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Episode 15 Transcript

HIV: Transmission, Prevention, Testing & Treatment

Erin Everett: Hey, everybody. Welcome back to Exclusively Inclusive. I’m your host, Erin Everett, nurse practitioner.

I’m excited for today’s episode because, aside from loving taking care of the LGBTQ population, in general, and subspecializing in hormone replacement therapy for the gender-diverse community, one of the other areas that I specialize in and that I absolutely enjoy doing so is HIV. I’m actually certified as a specialist in HIV through the American Academy of HIV Medicine. What that entails, that just basically means that I have taken care of a certain number of patients living with HIV, I have completed quite a number of continuing education credits to make sure that I am keeping my finger on the pulse and staying up to date with the latest information about HIV and then also passed a test for it, which I’ll be coming up for recertification this year.

HIV Overview: Increasing Awareness

All that to say I’m really excited to talk about HIV today and get a little bit more education and awareness out there to my listeners. It’s still a very relevant healthcare concern, unfortunately. The goal is to, at some point, just be taking care of patients who are already living with HIV and really greatly diminish the number of new diagnoses. We are slowly working towards those numbers, but we really need to work a little bit harder as a community, as a country.

Recent HIV Diagnoses Statistics

Just to give you a little perspective on that, last year, or actually, I guess not last year, 2018… I still forget that we’re in 2020. In 2018, there was 37,832 new HIV diagnoses in the United States. That’s a lot but, of those, 69% were among gay, bisexual and other men who have sex with men. Lumped into that number, actually, is transgender women because they actually don’t ask about gender identity in this particular number.

While we can find other specific data rates for trans people, this 69% does not break that down. 24% were among heterosexuals and 7% were among people who inject drugs, so obviously, we have a lot of healthcare disparities amongst the LGBTQ community and one of them being the rate of HIV diagnoses.

Unfortunately, too, the South is holding steady at having some of the highest rates year after year. The other areas, the Northeast, the Midwest, and the Western areas are doing a little bit better. Some have stabilized. The Northeast has reduced its numbers quite a bit and so has the West. The West has greatly reduced its number of new diagnoses. Here in the South, we need to do a little bit better. That’s part of the reason why I have this podcast. Although it may not make a big impact, hopefully, somebody out there listening will feel motivated to talk to their friends, maybe themselves go get tested, and encourage their friends to also do so.

What is HIV?

Okay, so HIV, what is it? Well, HIV stands for human immunodeficiency virus. It’s a virus that, once infected into the host cell, it attacks the CD4 cells, which is probably better known amongst lay people as the T-cells. You know that everyone needs to talk about their T-cells, “What’s your T-cell count?” Now we refer to it as the CD4 cell even though it’s the same thing.

How HIV Infects Cells

When the HIV virus enters that cell, it replicates. During that replication process, the CD4 cell can no longer function as an immune cell for the host. Basically, as a healthcare provider, when we’re measuring and staging somebody’s HIV virus, we’re looking at the number of those CD4 cells because a lower number is representative of being more immunocompromised, meaning your immune system is a lot weaker. If you have a very nice high CD4 count, your immune system is still holding strong.

Over time, without treatment, the number of those CD4 cells continue to decrease and become destructed, so you have less functioning immune cells. We also see a rise in CD8 cells, which are also component of the immune system, but they also create a lot of inflammation, and so we look at those cells, not so much to show whether treatment or not is working, but also to kind of track longterm prognosis for patients.

Three Stages of HIV

Overall, there are three stages of HIV.

Stage 1: Acute Infection

After somebody contracts HIV, they’re in Stage One, the acute infection. Typically, during this time, people aren’t necessarily aware that they’ve contracted HIV. Sometimes, in very few cases, you might present with symptoms three days after contracting the virus, but that’s less likely. More often than not, people will present with symptoms two to four weeks after having an exposure to the virus.

Stage 1: Early Symptoms of HIV Infection

When I say symptoms, usually most commonly, if people are going to have symptoms, because of course, some people do not have symptoms, they may experience flu-like-illness-type things where you’re going to have a sore throat, a very high fever, chills, body aches, pains. You may even present with a red inflammatory rash that’s kind of itchy that usually doesn’t last for too long. That’s coined the HIV rash. I would say the majority of people that I’ve dealt with have not experienced that, but it’s definitely possible.

Stage 1: Rapid Virus Replication

During this stage of the acute infection, the virus is taking over the immune system, and that’s why the immune system is having a response that presents as fever and illness. It’s also when it’s rapidly replicating, so during this acute phase is when somebody is extremely contagious and most likely to transmit the virus but least likely to know that they even have the virus.

It’s a very important distinction because, if you are someone who is at risk for contracting HIV and you know that you may have had a high-risk exposure within the few weeks prior to you having these symptoms, it’s really important to go get tested even if you are on PrEP. PrEP is 99% effective, 99 not 100%. Unfortunately, some people, for various different reasons do contract HIV while taking PrEP, so if you are having these symptoms and you’ve had an exposure within the last three to six weeks, actually, really we could say, then it’s really important that you go and get a repeat HIV test.

Say you’ve had acute HIV infection and you did not seek care, perhaps you thought it was just a common cold or an actual flu.

Stage 2: Clinical Latency

After the acute stage is over, the second stage is the clinical latency, which is kind of a period where HIV is inactive or dormant. Really, that’s kind of a misnomer because it’s not dormant. It’s still replicating, just at a much slower rate. People will still have a viral load, but we’re talking about how a viral load may have gone from the millions now down to the low thousands. It’s kind of just steadied out.

Stage 2: Reduction of Symptoms

During this time, people will often not have any symptoms of HIV. They have no idea they have it. They’re at risk for transmission because they don’t know they have it and they still have a viral load. That means circulating virus in their blood and in their bodily secretions. This phase is really dependent on how long it can last for. I’ve seen patients in the clinical latency phase without treatment for five or so years before their CD4 count drops. Other people can live like for a long time, and that’s less likely.

However, regardless of how long someone can live within this Stage Two without treatment, it’s never recommended because, during that time, you’re still able to transmit the virus and, also, you’re creating extra inflammation in your body, slow destruction of your immune system. All that inflammation can cause all their chronic illnesses, which we’re not going to really touch on today, but of course, we will on another episode.

Stage 2:  Slowing of Virus Replication

The other important thing to remember about Stage Two is that, even though the virus is not replicating at the rapid rate that it is during the acute phase, it’s still replicating. It’s still taking over the CD4 count. When you have a high viral load, your CD4 count is going to be lower. As the viral load’s persistently elevated, the CD4 count will continue to slowly decline. At what rate? We don’t know because it’s different for different people, but that will eventually progress to Stage Three.

Stage 3: Acquired Immunodeficiency Syndrome (AIDS)

Stage Three is acquired immunodeficiency syndrome or AIDS, technically defined as when the CD4 count drops below 200 or if there’s an AIDS-defining illness attached to it. An AIDS-defining illness would be an opportunistic infection, an infection that people with healthy immune systems would not get. There’s a cluster of these infections. I won’t go into all of them because I want to keep this simple for listeners, but there are a lot of different infections that, as providers caring for this community, when we see them, we can kind of tell what someone’s CD4 count would be.

Stage 3: Prognosis without Treatment

Without treatment, people typically don’t live very long in the AIDS stage. Their immune system is completely suppressed. They can get a slight cold or flu or other infection that’ll eventually… their body won’t be able to fight. Technically, they’re not dying from AIDS. They’re dying from another infection, but it’s because of the AIDS. With modern day treatments, we have excellent antiretrovirals, which are drugs that we take for HIV that, when someone gets tested frequently, we can catch them before they get into Stage Three. If you are on treatment and you stay on treatment, there’s really no reason why you would go to Stage Three. We have great drugs.

That’s another reason why we’re dealing with a lot of chronic illness in HIV patients that we didn’t have to deal with before, because the drugs are so good. Now we’re worried about, okay, well, it’s not going to be HIV that’s going to take you out. What else is it going to be? Is it going to be your diabetes? Is going to be your high blood pressure? Is it going to be your sleep apnea, your heart disease just like anybody else?

Stage 3: Prognosis with Treatment

In fact, if people are diagnosed with HIV and get started on treatment relatively quickly, their life span is only, on average, nine months shorter than someone not living with HIV. That’s pretty darn good considering the epidemic that we’ve been through and all the years of fighting this virus and getting people to live through it.

I also just want to state people are really infectious, like I said, in the acute infection stage or Stage One, but they’re also very contagious and infectious in Stage Three because, like I said about Stage Two is when you have… The viral load is increased, and the CD4 count’s continually dropping. If someone has less than 200 CD4 cells, their viral load is going to be high. It’s going to be up in the higher thousands. Maybe for a few years, they were stabilized. Their viral load might’ve been somewhere between three and 8,000. Well, now they’re down to the AIDS stage. Their viral load’s probably going to be in the 50 to 60, 70, 80,000, and the CD4 count’s going to be very low.

The more amount of circulating virus in your blood and your bodily secretions, the easier it is for you to transmit the virus to somebody else, so that’s really important to note. Aside from your own personal health and journey, it’s so important to stay on treatment and to get treatment if you are HIV-positive so that we can reduce the rate of transmission.

I know that’s a lot of information, and I try my best not to explain it too complicated, but if you do have any questions about the stages of HIV or any questions relating to any of it, please feel free to email me at erin@exclusivelyinclusivepodcast.com.

HIV Testing

Now that we’ve talked about what HIV is and the three main stages of HIV, I want to talk to you about testing and transmission.

Types of HIV Testing

If you feel that you’re at risk for HIV, it’s really important that you get tested. There are multiple different ways to get tested. The most reliable way is through the fourth-generation HIV test. There are some clinics that do a rapid version of this where they can process it and look for the p24 antigen. That’s the important part about the fourth generation. It’s not just testing for the antibodies. It’s also testing for the antigens, and it’s also specifically looking for the p24 antigen, so it’s the most reliable. You can actually get a positive test with a fourth-generation as early as 15 days after an exposure.

Some of the other tests take a little bit longer because they’re just looking at the antibody. If you do a oral swab, they’re also very reliable, but they’re not as reliable in the early stages of HIV because there’s less concentrated HIV virus circulating in the saliva. If it’s been a while since you’ve had an exposure, the oral swabs are about 98.1% effective in detecting HIV, but if it’s been like two weeks, you’re really likely to get a false negative, so it’s important to keep that in mind.

If you do believe that you’ve been exposed to HIV and you want more reliable testing, I highly recommend that you find a clinic that’s offering testing. Talk to your healthcare provider about whether they’ll test you in office. There’s a lot of free testing centers. There’s also health departments that will do testing. They all do the fourth-generation testing as well. Actually, and I’ll post some resources, but the CDC does have a great website called gettested.cdc.gov where you can actually visit that website, and you can put in where you’re located, and they’ll find testing centers around you.

Rapid HIV Tests

One of the things that’s important to note, as well, is some of the rapid testing. Like I said, there’s the fourth generation that looks at the antibody and the antigen that is really reliable, but it can also be done as a rapid finger prick. It takes about 30 minutes, though, for it to result, so when I say rapid, you don’t have to wait a few days, but you do have to wait at least 30 minutes.

The other one was the second generation, which is just looking at the antibodies. That one takes about 20 minutes. It’s still pretty reliable. It’s just going to be less reliable in that acute phase, so if you’ve had a recent exposure, you definitely want to go and get tested with the fourth generation where you’re going to get the most accurate results.

All of these, if you’re concerned about it and you test negative, the recommendation is to test, really, once a month for the next three months, but with the fourth generation, if you know you haven’t had any sexual intercourse or IV drug use within the previous three months to testing and you get a negative, you can feel very confident that you’re negative for HIV.

Nucleic Acid HIV Test

There is another type of testing called the NAT or nucleic acid test, which is really just testing for viral load. If somebody comes into our clinic and they feel like they’ve been exposed to HIV within the last three to four weeks, what we often will do is the fourth-generation HIV test, and we can also run a viral load, particularly if they feel like they might be showing signs and symptoms of HIV like that fever, chills and whatnot, and they’re concerned about an exposure. We’ll normally run the regular HIV panel but also do the viral load. The viral load will obviously be a great confirmatory test because if there’s no detectable viral load and the HIV test is also negative, you can feel pretty confident with that result.

Anonymous HIV Testing

Okay, so we covered what HIV is and the different types of testing you can get to get tested for it. Aside from the types of tests, there’s also anonymous testing. Certain centers will offer this where you just get a unique number to identify you. Your name and your date of birth and nothing is tied to it, and so it’s strictly anonymous. Of course, if you get an over-the-counter or a mail-order oral swab, that’s also going to be anonymous because the results are not going to be reported to the health department or your primary care provider.

Outside of that, all the other testing is confidential. It’s not confidential if you decide to tell somebody or sign a medical records release allowing somebody else to know about it. Confidential testing is like if you came into my clinic and we’re doing a routine testing. That’s considered confidential. Yes, your test results are tied to your name, your date of birth, and it is reported to your insurance carrier because we bill for the test, but it’s confidential. It’s against the law for me to share that information with anybody.

I do encourage patients to tell their partners or anyone that they may have exposed to the virus, and you can do that anonymously through the health department as well or you can have that conversation with your partners, but it is really important because, if you have contracted HIV and you’ve had sexual or IV drug use with other people, it’s important that they get notified so they can get the appropriate testing and potential treatment.

HIV Transmission

Okay, so how is HIV transmitted? Hopefully, people are a little bit more educated on this than in previous years, but it’s still really important to go over it.

How HIV is NOT Transmitted

First things first, HIV is not transmitted through air or water or saliva or open-mouth kissing or sharing toilets or through vectors like mosquitoes or other insects. No, you cannot get HIV that way.

Most Common Ways HIV is Transmitted

Sexual Intercourse

The most common form of HIV transmission is spread through intercourse, whether it’s anal or vaginal sex.

IV Drug Use (Sharing Needles/Syringes)

The other most common transmission is sharing needles or syringes. It’s really important that for, even if somebody is struggling with IV drug addiction, to use clean needles because, even when on PrEP, PrEP’s only effective for IV drug users up to about 74% of the time because it’s so much more of a high-risk exposure because you’re literally taking the other person who is living with HIV’s blood and injecting it into your vein, so it’s nowhere near as effective for IV drug use as it is for sexual intercourse.

For the HIV-negative partner, any kind of receptive sex either… if you’re having anal sex, it’s commonly called bottoming, is the highest risk sexual behavior, but you can definitely still get it from topping or insertive anal sex. The same thing true is for vaginal sex, which is if someone’s penetrating the vagina and the person penetrating has HIV, you’re more likely to get it because both the vagina and the anal area create a kind of a perfect environment for HIV transmission. They’re both closed off from oxygen because… HIV is a fragile virus. It doesn’t live very long on the surfaces. It has a lot of vascular tissue. There’s always a little bit of trauma even though it’s not felt as trauma, but during penetration and intercourse there’s a little bit of trauma that makes those tissues a little bit more friable, so if there’s a high viral load in the person’s semen and it is ejaculated into the vagina or anal area, then it’s very high risk for transmission.

Mother-to-Child During Pregnancy

One of the less common ways that HIV could spread is from mother to child during pregnancy or birth of breastfeeding. I mean the risk can be high if the mother actually is living with HIV but not actually on medication, they have a high viral load. It can definitely pass through the placenta, but if the mother is on treatment, it’s very, very unlikely that it would be transmitted to the child.

Accidental Needle Sticks

Also, healthcare workers, sometimes they’re concerned about needle sticks. It can happen, but it’s less likely to because, again, the person who had the blood in the needle would have to have a very high viral load, and it would have to be kind of into the vein rather than just the skin bed depending on where the needle got stuck, so it is a risk, but it’s less risky. It is important for healthcare workers to know that, though, because if you did have a needle stick at work or anything like that or came into contact with bodily fluids and it went into the eye socket or anything like that, you’d want to go and talk to your occupational health and get on postexposure prophylaxis.

Oral Sex is Low-Risk for Transmission

In general, oral sex is extremely safe as far as HIV transmission is concerned. It’s very unlikely that someone would contract HIV through either oral sex or fellatio, cunnilingus or rimming. In general, it’s just difficult because there’s not a lot of HIV circulating in the saliva. Unless somebody had a lot of sores in their mouth or around the anal area and they were performing oral sex on you and their saliva that had a high viral load in it was able to get into one of the sores or penetrate one of the sores, then you’d have a higher risk of transmission, but in general, oral sex is considered a very low risk and safe sexual practice when preventing HIV transmission.

STDs Increase Risk of HIV Transmission

One of the other things I think is really important to mention is HIV risk and transmission can actually increase if there’s other STDs present. HIV is often diagnosed in conjunction with syphilis, but also, especially for someone who’s bottoming, if they have any rectal gonorrhea, chlamydia, there’s extra inflammation and swelling of that tissue and, 9 times out of 10, the rectal chlamydia and gonorrhea is asymptomatic. However, if the person who’s topping you has HIV and they’re not on medicines, then you’re more likely to get HIV because you have just taken already a friable and perfect environment for HIV and made it even more perfect by having the swelling and inflammation. It’s just, with the trauma, the burden of the amount of HIV and STD on the rectal tissue is just too much for PrEP to even really prevent it.

In some of the cases where we’ve seen PrEP fail has been when there’s a high STD burden in the rectal tissue, so it’s really important… I know I preach about this all the time, but it’s really important to go into your healthcare provider and make sure you’re getting your gonorrhea and chlamydia swabs both in your throat and your rectum and then also sending off urine for testing as well. One of the main reasons, too, is not only for your long-term health to stop the spread of STDs but also to reduce your risk of getting HIV while you’re on PrEP.

Undetectable = Untransmittable

Recently, there’s been a lot more talk about U equals U. That means undetectable means untransmittable. According to the Health and Human Services Task Force, that means anyone’s viral load less than 200 which, of course, if you’re a person living with HIV and listening to this or your partner has HIV, you know that, in the office, when we’re talking about HIV being undetectable, we’re talking about less than 20 copies.

That actually gives a lot of people more comfort because, every now and then, someone’s viral load may blip up is what we call it, so go from less than 20 or being undetectable, and it might blip up to like 50 or 80 if they’re sick or they had a flu shot or something else is going on, but that’s not healthy virus and it’s not likely to be transmittable to other people. That’s why the Department of Health and Human Services actually call undetectable less than 200 viral copies, so you have wiggle room there.

People don’t have to stress out that, if their viral load went from less than 20 up to 50, that they’re going to transmit it to their partner, because that’s just not the case at all, according to the CDC and the data. Of course, nothing is 100%, so I still tell patients to exercise caution, but we do know that, if you’re undetectable, it’s you’re untransmittable.

HIV Treatment

We’ve covered the main reasons and the main ways that HIV is transmitted. What about treatment? Say you found out that you have HIV and you want to get treatment. Should you start treatment right away? Should you wait to get treated? What types of treatment are there? We’re going to cover all of that.

Like we talked about before, HIV is a type of virus. Well, it’s specifically a retrovirus, so the treatment that we use for HIV is called antiretroviral therapy or ART. There’s a lot of different regimens that a person can take, and thank goodness for science. We’ve come a long way on the types of medications that we have and their tolerability.

There’s a lot of different options for someone who’s, what we call, treatment-naive or have never been on HIV medications before. I’m not really going to cover people who have been on different types of regimens and might have resistance and drug switching and that type of thing. I just want to keep it simple with treatment-naive. We can cover those other things in following episodes.

Importance of Starting HIV Treatment Right Away

In general, when someone is tested for HIV, it’s important that they start treatment as soon as possible. We used to think that waiting until the CD4 count dropped a little bit was better, but now we’re finding that the sooner that a patient gets on treatment, it actually reduces their risk of chronic long-term illness related to HIV. Not only does it reduce their risk, but it also reduces the risk of transmission to other people because, the sooner you start treatment, the sooner you can become undetectable.

Viral Load is an Indicator for Development of Comorbidities

There’s a lot of correlation between how high the viral load and how low the CD4 count was to long-term prognosis as it pertains to the development of diabetes, heart disease, HIV-type cancers and things like that. If somebody is tested and treated right away, we’re hoping that it’s going to be closer to when they’re in the acute phase or they’re not too far into Stage Two, the clinical latency phase, so that we can prevent them from having additional long-term side effects of their HIV.

As I mentioned before, people who are treated with antiretrovirals and stay on their treatment have a similar life span to somebody who’s not living with HIV.

Side Effects of HIV Treatment Medications

Of course, some of the HIV medicines does cause side effects. However, none of the side effects, at this point with the new medicines that we have, include death, so they’re always going to be a better option to not taking medicine. Let me just say that. For the most part, a lot of the newer drugs are very well tolerated. When first starting the medication, you might experience some GI upset like nausea, vomiting, maybe a little bit of diarrhea, dry mouth. Some people might notice changes in their sleep patterns. That’s not as well documented. That was more so with some of the older drugs that we use that we’re currently phasing out.

We’re getting a little bit of data that maybe some of the drugs now might cause a little bit of weight gain, but it seems to be pretty minimal, maybe five to eight pounds. Depending on when you started treatment, being off treatment and living with HIV can cause weight loss, so sometimes it’s a good thing if you’re gaining weight. It means it’s like your return to health weight, and we expect that.

Importance of Adherence to HIV Medications

In general, HIV medication is designed to be very adherent. If somebody is not ready to be on medication or has a hard time remembering to take medication, it is a really good idea to have that conversation with your provider because someone who’s specialized in HIV medicine is going to be able to sit down and talk you through it because there’s going to be medicines that are a little bit more forgiving for busy schedules. Some of the medicines can be taken with or without food. Others you have to take with a small meal, and you have to very careful with over-the-counter supplements, and so it’s really important that you sit down with your provider and we come up with a plan that’s going to be best suited for you.

I take care of a lot of flight attendants. I take care of a lot of people who travel for business and are on different time zones and who can’t take something at the exact same time every day. That’s okay. There’s an option for them too. That’s why it’s so important to have these conversations at diagnosis or, if you’ve been diagnosed and you’ve been too scared to get treatment, I highly encourage you to get on the CDC’s website. They have provider finders who can link you with good care.

Don’t be scared. You deserve to be on treatment. You deserve to live a long, happy life. It can be scary at first, but once you find the right provider to hold your hand and walk you through it and give you all the tools and the information, for the one time ever, you’re going to feel in control of your virus because you will have control. You will have all the control as long as you take the medication and you can tolerate it and you have access to it. You’re in full control of your HIV course and your journey.

Missing Doses of Your HIV Medication

I said HIV medicine really needs to be taken every single day. What happens if you miss a dose? Well, that just depends. It depends on the medication that you’re on. It depends. When you say miss a dose, is it miss a dose or you missed it for a week and then started it for a week? In general, missing one to two doses a month is not going to cause a huge issue. Missing several days at a time and starting and stopping your medication will cause you to become resistant to that medication depending on which one it is, but for the most part, you will develop some sort of resistance to your regimen.

Each regimen is consisting of three different drugs, and they all have different types of resistances that they can get, and so if you’re really having spotty adherence or forgetting your medication for weeks at a time and then restarting it again, you need to have that conversation with your provider so we can get you on something that’s going to work better for you. Otherwise, you’re going to put yourself into a category where you’re not going to have a lot of options for your HIV treatment, and you could have a more advanced illness because it’s harder to find medications that work for your virus.

If it’s side effects that stop you from being able to tolerate your medications, have a conversation with your provider. There are other medications that you can try. There are other things that we can do to combat side effects. If it’s swallowing pills, there are certain that are available in liquid. Some can be crushed. Some of them now are so tiny that, for most people, it’s not an issue to swallow them.

We talk about busy schedule getting in the way. That’s a really important one because even… We’re all human. We all have the best intentions. I really truly believe that, after I go over this with my patients and they leave with a new regimen, they have every intention of taking it and being adherent to it, but sometimes life gets in the way.

The other thing is someone is tired or depressed or anxious. It’s really important that we manage those things, as well, to make it easier for them to stay on their regimen and live a long, healthy life. HIV aside, anytime somebody is anxious or depressed, they deserve to feel better, and your provider can equip you with tools, whether it’s medications or psychotherapy, but particularly those living with chronic illness because it is really common to have depression related to chronic illness. People can get burnt out on their regimens and get burnt out on, quote, living with HIV.

Seek out a Provider to Help Manage your HIV

I don’t know what it’s like to live with HIV, but I can help you through any piece of the treatment, any piece of the medical side of it, and link you to ways to feel better, connect you with support groups involved with other people who are living with HIV who can help you through it. Everybody’s experience is going to be different regardless. Yeah, I definitely like to talk to my patients about that because if they’re feeling burdened by their illness and their diagnosis, then that’s something that we can troubleshoot together as well.

Well, I think that that was a nice little summary of HIV. Of course, I could talk a long time about HIV. It’s a very complicated virus, as I mentioned and as you may be aware after listening to this, and so we’ll continue to talk more about different subjects as it pertains to HIV, but if you have any specific questions or concerns, please feel free to email me at erin@exclusivelyinclusivepodcast.com. That’s erin@exclusivelyinclusivepodcast.com.

Well, thanks again for tuning in, and remember, stay fierce and live your truth, and go get tested.