellence joins as a guest host for this episode. She met with Dr. Sandy Springer from Yale University for a wide ranging conversation about her experiences as a joint Infectious Diseases and Addiction Medicine specialist from the early in the HIV epidemic to the present day. Listen as they discuss the progress in the field and some future directions of research at the intersection of drug user health and infectious diseases.
Future podcasts can be found at ‘Conversations with CEI’ and will focus on drug user health, Hepatitis C, sexual health and HIV care and prevention. Come join us there.
Dec 07,2021 46:56 -
15. Pre-Exposure Prophylaxis (PrEP): What Clinicians Need to Know
[The following episode was initially recorded as part of "Any Positive Change", which has since merged with Conversations with CEI]
Pre-exposure prophylaxis, also known as PrEP, is a highly effective way to prevent HIV infection. While we are most familiar with the pill that is taken every day, there are new long acting injectables coming down the pipeline, with the potential to improve PrEP adherence. Roughly 1 in 5 people who use drugs are at very high risk of getting HIV. Despite this, very few of them are actually getting PrEP. To hear more about these new advancements in PrEP, and how we can close the treatment gap for people who use drugs, Dr. Linda Wang interviewed Dr. Tony Urbina, an infectious disease physician and Professor of Medicine at the Icahn School of Medicine. Dr. Urbina is also the Medical Director of the New York State Clinical Education Initiative HIV Primary Care and Prevention Center of Excellence.
Jun 28,2021 56:35 -
16. Updates in Sexually Transmitted Infections and Sexual Health
[The following episode was initially recorded as part of "Any Positive Change", which has since merged with Conversations with CEI]
In this episode, Dr. Linda Wang interviews Dr. Margie Urban, an infectious disease physician and Professor of Medicine at the University of Rochester and the Medical Director of the New York State Clinical Education Initiative Sexual Health Center of Excellence. Listen as we discuss the rising number of sexually transmitted infections affecting communities across the country and in New York State, and how clinicians and the New York State Department of Health have been responding to this crisis in the middle of a pandemic.
Jun 04,2021 40:17 -
17. “Where they feel honored as a human being.”
[The following episode was initially recorded as part of "Any Positive Change", which has since merged with Conversations with CEI]
The medical clinic at New York Harm Reduction Educators (NYHRE) provides access to healthcare right in the middle of the drop-in center. Participants who come for sterile injection equipment can also receive treatment for hepatitis C and be prescribed buprenorphine, a medication for opioid use disorder, on-site at NYHRE. Perhaps more importantly, they receive all of this at a clinic that is loving, nurturing, and provides non-stigmatizing care to people who use drugs. Hear about how the NYHRE clinic operates and why it is so important to provide this low-barrier model of care to people who use drugs, from Brianna Norton, DO, Medical Director of the NYHRE medical clinic, and Christine Fitzsimmons, RN. Brianna and Christine also talk about the challenges faced during the pandemic, and how they are staying connected to their patients to keep them safe and healthy.
Jan 22,2021 53:46 -
18. Addressing the Intersections of HIV and Health Inequities: Considerations for Providers
It has been 40 years since the first known case of HIV was documented and we have come a long way in the past 40 years. HIV is now a chronic disease, we have highly effective HIV prevention options like PEP and PrEP, and we are now able to offer long-acting injectables for HIV treatment and soon HIV prevention. While we can celebrate these achievements, HIV health disparities persist. We see that communities who experience multiple forms of oppression have not benefitted as much from medical advances in HIV treatment and prevention. In this episode, Dr. Antonio E. Urbina, Medical Director for CEI’s HIV Primary Care and Prevention Center of Excellence, speaks with two experts to learn more about these disparities and what providers can do to address them: Kenyon Farrow, a public health and infectious disease activist, writer, and editor, and Dr. Sabrina Gard, a primary care provider specializing in HIV.
PrEP4All: https://www.prep4all.org/Not Just a Black Body: https://notjustablackbody.com
Dec 09,2021 01:05:49 -
19. ”It‘s already rough out here.”
[The following episode was initially recorded as part of "Any Positive Change", which has since merged with Conversations with CEI]
Syringe service programs play a critical role in the lives of people who use drugs, providing not only sterile injection equipment and naloxone kits for overdose reversal, but also a safe and welcoming place to take a shower and get a cup of coffee. Some programs, like New York Harm Reduction Educators (NYHRE) in East Harlem, also provide medical care, including hepatitis C treatment and buprenorphine, a medication for opioid use disorder. In early 2019, when the Covid pandemic hit New York City and led to widespread disruptions in routine healthcare delivery, syringe service programs like NYHRE rapidly adjusted their model of care in order to sustain their life-saving programming. Hear from Sheree, a participant at NYHRE as well as Pia Marcus, Director of Syringe Access and Outreach for NYHRE and Washington Heights Corner Program, about their experiences.
Jan 13,2021 46:15