Chapters Transcript Video Addressing Social Injustice: Intersection of Health Disparities, COVID-19, and HIV Addressing Social Injustice: Intersection of Health Disparities, COVID-19, and HIVOriginally Broadcast: Sunday, October 25, 2020 | 12:30 - 1:30 PM PT Hi. My name is Chancey Watson, and I am a senior product manager at Gilead Sciences in HIV franchise marketing. And on behalf of Gilead Sciences. We welcome you to today's program. This program is entitled Addressing Social Injustice. Thean Intersection of Health Disparities, Covert 19 and HIV. I first want to begin by thanking all of you all both our speakers as well as all of you all attending this program for all the work that you do to support our communities in ending HIV. We share that common goal together as a company but also as a member of our communities that we're ultimately trying Thio end the HIV epidemic and now to our program. I would like to first introduce you to our first speaker and moderator for today's panel. Dr Patrick Sullivan, who is the Charles Howard Chandler professor of epidemiology at Emory University. Rollins of School of Public Health in Atlanta, Georgia. In addition to Dr Sullivan, today's Panelists includes days on Dixon Diallo, who is the founder and president of Sister Love Incorporated. Dr Leandra Mena, who is the chair and professor of population health science at the John Brower School of Population Health as well as a professor of medicine at the University of Mississippi School of Medicine and Dr Tony, a Petite who is an assistant professor of social medicine at the University of North Carolina, Chapel Hill, Tar Hills. And now, without further ado, I would like to turn it over to Dr Patrick Sullivan. Thanks so much chance. And thanks to everyone who's attending today, I think that the main event here is gonna be the great discussion we're gonna have with our Panelists. I'll just take a few minutes to introduce some of the topics that will be talking about today. We find ourselves in a nera of both longstanding and new challenges for health and health equity. Even as we're aspiring as a country to try to achieve major reductions in new HIV diagnoses and reduce disparities as part of the ending the H. I V Epidemic initiative, we're faced with a global pandemic covert 19 and it's disproportionate impact on minority communities. The convergence of two viral epidemics has revealed longstanding impacts of hiss, systemic health and social inequities on health outcomes among black and brown people in the United States. In the next slide illustrates that the issues of health and equities for black Americans run deep. Greg Millet recently reviewed at age 2020 the overlapping socioeconomic and health conditions and counties that are considered to be disproportionately black, meaning the proportion of black Americans in those counties is higher than the national average of 13%. There's 677 of these counties in the U. S. Is the maps on this slide show the great majority 91% of those counties air concentrated in the southern United States. And if you look at the other panels, which illustrate things like poverty and unemployment, lack of health insurance you can see that the South also has relatively higher numbers of poor uninsured adults than in other regions as higher rates of uninsured and more limited Medicaid eligibility than other regions. And in fact, nine of the 14 states that have not yet opted to expand Medicaid are in the South, and as a result, more than nine and 10 people in the coverage gap reside in the south, according to the Kaiser Family Foundation, not on Lee. Our rates of unemployment and lack of health insurance high in these 677 677 counties. There are also higher concentrations of diabetes, heart disease and HIV, and these pre existing conditions complain important role in poor clinical outcomes from Cove in 19. In these counties, we know that the complexities of health care and health inequities in the South arrives from multiple causes. And so things like transportation, the physical accessibility of services, a swell, a social and health services are inadequate in rural areas and factors that can fuel stigma and discrimination or prevalent. And as a result of these factors, there could be a slow adoption of the latest testing, treatment and prevention services in the South. This slide highlights the disparities in the impact of covert 19 by race and ethnicity, with a focus on the impacts of covert 19. Among black Americans, black Americans account for 12.4% of the total population, but over 22% of deaths from Cove in 19 and after adjusting for age compared toa white, non Hispanic Americans, the rate of death for black Americans and Latin X people were both over three times higher than for white, non Hispanic Hispanic Americans. And when we hold this up against where we are in progress in the HIV epidemic, we can see that in the United States, progress is being made to reduce new HIV diagnoses. Overall, that progress hasn't been shared equitably across populations in geographic regions. From 2014 to 2018 HIV diagnoses decreased 7% among adults and adolescents in the United States. But those trends varied for different groups of people. The United States infections remain highly concentrated among men who have sex with men. Those of certain races ethnicities, especially black Americans, and those who live in the southern United States. In 2018 black people accounted for 42% of HIV diagnoses, but only 13% of the US population. If we consider black and Latin X people together, they accounted for 69% of HIV diagnoses, compared over only 31% of the population. And they're also disparities by region between 2010 and 2016. The southern states accounted for over half of new HIV diagnoses annually, even though just 38% of the US population lives in the southern region. In addition, the south has a higher proportion of new HIV diagnoses in suburban and rural areas compared to other U. S regions and this this poses unique prevention challenges. So the next slide really just tries to give us a framework that I hope will guide our discussion today. The information on this slides highlights that health disparities, including disparities to Cove in 19 are really symptoms of broader underlying social and economic inequities that reflects structural and systemic barriers and biases across sectors. We know that social determinants of health, the conditions in which people are born in which we grow live work in which we age are primary drivers of health and these social determinants include factors like socioeconomic status, including economic stability, neighborhood and physical environment, characteristics, employment and education, access to healthy food, social support networks and access to health care. And this will set the stage for our discussion today of inequities with respect to HIV. Specifically, we want to point out that for people living with or at risk for HIV, HIV status is just one element of a person's health, and it's part of a bigger picture, comprehensive behavior on biomedical risk reduction services for the prevention of HIV and for treating those who are living with HIV require engagement in care, and I think we've reached a great point in how we're thinking about addressing the HIV epidemic and that we no longer thinking of this is to tracks for different groups of people. But we have an HIV status neutral care continuum that lets all people engaged regardless of their HIV status. One other commonality between these two branches of the care continuum is that in both cases, sustained engagement and care is important to achieve and maintain health, and particularly H. People who are not living with HIV may not be accustomed to the importance of this sustained engagement care, and we think about sustained engagement and care to maintain, to achieve and maintain health. We have to be aware that all these things that air clustered across the top misogyny, racism, transphobia, homophobia, homelessness, poverty and marginalization are actually factors that can influence the care continuum and people's ability to enter that care continuum and to stay engaged and so to develop these optimal health outcomes. There's no no way to do that without addressing these barriers that we've identified. Top of the this slide and as we wrap up this introduction section. I think it's it's important to note that with respect to the HIV epidemic, we really are in a new a new day, and having a new discussion because of you equals you u equals U, which stands for undetectable equals un transmittable. It's a campaign that really underscores the fact that people who are living with HIV and take their medications every day and achieve and maintain an undetectable viral load, which means the virus can't be measured by a viral load test. And if they do that for six months or more, they have effectively no risk of transmitting HIV through sex. And so when we think about these concepts of prevention, whether it's a care continuum for people living with HIV, with an endpoint of viral suppression to improve health and U equals U or whether it's a prevention continuum for people who are not living with HIV, it may include testing assessments, Andi and pre exposure prophylaxis. It's important to say that even with an undetectable viral load, even with uh protection from pre exposure prophylaxis, that guidelines still recommend the use of condoms and other forms of HIV prevention, so that it really is not a monolithic, um, not a monolithic approach on either part of the prevention or care continuum. So a zoo we move into the discussion. I just want oh set the stage by saying that this heightened heightened focused on an understanding of health inequities can provide us with an opportunity to think about how we move to advance health equity, thinking about health care system, measures to enhance access and equity cross sector approaches to address the underlying social and economic barriers, to equity and recognition and of, and commitment to addressing racism, discrimination and histories on acknowledging the importance of in the existence of histories of stress and trauma that could be barriers to achieving full and robust health. So with that, we're gonna move toe. What a Zai mentioned before I think is the is really the main course today, which is a discussion with 33 colleagues who I'll just say. I've learned a lot from each of them through the years, and I, I think will come out of this discussion is the deep and distinct ways in which they're engaging around these issues in serving communities through program through clinical medicine, through research and we're so, so lucky. And I'm so honored to be with this group today. So thanks to each of you for being here, I wanna have address a few topics here and and we'll spend about 10 minutes on each of them. And this is an open discussion, so I'll try and get things rolling. But I hope you'll jump in and build on each other's comments. So ah, talking about this idea that we're now trying to engage around health disparities at the convergence of three pandemics and and I think this offers obviously challenges their also maybe some progress that can be made that would would act towards mitigating the impacts of HIV of co vid and of these systemic inequities. So I'm going to start by just, uh, by just saying that the communities of color disproportionately affected by the three challenges that we identified at the outset here a pandemic, uh, systemic racism and HIV. So how do we use public health advocates respond to these crises while they're all happening together, and just to get things kick things off? I'll ask Leandro if you can, uh, take a crack at that one first. Good afternoon, everybody. And thank you, Patrick. And for in addition, to be here, Onda settling there is a tremendous honor to be part of this panel with a very esteemed colleagues. Um, again, you know, part of you lay down, you know, beautiful introduction. You know, we know for all of us, you know, working HIV. I mean, we understand. We see the HIV is not just a disease, but a social phenomenon that really exposed for four decades and exposed inequities, you know, in society can continue toe that, you know, moving forward. Um, And as we HIV, you know, we see clear patterns, you know, where communities of color that you presented Another groups, you know, bear the brunt off Kobe. 19 cases and death. There's something with from structural racism. Another longstanding systemic immigrants. Um, you know, and it's important to recognize the social components, you know, both HIV, you know, eventually, you know, create as many challenges you know, as a medical facets of it. Andi have to, you know, again, I think as a public health, you know, a advocates we can think about reflect, You know how you know in HIV you know we have being able to transfer in many ways. You know how public agencies, you know how other parts of government how health care, you know, systems, you know, on parts of society have, really, you know, figure out the way toe work with the federal communities. You know, I think in our own presented way, you know, I think HIV works, you know, with a community based organizations to really, you know, a creative solutions. And we have so much to learn both, you know, from the successes, You know, that we have seen HIV, you know, a swells from the failures in terms of how to address this epidemic s Oh, I think we are in a very people, you know, time when the reckoning of these challenges. You know, I same time, you know how created in order, medals, opportunities. You know, I think it's important. Assad advocates probably has advocates. You know that we, uh, include the voices of those affected communities Way don't do that. Always. We don't always do that. Andi. We need to make sure that they're at the table both trying to understand this issues. But as we're trying to look at the mechanisms. You know that by which, you know, they developed on We plan for solutions, Andi, especially making sure again that these solutions are being formed by the communities you know, by communities, you know, prior experiences. We talked about that a long standing, you know, impacting the legacy of slavery and institutional racism on then how, as we figure out these solutions, they address the community needs on their consistent also with the community's expectations. Right. Thank you so much for that for that response. And I want to sort of sort of maybe take that a step further, Um, and days on asked you if you could think about the idea that the cove in 19 pandemic has really exacerbated disparities in health and health care and access to health care that were already there, um, that were affecting communities of color. And so I wonder about what are the mechanisms to try to alleviate those disparities during this critical time? What are the roles of of health public health professionals, health care providers, advocates? How how does this come together to help alleviate those disparities? Sure. And thanks for the question, Patrick and I, too like Leandra. Hi, Leandro. So good. Thio, Uh, as well as Tanya, I am. I'm excited to be here and have and be a part of this conversation. So throughout this conversation, I might end up sounding like a broken record on purpose. And that's because the thought around a lot of these questions is pretty simple. And some of it is simplified, but not simple to respond to. So the answer that simple is to really center the people who need what what they need the most is to center those who have less access to health care, people who have less access to equitable pay, wages, housing, communities, clean environments, uh, safety nets that when we center and in a large respect in this country, when we're centering that on blackness, when we're centering that on black people on people who are indigenous and people of color, then we're solving a lot of problems for everybody. So that is really a simple answer that has many, many, many, many, many layers to it that the response and the way to actualize and make practical or pragmatic around be pragmatic. Around those answers is what's complicated. So toe unpack that a little bit. I start with thinking how Congresswoman Ayanna Pressley, for example, has one of my favorite quotes that helps me define and frame so many parts of the work that we're doing. And she says that the people who are closest to the pain must be closest to the power right. So the first thing that we have to do, especially as providers, is to remind ourselves that community engagement is a lot deeper than having a once every now and then advisory board that community engagement is important in terms of how health services are decided, how they're designed, how they are delivered, and then how they are measured in terms of what those outcomes are. And those outcomes are not always on Lee good numbers or better figures in terms of their adherents. But it's also about their quality of life, their mental well being there, since of belonging, their sense of value, the self worth, all of that becomes really, really important, and a large part of that means we also then have to trust the communities we have to trust when we say what we say we need that were responding to that uh, that there's another one that people don't live Siloed lives. We don't deal with HIV on one day or deal with housing on another day or deal with violence on another day, every human being walks in a door or in our doors or even on our screens, right, with all of these things going on at the same time. So they live intersectional lives, and what we have to be ready to do is have intersectional responses to those needs. So they're not just on Lee coming in to get a test for HIV, for example, they're not only looking for covitz screening or covert testing because there's usually other issues that are already going on, and we have to be ready to do that. Even in the midst of trying to deal with the pandemic, it's still been important to test people for HIV. It's still been important and essential to make sure that folks have pregnancy screenings and access to reproductive health care. I would close on this one is that I also want health providers to take more risks. I want people to not wait for law and policy to do the right thing, not wait for regulations to make better decisions about how we engage with patients and folks in the system in our health systems, and then be willing to work to dismantle the parts of the systems that aren't working. And if you want to call it innovation, call it innovation. If you wanna call it disruption, call it disruption. But do it differently because you want to try something different because doing it the way we've been doing it isn't working. And I don't think we're insane. I just think that we're not being as bold and as brash, even, but also as audacious as we need to be to really dive deeper into these injustices and disparities. Right? Um, telling you, I wanna turn to you now and with this idea of the introduction ality and on thinking about how social movements like black lives matter relate to HIV related thio to the health inequities that were, um, that we're experiencing and how the social activism of black lives matter can be leveraged to confront front, other challenges of HIV, disparities of covert disparities and of the sort of structural pieces that I think we all agree we need to deal with Thank you, Patrick and high days on and highly andro. I am also honored to be with this wonderful panel of activists and human beings. Um, and I'm excited to be asked this question. I think the answer that I, when I feel like, is the answer, really brings together what Leandro's said and what days on said. Like the black lives matter. Movement is audacious. It is bold. It is broad it in looking at how we can make visible that black lives matter. It's not simply about this one policy or this one action. It's about a broad umbrella of changing how we've structured our society because the same systemic factors that increase vulnerability to HIV that increase vulnerability to covert 19 also Servas barriers to accessing Cove in 19 testing, HIV testing, access to care and treatment. They're all intrinsically connected, and I think it's going to take us being radical in going to the root of those problems to really see sustained change. And I think being bold about addressing racism, being bold about addressing transphobia, misogyny, nativism, all of these things that are bound together to increase vulnerability for some people and deprive them of power and access and increase power and access for other people addressing that at the root means that we don't have to be like Here's arc over 18 program and here's our HIV program. And here's our diabetes program. We can be We're going to address the structures and the underlying forces that lead to those inequities and that can move us forward in a lot of different arenas. So those are my thoughts about that now. Fantastic. And I want to just reflect Aziz. We wrap up this section that although you all came at this question from different angles, there are some key core, you know, pieces that come through all your answers that I think we should take away as a t least some of the guide posts and I think across your responses, hearing about meaningful engagement, Leandro and days on you guys put this in slightly different ways but meaningful engagement with communities which is not just an advisory board but which is more sustained, which goes to deeper levels and which really addresses not just trivial but also substance. Substantive aspects of how care is sought delivered what people need on the ways in which the current systems may not be meeting those needs and then on. And I think, uh, Leandra had the spirit of it, and Daisann said, bold, brash, audacious. I think the 3 10 you really picked up on built on that that that whether it's thinking about how we offer services and and how we take an approach to dismantle the systems that aren't serving people well or whether it's how we challenge the systemic, um, and structural aspect of structural and systemic racism to make it difficult to move toward those, um, those goals, that there's a need to be bold, there's a need to be on unapologetic Andi, uh, to go to go big. And I also want to be sure that I I get the quote. Uh, there's on that you said, Which is that the the people of the pain, the people who have Can you say that one more time? People closest to the pain must be the people closest to the power. Thank you. And a good place to wrap up, I think pulls in a lot of these, um, these ideas Alright. So as we move to the next topic I just want to remind people that you can. You should have people who are viewing our discussion today. You should have a button at the bottom of your screen that will let you submit questions. And if you'll submit those questions, then we'll work them into the conversation. I think this conversation will be, um, will be best and most engaging if we're also bringing in the thoughts and the reactions and the questions of our folks were listening. So please use that button, descend on questions and we're gonna move on and talk a little bit about the idea of, um, of progress towards HIV prevention in the United States, but that the reduction in new diagnoses haven't really been shared equitably across populations, Andi regions. And for this, I I wanna I wanna start with Stigma and Tony. I'm going to direct the first question to you, which is that we recognize that people who are living with HIV often face stigma and discrimination on multiple fronts. Racism, prejudice against those living with HIV presidents, prevalence around sexual orientation or gender identity. So we have these sort of intersecting layers of stigma, and can you talk a little bit about about what we can do to combat those stigmas. What what should we be thinking about? As as remedies for that, Thank you for that question. Patrick and I also think I'm going to be a broken record like days on. I think stigma is often academic word that's used to describe things that we in lay language would call racism, sexism, homophobia, transphobia. But when you write your N i H. Grant, you have to call it stigma and stigma reductions instead of anti racism work or anti transphobia work. But I think the solutions are very similar, if not the exact same, um, and Thio to build on what Days on said people who are closest to the pain are also should not also on Lee be closest to the power. But those are the people who have the answers, actually, because they have felt intimately, the impact of what these systems of oppression have created and listening carefully to their voices and responding to what they recommend, Um, and giving them resource is toe lead. Um is going to be critical toe having realistic, sustainable, relevant solutions to the an excuse that we see I think those of us who are in positions of relative greater privilege in addition to listening and responding also need to interrupt those systems where we see them, even if the people that we think are affected are not in the room. So, for example, if I hear somebody say something transphobic or do something transphobic, I don't look around and go. Well, I don't see any trans person here, so I'm just gonna let that go. But we have to create an environment also where those things are unacceptable. Great. Thanks for that. Um, I wanna I wanna come to a little more specific, Uh, a little more specific question on blander. I'll ask you to take a first stab at this one, which is that we know by looking at data about, um, particularly about pre exposure prophylaxis, but but also other prevention services that the main beneficiaries of some of these prevention modalities or white men So what can we do to widen the availability of these services? Um, two individuals from African American and Latin X communities. That's a great question on. I think, you know, we have to be very intention. I mean, we really have to have a true commitment. That's what we want to do. We have to invest, You know, in this communities on again, with this communities, you know, figure out what is it that has to be done. I could tell you what I think, but what I think may still fall short toe what people really think. I mean on each one of us, you know, I don't focus groups with their communities and they have told us you know what they want. You know very often what they want is really not practical for us, you know, off our founders, you know, But the solutions are there. So I think again, you know, there needs to be a really true investment. There has been tremendous investment so far towards the end of the HIV epidemic towards, you know, addressing this disparities. But the evidence is that none of this is enough, right? Because the results are not there, You know, taking care of individuals who do not have reliable transportation toe come, you know, toe a medical appointment, right? Individuals who I know how paid medical leave, right, Toby ableto work, you know, to be able to live work to come to an appointment requires, you know, a different approach on that different approach. You know, it's gonna be require different resource is that we can really have a part of the standard of care. I mean, that means, you know, transportation system assistance. If you need people to come to you, needs to be part of the standard of care. Know something, You know, a special that happens. You know, if I need I need I need, you know, and you go through 20 different pay steps, so yeah, so? So I think again, we didn't really true commitment recommitment, You know, on that commitment with significant resources, you know, that go into those communities making sure again that we are addressing the needs of these communities as we're learning from them. No us, you know, trying toe using our studies information inside that take four or five years, learn what the community has no forever eso and, er, can I just ask you to take that one step further, which is I think it's really helpful to say that, um one. I appreciate that sort of the humility and but what Both what Tony had to say and what you're saying about how we work with communities to so learn on Go ask the people who were trying to serve how you know how they want to be served and what changes need to happen. But what are those steps that aren't yet happening between you? Sort of mentioned the focus groups of people to ask about. You know how they might want to get services. And what are the barriers between that that kind of information being exchanged and those steps being taken? Is it is it research gaps? Is it programmed gaps? You you alluded to this a little bit that are there. Where in that system are we losing the messages of of what needs to be done? I mean, I think it's happening at a different steps. I think very often the research is not done, you know, in the communities that can benefit from that, I mean, give you an example. I mean, they're 453 or four, you know, in the South, you know, besides Atlanta, uh, Birmingham on North Carolina, you have the whole southern region, you know, on the assumption that the evidence you know, that is developed right in Atlanta can be easily translated Toe Montgomery, Alabama, or to Alexandria, Louisiana. Let me It is not there. So I think again, I think the translation in the the knowledge that is nearly or they they the approach that is needed to implement No, this evidence based intervention in this different areas that do not have the resources. You know, that exists a in a well founded any, you know, our one, you know, clinical trial that do not have, You know, the culture that embraces change, you know, that exists in that kind of a academic environment. So So all those things I mean represent important. Got second You have, you know, the health department, you know, in health departments in general, no matter where. That, with the exception of a few health department in our country that are very well connected to academic centers who are more prone to innovation and change, right, most of them are very, you know, uh, a stagnant pond on persistent, you know, to do anything. No, to do anything different. I'm very often are content to check the box right to do something because they got the graph requires, you know, with very little, you know, attention, Toe. Make sure that the objective that the purpose what you are, you know, given the phone are meant. I mean, I can give you many examples of that. Can give you, for example, 15 years ago. You know, all the grants, you know, Still, today requires condoms be giving right toe people to reduction in transmission of HIV, especially among MSN. Right. So you go to a STD clinic. Most health departments, you know, in the country on settling the south will not give lubricant. So what is the purpose of giving someone condom? Because you assume that they don't have condom. Right? And they didn't give a lubricant so they can use the condom. Right? So that's just an example how things don't make sense. So someone s so there is this again intention, right at the local level, at the policy level of the practice Public health practice level. You know, Toby, ableto toe translate that signs. I mean, that evidence, you know, best evidence best practices into these environments where people can really have access and benefit from them. Can I Can I add something to that Teoh, please. I think that was beautifully, that I loved your example, Leandro. I also think that we do something that, as I reflect on it, is quite strange. We develop prevention interventions, and then we do research to try to figure out how to get people to use the prevention interventions that we've already created instead of doing what every other successful company has done, which is to go, What do people want? What people need. Build that and then people come and use it. And I think we haven't gotten there in public health and responding initially to what people need. Instead, we try to figure out How does the lots of resource is convincing people toe want what we can provide? I think that's a visual of a fundamental shift that we can make and how we do what we dio. Yeah, I wanted to come in on that exact thing, too, because just next to that quote from Mariana had also written one of my favorite quotes from yes, Parliament Funkadelic. And that's one of those lines is give the people what they want when they want it, because they want it all the time and you wouldn't know what to give them if you didn't ask. And I also think that what we ask is important. We often, uh, think about asking because we want to know. So we want to do a better job or we want to change the trajectory of the epidemic or some other solution. But what do we need to know to change things? What do we need to know to help people change things for themselves the way they can and want to change things for themselves? And we rarely do that because we don't trust them to do it for themselves, because that's really not the way most folks are socialized are educated because whether it's white coat, whether it's extra letters, whatever it is that comes with being in the powerful positions that we have. The other thing is remembering that every person is a person, regardless of all of those other determinants in their lives, and that there's no such thing as an African American community that you're going to respond. Teoh is gonna be that person who happens to be black. That shows up that has all of these other oppressions and understanding that some of them are social, which means they can be changed. So those are the social determinants. But we don't query whether these determinants are social or life. There is something that I've born with that no one is going to change. You're not going to change my race. You're not going to change the color of my skin, the shape of my skin or the family I'm born in. So what are those kinds of determinants that you can't change those aspects? But you can change how I'm treated based on those aspects or what I have access to based on based on those acts aspect. And so another example I would give similarly to that beautiful um, example that Leandro wrote raised is that we consistently talk in terms of prevention around risk, risk for us, for HIV as public health providers may not be the same meaning of risk for people who are living in situations or engaging in things that, for us, put them at risk for HIV, but for them might be doing something else to save their lives. So how we define risk and how an individual defines risk. If it's not congruent, then it is not their job to figure out whether what we're saying is right about them. It is our job to figure out what we need to do to make sure that their understanding of risk and what to do to mitigate that risk is what they want and need. And for women, talking about high risk in terms of sex is not what's going to get them to think about HIV risk thinking about their sexual expression, thinking about pleasure. They enjoyed their trust in their partners. Those are the kinds of things that we're gonna have to figure out how to respond to and say, We'll hear some of the tools that we have. Maybe we don't even have the tools that are going to meet those needs right now. So what do you think we should do? Love? That's how we should be. Austin. Great. Um, all right, I wanna I wanna take a least a closing opportunity in this section because I talked some about, like, the progress that's been made in reducing diagnoses and and groups by risk or by Sachs or by, um or by geography, where that progress hasn't been made. But one area where we don't even have enough data. Thio document. Um, the success or lack of success is eyes the how we're approving the care for transgender individuals who we know are disproportionately affected by HIV and also by stigma and discrimination. So when you said you might become a broken record in it and maybe we'll take another pass here. But I think it's worth paying specific attention to say, Like, What does it mean that we don't have data to be able to say how well we're doing or not in terms of surveillance systems? And what are those steps that we should be? Are they the same kinds of steps? Are there specific things that we should be doing thio to think about, um, the types of stigma discriminations that are there preventing appropriate prevention and care for for trans folks. Thank you, Patrick. That's a great question. And I think yes, and I think all of the oppressions that we've already talked about our experienced by Trans people in addition to Transphobia. And I think one of the major challenges that we face is that I'm going to digress in a daze on digression and that I recently saw a movie called Disclosure by Laverne Cox. And you know, I think of myself is pretty savvy and aware about gender issues. But I realized as she walked in this documentary, through how Trans people have been presented in the media as not even really people not like human beings with feelings and thoughts and aspirations and hopes, but as caricatures of humans and is the butt of jokes, um, that we have as a society incorporated that into how we see trans people, and I think that's contributed to making them invisible in the data like not even. I mean. This week I'm writing a letter to a journal that I won't name here about how they had a special issue on M S, M and transgender women that included no transgender women. So there's still this and difficulty seeing trans people as like fully human and deserving of attention to their specific needs. And I think some of that is our own societal discomfort with our own sex and gender and our own sort of policing of what it means to be a woman and what it means to be a man and what it means to not be any of those things makes us really uncomfortable. And I think we have to confront that, dig deep into our empathy and understand who we are. And listen. Thank you. Thank you for that. Um, all right, we're gonna move topic and which is sexual health and HIV. And what I'd like to do is ask way talk about a lot of these terms, and we use them in our conversations about prevention. But what I'd like to do is ask each of you to talk about how you understand or how you think about or how you would explain to folks who aren't in our circular, insular world here. One aspect of this s o does not. I'll start with you and just ask how, how you understand a status neutral care continuum. Why is this status neutral care continuum important? And and how does it give us different tools and opportunities than when we were saying, like, let's talk about people living with HIV and how we engage with with those folks. And let's talk about people at risk for HIV, And you guys have have rightly redefined risks here so that that context but What what do we get and what are the opportunities we get from a status neutral care? Continue. I love this special because you know there's when you're in the community and you're just doing what you do. It's really cool when somebody comes up with really catching, you know, nomenclature. Thio. Define what it is. You already know about what you're doing. We start at my organization with Sister. We have started. We said, No matter what your status is, when it comes to HIV, everybody needs something. I mean, that's just how we approached it, right? So it didn't we didn't have, ah continuum, so to speak, that look both at prevention and treatment. But what I know is when the care continuum came about, My first question is where is the prevention strategy? And here for people who are not living with HIV because people are not different. It's just a matter of when they got tested for HIV and what that test said to them. But other than that, everybody is still going to need something, whether it's education, whether it's a different tool, whether it's a prescription for something, now that we have that even as those prescriptions change in modalities and deliverance of certain kinds of tools or drugs that are going to help them prevent HIV in the future. So what it means to me is that is neutral is an opportunity to sort of erase that dividing line between people living with HIV and people who aren't living with HIV. Everybody deserves equitable access to health care based on what your healthcare needs are, regardless of your HIV status. You may need information differently because of those health care needs, but the fact that you have those needs is no different. The other thing that status neutral does or says for me is that this gives us an opportunity to sort of broaden it and make sure that when people are thinking about whether or not to get tested, what to do with their result. It's a matter of understanding that you are part of a whole and that there is a pathway for you and there's a pathway for your partner or there's a pathway for all any of your partners or your family. Members may not be the same path, but we all have to be on a path and that actually gives you a chance to get more support. It may actually encourage more people around disclosure early, getting connected to care early enough. And it also gives away to make sure that folks are able to support each other regardless of the continue that they find themselves following. I I just think that it's way past time to really deep dis uh, you know, in this by far cation between HIV positive and HIV negative, I know that there are plenty of folks who can sit in a room regardless of their HIV status and their relationships of the same. How they felt when they had their first kiss was the same when they lost their virginity. They have. They know what those feelings are. All of those kinds of things are all the same. And that, too, is status neutral. Mhm. Fantastic. Um, so I'd like Thio. I wish we could just ask on the fly for another half hour. Um, here, Thio, keep talking. We have about 15 minutes left. Um, I want to get Thio. We have a couple audience questions which I really appreciate and and I wanna get a couple more sort of hot takes here on these some of these terms that we use until you I'm going to come to you next and and ask you to sort of react Thio What it means when we when we say that HIV prevention should be a holistic practice to me, I think it it means exactly what days on just described that we're all humans. And, um, I think what did I think that I've said to my my friends is like, only can HIV only HIV providers can make a virus that is transmitted by sex be sexless. And we do a lot of like, not sexy talk. We don't talk about pleasure. We don't talk about love. We don't talk about the reasons that people are intimate with one another and I think a holistic practice. In addition to looking at all these sort of structural issues around racism and sexism and homophobia also understand that as human beings like desiring love and desire, ing sex and intimacy with other people is a normal and natural and healthy and good thing, and that our job is to help people to do that in ways that are, um as healthy for them as they can be. And that's what a holistic approach looks like to me versus sort of targeting at risk. People are, um, doing those things that feel very sort of accusatory and blaming and completely unsexy. Thanks. Thanks. Like a Patrick. You know, the other thing is that, I think is the recognition that you know, the simple populations that artist proportion affected by HIV are disproportionately affected by many other. You know, despite right on dso sometimes I mean, he's like a is a missed opportunity, right for primary prevention, you know, for, you know, cardiovascular disease, metabolic diseases, you know, mental health disorders. Um, there's so many things, right? You know, we have this tremendous opportunity because this population at risk of HIV or very often, you know, prison Lana's HIV are relatively young individuals. You know who never before had access. You know, any kind of health care. We have a tremendous opportunity to really have an impact, you know, in their health, you know? Ah, low cost, you know, investing in the health of us individuals. You know, that can be done very efficiently by education, you know, early detection, the screening, and early detection off a chronic diseases if I can. I think the other thing that we need to be future forward or thinking about in this way is that so we have a lot of conversations around HIV and integrating that, for example, into other aspects in terms of our primary health, our overall health thinking, including our mental well being and our spiritual and our emotional well being. But integration sometimes means because in the real world, integration has also meant invisible izing. Some things, I mean. And I mean that in the rial sense of integration, given the where we've come from Jim Crow and now, and the fact that black lives were still in visible and unseen, even if we were no longer separated or segregated. So I don't want us to think about integration in the same way I want us to think about the intersectionality that HIV brings toe our primary health needs as well as others and begin to plan how we d exceptional eyes it because that's how people are dealing with it in their own lives. It is not this big, shiny thing that sits over and on top of everything else that they have to deal with every day or the things that they want to be preventing. It could be a part of everything else that they have to address. So and I'm saying that we have to be very proactive about it, because we are. We're hitting on 40 years of an epidemic that people are already fatigued around. The funders are getting fatigued around it. We have other really big challenges that air coming and needing more resource is. And if we're not prepared to figure out, to continue to bring HIV is importance and ending the epidemic as the important moment. Then we're going to lose the opportunity to sustain how we address HIV because it will be taken away from us because we didn't have a plan for how to be intersectional about it. And I think that that's a danger that faces us right now. All right, Thank you for that. So I'm gonna try Thio, bring us in for a landing here by asking each of you, um Thio to make a quick comment about one more key issue, and it will take a couple questions from the who came are coming from the audience and then we should come in close on time. So I'm just gonna ask each of you were now at this time that we're where we started this discussion, which is the intersection of co vid and systemic inequities and HIV And one of the things that's really changed about that is our ability toe interact with people in groups and individually, and the practice of seeking healthcare has changed. So I wanna ask each of you for a quick thought about when all this is over. Uh, let's just put ourselves in 2022. Um, what aspect of telehealth and how we've how we've adopted telehealth will remain after. After that, when this is in the rear view mirror. Um, what are the what are what are the aspects of? Telehealth is a tool that could still be working to help address health inequities at that future time? Um, and anybody who's brave jump in first jump in because I don't think it's going to change. I only think it's going to grow. I only think it's going to become I mean, we are already like pre Jetsons right now, so I don't think that's I'm sorry. I'm I I think you know, I have to work in community and pop spaces. So pop culture is really important in terms of how we use analogies to get on a zoom. Call the Jetsons. Exactly. You see my dogs helmet? No, I'm just kidding. But what I do think Telehealth has is going to help us realize is that for a lot of these disparities, it's also helping us deal with other barriers. Just like Leandro has already talked about issues around transportation, child care, even linguistics and language Justice, if you don't, if you if you will, dealing with more safety and security, even dealing with privacy and protection of and being able to personalize the care that people are able to get because they're not even sitting in a waiting room full of other people that they you understand so dealing even with as internalized stigmas are important. It is also going to force us to and or least eliminate this ridiculously huge digital divide that we have now it's going to force that, but more more importantly, telehealth ain't gonna be the only thing. I think there's gonna be other ways that we're going to electronically disrupt Ah whole lot of ways that we're doing health, education and messaging. I think the public health community needs to take up as, uh, as uncomfortable as it seems. People are obviously not that concerned about how much you know about them on the Internet now. And so we're going to have to learn how to use the same micro targeting for our messages, for our information sharing, as well as for getting people access to services as the people who are selling us. Our everyday products are toothpaste down to our tennis shoes that the same way they find me on the Web. We should be finding people on the Web based on their footprints and what they look for and what they need. Public health should be in that same space. So I see it doing a whole lot more to reach individuals where we are, because we're all going to be electric and Elektronik and digital and hopefully, you know, not in the black mirror way with a chip in my neck. I'm just saying e totally agree with what they saw, you know, mentioned. I mean, the one thing that I would say I'm very specific to use off telehealth, right, Delivering off healthcare, telemedicine, You know, through, you know, video or telephone Is that you know, again, we look at the beginning, Patrick, You know, when you presented the geographic disparities, you know, both HIV and covering and other diseases we have to think about, you know, making again the necessary investment. So the infrastructure that will allow access to everyone who needs it, you know, off this amazing too right is there for everyone because other otherwise, right, well, they have the wrist that all these amazing advances just dipping. You know, the deal, the disparities, you know, in between they also have access and those who don't thank you quickly. I see the chances here, but I'll just say quickly that I think what it taught me in addition to those things that have already been said, is that anything is possible if you want it bad enough, you know, it used to be all these things could we couldn't do, they weren't allowed. And then within a week, everybody suddenly could do telehealth and you could do it across many lines and we could provide hot spots for people, and we could teach people from home. So just remembering that if we have the will, there's so much we could dio um, So I just wanna make a comment before we turn to our closing, Um, which came in from an audience comment. But I think it's so important to talk about toe. Make this connection. We're talking about stigma and these sort of overlapping epidemics, which is a Nadie Insp. Has asked us to acknowledge the stigma of calling Cove in 19 the Wuhan virus or some other terms that I won't repeat and the effects and that that can have on Asian American Pacific Islanders. Um, and on just how insidious this kind of social stigma is a zit relates to seeking health care services. So I think it's right. I appreciate someone writing into this and on. I think it's right for us toe sort of Call it out. And part of this is about naming on being explicit about naming the things that we see. And and I think you guys have done such a great job of, you know, answering tough questions, but also of getting down to the mechanisms, and so we may have all started this discussion within agreed understanding about, you know, the challenges of systemic racism and of structural inequities. But what I really appreciate each of you did was naming things, putting it in terms that are actionable and starting to get towards those steps and those things that we need to do, Uh, thio change things. And so I just as we as we can get ready to hand things back over, I just wanna say again what a what a blessing it has been toe be with the three of you and to have the opportunity in this forum to have this discussion and on how how deeply I appreciate your thoughtfulness and all the experience that brought you to be able to share these things with us on the work that you'll do tomorrow and the next day. So, um, so thanks for that. All right. One sentence about that is that when we do get past this particular pandemic years from now or however many when people are looking back, folks, we're not going to remember how it got started. Folks are gonna remember how it ended, and it will end up being the U. S s responsibility, period. Thank you. Alright. On that note, I want Thio. Thank Are the folks who came to share in this discussion with us today I am going Thio share the questions that came in that we didn't have time to get Thio um, back with the Panelists as well on day. Thank you for those. And if there's a way that we can follow up, we will do that. I'm gonna hand things over to chance cto sort of some things up for us and give some closing remarks. Awesome. Thank you, Patrick. Thank you, Panelists, for on an amazing, robust discussion, I think when we really start to look at this and I sum it up, I think Patrick, you did an amazing job of really articulating the things that came out of today's discussion in really that actionable step forward that provides the blueprints for how do we successfully in the HIV epidemic? But understanding that I'm left really with a quote from my Angelou that really says, I've learned that people will forget what you said. People will forget what you did, but people will not forget how you've made them feel. And today's conversation is about feeling our way through this pandemic that is really systemically impacting not only black and brown indigenous people, but also people of color that access our care continuum. So, on behalf of Gilead, we just want to say thank you so much for attending today's program. Thank you to Dr Sullivan as well as our esteemed guests and Panelists. And have a great afternoon. Enjoy your American Public Health Association conference and we on behalf of Gilead. Thank you for attending. Have a great one. Created by