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Newsletter: EHE

Ending the HIV Epidemic Newsletter

Mike Weir, M.P.H

NASTAD, with collaboration from the National Association of County and City Health Officials (NACCHO), the Council of State and Territorial Epidemiologists (CSTE), and the National Coalition of STD Directors (NCSD), distributes a monthly newsletter to Phase 1 Ending the HIV Epidemic: A Plan for America (EHE) jurisdictions. The newsletter informs recipients of EHE-related policy updates, communications from federal partners, success stories, and other related EHE information. As the CDC PS19-1906 National Partner and HRSA-20-089 Systems Coordinator Provider recipients, NASTAD also launched an EHE website to house programmatic updates, share strategies and outcomes from Phase 1 jurisdictions, and connect health departments with the community. For questions, comments, or content contributions, please contact Mike Weir. 

Hill Happenings 

Fiscal Year 2022 Appropriations  

On March 10, Congress resolved a months-long budget impasse and passed the Consolidated Appropriations Act, 2022 (H.R.2471). The House of Representatives advanced the bill on March 9, and the Senate promptly took up and passed the spending omnibus ahead of the March 11 federal funding deadline afforded by a continuing resolution.

Although lawmakers approved higher discretionary funding levels for the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), some health programs only received marginal gains. Final Fiscal Year 2022 (FY2022) funding levels included the following:

  • Centers for Disease Control and Prevention 
    • Division of HIV Prevention 
      • HIV Prevention – flat-funded at $755.6 million 
      • EHE Initiative – $20 million increase, totaling $195 million 
      • School Health – $2 million increase, totaling $36.1 million 
    • Division of Viral Hepatitis – $1.5 million increase, totaling $41 million 
    • STD Prevention – $2.5 million increase, totaling $164.3 million 
    • Infectious Diseases and the Opioid Epidemic – $5 million increase, totaling $18 million 
  • Health Resources and Services Administration (HRSA) 
    • Ryan White Program – $71 million increase, totaling $2.495 billion 
      • Part B: Base – $29.2 million increase, totaling $443.9 million 
      • Part B: ADAP – flat-funded at $900.3 million 
      • EHE Initiative – $20 million increase, totaling $125 million 
    • Community Health Centers EHE – $20 million increase, totaling $122 million 
  • National Institutes of Health (NIH) 
    • Office of AIDS Research – $104 million increase, totaling $3.194 billion 
  • Department of Housing and Urban Development (HUD) 
    • Housing Opportunities for People With AIDS (HOPWA) – $20 million increase, totaling $450 million

Due to Republican opposition, Democrats were unable to remove a provision banning the use of federal funds to purchase sterile needles or syringes. Additionally, the bill extends the schedule I status of fentanyl substances through the end of 2022, despite advocates objecting to the class-wide scheduling of fentanyl-related substances. However, language in the spending bill encourages the NIH National Institute of Drug Abuse (NIDA) to support research on the potential public health impacts of Overdose Prevention Centers. 

President Biden signed the spending omnibus into law on March 11. Now that the protracted FY2022 appropriations discussions are finally completed, Congress is expected to quickly pivot to FY2023 discussions. NASTAD is monitoring the FY2023 appropriations process and will advocate for the highest possible funding levels on behalf of HIV and hepatitis programs. 

Administration Updates 

CDC Regional Virtual Community Engagement Town Hall 

The CDC Division of HIV Prevention will begin convening its first HIV Prevention and Care Priorities – Regional Virtual Community Engagement Town Hall on March 24, 2022, 10:30 – 12:00 PM ET, for HHS Region 3. The Town Hall will provide a venue for discussion and collaboration focused on barriers to and opportunities for improving HIV diagnosis, treatment, prevention, and outbreak response. 

This town hall will focus on activities within HHS region 3, but is open to all to attend. Subsequent town halls will be held to cover other regions of the country. Please register here for the event. 

President Bident Delivers Health Message During State of the Union Address 

On March 1, President Biden delivered the State of the Union Address before Congress, detailing the major issues facing the nation and his Administration’s plans to address them. During the address, President Biden highlighted the key healthcare priorities for his second year in office, including lowering the price of prescription drugs and leveraging community-based harm reduction to address the substance use and overdose crisis. In particular, President Biden called on Congress to empower the HHS Secretary to negotiate the price of prescription drugs for the Medicare program. Democrats are renewing efforts to pass legislation authorizing drug price negotiation after the Build Back Better Act, the legislative vehicle used to advance the drug price negotiation provision, did not receive enough support in 2021 to become law.

Notably, President Biden made history by becoming the first president to publicly endorse a harm reduction approach to ending the overdose epidemic. President Biden called on Congress to increase funding for harm reduction programs and endorsed removing burdensome restrictions that prohibit many providers from prescribing medication for opioid use disorder. After the Address, the White House released a fact sheet reiterating the Biden Administration’s commitment to supporting syringe service programs through funding opportunities to boost harm reduction providers’ capacity to provide fentanyl test strips, sterile syringes, and naloxone. Additionally, the Director of the White House Office of National Drug Control Policy (ONDCP) issued a statement in support of the strategy.  

Biden Announces Nominee for Director of Indian Health Service 

On March 9, President Biden announced his intent to nominate Roselyn Tso for Director of the HHS Indian Health Service (IHS). Tso, an enrolled member of the Navajo Nation, has worked with the IHS since 1984, where she currently serves as the Area Director for the Navajo Area IHS and coordinates the delivery of health care for over 244,000 American Indians. As IHS Director, Tso would coordinate the healthcare of more than 2.5 million Native Americans and Alaska Natives. 

National Women and Girls HIV/AIDS Awareness Day 

National Women and Girls HIV/AIDS Awareness Day (NWGHAAD) is observed annually on March 10 and serves as an opportunity to highlight the challenges, barriers, and disparities women continue to face in HIV prevention. In 2019, women accounted for 18% (6,400) of estimated new HIV infections in the United States. The division leaders of the CDC NCHHSTP issued a Dear Colleague Letter highlighting the Center’s progress and challenges in tailoring HIV prevention approaches for women. Additionally, the HHS Office on Women’s Health released a fact sheet and updated materials to help advocates and providers to raise awareness on NWGHAAD.

CDC NOFO: Strengthening Syringe Services Programs 

This Notice of Funding Opportunity (NOFO) aims to increase access to harm reduction services for people who currently inject, or have a history of injecting, drugs and reduce incidence of infectious diseases and other complications of injection drug use through two components. Two Pre-Application Technical Assistance webinars will take place on March 16, 2022, and March 30, 2022, from 3:00 - 5:00 PM ET to provide potential applicants the opportunity to hear an overview of this NOFO and to ask CDC representatives specific questions related to it. 

CDC NOFO: Enhanced Surveillance of Persons with Early and Late HIV Diagnosis 

This NOFO will support the identification and recruitment of adults with recent HIV diagnoses at stage 0 and stage 3 to improve understanding of barriers and gaps associated with new infection and late diagnosis in the era of multiple testing modalities and prevention options such as PrEP. These enhanced surveillance activities will identify actionable missed opportunities for early diagnosis and prevention, thus informing allocation of resources, development, and prioritization of interventions, and evidence-based local and national decisions to improve HIV testing and address prevention gaps. Applications close April 26. 

CDC Article in Clinical Infectious Diseases: Characteristics of persons treated for hepatitis C using national pharmacy claims data, United States, 2014–2020 

“Using national pharmacy claims data, during 2014–2020, 843,329 persons were treated for hepatitis C at least once. The proportion treated increased annually among persons aged <40 years, insured by Medicaid, and treated by primary care providers. Monitoring hepatitis C treatment is essential to identify barriers to treatment access.” 

CDC Issue Brief: The Role of HIV Self-Testing in Ending the HIV Epidemic 

“In 2020, HIV testing decreased noticeably across the country as the COVID-19 pandemic made it more difficult to access traditional, in-person testing services. HIV self-testing programs offer an innovative way to bridge gaps in access to HIV testing and ensure that HIV testing is simple and more accessible for all.” 

CDC: Proposed Data Collections Submitted for Public Comment and Recommendations  The CDC is seeking comment on a proposed information collection to better understand preferences for Longer-Acting Preexposure Prophylaxis (LA-PrEP) products used to prevent the spread of HIV in populations with the highest need for prevention services, including gay, bisexual, and other men who have sex with men, Black or African American heterosexual persons, transgender women, and people who inject drugs. Comments are due by May 2, 2022. 

Resources 

Systems Coordination Provider Project  

NASTAD Systems Coordination Provider (SCP) staff participated in HRSA Ending the HIV Epidemic Programmatic Site Reviews. SCP staff participated in six site reviews in February. The site reviews serve as an opportunity for the SCP and CAI, the Technical Assistance Provider (TAP), to provide an overview of the SCP and TAP-in projects and hear directly from jurisdictions about their EHE program and activities, and identify TA requests.  

NASTAD’s EHE mentoring program launched its first monthly learning session with twenty-three mentees in attendance. The Association of State and Territorial Health Officials (ASTHO) presented on The Basics of HIV and Four Science-Based Strategies. Currently, there are 27 mentees from 18 jurisdictions engaged in the program. For additional information, please contact Darion Banister. 

Social Determinants of Health (SDH) Monthly Highlight  

NASTAD is conducting an ongoing monthly series that highlights the intersection of HIV prevention and care with a specific social determinant of health (SDH). March’s topic is Mental Health. You can look forward to more information about this being released later this month. 

Integrated HIV Prevention and Care Plan Guidance, CY 2022-2026 Frequently Asked Questions (FAQs) 

On March 14, 2022, HRSA HAB, and CDC DHP released a frequently asked questions (FAQ) response document to clarify recipient questions about the Integrated HIV Prevention and Care Plan Guidance, including the Statewide Coordinated Statement of Need, CY 2022-2026, which outlines the planning requirements for Ryan White HIV/AIDS Program (RWHAP) Parts A and B recipients and all DHP-funded state and local health departments. In addition to the FAQ response document, recipients of both agencies can access a number of technical assistance (TA) resources. 

HRSA HAB and CDC DHP recipients can visit the Integrated Planning landing page on the Target HIV website to find a number of TA webinar recordings and resources, including:

Recipients can visit the Capacity Building Assistance Provider Network to view future TA opportunities.

If you have questions and/or need TA to assist your jurisdiction in the integrated planning process, please contact your HRSA and CDC project officers. HRSA and CDC look forward to continued work with all partners and stakeholders involved in HIV prevention and care planning to accomplish the national goals set forth in the National HIV/AIDS Strategy (2022-2025). 

NASTAD Status-Neutral Webinar Series  

NASTAD hosted a four-part webinar series, “Employing Status-Neutral Approaches to End the HIV Epidemic”. The series focused on status-neutral approaches for CDC- and HRSA-funded health departments working to end the HIV epidemic.

The first webinar in the series, “Status-Neutral Approaches 101” was held on December 14, 2021. The recording and slides can be viewed here. 

The second webinar in the series, “Trauma-Informed Approaches to HIV Services” was held on January 14, 2022. The recording and slides can be viewed here.

The third webinar in the series, “Addressing Social Determinants of Health through a Status-Neutral Lens” was held on February 8, 2022. The recording and slides can be viewed here. 

The final webinar in the series, “Status-Neutral Messaging and Promotion for EHE” was held on March 8, 2022. The recording and slides can be viewed here. 

EHE Spotlight Video Series 

The EHE video series shines a spotlight on the disruptively innovative work of eight EHE jurisdictions across the U.S. The series comes just after the Biden-Harris administration renewed the U.S. government’s commitment to ending the HIV epidemic on World AIDS Day by requesting $670 million to support the EHE initiative in FY22. With the ambitious goals of reducing new HIV transmissions by 75% and increasing viral suppression of people living with diagnosed HIV by 95% by 2025, EHE jurisdictions are charging ahead to bridge the gap between prevention and care. 

With the aim of advancing EHE goals and supporting the 57 EHE jurisdictions in their efforts to diagnose, treat, prevent, and respond to the HIV epidemic, each video offers real stories of action, lessons learned in the field, and tips for replication. Viewers can expect to learn about strategies and activities including: 

Click here for additional information.

NASTAD Webinar Recording: Diversifying PrEP Financing: Strategies to Leverage Funding across the PrEP Care Continuum 

On March 9, 2022, NASTAD hosted a webinar as a follow-up to the release of the, “Diversifying PrEP Financing: Strategies to Leverage Funding across the PrEP Care Continuum” resource. Recent changes to the PrEP medication landscape have impacted the way 340B covered entities are able to generate program income from PrEP medications. These changes have led to declining revenues resulting in the potential destabilization of program and client support systems aimed at increasing PrEP access. This tool provides an overview of these landscape changes, discusses the impacts of these changes, and explores opportunities to meet the funding needs of PrEP ancillary services.

Minor Consent and Confidentiality Laws for PrEP and HIV Treatment 

NASTAD is pleased to announce the publication of a new resource, Minor Consent and Confidentiality Fact Sheets. This resource was designed specifically for EHE jurisdictions and details statutes related to minor consent and confidentiality for STI and HIV preventive measures, testing, and treatment. It includes separate fact sheets for each of the EHE jurisdictions. The fact sheets interpret and analyze various statutes related to minor consent and confidentiality around a minor’s ability to seek STI and HIV treatment without the consent of a parent or guardian. Additionally, they further interpret statutes’ applicability to a minor’s ability to receive PrEP without parental or guardian consent and detail potential protections or release of information regarding a minor’s treatment through Explanation of Benefits (EOB) from insurance companies. The fact sheets can be found on NASTAD’s website and are linked here. Please contact William Lee if you have questions.

Cross-Jurisdictional Data Sharing: Legal, Practical, and Ethical Considerations for Improved Infectious Disease Cluster Response 

NASTAD, in partnership with the ASTHO, released Cross-Jurisdictional Data Sharing: Legal, Practical, and Ethical Considerations for Improved Infectious Disease Cluster Response. The resource seeks to address legal, practical, and ethical considerations to support health department decision-making concerning cross-jurisdictional data-sharing practices relating to HIV and viral hepatitis clusters and outbreaks and offers recommendations for how health departments can improve outbreak preparedness measures through preemptive cross-jurisdictional data-sharing arrangements. 

Lancet Article: Estimating naloxone need in the USA across fentanyl, heroin, and prescription opioid epidemics: a modelling study 

“Opioid epidemic type and how naloxone is accessed have large effects on the number of naloxone kits that need to be distributed, the probability of naloxone use, and the number of deaths due to overdose averted. The extent of naloxone distribution, especially through community-based programmes and pharmacy-initiated access points, warrants substantial expansion in nearly every US state.” 

NACCHO Releases an STD Registry – Guide to Sexually Transmitted Disease Clinics in the United States 

NACCHO has developed an STD Registry, a searchable tool for locating STD clinics and services. We encourage any clinic devoted to examining and treating STDS and/or clinics that have staff and service hours dedicated to STDs to register. Please use the following submission form to add your site to the registry.

2022 Model and Innovative Practice Award Applications Now Open

NACCHO’s annual award cycle for local health departments is now open, and local HIV programs are encouraged to use this opportunity to share about your ongoing Ending the HIV Epidemic work. In particular, the Innovative Practice Awards recognize adaptations and innovations created in response to the COVID-19 pandemic and related challenges such as changes in staffing structures and outreach practices. These awards are vital to highlighting and sharing promising practices at the local level. Please consider this opportunity to showcase your teams’ hard work and/or share this opportunity with your local health department partners! For questions, contact model-practices@naccho.org and CC ehe@naccho.org.

LEARN Harm Reduction (HR) Applications Are Open! 

LEARN HR consists of virtual group sessions, coaching sessions, and completion of a harm reduction-centered project over the course of 7 months supported by a $10,000 stipend. Individuals must be located in the 12 Southern states (AL, AR, GA, FL, LA, KY, MS, NC, OK, SC, TN, TX) to apply for this program. Organizations in EHE jurisdictions are encouraged to apply. No prior experience in harm reduction necessary, and applicants will work with coaches to develop their projects after selection for participation. More information can be found within the application. Please reach out to Katie McCormick with any questions. 

Share the STD Registry on Social Media Now and Through STD Awareness Week (April 10th – April 16th)  STD Awareness Week is April 10th - 16th, so start spreading the word about NACCHO’s STD registry! The STD Registry will serve as a searchable tool for existing STD clinics and their services. Any clinic devoted to examining and treating STDS and/or clinics that have staff and service hours dedicated to STDs can register. View suggested tweets, posts, newsletters entries, and images by clicking the link above!

NACCHO Wants to Know More About Health Departments and Telehealth Services/Practices!  NACCHO is interested in learning more to ensure LHDs have the resources and support to optimize telehealth services and highlight best practices so LHDs can continue to learn from each other. This survey assesses LHD telehealth services. Please complete this survey by 11:59 PM ET on Friday, March 18. For questions or extensions, please contact Shalesha Majors at smajors@naccho.org. (This survey is part of NACCHO’s Sentinel Network, which gives participants an opportunity to shape national technical assistance & engage with colleagues nationwide. Members engage in topics such as HIV, STI, & Viral Hepatitis programs, partnerships, needs, challenges, etc. Sign up here or visit our website for more information.) 

NACCHO Event: Webinar: How do the latest CDC’s Clinical Practice PrEP Guidelines affect you, your patients, and your practice? (Thursday, March 24 at 1 PM EST) 

CSTE Annual Conference Registration is Open  

Early bird registration for the 2022 CSTE Annual Conference June 19-23rd in Louisville, KY is now open and will close on May 5th. The Annual Conference is currently hybrid with virtual and in-person sessions. For the most up-to-date information, please visit the conference website. 

HIV Resources Inventory Compiler – IHAP TAC’s New Tool for Integrated Planning  

The Integrated HIV/AIDS Planning Technical Assistance Center (IHAP TAC) is excited to share its latest tool to support Integrated HIV Prevention and Care Plan development. The HIV Prevention, Care and Treatment Resource Inventory Compiler supports data collection, generates a formatted HIV Resources Inventory table, and includes a dashboard for easy data analysis. The Excel tool can be shared with multiple users to input data for the HIV funding sources they receive, and then combined into one, comprehensive file of all HIV resources in the jurisdiction.

The tool is now available on TargetHIV.org. From this page, you can access the tool, instructions and best practices for use, and a recorded demonstration of how to use the tool. Contact ihaptac@jsi.com with questions or if you need assistance with the tool.

NCSD Webinar: The Availability of HIV and STI Testing and Treatment Services at Crisis Pregnancy Centers 

Date/Time: March 16th, 2022, at 2:00 PM ET 

Crisis pregnancy centers (CPCs) frequently use deceptive tactics, present themselves as health clinics, and provide inaccurate health information toward their goals of deterring people seeking abortions and promoting sexual abstinence before marriage. In this presentation, Dr. Andrea Swartzendruber and Dr. Danielle Lambert will provide background on CPCs and present findings from a recent national study that assessed STI/HIV services provided by CPCs. You can register here. 

NCSD Clinic+ Connect Community Call 

Date/Time: Friday, March 25th, 2022, 1:30-2:30pm ET  Join NCSD to hear from James (Jim) Matthias, epidemiologist, Division of STD Prevention, who will discuss syphilis reinfections. During this presentation, NCSD will cover defining syphilis reinfections, the epidemiology of syphilis reinfections, screening and treatment recommendations, and more. You can register here. 

CheckYourself: A Public Health Solution for Non-Clinic-Based, Self-Collect STI Testing 

NCSD, in partnership with LetsGetChecked, a leading virtual care company, is pleased to announce Check Yourself, a groundbreaking joint program to empower consumers and transform the way state and local health departments offer STD testing. Join us as we walk through the program and conduct a portal demonstration so you can experience workflows, ordering, resulting, and reporting first-hand. You can register here.

EHE Community of Practice (CoP) on NASTAD’s Online Technical Assistance Platform (OnTAP) 

NASTAD and NACCHO manage a virtual Community of Practice (CoP) to support peer-to-peer learning and mentorship for EHE jurisdictions. The EHE CoP is housed on NASTAD’s online technical assistance platform (OnTAP) for those leading their jurisdictions' EHE efforts at local and state health departments, to share resources and news, discuss challenges and successes, access notes from monthly EHE Office Hours calls, and request technical assistance (TA). If you need access to OnTAP, please contact Krupa Mehta. 

Ending the HIV Epidemic Jurisdictional Directory 

NASTAD maintains an Ending the HIV Epidemic (EHE) Jurisdictional Directory. Health department staff members are encouraged to update their jurisdiction’s information using this brief form.   

Jurisdictional Map of Phase 1 EHE Final Plans    

NASTAD released a resource that provides access to Phase 1 EHE websites and plans. Please email Krupa Mehta additional Phase 1 EHE plans for inclusion in this resource as well as any changes to existing plans. 

Job Postings 

Disease Intervention Specialist – Dallas County, TX 

The Dallas County Health and Human Services seeks a Disease Intervention Specialist as part of their EHE initiative. The position: interviews and counsels HIV/STD patients, educates patients regarding the prevention and protection against sexually transmitted diseases and conducts counseling regarding pre and post HIV tests; conducts field visits to identify, locate, and notify patients partners of possible transmission of disease and ensures proper medical care is received; draws blood for HIV/STD tests; conducts seminars to educate private physicians and clinics regarding STDs. 

Peer Navigator – Dallas County, TX 

The Dallas County Health and Human Services seeks a Peer Navigator as part of their EHE initiative. The position: Assists with the initial engagement and linkage to care for HIV positive clients; researches and investigates clusters to identify clients who no longer have care; engages with outreach and Public Health follow-up teams to conduct HIV counseling and testing; disseminates health information in the community to high risk and HIV positive individuals; initiates immediate contact with individuals at high risk of acquiring HIV, people living with HIV, and lost to care and makes appropriate referrals for care; works with the community to provide peer support, assists with the enrollment and retention in medical care and execution of case management and other social services as needed; maintains and reports statistical data as directed by the Operations Manager.

Director, HIV and Harm Reduction - NACCHO 

NACCHO is excited to recruit for a director to oversee HIV and Harm Reduction projects within the HIV, STI, Viral Hepatitis portfolio. The director will lead a fantastic team and projects aimed to strengthen the capacity of local health departments and their partners by providing learning opportunities, developing tools and resources, and providing technical support. An ideal candidate will have familiarity with national HIV programs, funders, and partners, experience working with HIV programs or harm reduction programs at the local level, and experience managing a diverse portfolio of projects. 

News Bulletin

How Jurisdictions are Using the AHEAD Dashboard 

“One avid user of the AHEAD dashboard is the Ryan White/HIV Services Program at the Marion County Public Health Department in Indiana. They work with EHE HIV priority audiences such as, African American men, Hispanic/LatinX women, young adults, foreign-born, transgender, and non-binary individuals. They use AHEAD to track their jurisdictional progress against the goals outlined in the EHE initiative in an effort to create their own county-level EHE dashboard.” 

Congress Slashes Proposed Funding for Overdose and HIV Prevention 

“On March 9, Congress released its proposed final appropriations package for fiscal year 2022. If approved, it will drastically reduce money that lawmakers proposed last year for the Centers for Disease Control and Prevention (CDC) to help prevent HIV/AIDS and overdose, as the United States endures the worst overdose crisis in its history.” 

Pandemic-Driven Health Policies To Address Social Needs And Health Equity 

“Stark disparities during the COVID-19 pandemic led to new health policy funding and interventions addressing social needs and social determinants of health to improve health equity. Lessons from these interventions and similar pre-pandemic initiatives can guide policy makers in designing more permanent approaches.” 

HIV Preventive Care Is Supposed to Be Free in the US. So, Why Are Some Patients Still Paying? 

“A national panel of health experts concluded in June 2019 that HIV prevention drugs, shown to lower the risk of infection from sex by more than 90%, are a critical weapon in quelling the AIDS epidemic. Under provisions of the Affordable Care Act, the decision to rate PrEP as an effective preventive service triggered rules requiring health insurers to cover the costs. Insurers were given until January 2021 to adhere to the ruling. Faced with pushback from the insurance industry, the Department of Labor clarified the rules in July 2021: Medical care associated with a PrEP prescription, including doctor appointments and lab tests, should be covered at no cost to patients. More than half a year later, that federal prod hasn’t done the trick.” 

Centering Sexual Satisfaction in the PrEP Conversation 

“PrEP is extremely effective. But the medical field hasn’t quite figured out how to get PrEP into the hands of people who need it. And part of this may be that conversations about PrEP leave out one important component: sex. Our heteronormative, sexually repressed society prefers not to talk about two men having sex. Historically, the medical response to HIV has focused on pathologizing queerness rather than embracing people’s actual, personal sexual experiences. But what would it look like if we centered sexual satisfaction in the conversation about PrEP? What if we talked about how PrEP actually affects people’s sex lives?” 

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