0:08

Well, hello, everybody, and welcome back

0:10

to the podcast. My name is James Waldron,

0:12

GP Notebook podcaster, and it's really great

0:14

that you can join us today. I'm

0:17

really happy to say that we are

0:19

introducing a bit of this new part

0:21

of the series focusing on HIV as

0:23

a really, really important topic that we

0:25

should be aware about in primary care

0:27

and certainly something we could be doing

0:29

better. I have two guests joining me

0:31

today. I have Dr. Grace Bertoni, GP

0:33

in Lewisham, an HIV and hepatitis E

0:35

champion, as well as a special guest

0:37

today, Dr. Mel Rosenvinger, who is

0:39

a consultant HIV specialist in Lewisham

0:42

as well. Welcome, guys. Thank

0:44

you. Thanks, James. Thanks so much for having us.

0:46

Thank you for having us, James. Oh, well,

0:48

I'm really glad that we've been able to get

0:50

you here to share your experience and your

0:52

knowledge about this topic. First of all, Grace,

0:55

you've helped me set these up

0:57

and we met when you were talking

0:59

about hepatitis C and the like, and you're

1:01

also the HIV champion. Can you tell

1:03

me a little bit more about your role

1:05

and why it's so important for primary

1:07

care? Yes, James. So as you

1:10

said, my name is Grace and I'm

1:12

a GP in Lewisham and I've

1:14

been an HIV champion now for a

1:16

few years. I'm employed by the

1:18

Lewisham Council and also more recently by

1:20

the Fast Track Cities London initiative. And

1:23

really my role is to

1:25

raise awareness about HIV. particularly

1:29

in primary care, focusing on

1:31

reducing the stigma amongst

1:33

healthcare professionals and healthcare teams

1:35

and increased testing really

1:37

in primary care. So I'm

1:39

hoping to be able

1:42

to give the GPs

1:44

listening a bit more confidence

1:46

surrounding HIV. And it's

1:48

a wonderful mission to have because I think

1:50

increased confidence and understanding about this is

1:52

so important for everybody involved. You managed to

1:54

link us with Mel today and so

1:56

glad to have you today, Mel. Would you

1:58

like to introduce yourself? Yes,

2:00

of course. My name is Mel

2:02

Rosenvinger. I'm a consultant. I work

2:04

at Lewisham and Greenwich Hospital. I've

2:07

trained in various hospitals around

2:09

London and have specialised particularly

2:11

in HIV medicine. I'm very

2:13

pleased to be on this

2:15

podcast. Well, we're so glad

2:17

to have you. So much expertise in the

2:19

room. Well, so I think without further ado,

2:21

let's really get into it. And it's going

2:23

to sound like a really straightforward question, but

2:25

I think it's important to start at the

2:28

beginning. What is HIV? Let's

2:30

just have a reflection on what we

2:32

mean by HIV. So

2:34

HIV stands for the human immunodeficiency

2:36

virus, which is a bit of

2:39

a mouthful, which is why pretty

2:41

much everyone says HIV. So

2:43

going back to basics, this is

2:45

what I tell my patients who've been

2:47

diagnosed with HIV. It's basically a virus

2:50

which infects the immune system. It infects

2:52

a type of white blood cell called

2:54

a CD4 cells, which I always liken

2:56

to being a bit like the generals

2:58

of an army that help your body

3:00

fight off infections. You can get sick

3:02

from the HIV virus itself. Like when

3:05

you first get the infection, you might

3:07

be really ill with like a flu

3:09

-like illness. You

3:11

can also get sick because your

3:13

immune system is no longer able

3:15

to fight off infections or repair

3:17

itself against damage that causes cancers

3:19

and things like that. It's

3:22

a very fascinating virus

3:24

and quite complex. And

3:26

it sounds like it impacts on

3:28

lots of different symptoms. You mentioned

3:30

there about cancers and general other

3:32

processes. Does it impact on, I

3:34

suppose, our health overall? Because I

3:36

know it's got some relation to

3:38

cardiovascular disease and the like. So

3:41

HIV is multisystemic and it

3:44

sort of presents itself quite

3:46

differently in each individual. I

3:48

think when we come to

3:50

understand a bit more about

3:52

our own genetic makeup, we'll

3:55

understand that a bit more.

3:57

So, yes, people can get

3:59

unwell from this sort of

4:01

more special HIV related things,

4:03

but also just because if

4:06

you've got that ongoing inflammation

4:08

in your body. then you

4:10

may be more likely to

4:12

have things like a heart

4:14

attack, which I think is

4:16

underestimated, actually. So just getting

4:19

somebody on treatment reduces their

4:21

all -cause mortality from HIV

4:23

and from related conditions. And

4:26

I think this is a really

4:28

important place where GPs can be

4:31

advocates and help update people. Grace,

4:33

what can we as general practitioners

4:35

do to help people understand that

4:37

sort of broader context of HIV?

4:39

Well, yeah, that's a really good

4:41

question, James, because I think what

4:43

historically, I guess, people think that

4:45

HIV is a condition that is

4:47

managed in secondary care and GPs

4:49

don't get involved at all. But

4:51

as Mel said, this is a

4:53

multi -system condition and many of

4:55

the conditions that do develop, like

4:58

cardiovascular disease, are managed in primary

5:00

care. So GPs are probably more

5:02

likely to get... more involved as

5:04

people living with hiv are living

5:06

longer and healthier lives and they

5:08

might develop chronic conditions that are

5:10

managed in primary care so it's

5:12

not something that we can ignore

5:14

yeah well brilliant and i think

5:16

that shows just how important it

5:18

is for us to date ourselves

5:20

about it and one of the

5:22

things that we can also do

5:25

is i suppose help educate people

5:27

on what hiv is and about

5:29

i suppose how how it's transmitted

5:31

we talk a lot about transmission

5:33

here but What do we actually

5:35

mean by transmission and how is

5:37

it transmitted? So

5:39

HIV is passed from one

5:41

person to another through contact

5:43

with certain bodily fluids. We

5:46

mainly think about sex for

5:48

this. So particularly if somebody

5:50

was to have unprotected sex

5:52

without a condom, then they

5:54

may get HIV. Also through

5:56

sharing of injecting equipment, which

5:58

actually is less of an

6:01

issue in the UK because

6:03

we have very good needle

6:05

exchanges. You can also

6:07

pass it from mother to

6:09

child, usually at the time of

6:11

delivery if someone's not on

6:13

treatment or through breast milk if

6:15

somebody's not on treatment. And

6:18

I'm mentioning about not taking

6:20

medications because actually, if somebody

6:22

is taking HIV medicines and

6:24

their virus is very well

6:26

controlled and they're not missing

6:28

any tablets. then

6:31

you can have sex without a condom

6:34

and know that you're not going to

6:36

pass it on to someone else. So

6:38

someone is basically not infectious at that

6:40

point. So we call it U equals

6:42

U, undetectable is untransmittable. Are

6:44

there any considerations for likelihood

6:47

of transmission through those different

6:49

routes that you mentioned? I

6:52

mean, the important thing about the

6:54

U equals U message is that

6:56

it is just incredibly reassuring to

6:58

people. So just to clarify, in

7:00

case I didn't explain it very

7:02

well, but when we say that

7:04

someone is... uh

7:06

undetectable what we mean their virus is

7:08

still there in their blood so if

7:11

they were to stop their medication the

7:13

virus would come back but that the

7:15

virus has basically got it under control

7:17

and we talk about a level of

7:19

less than 50 copies per mil as

7:21

being undetectable and we really want to

7:23

spread this good news message to everybody

7:26

that if somebody's taking their medicines properly

7:28

and their virus is undetectable then they're

7:30

not going to pass it on to

7:32

someone even if they have sex without

7:34

a condom. Also

7:36

for mother to child during

7:38

birth as well, which is just

7:40

a wonderful thing because then

7:42

we can reassure families that they

7:44

can have children without worrying. about

7:47

infecting their children, which I think

7:49

is important. I've also had patients who've

7:51

been reassured who actually aren't sexually

7:53

active anymore. And I had a grandmother

7:56

who said to me, oh, I

7:58

can sleep in the same bed as

8:00

my daughter now. And I was

8:02

like, but you could always sleep in

8:04

the same bed as your daughter

8:06

because HIV is quite difficult to get,

8:08

actually. It's through

8:10

sexual bodily fluids and

8:13

mucosal surfaces. You

8:15

can share drinks. with people that's

8:17

not a problem um and I

8:19

think I think even for people

8:21

who aren't sexually active it's a

8:23

really lovely um reassuring feeling that

8:25

they can go about life as

8:27

normal and we really hope that

8:29

it will reduce stigma because actually

8:31

HIV is not it's not easy

8:33

to transmit and it's quite easy

8:35

to prevent transmission and therefore things

8:37

like sharing cups and glasses and

8:39

things like that is of no

8:42

problem at all Absolutely.

8:44

And toilet seats as well. Because

8:46

I think a lot, you know, I've

8:48

had a lot of patients who are

8:50

worried because they went to a public

8:52

toilet and they're worried that they might

8:54

have acquired HIV. I

8:56

don't know where this information came from, that

8:59

HIV can be transmitted through urine, but it's

9:01

not the case. But

9:03

I mean, there's lots of myths

9:05

and disinformation out there and a

9:07

lot of deeply held worries from

9:09

people. And so I think getting

9:11

the information from really good sources

9:13

and their GPs often being one

9:16

of those sources is so important.

9:18

Exactly. And there's also the misconception

9:21

of who might be living

9:23

with HIV or who we should

9:25

be testing for HIV. I

9:27

think because historically... you know it

9:29

was seen as a gay

9:31

disease back in the 80s and

9:33

it's you know we know

9:35

that that's not the case anymore

9:38

it's you know anyone could

9:40

be living with HIV or be

9:42

diagnosed with HIV and that's

9:44

why we should be offering to

9:46

attest to anybody who asks

9:48

for one but also you

9:50

know, we should be offering it to

9:52

anyone, especially in areas of high prevalence.

9:55

And if you're not sure if

9:57

you're living in an area of

9:59

high prevalence of HIV, you can

10:01

just go on the NICE CKS

10:03

guide, but it's got a link

10:05

to the UK HSA data and

10:07

you can look at your area

10:09

to see if you're living in

10:11

a high prevalence area. I

10:14

mean, my take home about HIV

10:16

testing is if you think about it,

10:19

you should do it. It's an incredibly

10:21

cheap test. When I was training,

10:23

we used to talk about testing people for

10:25

glandular fever. And that was a far

10:27

more expensive test that arguably didn't do very

10:29

much with the result. There

10:31

are certain indicator conditions where we

10:33

think more about testing for HIV.

10:36

um this is um these

10:38

are important to think of

10:40

that we are also now

10:42

rolled out um hiv testing

10:44

in accident emergency departments in

10:46

high prevalence areas so throughout

10:48

london um to pick people

10:50

up because um hiv can

10:52

affect anybody and um Most

10:55

of the late diagnoses that

10:57

we have, so they're diagnosed when

10:59

their immune systems are very

11:01

low and they have a low

11:03

CD4 count. There have been

11:05

multiple opportunities before to test them

11:07

earlier. They've had multiple contacts

11:09

with health professionals. And particularly if

11:12

you don't fit the health

11:14

professionals kind of. idea of who

11:16

might have HIV you can

11:18

be quite delayed in getting an

11:20

HIV test and certainly when

11:22

we first rolled out HIV testing

11:24

in Lewisham A &E we had

11:26

wondered about having an upper

11:28

age limit of the people that

11:30

we tested and the first

11:32

person that we diagnosed was 85

11:34

years old and that pattern

11:36

carried on actually with 20 %

11:38

of our diagnoses being in much

11:41

older adults who It hadn't

11:43

been considered as a diagnosis from

11:45

other people. So it was

11:47

incredibly useful to test those people.

11:49

Well, and like you said,

11:52

Mel, it's about missed

11:54

opportunity sometimes in primary care.

11:56

I remember doing an

11:58

audit locally and the people

12:00

with the late diagnoses, some

12:03

of the things that they

12:05

presented in general practice were things

12:07

that we saw quite often.

12:09

So, for example, seborrheic dermatitis. very

12:12

severe psoriasis, unexplained

12:14

weight loss, unexplained

12:17

lymphadenopathy. What

12:19

was the other one? I think it

12:21

was recurrent thrush as well. And

12:23

chronic diarrhea, that's the other

12:25

one that is seen quite often.

12:29

And also anyone who has an STI,

12:31

who's been diagnosed with an STI,

12:33

don't forget to also offer a blood

12:35

test for HIV and syphilis if

12:37

they've had positive chlamydia or gonorrhea. And

12:40

also with anyone who's had an

12:42

abnormal smear, that's who we should be

12:44

offering an HIV test to. I

12:46

think it's good for us to understand,

12:48

I suppose, to broaden our thoughts as

12:50

to who we might be testing for

12:52

HIV and make it a bit more

12:54

part of the normal conversation that we

12:56

have and, I suppose, reducing some of

12:59

our internal bias and stigma to that.

13:01

Actually, this isn't a big deal. This

13:03

is something we test everybody for because

13:05

of the prevalence locally. Do you think

13:07

that's a good approach? Definitely.

13:10

I mean, we need to normalise HIV

13:13

testing. We've always exceptionalised it. So,

13:15

I mean, there are some things that

13:17

are different in the past. So

13:19

many, many years ago, if you offered

13:21

somebody an HIV test, even if

13:23

it was negative, that would count against

13:26

them in insurance sort of claims

13:28

and profiles, putting that together. Actually, now

13:30

a lot of insurance companies ask.

13:32

somebody to have an HIV test before

13:34

they offer insurance and they do

13:36

offer insurance to people with have who

13:39

have HIV as long as they're

13:41

well controlled and on treatment. And

13:43

I would argue that HIV has

13:45

such a good prognosis and outlook

13:47

with very simple medications to take that

13:50

actually it requires less counselling really

13:52

to talk about it than a lot

13:54

of the other tests that we

13:56

do. You know, if you were going

13:58

to diagnose somebody with end stage

14:00

renal failure, for example, I think that

14:03

would have much more of an

14:05

impact on that person's life. than

14:07

HIV, certainly from a

14:09

sort of medical perspective anyway.

14:13

And it's just, we just want people

14:15

to do the test. So we

14:17

almost want people to deal with if

14:19

it's going to be positive later.

14:21

So when you talk to somebody about

14:23

doing an HIV test, just saying.

14:25

going to do an HIV test we're

14:27

trying to do it in more

14:29

people it's you know a good thing

14:31

to do or I mean in

14:33

A &E departments and we don't even

14:35

necessarily say it anymore as long as

14:37

it's up on the posters around

14:39

for people to see we do have

14:41

to reduce people's concern around offering

14:43

it you are not passing judgment on

14:45

the person in front of you

14:47

you are offering them good care. Absolutely

14:50

I completely agree I think

14:52

a lot of the GPs or

14:54

Healthcare professionals in primary care

14:56

do worry that their patients might

14:58

get upset if they're offered

15:00

an HIV test, so they might

15:02

get angry. But

15:05

even, you know, the worst thing they

15:07

could say is, no, I don't want

15:09

a test and that's fine. But you've

15:11

started that conversation and it might be

15:13

in sort of, I guess, an educational

15:15

moment because you could say, well, you

15:17

know, that's fine. You don't

15:19

want one. That's not a problem. We

15:22

just have to offer it to you. And

15:24

just so you know, HIV is no

15:26

longer a death sentence and there is treatment

15:28

available. And if people are on the

15:30

correct treatment, they can't pass it on. I

15:33

love being able to tell people that it

15:35

really shouldn't affect their life in terms of certainly

15:37

younger people. So I'm like, you can be a

15:39

pilot now. All you need to do is

15:41

take your medicines regularly. You can be a midwife.

15:43

You can be a surgeon. You just need

15:45

to take your medicines regularly. There is nothing that

15:48

you can't do, basically. And so

15:50

when we do see people who

15:52

are HIV positive, we don't use

15:54

old terminology like AIDS, which we

15:56

tend to shy away from because

15:58

there's huge stigma attached to that.

16:00

And we talk about HIV or

16:03

advanced HIV if their immune system

16:05

is quite low. And it's very

16:07

positive because actually there is so

16:09

much that we can do and

16:11

we can keep people healthier. And

16:14

arguably, for some people,

16:16

they get more input from

16:19

medical services. I mean,

16:21

I worked overseas for a

16:23

year and I certainly saw that,

16:25

that the people who were

16:27

in the HIV clinic had better

16:29

treatment of their diabetes and

16:31

their blood pressure and that sort

16:33

of thing than those who

16:35

didn't, which was an interesting outcome.

16:38

And I think... it's

16:40

very important that we

16:42

help people with HIV because

16:44

often they come from

16:46

very poor communities, lots of

16:48

social deprivation, housing, immigration

16:50

issues, stigma, maybe

16:53

even things like domestic violence

16:55

and that sort of thing.

16:57

And as clinicians looking after

16:59

them, we can help them

17:01

navigate the system and we

17:03

can help them to have

17:05

healthier lives. And

17:07

I think desigmatising this as a condition

17:09

and the screening of it particularly,

17:11

which feels like, you know, a thing

17:13

that we should be able to

17:16

do quite easily, feels like a great

17:18

goal to have for primary care

17:20

and inter -extreme primary and secondary care.

17:22

And I think it's also quite nice

17:24

to think that because they are

17:26

getting frequent engagement with healthcare, that they've

17:29

got... you know improve outcomes in

17:31

other respects it's good to hear that

17:33

the diabetes can be better controlled

17:35

but of course you've got to remember

17:37

this the multi -system aspect of this

17:39

and um you mentioned earlier a

17:41

little bit about premature aging and and

17:44

uh and that being a challenge

17:46

for people and of course that just

17:48

makes everything much more complicated yeah

17:50

we've definitely noticed that so um i

17:52

mean we're learning all the time

17:54

um when hiv first became a phenomenon

17:56

that we were aware of in

17:59

1980s obviously at that time there was

18:01

no for it and um and

18:03

people were put on palliative care pathways

18:05

and unfortunately um didn't make it

18:07

and now we then we got better

18:09

drugs against hiv but they could

18:12

still cause some toxicities to the to

18:14

your body um and then um And

18:16

we were able to treat

18:19

HIV and people were surviving.

18:21

Now we have developed even

18:23

better drugs. And there are

18:25

actually also even injections to

18:27

treat HIV. And people don't

18:29

have the same toxicities from

18:31

the medications. But we are

18:33

noticing that perhaps people living

18:35

with HIV, especially those who

18:37

were diagnosed late with very

18:39

low immune systems, they probably

18:41

are aging a bit more

18:43

prematurely. They do seem to

18:45

be at increased risk of

18:47

certain cancers, for example, lung

18:49

cancer. And we

18:51

really need to be

18:54

trying to help them diagnose

18:56

these comorbidities earlier and

18:58

manage them appropriately so they

19:00

can live good and

19:02

productive lives. But really, well,

19:04

what saddens me is

19:07

just that the people who

19:09

are diagnosed late are...

19:11

who tend to be affected

19:13

by health inequalities anyway

19:15

in the UK? Because

19:17

we know that the people who are

19:20

more likely to be diagnosed late,

19:22

and by that we mean with a

19:24

CD4 count, is it less than

19:26

200 ml? Is that right? We talk

19:28

about late. It's a bit historic,

19:30

actually. We used to not give treatment

19:32

to everybody. So we used to

19:34

wait for someone's immune system to drop

19:36

below a level of 350 before

19:39

we started them on treatment. That

19:41

stopped in a sort of

19:44

landmark study back almost 10

19:46

years ago now where they

19:48

randomised people to follow that

19:50

and start treatment when their

19:52

CD4 counts were less than

19:54

350. um and others

19:56

just to start immediately and they

19:58

found that they had to stop the

20:00

study early because there was um

20:02

a reduction in in all -cause mortality

20:05

in those who were on treatment straight

20:07

away and that was like a

20:09

reduction in heart attacks a reduction in

20:11

people having terrible thrombocytopenia um so

20:13

lots of not sort of traditionally necessarily

20:15

thought of to be HIV related

20:17

issues. So we call those who are

20:20

late, those with a CD4 count,

20:22

less than 350. But as you mentioned,

20:24

when your CD4 counts less than

20:26

200, that is a very late diagnosis.

20:28

And at that point, you are

20:30

much more likely to get the sort

20:33

of weird and wonderful infections that

20:35

we associate with HIV. The

20:37

fungal meningitis called cryptococcal meningitis,

20:39

for example, tends to happen to

20:41

people whose CD4 counts less

20:43

than 100. And often when people

20:45

get to that level, they

20:47

can have multiple diagnoses like this

20:49

all at the same time.

20:52

And their chance of becoming very

20:54

unwell and sadly dying is

20:56

much higher if they are diagnosed

20:58

late. So we're really trying

21:00

to get people diagnosed early and

21:02

also because... somebody knows that

21:04

they have HIV, they immediately change

21:06

their sexual behaviour. And if

21:08

they're on treatment and effective treatment,

21:10

then they won't be able

21:12

to pass it on to others.

21:14

So it's not only helping

21:16

the individual, it also prevents onward

21:19

transmission, which is incredibly important. And

21:21

I mean, I think that's a wonderful

21:23

point that we've ended at here, that by...

21:26

The only way we can really help

21:28

people and help people earlier, and we know

21:30

that the outcomes are so much better

21:32

if we get that early, is by screening

21:34

and by thinking about it and by

21:36

incorporating it to our day -to -day practice, being

21:39

good at asking about it, screening. You

21:41

mentioned checking in A &Es. I'm not sure

21:43

if that's, is that around the country or

21:45

is that just in London? It is

21:47

around, it's definitely around England. More

21:49

than 100 emergency departments around England

21:51

are now doing opt -out testing and

21:54

more to come, I think. Yeah,

21:56

so NHS England have been rolling it

21:58

out. It's been such a successful project.

22:00

So they've been rolling it out in

22:02

areas of higher prevalence of HIV. So

22:05

it does depend on what the

22:08

local sort of rate of HIV

22:10

is. What I would say, though,

22:12

is even when the... when

22:14

the sort of pickup rates drop

22:16

it will still be so useful

22:18

to do that because if we

22:20

actually want to get to the

22:23

um you know the who and

22:25

the uk intention of us having

22:27

zero hiv transmissions by 2030 we're

22:29

going to have to you

22:31

know, work harder at finding those

22:33

cases. Because if somebody knows

22:35

they have HIV, then we are

22:37

going to prevent them giving it to

22:40

somebody else. And that's

22:42

where I worry a

22:44

little bit about things

22:46

like the funding of

22:48

international HIV projects. If

22:51

that is reduced, as we've heard

22:53

in the news just recently, that may

22:55

mean that more people go without

22:57

treatment. And then when they become viremic,

22:59

they may be more likely to

23:01

pass it on to others. And we

23:03

cannot treat HIV in isolation as

23:06

the UK. We know this from the

23:08

COVID pandemic is that, you know,

23:10

we're all linked. So

23:12

it does need an international approach. And

23:16

advocates, you know, such as Grace, such

23:18

as yourself, such as hopefully everybody that's

23:20

been listening to the podcast today is

23:22

going to become an advocate for more

23:24

testing, you know, opening up those conversations

23:26

and really taking that message out there.

23:28

And wouldn't it be great if we

23:30

could take this across the UK and,

23:32

in fact, to the rest of the

23:35

world to encourage that collaboration and free

23:37

medication? Well, the UK

23:39

are complete leaders in this. Actually,

23:41

what we've done in terms

23:43

of managing people with HIV since

23:45

the beginning of the pandemic

23:47

is fantastic. In terms of getting

23:49

people diagnosed and on treatment, we

23:52

should give ourselves a bit

23:54

of a... a pat

23:57

on the back for doing quite well

23:59

with that although I do worry that

24:01

sometimes some of our publicity campaigns and

24:03

things like that in the past unfortunately

24:05

did increase stigma quite a lot and

24:07

I would really like that to be

24:09

something that we looked at going forward

24:11

is that you know people with HIV

24:13

on treatment they're not going to pass

24:15

it to anyone else please you know we

24:18

should stop making assumptions about how they

24:20

got it and people's lifestyle choices because it

24:22

really can affect anyone. So we've talked

24:24

about a lot today. We've talked about transmission.

24:26

We've talked about screening and really the

24:28

importance of picking things up. And I'm glad

24:30

to say that we've got a second

24:33

part of this first opening bit of our

24:35

HIV podcast series on treatment and about

24:37

what actually happens after that, you know, that

24:39

we detect it in primary care. So

24:41

I'm really looking forward to that. And then

24:43

also we're going to be doing... one

24:45

a little bit later on on stigma and

24:48

language and trying to understand the impact

24:50

on the patient. So we're really covering all

24:52

of the bases here. And finally, another

24:54

one on PrEP and helping to prevent that

24:56

as well. So we've got an awful

24:58

lot of things to cover and I'm really,

25:00

really looking forward to those future conversations

25:02

and bringing this education to people across the

25:05

country. So for today, thank you very

25:07

much, Grace. Thank you. Thanks for having me.

25:09

And thank you so much, Mel. Thank

25:11

you. Thank you for having me. And we'll

25:13

speak to you again very, very very

25:15

soon and to you listening at home thank

25:17

you for listening and we'll see you

25:19

at the next podcast thanks