0:13

I'm Valerie Earnshaw.

0:14

I'm C arly Hill.

0:15

And this is Sex, Drugs and Science. Today's

0:18

conversation is with Drs. Gabriel

0:21

Culbert and Agung Waluyo. Gabe

0:23

is an assistant professor in the College of Nursing

0:25

at the University of Illinois, Chicago,and Agung

0:28

is the Director of Community Engagement

0:30

and Empowerment at the Universitas Indonesia.

0:34

Just as a warning, guys, you are going to hear a

0:36

little bit of traffic in the background of this podcast.

0:40

Yeah. So Agung was joining us

0:42

from halfway around the world. He's

0:44

joining us from Jakarta, and Jakarta actually

0:47

ranks in the top 10 cities sometimes

0:49

per year for traffic

0:51

and congestion. So you can certainly get, you

0:54

know , those traffic noises in the background,

0:56

but we hope that you

0:58

enjoy the episode, nonetheless . All

1:14

right . Gabe and Agung, thanks for joining us today.

1:18

And I thought that we might start

1:21

by hearing a little bit about your origin

1:23

story. So Gabe, you're in Chicago,

1:26

in the US, and Agung you're in

1:28

Jakarta, in Indonesia. So we were

1:30

hoping that maybe you could tell us a little bit about

1:32

how you met each other.

1:34

Sure. I, I

1:37

met Agung in 2003,

1:40

and we always laugh

1:42

about the fact that it's been 15 or 17

1:44

years since we met. I

1:47

had the opportunity as a undergraduate

1:50

in nursing to travel

1:52

overseas to study

1:56

the nursing research process.

1:58

And so I was

2:01

really lucky at that time. The National

2:03

Institutes of Health had a program

2:04

that provided support

2:08

for undergraduate nurses in the United

2:11

States to travel to a , a host

2:13

site internationally to learn

2:17

firsthand and up close what

2:19

the nursing research process looked

2:21

like. And so my

2:23

mentor came to me in the

2:25

spring of 2003

2:27

and she said, "Gabe, do

2:30

you want to go to Malawi, Chile,

2:32

or Indonesia?" And I said,

2:34

"Well, let's see, Indonesia is about, about

2:37

as far away as you can get from Chicago,".

2:40

And so I said, "How about Indonesia," and

2:42

knowing nothing about the country or the culture, I

2:46

think I had seen a few movies on in

2:49

my youth that had peaked my interest

2:51

in , in Indonesian history. I said, "Well,

2:53

let's go with Indonesia,". And programs

2:58

like are incredibly

3:00

important for developing

3:04

scientists. And I get

3:06

a lot of students who come to me and they want to learn

3:08

about research. And so they're , they're

3:10

very interested in methodology and

3:12

statistics and making sure that

3:14

they ask the right research question

3:17

and that they have the tools to answer those questions.

3:20

And I try to help them and guide them. And,

3:22

and, and I think all of those things

3:25

are important to learn, but what

3:28

will sustain your interest? What has

3:30

sustained my interest over

3:32

the long haul and what I'm talking about as a 20-30

3:35

year career is

3:37

not the statistics and methodology,

3:40

although it becomes interesting later on what

3:43

sustains your interest are those human

3:45

connections and those early

3:47

experiences that are, that

3:49

become part of who you are and

3:51

your identity. And I

3:55

went to Indonesia in 2003. Dr.

3:59

Waluyo , Agung was my mentor. And I'm

4:04

not sure that I produced

4:06

the most interesting or,

4:08

or well conducted research project,

4:11

but that was not really the point.

4:14

I had a wonderful time and

4:16

I met wonderful people. And the

4:19

dean at that time, Ellie, who was

4:23

the Dean of Nursing at the University

4:25

of Indonesia, which is the largest

4:28

nursing program in the country made sure

4:31

that I had a variety of experiences

4:34

that would, that left

4:37

an indelible impression on me. I,

4:39

I, I had the opportunity

4:41

to work with nursing students and faculty

4:43

in Jakarta, had the opportunity to go

4:45

to Bali and be parts of,

4:48

be part of workshops and seminars there.

4:51

And so when I came back

4:53

to the United States, I had had this really

4:55

rich experience. And it

4:59

was many years before I returned to Indonesia,

5:02

but those experiences left a real

5:04

impression on me. And so here

5:06

we are 17 years later. And

5:09

I, I think of Indonesia as my

5:11

second home. I've immersed

5:13

myself in the language and the culture,

5:15

my family lived there for a year in

5:17

2013. And so

5:20

it's, it's, it's a building process. And

5:22

so now when I talk to students about kind

5:24

of their, these first forays

5:26

into global health research, I

5:28

say , don't underestimate

5:31

the importance of hanging out and

5:33

spending time with people, and

5:36

enjoying ice cream on the side of the road

5:39

and doing things that will,

5:42

that really sustain your,

5:45

your interest in your engagement with

5:47

a site, throughout the

5:50

rest of your life. I think

5:53

Agung may w ant t o talk about that a little bit. He

5:55

has a sort of a funny story about when we met at

5:57

the airport.

6:00

Yeah, well, before I

6:02

, telling about that moment

6:04

, actually

6:07

, area

6:12

of HIV is not my

6:14

area of interest in teaching

6:17

or research in the beginning,

6:19

but since , in typical hospital

6:24

, the word

6:26

for taking care of

6:28

HIV patients is put

6:32

side by side with a

6:34

patient with cancer or

6:38

oncology cases. So , by

6:42

the time I have to supervise the students,

6:46

then the students have the opportunity to see

6:50

and taking care of them.

6:52

Although in the beginning, they are

6:54

scared because

6:57

they don't know anything

6:59

about HIV. So I

7:02

was trying to

7:04

make them understand, although that was 2002

7:10

or 2001, I, I

7:12

see that HIV is still

7:15

a very scary

7:19

disease, like COVID-19 right

7:25

now. So , uh, everyone

7:28

tried to , uh, see

7:30

the patient from the windows,

7:33

not , some of them , like

7:36

precision , uh, not

7:38

trying to touch the patient so

7:40

important. So, and

7:42

then when professor Ellie

7:49

was having postdoc in UIC

7:51

, uh, when she returned

7:54

back to Indonesia, her duty

7:56

was to make

7:58

an initial, a

8:01

working group of HIV/AIDS

8:03

, research center. And

8:09

then , um, before she

8:13

can expand more

8:15

on that dream and

8:19

, uh , suddenly she received email

8:21

from Dr. Michael Laurie that one

8:25

of the students of UIC would come

8:28

and do some internship

8:32

or something or , and research activity.

8:35

So since I'm the

8:37

only person in the faculty

8:39

of nursing who deal

8:41

with the patient of HIV

8:44

, then I

8:46

was appointed to

8:48

become a mentor of Gabe

8:51

. So that is the, the start

8:53

and the, of

8:55

the insights person, including

8:58

all of the activity

9:00

A to Z, including picking

9:03

, picking him up

9:05

in the airport. And

9:09

I didn't expect to see

9:11

a very tall , uh

9:14

, white people wearing

9:18

a hat , with a backpack

9:20

, enjoying the

9:23

, uh, hot chocolate of Dunkin

9:24

Donuts in the airport. So

9:29

, at the beginning, I, I

9:31

holding the paper

9:36

written name of Gabriel Culbert

9:39

UIC , since probably

9:42

gave it an expect to

9:44

see me as a person

9:47

who would pick him

9:49

up in the airport. So it's just

9:51

passing through, but then I'm

9:55

sure that this is the kind that

9:57

I have to pick in the

9:59

airport. Because he

10:02

is the only, we call it bully,

10:04

like the white people in the building.

10:07

So I'm just like, "Hey,

10:09

I'm sorry, are you Gabriel Culbert?" Because yeah

10:12

, I do that . We start

10:15

to have a chat and finally

10:18

, the dropping to the

10:21

, we call it what

10:24

hotel gate, right? It's like

10:29

some small house for international

10:33

guests located in

10:35

central Jakarta . So that

10:37

is the, at the beginning. And then, and I

10:42

didn't know that that is become my

10:44

first step stone

10:48

to the world

10:50

of HIV research

10:52

area.

10:53

And then from that the

10:55

year , then I

10:59

start to have a workshop

11:02

conducted by

11:04

a School of Public Health UIC

11:07

where Dr.

11:09

Levy was the host. It

11:13

was about the drug

11:16

, uh, drug

11:20

users and HIV/AIDS, like,

11:27

like , uh, introducing

11:30

about HIV AIDS and the

11:33

relation to the users. So

11:36

that , from that year

11:38

I start to, I

11:40

didn't, I didn't expect

11:43

that , I have to deal

11:46

with, or listen to the topic

11:49

of drug users because I

11:51

, uh , I'm like

11:54

a person who really , a

11:57

house boy or homeboy

12:00

, like never go out for

12:03

something like , exploring

12:05

new things. I

12:07

enjoy staying at

12:10

home and just accompanying my

12:13

parents to go out and just

12:16

a nice boy of the house. So

12:19

when I listened to that topic,

12:21

I was like, wow. It

12:26

was a really new topic. And

12:28

, yeah, I, I

12:32

start to learn a new things , including , uh,

12:36

how the police officer

12:38

try to use

12:41

them as a source of money

12:43

because when the

12:45

drug users starting to have

12:48

methadone and when they

12:50

have a urine test and

12:55

the result is positive of using

12:57

, um, drugs

13:00

or something. And they put

13:02

in jail were supposed to stay

13:05

put in the rehabilitation process...when

13:08

, uh,

13:11

the , the family give policemen

13:14

the money and they transfer

13:17

to the rehabilitation process. So,

13:19

so that is the , the start

13:21

, how I met Gabe at the

13:24

beginning.

13:27

Well, I would give you an A plus right there,

13:29

because, you know, just in terms of mentorship

13:31

that you're schlepping over to the out, schlepping

13:34

over to the airport, because especially, you

13:37

know, traffic in Jakarta was that like

13:39

a full day affair to go get Gabe from the

13:41

airport?

13:43

Right. Right.

13:45

And then you show up and the guy's drinking Dunkin

13:47

Donuts hot chocolate, that

13:49

was the real stand out there.

13:53

And it's hot in Jakarta.

13:55

It is , it is. I think

13:59

it's still in the, in the building of

14:01

the airport. So the air can

14:03

air condition. Uh,

14:05

yeah.

14:05

We'll forgive him a little bit. Oh,

14:10

this is really interesting to learn

14:13

a little bit more about you both. So Agung

14:15

it sounds like, you know, when

14:17

you're describing your background that you, you

14:20

grew up a little bit sheltered, maybe is

14:22

how I might describe it. But now

14:24

you're doing all of this work related to

14:27

HIV, drug dependency,

14:29

stigma. So how did, h

14:31

ow did both of you,

14:33

and you've already talked about this a little bit, but start

14:36

focusing in on this area. What

14:39

got you interested in it?

14:43

Uh, starting with me first , probably

14:46

I choose when I choose

14:48

, my topic for my dissertation

14:51

, since I

14:53

knew the timeframe of international students

14:57

, uh, I only have

15:00

like maximum four years , doing

15:03

my research and the scholarship

15:06

also maximum four years then.

15:09

Telling to myself that I

15:12

have to do research where

15:14

it's related

15:17

to the

15:19

, uh, healthcare workers related

15:21

to the people living

15:23

with HIV. So

15:26

, when I read a

15:28

few things about nurses

15:31

and HIV things , most

15:34

of them telling about stigma. So since

15:38

there is no study conducted on that

15:44

time in 2007, a

15:47

study about stigma from

15:49

the nurses, then I

15:51

stick on that idea. And

15:54

whenever I got

15:56

into the classroom

16:00

of PhD study , when

16:04

the faculty asking me, Hey

16:06

, you, Agung, what is your

16:09

research interest ? And I keep

16:11

telling that I'm going to do assessing the

16:18

level of stigma of the nurses.

16:20

And I

16:24

didn't expect that when I

16:28

choose the place

16:31

of collecting data from

16:34

four different hospitals affiliated

16:39

from different religions.

16:42

But on that time,

16:44

I was thinking that , I

16:47

think if we see

16:51

if , if the hospital

16:53

affiliation, I may

16:56

, I

17:00

may , collect some

17:02

of the

17:05

data like they are different,

17:07

but I didn't expect that the difference

17:10

is because of the religious

17:13

background. I start

17:18

to understand what

17:20

I'm doing , when

17:23

I was , asking

17:26

by the IRB

17:29

in faculty of medicine

17:31

in University of Indonesia. They warned

17:35

me that you can

17:38

be put in jail if you're

17:40

still doing this study. And

17:43

I didn't understand what

17:45

they are , telling

17:48

me. But this professor

17:53

telling that , you know,

17:56

the , the result would be the

17:58

nurses from this hospital have higher stigma

18:06

compared to the others, or Muslim nurses

18:11

can have higher , stigma compared

18:14

to the other nurses in the hospital.

18:17

But on that time, my ego

18:19

was so high and I say that

18:22

if you are not allowing me to do this

18:24

rearch in your hospital,

18:27

fine, I have one of the received

18:30

three IRB approvals

18:38

approvals from three different hospitals.

18:40

So thank

18:44

you very much for allowing me

18:47

to sending this proposal in

18:49

front of you. And after that , among

18:52

them, they are mumbling and

18:54

say, no, no, no, we are not telling

18:57

that you cannot do that research

18:59

in our hospital. But we

19:01

try to ask you

19:03

to change a little bit in some of

19:05

the question and blah, blah, blah.

19:07

Oh, in that

19:10

case, I do the change that

19:12

I have to change

19:16

the topic of the stigma measuring

19:18

on the nurses in your hospital.

19:20

I cannot do

19:22

that. And finally, I can

19:26

collect data on that, that hospital,

19:28

although it was like at the end of

19:31

last week, I stay in

19:33

Jakarta because I can only

19:36

be collecting data in Jakarta like

19:39

two months that

19:42

is programmed from the eighth trip in my age. So

19:47

the day at the end of collecting , done,

19:50

then I flew back to Chicago.

19:54

So , from that

19:57

, from that

20:00

data , uh, just realize

20:05

after like one or two years,

20:07

I graduate and

20:10

return back to Jakarta. And Gabe

20:12

starting to have his postdoc

20:15

program. And when, you

20:19

know, like we were , having

20:22

a discussion on how to

20:25

start a Gabe's research on

20:27

his postdoc , in

20:30

the meantime, because of a very

20:32

long time of waiting approval

20:37

from many ministries, you

20:40

can tell a complete story

20:43

about that experience. But meanwhile,

20:46

that Gabe asking me "Agung, what

20:49

do you want me to help you? You

20:51

helped me a lot,". And I say, "Well, I still

20:53

have my raw data

20:56

of my dissertation that has not been

20:58

published,". And Gabe said,

21:02

"Oh, how about we see

21:04

the data? And we can have a discussion,".

21:07

And from that gives

21:09

you "Agung, you have a very good data

21:11

and you can there's

21:13

this. And, Oh, well , why don't we

21:15

just like, start to writing up?" And

21:18

I say, "Okay, fine,". I just remember

21:21

sometime we have a

21:23

discussion of the afternoon. Actually

21:29

Gabe you stayed in a very spooky hotel

21:32

that time , really , many,

21:36

many faculty say

21:39

that sometime the night

21:42

they can see, you know, like ghosts

21:44

or something, but , yeah, lucky

21:47

Gabe and his family didn't see

21:49

anything unless. Unless small snakes

21:53

when they have a , you know, a

21:55

small walk

21:58

in the morning, I believe. So, so,

22:01

so that is the very start

22:03

, um, you know, connected

22:06

to the very sensitive

22:09

study then. If

22:12

you asked me, how

22:15

can I do

22:17

some study on the prison?

22:20

That is because of Gabe's

22:22

proposal. I remember like

22:27

a week before I leave Chicago,

22:29

I'm just like this one to say

22:31

goodbye to Gabe and

22:33

have a chit chat, but

22:35

then the chit chat is so interesting

22:38

because Gabe say "Agung, don't

22:40

you, do you know about the issue of

22:43

recent in America,

22:46

and I believe the problem in the United States have the

22:52

same in Jakarta or even

22:54

more interesting. Do you want

22:56

to work together

23:00

research in Jakarta, based in Jakarta? And

23:03

I said yes, although on

23:05

that time, I was thinking. Okay , Gabe.

23:07

I just want to go back

23:09

home,". But

23:12

I didn't expect

23:15

that, that crazy

23:16

idea, it happens

23:19

finally. So when,

23:22

like in 2011,

23:26

Gabe start to send

23:29

me email and us , uh,

23:31

many information about our condition of

23:35

prison in Indonesia. And just like I,

23:38

I try to help you, the things that I

23:41

know. So , uh, I'm

23:43

sorry if I cannot give you

23:45

complete data or the data that you expect

23:48

me to share. So

23:50

that is the situation.

23:54

When, when Gabe

23:56

start to ask me to represent

23:59

him presenting our proposal

24:03

or Gabe's postdoc

24:05

proposal in from of the Ministry

24:08

of Research and Technology, I,

24:11

that was the first time

24:13

for me stepping on that

24:15

ministry building. That was

24:17

so huge we'll

24:20

pack with the...army from

24:25

the United States because Gabe's schedule

24:29

was put in

24:32

the same date and the same time with

24:34

the idea of doing research

24:37

from the army. They are going to

24:40

try to find the skeleton

24:42

of the army

24:45

from the World War II, that

24:50

it in , Island of Celebas . And

24:56

on that time , they , they

24:59

, they

25:09

talk about the project as

25:11

if there is nothing

25:13

, there is no, no one in the building

25:16

, uh , representing of United

25:19

States person or researcher, but from,

25:22

from their discussions , uh,

25:24

they say like, we have to be

25:26

very careful with the United States researcher

25:29

because they

25:31

might collect something

25:35

valuable from our country. So

25:38

we have to protect blah, blah, blah, blah, blah,

25:40

blah. So I was like,

25:42

so scared when Gabe's name was called. And , and they

25:55

asked , is there any represent from Indonesian

25:57

art? And I just raised my hand, I and

26:01

I said, Oh, okay. You, you didn't

26:04

expect me just sitting next to

26:06

them when they talk

26:08

about the study

26:11

of the army. So , uh,

26:14

yeah , uh, Gabe gave his presentation. And

26:18

then when the

26:20

discussion coming and they

26:24

are trying to use Bahasa Indonesia,

26:26

and , uh, they

26:29

stop , presentation

26:32

of Gabe. And they asking

26:34

me with some questions that

26:37

, yeah, I,

26:39

that is my very first

26:42

valuable experience

26:44

. Never have that , that kind

26:46

of activity before. So , I'm

26:50

so lucky, although at the

26:53

same time, it's so scary. I

26:58

never expected to have that kind of meeting

27:00

before. Yeah,

27:04

Well, Agung, that's pretty incredible. I mean, for you

27:06

to go from your

27:08

dissertation proposal, when you're

27:10

talking about what you're going to do, and

27:12

folks are like, well, you might

27:14

go to jail for this, and then you do it anyway.

27:17

That's incredible all the way up to sort

27:19

of advocating, you know, for this research

27:21

partnership at

27:24

that sort of higher level. That's really, that's

27:26

really intense. I would have to say. Yeah,

27:29

but I feel like I've got like a million

27:31

questions now. So first off,

27:34

Gabe, everyone wants to know if that house

27:36

actually was haunted that you stayed in, and

27:38

then also, you know, to follow up

27:40

with the same idea, how did you get interested

27:43

in all of these issues related to HIV

27:45

drug dependency, stigma?

27:48

Well, I'll just comment briefly on the

27:50

ghost issue and that's you know,

27:54

Indonesia is often referred to as the largest

27:56

Muslim majority country in the world,

27:58

and that that's true. There are the most

28:00

numerous followers of the Islamic faith,

28:03

but Islam is layered

28:05

over many other religions and some , one

28:07

of those is Animism. And so certainly

28:10

there's the belief that spirits reside in

28:12

inanimate objects. And so, you know,

28:14

I always take that into consideration when I'm,

28:16

when I'm walking through the natural world

28:18

in Indonesia. I

28:20

want to back up a little bit. I think I'm going is maybe

28:22

not doing justice to the,

28:25

the the work

28:27

that, that , the risks that

28:29

he took to carry out the work that he was

28:31

doing. Agung was sponsored

28:34

through an National Institutes of Health

28:36

fellowship to come to the United

28:38

States. So kind of building on what we talked about earlier,

28:40

Agung was my mentor for many years. And

28:43

then I said, Agung, why don't you come get your PhD

28:45

in the United States? And

28:47

so he took a huge, ah , he took

28:49

a huge risk by doing that. He left his family,

28:51

he left his country, he left his position.

28:54

Ge left a very good job at the World Health Organization

28:57

in Indonesia with no, with no

28:59

promise of a payoff. And he came

29:01

to the United States and he did a dissertation

29:04

looking at stigma towards

29:06

people with HIV that

29:08

was being enacted by healthcare

29:11

providers. So that right there

29:13

is risky because you're really, you're , you're putting

29:15

healthcare providers under a microscope and you're saying, what

29:18

is it that you do? Or you don't do that contributes

29:20

to the perpetuation of this disease? Then

29:23

his findings. We said, well, let's look at things

29:25

like knowledge does knowledge affect stigma.

29:28

Does the degree of religious involvement

29:30

affect stigma? While we're at it, let's look

29:32

at whether Catholics and

29:35

Muslims enact stigma differently.

29:37

And by way of background in Indonesia,

29:40

there's many types of hospitals. Some

29:42

of those hospitals are public institutions.

29:45

Some are run by Islamic religious

29:47

centers. Some are run by Catholic or Protestant

29:50

religious centers. So hospitals look very

29:52

different in Indonesia in terms

29:54

of their institutional affiliations. Well,

29:57

what Agung found was that

29:59

, um, people

30:01

who were , uh, nurses who were

30:03

practicing in Islamic hospitals

30:06

on average , endorsed

30:09

more stigmatizing attitudes towards

30:11

people with HIV. And

30:13

this is where Agung was getting pushed back.

30:15

And I think he immediately saw the risks

30:17

of coming forward with this sort of

30:19

data in a country where the,

30:21

the ministry of religion , um,

30:24

has significant sway over

30:26

public policy and is very influential

30:28

within government. And this may be something that

30:31

we're unaccustomed to in the United

30:33

States. But if you're going to say things about religion

30:35

in Indonesia, you have to take into consideration

30:38

the fact that , um , the ministry of religion

30:41

and in general, in , in people's

30:43

daily lives, religion is incredibly

30:46

important. And there's not

30:48

the same distinction perhaps between

30:50

the public sphere and the private sphere that, that,

30:54

that might allow some of those comments to

30:56

pass. But what's interesting

30:58

is because of these risks, we said,

31:01

well, let's look at the data a little deeper.

31:04

And so we started to dig in a little bit

31:06

and we found something interesting, which was

31:08

that it wasn't so much that nurses

31:10

were coming from Muslim hospitals

31:12

or Catholic hospitals. It's

31:14

that Catholic and Protestant hospitals

31:17

tended to be more diverse in

31:19

terms of who they hired. So

31:21

in a Muslim hospital, you're more likely

31:24

to be practicing alongside another

31:26

Muslim nurse. And

31:28

so we can think about the normalization of attitudes

31:30

and things like this, but where

31:32

we landed with this was that it wasn't

31:35

so much that these were Muslim hospitals

31:37

or public hospitals. It was that

31:39

public and Catholic hospitals tended

31:41

to employ a more diverse array

31:43

of students. So you can think about any work

31:46

setting anywhere in

31:48

the world. If you're practicing next to people

31:50

whose opinions and hopes and

31:52

fears may look a little different than your

31:54

own, you're , you may be more tolerant.

31:57

And so , in, in a way,

31:59

the risks that we had to think about in

32:01

terms of publishing or disseminating, this

32:03

information actually led us to scrutinize

32:05

the data further, which led to these

32:08

insights about maybe it's diversity

32:10

in the workplace that's really driving this.

32:12

And, and subsequent to this, Dr.

32:15

Waluyo has continued this line of research

32:17

recently with 500 healthcare

32:19

providers in three different parts

32:22

of the country. And again, we're

32:24

seeing a similar pattern is that people

32:26

who are practicing in more diverse

32:28

workplace settings are on

32:30

average endorsing fewer stigmatizing

32:33

attitudes. So

32:36

that's one thing I wanted to touch on. The

32:38

other thing is back in 2003,

32:41

Agung and I weren't aware of what

32:43

was happening with the HIV epidemic

32:45

in Indonesia.

32:47

Okay.

32:47

Neither one of us understood what was

32:49

going to happen during the next 10 years.

32:52

And so, as we were getting our PhDs,

32:54

and we were forming ideas about what

32:56

we wanted to do, and the HIV

32:59

epidemic in Indonesia was becoming

33:01

one of the least well controlled epidemics

33:03

in the world. So that by, by

33:06

2013, Indonesia

33:08

had been singled out by the United

33:11

Nations. U h, the joint United

33:13

Nations Program on HIV AIDS

33:15

known as UN AIDS, had singled

33:17

out Indonesia as one of the countries

33:20

where mortality and HIV

33:22

incidence, o r the number of new cases,

33:25

had increased. And that this was in contrast

33:27

to most other countries in the world. And

33:30

so Indonesia's HIV epidemic

33:33

had started out in people who inject drugs,

33:36

and because of the punitive drug laws

33:38

i n Indonesia, those people were

33:40

disproportionately being incarcerated.

33:43

I read one estimate that a third of all,

33:45

people who inject drugs in Indonesia had

33:47

gone to jail or prison. And

33:50

as a result, the, t he prison

33:52

population swelled tremendously

33:55

over the seven year period that we

33:57

were, we were

33:59

becoming researchers. And so the epidemic

34:01

was u nfolding a nd in, in really

34:03

devastating ways, while both of us were

34:06

getting up to speed as researchers. So

34:09

that by 2013, the Australians,

34:12

the Dutch, several other governments had

34:14

invested heavily in HIV

34:17

reduction in Indonesia, and

34:19

with a special focus on prisons because

34:21

they knew what was happening or not happening

34:23

there. And so I'll, I'll

34:26

give a little bit of background on that. Indonesia

34:29

has the eighth largest prison population

34:31

in the world. That's because

34:33

it's a huge country. The incarceration

34:36

rate is actually far lower than

34:38

the mean incarceration

34:40

rate for the world, which is about 145

34:43

per a hundred thousand. Indonesia only

34:45

incarcerates about 78 per a hundred

34:47

thousand. So the incarceration

34:49

rate is incredibly low, not even close to the

34:51

United States, which incarcerates about a quarter

34:54

of all the world's prisoners.

34:56

Wow.

34:57

Nevertheless, because

35:00

of the punitive drug laws, Indonesia's

35:02

prisons tend to concentrate,

35:05

tend to incarcerate people

35:07

who are at risk for HIV

35:10

and, and the majority of

35:12

whom are people who injected drugs.

35:15

More recently, as we have seen

35:17

a shift away from injectable opioids

35:20

towards amphetamine type substances,

35:23

we've seen increasing incarceration

35:25

or among gay men. Why? Because club

35:28

drugs, stimulants, ecstasy, those

35:30

kinds of things tend to circulate in the

35:33

club circuit. And so it

35:35

was striking to me to go back into

35:37

the prisons and in 2015,

35:40

and to see that there

35:42

was sort of this older generation of men

35:45

who had injected heroin, and that was their pathway

35:47

into prison, but then also , younger

35:50

gay men who were being drawn into the

35:52

prisons because they were being , they

35:55

were being singled out in police raids

35:57

and other police. In Indonesia,

36:01

there's sometimes vigilante groups

36:04

that will raid nightclubs. And that will

36:06

result in, in young gay

36:09

men being incarcerated. But

36:13

we see it history repeating itself,

36:15

right? The , uh , the , the drug, the

36:17

drug market has shifted. It's shifted

36:19

towards another population where , that

36:22

is at risk for HIV gay men. And

36:24

now we're seeing them in the prisons as well.

36:28

Well, there's a , there's,

36:30

there's a , there's a global discourse on what to

36:32

do about this. Incarceration is

36:37

probably the, the, the, the

36:39

least productive way to address

36:42

an epidemic. Incarcerating people

36:44

who have, who have a disease is, is

36:47

tremendously counterproductive to reducing

36:50

the spread of infection. We

36:52

knew from second hand

36:55

information, some of it done in

36:57

collaboration with the Indonesian prison authority

37:00

and , and AusAID, which is sort of Australia's

37:03

version of USA ID , that there

37:06

was drug use in the prisons. And

37:10

when we went in, in 2013, certainly

37:12

we, we saw evidence of this as well.

37:15

It wasn't just that the prisons were

37:17

incarcerating people at risk for

37:19

HIV or living with HIV, but

37:21

then people were renting needles.

37:23

They were sharing syringes and

37:26

, and there was, there was an increase

37:28

in drug use that happened when

37:30

people were in prison because the boredom,

37:32

being in contact with other people with substance

37:35

use disorders . So that by the time they

37:37

left prison , they had

37:39

been exposed to , they

37:42

had been exposed to HIV and other bloodborne

37:44

pathogens like hepatitis C. And

37:46

so a very, a

37:48

recent study that looked at people who inject

37:51

drugs in Jakarta found that

37:53

incarceration was the single most

37:55

important risk factor for the acquisition

37:57

of drug resistant HIV. And

37:59

so Agung and I looked at each other and we were

38:01

like, this is what we've been saying. So

38:05

these prisons are extremely high risk

38:07

settings. And we also see this in the former Soviet

38:09

Union, Malaysia and other countries where

38:11

incarceration is sort of the national strategy

38:14

for dealing with people at

38:16

risk for HIV.

38:19

People at risk of HIV right type

38:22

policy...

38:22

Right. T he, the war on drugs, the one drugs

38:25

has really resulted in prisons being

38:27

one of the main places where people with

38:29

HIV are diagnosed and first offered

38:31

treatment. And when we went and we found 77%

38:35

of the men with HIV had been diagnosed

38:38

in prison. Half of them

38:40

during the current prison term. In the U

38:42

S it's 1%.

38:45

So does that mean that they're not testing

38:47

enough outside of prisons?

38:50

That's exactly right. It represents

38:52

a failure to kind of connect with these men

38:54

in the community. And Indonesia,

38:58

I should back up and mention here though, that

39:00

at the same time, Indonesia has been ahead

39:03

of many other countries in terms

39:05

of its public health response in the community.

39:09

So Indonesia embraced a harm reduction

39:11

model early on. But

39:13

the, the drug policy was sort

39:15

of working against that. I

39:18

should also mention here that Indonesia in,

39:21

in many respects is ahead of other

39:23

countries in terms of public health in

39:25

prisons. And so often when we

39:27

read about Indonesian prisons in the media,

39:29

it's often proceeded by the word notorious.

39:32

I often I challenged someone once

39:34

I said, I, I challenge you to find a

39:36

news article about Indonesia prisons,

39:39

where the word notorious is not used.

39:41

Yeah. I think a lot of journalists use it reflectively

39:44

cause they're like, they've never been to an Indonesian prison,

39:46

but they know they have a reputation.

39:49

Our prisons are niche notorious. I

39:51

feel like in the States, like not

39:54

only at our, like our system that incarcerates

39:56

so many people, but then like, you know, we've got

39:58

all this, like Mister on like Shawshank

40:01

and like Riker's Island and we've got,

40:04

so.

40:04

Well, there's a whole mythology around prisons.

40:06

And I get that, like when I talk to people

40:09

about what I do, one of the first

40:11

questions they ask is like, well,

40:13

everybody's having sex in prisons

40:16

and everybody's using drugs in prisons.

40:18

And sort of, they have these, these, these

40:21

beliefs that a lot of them are from,

40:23

you know , watching Oz or other, you

40:26

know, Shawshank Redemption. And

40:29

, some of that fits

40:31

with reality to

40:33

the extent that we understand reality

40:35

in these spaces. And some of it doesn't,

40:38

doesn't fit so well with, with, with

40:40

the things that we've seen and the things that we've heard.

40:44

One of the , when

40:48

we started working in prisons in 2013,

40:50

it was really a, it

40:52

was really just a long shot. As,

40:55

as Agung mentioned, we had to go in

40:57

front of several panels of government

40:59

representatives and kind of make the

41:01

case that this was important work

41:04

and that we could be trusted

41:06

to be good collaborators over

41:08

the longterm . And

41:12

I think that our

41:14

relationship has gotten

41:16

better and better. A couple

41:19

of years ago, the University of Indonesia signed

41:21

the first memorandum of understanding

41:24

with the National Prison Authority,

41:26

and that has led to service teaching

41:29

and research. And that to

41:33

me indicates an openness and a willingness

41:36

to, to , um, to

41:39

serve the interests of people who end

41:41

up in prisons and jails and to bring

41:43

expertise from outside to inform

41:45

policy and practice. So we're very,

41:48

very enthusiastic about that. Um,

41:51

and we have maintained a balance

41:54

and I think we've done a good job about being candid

41:57

with the scientific community and with

41:59

our, our readers, people

42:01

who are interested in our research about what we're

42:03

finding while at the same time,

42:05

not being sensationalist or

42:07

misrepresenting in any way what's

42:09

happening and to provide a balance of the good

42:12

and the bad. As

42:14

an example of, of a public health measure

42:17

that Indonesia has implemented, they have

42:19

methadone for the treatment of

42:21

opioid use disorder in the prisons.

42:24

Now it's probably not reaching

42:26

as many people as it should. But

42:31

you'll find many prison jurisdictions

42:33

in the United States that don't even have

42:35

methadone. It's not even an option. And

42:38

this is a who essential medicine.

42:41

This is not a , a, a , you

42:43

know, this is a mainstream treatment

42:46

for opioid use disorder, and we don't have

42:48

it in...

42:48

Many decades...

42:50

Right. It's been around. Safety

42:53

is very well established. Efficacy is very

42:55

well established. So

42:57

I think when we talk about Indonesian prisons, we

42:59

have to think about, we

43:01

have to look for the bright spots and kind

43:03

of see what's happening well, and who are championing,

43:08

w ho, w ho, who is it that's getting behind these initiatives,

43:11

and then connect with those people and say, what could

43:13

we do better? Or what could we do more

43:15

of if we had additional inputs? And

43:18

so we've, we've identified some of those champions

43:21

and we've built up a network of, of,

43:24

of scientists and practitioners

43:27

in Indonesia to try and move some of

43:29

these projects forward.

43:31

I feel like the idea of champions comes up a lot

43:34

in research. I remember doing

43:37

work in hospital settings with pregnancy,

43:40

and it was the same thing. You know, if we can find

43:42

those champions in these spaces, then

43:44

we can really do nice

43:47

interventions here. And

43:49

talk about this. I'm curious just about what the experience

43:52

is like for someone to be

43:55

, diagnosed with HIV.

43:57

And then Carly and I were having a conversation earlier, we

43:59

were really curious about, what's it like if you,

44:01

once you are diagnosed with HIV in a prison

44:03

setting, what's it like to start

44:06

accessing medication? Or maybe

44:08

if you have an opioid use disorder,

44:10

what , what's it like to start accessing

44:13

methadone? Sort of , what, what does that process looks

44:15

like? Look like for someone who is

44:17

in a prison in Indonesia or in Jakarta?

44:20

Let me start out by talking about

44:22

what I think it's like in the United

44:25

States. This is what I, this was

44:27

my dissertation work. Most

44:30

people with HIV

44:32

in prison in the United States knew their

44:34

status before they were incarcerated.

44:38

Some are diagnosed in prison in jail.

44:41

But most of those who are currently

44:43

in a prison or jail knew their status beforehand.

44:46

So the issues for

44:48

that individual are, do I disclose

44:50

my status? Do I tell a guard?

44:53

Do I tell the, the first doctor or

44:55

nurse that I see that I'm on treatment

44:57

and that I need my treatment? If I

44:59

do, what are they going to be the costs? And

45:02

so we found in

45:04

a few cases that in the United

45:07

States, your HIV status can sort

45:09

of be used as a weapon against

45:11

you by , by

45:14

correctional officers or

45:16

by the other inmates. And so

45:19

prisons are very hierarchical. You , there's

45:21

a , there's a pecking order. And

45:23

someone with HIV is as

45:25

it is, it occupies

45:27

a very low status on that pecking order.

45:31

At the same time , people

45:33

are looking for support in prison.

45:35

One of the first things that they, what

45:38

I heard many men say is

45:40

that when they got into the jail and

45:42

they were in the holding cell, one

45:44

of the first things they were trying to figure out is,

45:46

how do I protect myself in this environment?

45:49

And so that more immediate threat supersedes

45:51

considerations of am I going to miss

45:53

my pills today? Maybe

45:56

I've heard people tell me, I just don't open

45:58

up my, I just go off my meds when I'm in

46:00

jail. Cause if I'm only there for 30

46:02

days, I'd rather go off my meds,

46:04

than take all the social risks

46:07

associated with disposing my HIV

46:09

status. And

46:11

it interferes with their ability to, to

46:13

develop the kinds of support or protection

46:16

that they need in order just to get through that

46:18

first 30 or 90 days.

46:20

That big sacrifice.

46:22

Yeah, that's a big sacrifice

46:24

to make. Especially if

46:26

you see the treatment i s something that you're going to

46:28

be doing your whole life and maybe

46:31

being off meds for 30 days

46:33

is not going to hurt your health. That's

46:35

an, that's sort of a choice that the

46:37

individual makes now

46:40

in Indonesia, where many

46:42

men are being diagnosed during the current

46:44

prison term, they're coming in, probably

46:47

with the understanding that drugs led

46:49

them to be incarcerated. Maybe

46:51

starting to think, is this becoming a

46:53

problem for me? Maybe

46:56

the inklings of do I, do

46:58

I have a drug use problem? There

47:02

is not the same level of discourse around

47:05

addiction a s a mental illness in

47:07

Indonesia. So in all

47:09

likelihood, many people are thinking of this

47:12

as a moral failing. O

47:14

kay. I failed my God.

47:17

I failed my family. I failed

47:19

my religion. Okay.

47:21

So a lot of guilt, a lot of shame. And

47:24

then at some point, either a few weeks or a few

47:26

months into incarceration, they take a blood

47:29

test and the doctor says you

47:31

have HIV. Now

47:34

in Indonesia, if you tell someone they have

47:36

HIV, the first association

47:38

is death sentence. Why?

47:42

Because it is still largely a death sentence

47:45

in Indonesia. Indonesia

47:47

has one of the highest mortality rates from HIV

47:50

of any country in the world. Now

47:53

the central paradox that has

47:55

driven my research is

47:57

how could that be in a country

48:00

that imports or produces

48:02

its own antiretrovirals and

48:04

has the largest universal h ealthcare system

48:06

in the world. So in the United

48:09

States, we typically say, well, you know, the reason

48:11

the medicine doesn't get into people's m

48:13

ouths is because we have such a botched healthcare

48:15

system. In other words, it's health

48:17

system issues. And

48:20

we say, gosh, if only we had universal

48:22

healthcare, if only we c ould get drug

48:24

prices down. Well, Indonesia did

48:26

both of those things and it did them early.

48:28

It did them before most other countries. SBY,

48:32

one of the past presidents, authorized

48:34

domestic production or importation

48:36

of like eight HIV medicines and

48:39

HIV activists w ere celebrating this

48:42

a s like, look what Indonesia has done. They really

48:44

they're really ahead of the curve in terms

48:46

of taking concrete

48:49

actions to address the epidemic at

48:51

the, at the structural level, by

48:53

making these medications. ART is

48:55

free of cost in Indonesia, right?

48:59

A few years ago, a bottle of a triple

49:01

a cost, a thousand dollars in the United

49:03

States. And a lot of that was b orn by

49:05

the insurance company, but in

49:08

Indonesia, antiretroviral therapy

49:10

is free and healthcare is universal.

49:12

Now, once you start to dig and peel back

49:15

the layers there's hidden costs and things like

49:17

that, nevertheless,

49:20

I, we're just

49:22

starting to understand how it

49:24

is in a country with universal h

49:26

ealthcare and free antiretroviral therapy. You

49:28

can have extraordinarily high mortality

49:30

rates. And, and up

49:32

until the last few years increasing

49:35

incidents, incidents h as started to go down

49:37

in the last few years, not by much,

49:39

but some

49:42

of this is making a difference.

49:45

So that's, that's so

49:47

interesting because this really brings up

49:49

the, you know, some of the issues of context

49:51

that we all struggle with. I mean, if you were to run

49:53

these studies in the States, or, you know, I've done

49:55

some work in South Africa around access

49:58

issues and, and these

50:00

like healthcare related factors, the

50:03

system, the systemic factors and,

50:06

and especially cost comes up all

50:09

the time. Okay. So,

50:13

so what are some of the , um,

50:16

so what are some of the reasons that

50:18

lead to people not then accessing

50:20

or taking their medication,

50:22

especially in prison settings?

50:26

Well, in the prison , although

50:28

many of them are diagnosed and offered antiretroviral

50:31

therapy in prison. The,

50:35

until recently the guidelines said that

50:38

ART should be set aside for people

50:40

who have compromised immunity who

50:42

have, who have depleted immunity

50:44

like 350 CD4 cells.

50:47

Now who changed the guidelines

50:49

based on several large global studies.

50:51

I think most countries are now saying, treat everybody.

50:56

There is a, there's a

50:58

delay to ramping the

51:00

healthcare system up. I mean, when you say,

51:03

when you say not everyone's eligible for treatment

51:05

now, there's , there's all these cost considerations,

51:08

there's supply chain considerations . So

51:10

part of that is just a lag in

51:13

getting things up to speed. Another

51:15

issue is that when, when

51:19

we think of medicine , it's

51:21

something we take when we don't feel well. When,

51:23

when we feel like we need medicine

51:26

to help us get better. And

51:28

for many people with

51:30

HIV will not experience symptoms

51:32

until a very advanced stage of illness.

51:35

So in Indonesia, as in

51:37

many countries, it may be hard to convince

51:39

someone to start lifelong

51:41

therapy or commit to lifelong

51:43

therapy when they don't feel

51:46

particularly unwell. The

51:49

problem is that in Indonesia, there's also

51:51

a lot of tuberculosis, and the

51:53

prisons are 400% over capacity.

51:55

You will often have 20

51:57

men in a cell, and they will take

51:59

turns sleeping because they

52:01

there's literally enough, not enough floor

52:04

space for everyone's body to fit

52:05

down at the same

52:07

time. And so these are conditions

52:10

that are, that are very conducive

52:12

to transmission of TB . Then

52:14

you add to that, that anywhere between

52:16

one and 14%

52:18

of the prison population is immune

52:20

compromised. These are

52:23

conditions for explosive tuberculosis

52:26

outbreaks. So it's very important

52:28

that that, that, that

52:31

people are being started on antiretroviral

52:33

therapy in prison. Also,

52:35

they're using some of the regimens that

52:37

are in use are a little bit older. And so they have

52:40

like a worst side effect profile.

52:42

And some of the side effects are very

52:45

undesirable. And so

52:47

people may say, but I really don't want to do

52:49

that. Some of it may have to

52:51

do with things like health literacy, or

52:53

how much people are really able to absorb

52:56

and understand information that they're getting

52:58

about this new treatment that

53:00

they're supposed to be taking, and

53:03

then the stigma. So if

53:05

you have to take HIV medicine in

53:07

prison, that means you have to line up once

53:09

a week and go to a pill line. And it's

53:11

possible that you're going to be identified

53:14

as someone who has HIV, and

53:16

that that's going to change where you are

53:18

in the pecking order. We've

53:21

also found that prisons are very busy

53:23

environments in Indonesia. People are working

53:26

, um, they're working for other inmates

53:28

doing their laundry , preparing food.

53:32

I think I went in thinking, well, everyone here just

53:34

has a , a ton of free time. Right?

53:37

And we would have people come in and they would say, you know,

53:39

I've only got 10 minutes to talk to you, and then I need

53:41

to get back to work. And

53:44

so they may have schedules

53:46

where they just don't feel like they

53:48

want to be coming to a clinic every day.

53:53

So you're, you're from this kind

53:55

of formative research that you did learning about

53:58

the situation you, you currently

54:00

have two different interventions that are up

54:02

and going that you , you both are collaborating on.

54:04

So one is an

54:06

adherence intervention to

54:09

get and it has the best name Athena,

54:11

which is my favorite. I think,

54:14

you know, intervention tagline out there,

54:16

but one is to get people to essentially

54:18

take their medication, to kind of get

54:20

over these barriers and to continue

54:22

to take their

54:24

medication as they, after they leave

54:27

prison. Right. Cause I think that some of

54:29

your work together has shown that

54:32

people are at risk of , of dying

54:34

due to HIV related complications

54:36

in the two years after they leave prison.

54:39

And then the other line of research that

54:41

you've been working on is a partner notification

54:43

study to help people once

54:45

they have been diagnosed. And so many people are

54:49

diagnosed in presence to help them notify

54:51

folks in the communities. So

54:54

this is, this just strikes me like a

54:56

lot of work you're doing

54:58

together. And we were wondering kind of

55:00

what it looks like for you to, to

55:02

keep this , this

55:05

research together, up and going

55:08

on , on the sort of day to

55:10

day basis, but Gabe in Chicago

55:13

and Agung in Jakarta. And

55:15

I don't know if you guys have like done the geography,

55:17

but it feels like, you know, you could probably like go

55:19

directly through the globe to

55:22

get to each other.

55:22

That might be faster.

55:24

Yeah. Just going to say might be a faster flight doing it that

55:26

way.

55:27

Yeah. So what does this look like for

55:29

you t o what's the ins and outs of

55:31

working together from halfway

55:34

around the globe? Is t hat a lot of like late

55:36

night or early morning phone calls

55:38

and...

55:40

Late night, early morning phone calls,

55:43

there's no substitute for

55:46

, um, people

55:48

in , in , in Indonesia who

55:51

are a hundred percent trustworthy

55:54

and reliable and , and,

55:58

and excellent with communication and decision

56:01

making. Agung has taught me a tremendous

56:03

amount over the last 10 years

56:05

about speaking diplomatically

56:11

and engaging with people in

56:13

a way that they will be receptive to.

56:15

I think one of the most amazing

56:18

things to me about Indonesian culture,

56:21

if I can generalize for a minute is

56:23

the, the value that they place

56:26

on, on engaging

56:28

people in respectful relationships

56:31

and ensuring that when two people walk

56:33

away from a conversation that they both

56:36

feel like they have their esteem

56:38

intact and that they

56:40

want to continue working with this person.

56:45

And so as someone steeped

56:47

in kind of American culture , you

56:50

know, I will often say things in a way

56:52

that for maximum impact or

56:55

what I consider to be maximum impact

56:57

or to , to make my, my

57:00

message as forceful as possible and what Agung has

57:02

taught me and just living there has taught me is that

57:04

that's the quickest way to a dead end

57:07

often. And so

57:10

in, in conversations with stakeholders,

57:12

like if we're immediate , if we're at a meeting

57:14

with the director general of corrections

57:16

or , um, someone in one of these

57:18

ministries , I

57:21

think I'm doing a better job. I have a long way

57:23

to go, but I'll often probably

57:25

wisely lit Agung take the lead

57:27

and, and , and model

57:29

how those conversations are supposed to go

57:32

and trying to understand what it is that, that

57:35

you're , you're the person that you're conversing

57:38

with, what their what's in their

57:40

mind and kind of, what are they hoping to walk

57:42

away from this conversation with.

57:46

Agung, has Gabe gotten better at this over the years?

57:50

Well, the actually

57:54

, not every

57:57

important person

58:03

in the ministry of connectional

58:05

have that a way of,

58:08

you know, or even in ministry

58:10

of health, but

58:14

in general. Yeah. They, they

58:17

tends to , say

58:21

to everyone not

58:26

we can solve the problem

58:28

of this station, but , you

58:31

have to know that I am

58:34

sitting in this position. So

58:37

I have my own goals.

58:43

Some of them are keeping the

58:46

position or they

58:48

are going to have a promotion

58:50

to the higher position.

58:54

So sometime if we endorse

58:56

with the idea of decreasing

59:01

the spread of HIV

59:03

in the prison , they,

59:07

they know that as

59:09

their , daily jargon, but they are

59:14

not... Sincerely put that

59:20

as their , they

59:25

are going to achieve that, but

59:27

more on , how this activity

59:34

is seeing , excellent

59:37

in front of the boss.

59:40

So , even we

59:42

are facing a very high

59:45

position in the ministry of correction.

59:48

Sometime they have also the higher

59:50

, uh, position that

59:52

, uh, observing

59:55

them. And , now

59:59

I'm sitting in the position of

1:00:01

the Director in University

1:00:04

of Indonesia, then I'm more understand

1:00:06

that , among the

1:00:10

hierarchies they are seeking

1:00:12

of surface or

1:00:19

they are seeking of , of

1:00:23

place and from their , their stuff

1:00:27

. Like I have , my

1:00:32

boss , up there. Although I'm the

1:00:39

one working on that job

1:00:42

, uh, from day

1:00:44

to night , uh,

1:00:47

A to Z, but the

1:00:49

credits should be put on my

1:00:54

boss name . So I think that it's

1:00:56

also , happens in

1:00:58

ministry of a correction

1:01:01

where, where, when

1:01:04

they talk to us, me

1:01:06

and Gabe, they are not talking

1:01:08

with our project. They

1:01:10

are talking with the

1:01:13

idea, how can I use

1:01:15

this activity to

1:01:19

boasting , uh, my name or

1:01:21

my position in front of my

1:01:23

boss. So sometime I

1:01:25

have to be, you know playing political nicely accepted

1:01:37

among them. So

1:01:39

like when we when

1:01:43

Gabe is sending the

1:01:45

proposal in English, and then when

1:01:48

this was , seems like a

1:01:51

bit allergic of

1:01:53

like forcing the result

1:01:57

of this study, so implemented

1:01:59

and blah, blah, blah. Seems like they,

1:02:02

they are not happy with that sentence.

1:02:04

So I'm telling that this

1:02:07

can be , endorse of

1:02:12

what, one of

1:02:14

the , uh, achievement of

1:02:16

your , KPI , um

1:02:20

, you know, KPI, right? Yeah. So

1:02:25

when you help us at

1:02:27

the same time you achieve

1:02:30

the goal of your ministries . So

1:02:33

we have to bring that idea

1:02:36

in terms of, to

1:02:39

make them understand not

1:02:41

always the , what

1:02:44

they do is only

1:02:47

pleasing their boss, but they

1:02:49

have to be, they have to play

1:02:52

smart. They have to work

1:02:54

smart by helping us, and

1:02:57

in doing this research in

1:02:59

order to achieving that

1:03:04

goal, their goals. So that is

1:03:07

, if you are asking

1:03:09

whether Gabe is noticeable about

1:03:16

this situation , uh,

1:03:21

since they, they , uh,

1:03:25

the situation of facing

1:03:28

the , the person is changing

1:03:31

, it depends on who are

1:03:33

sitting there. So I,

1:03:37

I think Gabe is more, I think

1:03:39

now it's , more , aware

1:03:42

and understand compared

1:03:45

to it at the beginning

1:03:47

of 2010 , when

1:03:49

Gabe showing me

1:03:52

, uh, around four

1:03:54

or five ID card

1:03:58

from each ministries. And

1:04:01

Gabe asking me "Agung, if

1:04:04

policeman stopped me, which ID

1:04:06

card that I have to show?" And

1:04:09

I cannot answer that question, because

1:04:12

that is only like, when

1:04:14

you are coming to this

1:04:16

ministry, they give you this ID card,

1:04:19

you come to this ministry, they , they

1:04:22

give you this ID card. So , uh,

1:04:26

the policeman will, they

1:04:28

don't care about that ID card.

1:04:30

They only ask your passport

1:04:34

and yeah, that's

1:04:36

all. So that, the

1:04:39

ID card is only to show

1:04:41

them that they have

1:04:46

the authorities to give

1:04:49

or not give the approval.

1:04:54

That's all.

1:04:55

You know, Agung, it just, I'm really struck

1:04:57

by the breadth of mentoring here. I

1:05:01

mean, it sounds like, I mean, you , you probably

1:05:03

also deliver like a

1:05:05

, uh, some pretty advanced training in social

1:05:08

psychology to

1:05:10

gave here along the way, too . You know, I did

1:05:12

have one more question, which is that I was really curious

1:05:15

, to get your, on

1:05:17

how nursing fits into the bigger picture

1:05:19

of HIV prevention and treatment and prisons.

1:05:22

But maybe also more generally since you're

1:05:24

a nursing PhD, and now you're on the

1:05:26

faculty at a school of nursing?

1:05:30

Sure. Well, I think with HIV

1:05:33

as with any global health

1:05:36

concern that we have

1:05:38

to, we have to utilize all

1:05:41

the tools that we have. And

1:05:44

globally nurses are underutilized.

1:05:46

When we take into consideration their

1:05:48

training, their distribution

1:05:51

, their professional code of ethics,

1:05:54

their ability to interact with patients over

1:05:56

90% of patient care

1:05:58

in the world is delivered by nurses. And

1:06:01

I nurses are

1:06:03

like the sleeping giant of the healthcare

1:06:05

system. Studies now

1:06:09

from sub Saharan Africa showed that nurses

1:06:12

with the right training can provide

1:06:14

HIV care at the same level as

1:06:17

physicians and achieve higher rates of

1:06:19

patient satisfaction. If

1:06:21

we look back to the 1800s in the U S

1:06:23

nurses were the pioneers of doing home

1:06:26

visits for tuberculosis care. And

1:06:28

so I think nurses for a long time

1:06:30

have just intuitively recognized that

1:06:33

it's not enough to be in a clinic and wait for

1:06:35

patients to come see you, that you have to go out

1:06:37

there in the community. You have to build

1:06:39

trust, you have to do

1:06:41

epidemiologic surveillance. You have

1:06:43

to understand, I mean, nurses are out there

1:06:45

and they're , they're doing ethnography,

1:06:48

they're doing epidemiology, they're doing

1:06:51

psychosocial care. They're caring

1:06:53

for the needs of the whole patient, but

1:06:55

in many parts of the world, including

1:06:58

the United States , um,

1:07:00

there's been a tension between physicians

1:07:02

and nurses for dominance

1:07:04

of the healthcare system. And we see this in things

1:07:07

like the contracts

1:07:09

that nurses have to enter into, to subordinate

1:07:11

themselves, to physicians when prescribing

1:07:13

certain medications. The

1:07:16

development of physician's assistants came

1:07:18

about in the 1960s because nurses

1:07:20

refuse to subordinate themselves to physicians.

1:07:22

So physicians said, fine, we'll just, we'll

1:07:25

come up with our own nurses. We'll call them physician

1:07:27

assistants . And we see even now

1:07:30

with prescriptive authority that physician assistants

1:07:32

got out ahead of nurses because they had that

1:07:34

, that, that relationship with physicians.

1:07:35

But I may

1:07:39

have mischaracterized that a little bit. And I think

1:07:41

some of that had to do with people coming back from the

1:07:43

Vietnam war and needing to enter into healthcare

1:07:45

positions. But anyway , the, in

1:07:49

Indonesia, for example, nurses,

1:07:53

are nurses are numerous they're distributed

1:07:56

throughout the country in a decentralized

1:07:58

healthcare system. That includes

1:08:01

lots of local mosques or

1:08:03

community health centers. And community

1:08:06

health centers are sort of the, the,

1:08:08

the primary care hubs

1:08:11

for the healthcare system. So that's where you

1:08:13

go, if you have the sniffles or if

1:08:15

you need reproductive

1:08:17

health information. It's also where

1:08:19

a lot of HIV treatment is being delivered

1:08:21

and, and methadone is also being done

1:08:23

at the level. So

1:08:28

nurses are, and

1:08:30

you and the university of Indonesia was the first

1:08:32

program in the country to start training

1:08:34

nurses at the clinical scientist level.

1:08:36

So at what we would think of as the nurse practitioner

1:08:39

level. However, it wasn't until

1:08:42

I think, 2014, okay, that

1:08:45

they had their first nurse practice act. So

1:08:48

nursing has not been codified in

1:08:51

the same way that it has been in the United

1:08:53

States. And the roles, the legal protections,

1:08:55

the responsibilities, the licensing

1:08:57

issues, all those are starting to get sorted

1:09:00

out in Indonesia, but

1:09:02

it's in a framework where physicians

1:09:04

still want to control the decisions.

1:09:07

And so we've seen things like

1:09:10

nursing has not had a seat at the

1:09:12

table. When they

1:09:14

build new hospitals, nursing gets put

1:09:16

under physicians instead of having its own

1:09:18

department. And these control

1:09:21

issues are important because if

1:09:23

, if you see a ceiling in

1:09:25

your profession, then it

1:09:27

discourages people from aspiring

1:09:30

to do the best that they can.

1:09:32

And that's everything from clinical practice to

1:09:34

research. And so,

1:09:37

as a result of this kind of the

1:09:39

ceiling, that's put on nurse practice

1:09:41

and nurse research, nurses

1:09:43

are not doing everything that they're capable

1:09:45

of. Who does that really hurt? Well,

1:09:48

the patients.

1:09:49

Yeah.

1:09:50

Right.

1:09:50

Absolutely.

1:09:51

So like prescribing an antiretroviral

1:09:54

therapy is , can be done using an algorithm

1:09:57

now, right. More complicated

1:09:59

decisions always need to be pushed over

1:10:01

to a specialist, but physicians already

1:10:03

do this. They don't make decisions that are out

1:10:05

of their training. They refer it

1:10:07

to a specialist. And so why aren't

1:10:09

we doing, especially only

1:10:12

17% of people with HIV

1:10:15

in Indonesia receive lifesaving

1:10:17

therapy. One of the lowest

1:10:19

rates of art utilization in the world.

1:10:22

And again, if the is free, so

1:10:24

why is it not getting it to the bodies of the

1:10:26

people that need it? Part of that probably

1:10:28

has to do with a bottleneck effect of

1:10:31

limited numbers of physicians. I

1:10:33

was told once by an infectious disease

1:10:36

specialist , that there's eight infectious

1:10:38

disease specialists for the country of Indonesia.

1:10:40

This is the fourth most populous country in the world.

1:10:44

Wow.

1:10:44

And I know two of the eight p

1:10:46

ersonally. So in addition, in addition

1:10:49

to increasing the number of physicians

1:10:51

that t hey're graduating and Indonesia

1:10:53

has always done a really good job of moving people

1:10:56

out, into practice settings, where they're likely

1:10:58

to have an impact they don't have, they

1:11:01

don't have probably the same degree of brain

1:11:03

drain a nd people going into specialties

1:11:05

where t hat are very lucrative, but

1:11:07

are not going to have a significant public health impact

1:11:09

of being in fact, up until a few years ago,

1:11:12

all physicians who graduated h ave had

1:11:14

to have some service or practice i

1:11:16

n, in what would be considered kind of a, a

1:11:18

lower resource or a community setting.

1:11:21

So that's always been a priority, but the

1:11:23

same needs to happen with nursing, where we're,

1:11:26

where we are. We have the

1:11:28

legal framework and the regulatory

1:11:30

framework that supports them, practicing

1:11:34

all the knowledge and talent that

1:11:36

they have. And that would include things

1:11:38

like initiating antiretroviral therapy

1:11:40

and people monitoring them. A

1:11:42

big part of what we do is when people

1:11:44

get out of prison, they simply need

1:11:47

somebody to be checking in with them and finding

1:11:49

out how are you doing, how is this going?

1:11:51

Let's have an honest conversation about why

1:11:53

it's difficult for you to take the medicine,

1:11:55

and what can we do to help you overcome these obstacles?

1:11:59

And so that seems straightforward enough.

1:12:01

If t here a re issues like, well, I have, I,

1:12:04

you know, maybe this person has g

1:12:06

enotypic resistance. Like the medicine just isn't working

1:12:08

for them anymore. That's a really important

1:12:11

problem. You want to catch it early. And yes,

1:12:13

it needs to be referred up to a specialist,

1:12:16

but we can think of nurses and probably

1:12:18

a lot of lay health workers who

1:12:20

could go and do the kinds of things that would

1:12:22

make a huge difference in the course

1:12:24

of this epidemic. In

1:12:27

t he l ast, in the study, in the study that I'm referencing

1:12:29

from Vietnam, Indonesia, and Ukraine, a

1:12:31

quarter of the Indonesian,

1:12:34

HIV infected Indonesian, people

1:12:36

who inject drugs h ad drug resistance.

1:12:39

This means the first line medication, the

1:12:42

free medication no longer works.

1:12:44

So not only is this bad for that individual

1:12:46

who will now have to switch to a

1:12:49

more aggressive therapy or a different therapy,

1:12:51

think about the ripple effects through the healthcare system.

1:12:54

This is a middle income country that

1:12:56

through bold action and, and

1:12:58

resource allocation has managed to provide

1:13:00

ART for free. Now, they're looking

1:13:02

at a second wave of drug resistant infections.

1:13:06

I t's because in large

1:13:08

part because there weren't health workers out

1:13:11

in the places where t hey were needed to monitor

1:13:13

people who were receiving therapy to

1:13:15

make sure that they were able to consistently

1:13:17

take those treatments.

1:13:19

Definitely seems like nurses can be a big part

1:13:21

of the solution.

1:13:22

Nurses can fill these gaps.

1:13:24

Yeah. As the, as the daughter of

1:13:26

a nurse, I totally am with you on

1:13:28

that. And Agung, if you could

1:13:31

sort of raise , if you could wave your

1:13:33

magic wand, what would you have nurses

1:13:35

doing , um, in Indonesia

1:13:37

for HIV prevention and treatment?

1:13:41

Well, I

1:13:47

actually, I still have faith

1:13:49

that although it's not

1:13:52

really easy to implement, then the

1:13:55

idea of empower

1:13:59

community nurse to do the job.

1:14:03

We are

1:14:06

now, have for

1:14:11

your presser from ministry

1:14:13

of misdemeanor, ministry of health

1:14:16

, where beforehand we

1:14:20

still have the nurse

1:14:23

, uh, for , uh,

1:14:26

some certain hospitals.

1:14:28

Now , for type

1:14:32

a or type A, we

1:14:34

have , the head

1:14:37

off nurse , in the

1:14:40

directorate , uh,

1:14:43

the type B, C, D there

1:14:45

is no nurse on

1:14:48

directorate . So , I,

1:14:51

I would like to offering my

1:14:57

hands to those

1:15:00

community , nurse specialists

1:15:04

or community nurse who

1:15:06

are working in public health center

1:15:10

to embrace that become one

1:15:13

of their

1:15:15

job. And if

1:15:18

they can, if evidence

1:15:20

that their work

1:15:23

can improve the

1:15:26

quality of life, people living in

1:15:29

, uh, HIV in the

1:15:31

prison or after they released that

1:15:34

probably , they , help

1:15:38

district center. A decision

1:15:42

maker and

1:15:44

make that job become

1:15:48

of their , uh, authority

1:15:52

to, to do.

1:15:54

And when they

1:15:57

have the authority to

1:16:01

become all the insurance person for

1:16:03

, uh, caring people, living

1:16:05

with HIV in the prison or in the community,

1:16:08

then they seems

1:16:10

like to have another

1:16:12

option to be , receive attention from

1:16:19

the decision makers in

1:16:22

the ministry or a district officer,

1:16:27

so , uh, yeah, it's... Now

1:16:29

we are not really easy to,

1:16:32

to work , uh, in

1:16:34

the environment where , everyone tried

1:16:38

to , uh,

1:16:41

like Gabe said, under

1:16:44

supervision or under the medical

1:16:47

or medicine. So it's,

1:16:50

yeah, it's... If

1:16:52

we have to , uh, if

1:16:55

we act too vocal, like we

1:16:58

yell too much to the ministry of health... Then

1:17:02

they, they built

1:17:04

a thicker and higher

1:17:06

wall where we cannot climb

1:17:09

and get through that

1:17:11

wall. But then with the

1:17:14

help of the nursing

1:17:17

associates , uh , with the president of nursing

1:17:20

associates , senior associates , as we have

1:17:22

now , uh, they

1:17:25

asked us to

1:17:27

, uh, act calmer.

1:17:30

So the ministry see

1:17:33

us not as a trend

1:17:36

or... They

1:17:40

feel threatened because of

1:17:42

the nursing voices

1:17:44

are made not really

1:17:49

feeling comfort in their comfort zone.

1:17:50

So we try

1:17:53

to play nicely with them.

1:17:56

Uh , but , uh , at the same time, we

1:17:58

try to use the opportunity to,

1:18:02

to be improve and show the

1:18:04

government that nursing can do something

1:18:07

for the nation. And also

1:18:10

, uh,

1:18:13

in the future, we, we

1:18:15

expect that the local government

1:18:18

or the district health officer

1:18:20

may give incentive for the nurses

1:18:23

who work in the prison and

1:18:26

the community better while

1:18:28

we, they caring for

1:18:30

people.

1:18:36

Well Agung I feel like if anyone has the social skills

1:18:38

to navigate this and you

1:18:40

to, to change, it's probably

1:18:42

you, so that's great, that you

1:18:45

know, you're on it . And you've got

1:18:47

this collaboration with Gabe to , to

1:18:49

keep it going too. I've been

1:18:52

so super grateful for the opportunity

1:18:55

to work with you both and to learn from your

1:18:57

boat from you both. And we're

1:18:59

really grateful for your time today. It's been

1:19:02

really neat to bear witness

1:19:04

to what I think is a really special

1:19:07

and a really effective collaboration.

1:19:09

So, yeah. Thank

1:19:11

you so much for all the work that you're doing, and thank

1:19:13

you so much for spending some

1:19:15

time to come on the podcast with us. We really

1:19:17

appreciate it.

1:19:22

Thank you.

1:19:23

Thank you, Valerie.

1:19:37

Wow. So what a great

1:19:40

conversation, and I just love that,

1:19:42

you know, right off the bat, these guys,

1:19:44

you know, Agung starts in about

1:19:46

his experience, you know, with the work and

1:19:48

where he got a little bit of feedback and that, you

1:19:50

know , he thought maybe it was uncomfortable because he

1:19:53

grew up a little bit, maybe sheltered

1:19:55

from, you know, these things that are happening

1:19:58

, um, and , uh , you know, at his home,

1:20:00

and that Gabe just stops and says like, no,

1:20:02

no, like you're not doing yourself

1:20:05

justice. The work that you're doing is, you

1:20:07

know, or at the time, especially really controversial.

1:20:10

And, you know, you really had to stick your neck out

1:20:12

on the line in , you know, sorta

1:20:15

like fight for, for what you believe

1:20:17

in. And that's why, you know, you

1:20:19

felt that way. And I just thought it was like, honestly,

1:20:22

like just the cutest thing that here are these,

1:20:24

you know, they're not just two scientists

1:20:26

at this point. And that's really, I think what that first

1:20:28

part highlights is that these are two humans

1:20:31

that are like, you know, in

1:20:33

it for the full human experience, you can tell that

1:20:35

they have such like a genuine relationship outside

1:20:38

of the science world. And

1:20:41

I just love that , that, that's how, you know

1:20:43

, we got to start off this conversation.

1:20:45

Yeah. You can tell they're buds. Yeah. And

1:20:48

yeah, no, I think it's really interesting. Cause if we

1:20:50

had only had Agung on the call,

1:20:53

because often we're only interviewing one

1:20:55

scientist, then we wouldn't have had this other

1:20:57

perspective from Gabe to say,

1:21:00

no , no, no, hold on a sec, like, right,

1:21:03

this was a really intimidating and challenging

1:21:06

situation for you to be walking into.

1:21:08

And so that

1:21:11

was super interesting and neat to

1:21:13

be able to, to, to learn

1:21:15

by talking to both of them together.

1:21:17

Right. And I feel like that's mirrored throughout the whole thing

1:21:19

too. It's just like that they both have, you

1:21:21

know, bring to the table such,

1:21:24

you know, seemingly radically different

1:21:27

upbringings and perspectives and like cultures

1:21:29

that are just like coming together

1:21:32

in such a wonderful way and

1:21:34

obviously, you know, really meaningful and

1:21:36

impactful way. So yeah .

1:21:37

Do you know what I mean? Yeah, it makes me think back

1:21:40

to the conversation we

1:21:42

had in our very first episode with

1:21:44

Carmen Logie about how what's good

1:21:46

ways to do international

1:21:48

research and, and,

1:21:51

you know, Agung and Gabe just seem

1:21:53

like the ideal way to

1:21:55

do international research. Like they are

1:21:58

partners right in their work. And

1:22:00

I know Gabe is always, you know, thinking

1:22:02

about Agung. And , you

1:22:06

know, it's , it just seems like that

1:22:08

isn't , that's an equitable research research

1:22:10

partnership for just

1:22:13

two people who happen to live like halfway

1:22:15

around the world.

1:22:16

Right. Exactly. Yeah. That

1:22:18

was just so, so neat to see.

1:22:20

Yeah. It was really neat. It's a , it's

1:22:23

a great research

1:22:25

partnership. And I think, you know, when Gabe talked

1:22:27

about going and

1:22:29

living in Indonesia for a w

1:22:32

hile, with his family during the interview

1:22:35

that was facilitated, I believe by a Fogarty

1:22:37

award. Right. And so F

1:22:40

ogarty a wards sometimes a re designed

1:22:42

to try to

1:22:44

really facilitate these l ike partnerships

1:22:46

and relationships. So in some way I feel

1:22:48

like these two could be like a poster, you

1:22:50

know, the poster children for the type

1:22:52

of award.

1:22:53

Yeah, absolutely. Totally agree.

1:22:56

Yeah. Well, the

1:22:58

research assistants had a few questions that

1:23:02

they thought might be useful about

1:23:05

background information to kind

1:23:07

of contextualize some of the science that

1:23:10

ongoing and Gabe were talking about. So they

1:23:12

wanted a little bit more information on

1:23:14

like on HIV in

1:23:16

Indonesia.

1:23:18

Right.

1:23:19

So I thought it'd be useful to know that

1:23:21

the HIV prevalence , uh,

1:23:23

which is the percentage of the population

1:23:26

that's estimated to be living with HIV

1:23:28

is 0.4%

1:23:31

in 2018 is what I found

1:23:33

from UN AIDS. And

1:23:36

I wanted to compare that to the US. We're at

1:23:38

0.3%. So it's actually

1:23:40

super close. And

1:23:43

then if we keep kind of going

1:23:46

down the line, HIV testing

1:23:49

though is , at

1:23:51

51%, which basically means

1:23:53

that they estimate that about 51%

1:23:55

of people who are living with HIV

1:23:58

have been tested for that and know that they

1:24:01

are living with HIV. So that's actually

1:24:03

kind of striking because it means that almost

1:24:05

half or 49% of people may

1:24:08

not know that they're even

1:24:10

living with HIV, which is really

1:24:13

, hard to

1:24:15

think about because, or , you know, sad

1:24:17

to think about. Because as

1:24:20

soon as you know, that you're living with HIV, you can

1:24:22

access medications that are going to help you

1:24:24

live a long and healthy and lovely

1:24:26

life. But if you don't have access to those

1:24:28

medications , you're

1:24:31

going to get sick a lot sooner and die

1:24:34

faster. By

1:24:36

comparison in the United

1:24:38

States, it's about 14% of people

1:24:40

with HIV are estimated

1:24:43

to not have been tested. And so don't

1:24:45

know that they're living with HIV. So that's actually, so

1:24:48

that looks quite different. So

1:24:50

number of people are about the same,

1:24:52

but the people who, the number of people who know

1:24:55

that they are living with HIV is smaller

1:24:58

in Indonesia. And

1:25:00

then if we look even further, if we think

1:25:02

about, if you're living with

1:25:04

HIV, are you accessing treatment?

1:25:07

In Indonesia, it's about 17%

1:25:10

of adults with HIV who are

1:25:12

accessing medication. So that

1:25:14

becomes a quite small number. Um,

1:25:17

interestingly UNH it's like all those

1:25:20

cells were blank for the youth , for

1:25:22

the US and , um, so

1:25:24

I couldn't find that specific

1:25:26

number to be a good comparison point, but

1:25:28

in the US 64% of people

1:25:30

living with HIV received some sort

1:25:32

of care in 2016 , 53%

1:25:36

of people living with HIV had

1:25:38

a suppressed viral load, which

1:25:41

would suggest that they are probably

1:25:43

on a medication that is suppressing the

1:25:46

amount of HIV virus that's circulating

1:25:49

through their blood. So, you know, we might

1:25:51

say that, you know , 17%

1:25:54

of folks in Indonesia are

1:25:56

receiving medications, whereas in the US that's

1:25:58

actually it's much higher. So that's

1:26:00

a big difference. Yeah. There

1:26:04

are 30 countries that

1:26:06

make up 89% of the world's

1:26:08

new HIV infections. They're called

1:26:11

fast-track countries by the UN AIDS. And they're usually

1:26:13

prioritized for our HIV

1:26:16

interventions and both

1:26:18

the US and Indonesia are

1:26:20

on, are on that list. So

1:26:23

, um, so yeah,

1:26:25

there's , I think important work to be done

1:26:27

in both of these places in both the US

1:26:30

and and Indonesia , um,

1:26:32

to try to do better on some of these statistics

1:26:34

for sure.

1:26:35

Right. Absolutely. And I think it's cool, you know,

1:26:38

it's not great that we're both on the fast

1:26:40

track, but how great that we have these two people

1:26:42

from both of those places that are working on the same

1:26:44

issue, you know , to get there.

1:26:46

Yeah, I think, yeah, absolutely. That's right.

1:26:50

The other thing that the RAs wanted to dig

1:26:52

into a little bit is , um,

1:26:56

incarceration . So why what's the situation

1:26:58

here about HIV and

1:27:01

substance use and , and

1:27:04

prisons essentially. So

1:27:06

what I thought I'd highlight here is

1:27:08

that Indonesia

1:27:10

is one of a handful of countries

1:27:13

in which there's sort of this like confluence,

1:27:16

or I don't know if it's like a tornado of substance

1:27:20

use disorders , um, and , and

1:27:22

specifically injection

1:27:24

drug use and heroin. And

1:27:28

then also HIV spreading

1:27:31

among people with substance use

1:27:33

disorders. And then third laws

1:27:36

that are sending people

1:27:38

with those substance use disorders are people

1:27:40

who are injecting drugs to

1:27:42

prison. So essentially

1:27:44

what you end up with is a lot

1:27:46

of people who have

1:27:50

injected drugs or who have substance use

1:27:52

disorders. And

1:27:54

then who also have HIV who are landing

1:27:57

in prison. And so Gabe actually

1:27:59

talks about this a lot. Like he writes about

1:28:01

this a lot in his work, and he draws parallels

1:28:04

between Indonesia and

1:28:06

maybe Russia and some other countries where you

1:28:08

have these things happening all together.

1:28:12

And I think it's really interesting because the US

1:28:14

is also experiencing this opioid

1:28:16

epidemic. I mean, we also have

1:28:19

, um, a lot of substance use disorders,

1:28:21

and then we also have

1:28:23

a war on drugs, which means that a lot

1:28:25

of people who use drugs

1:28:27

or who have substance use disorders

1:28:30

also end up in prisons here.

1:28:32

But our HIV epidemic looks a little

1:28:34

bit different. And I

1:28:37

think, you know, one of the interesting things

1:28:39

that happens in the US but doesn't

1:28:41

happen everywhere is some of the delivery of

1:28:45

what people call harm reduction strategies.

1:28:48

And so, you know, in

1:28:51

the earlier years

1:28:53

of the HIV epidemic,

1:28:55

they began things like needle exchange programs,

1:28:58

where people who are injecting drugs can

1:29:00

bring in their used needles and change

1:29:03

those out for sterilized

1:29:05

needles. And they found

1:29:07

that actually just letting

1:29:10

you know, just letting people change out their needles

1:29:12

has been a really fantastic public

1:29:14

health strategy to reduce

1:29:17

HIV among people

1:29:19

who inject drugs. And so

1:29:21

that's, I think one of the, maybe,

1:29:23

probably one of many differences

1:29:27

between, you know, the US and

1:29:29

other places. It was,

1:29:32

it was interesting. I don't know, Carly, if you were at this

1:29:34

meeting. When I first got to Delaware, I went

1:29:36

down , uh , to an HIV

1:29:39

consortium meeting, which is this really cool

1:29:41

umbrella group , where

1:29:43

our local stakeholders come together and

1:29:45

talk about issues related to HIV

1:29:48

in our state. And there was as amazing

1:29:52

a guy there from public health who is just

1:29:54

kind of like losing his mind

1:29:56

about how we didn't

1:29:58

have a syringe exchange van going

1:30:00

to southern Delaware. And,

1:30:03

you know, despite the fact that we know

1:30:05

that we have like an,

1:30:08

an issue with injection drug use down

1:30:10

there as a result of the opioid epidemic.

1:30:13

So when I

1:30:15

first got here, that was one of my

1:30:17

first things that I was learning about Delaware

1:30:19

is that A we need, we

1:30:21

need some more spread out harm reduction

1:30:24

in the state, but then also we had these

1:30:26

really cool advocates who were like.

1:30:28

Right. I was just going to say, yeah, in special

1:30:30

shout out to the HIV consortium

1:30:32

for, you know, all their work

1:30:34

with that. Cause they , they now have one, right?

1:30:37

Yeah. They had , there is a van that now goes

1:30:39

down there and , um, which is excellent

1:30:42

because there's such good data showing

1:30:43

that when people

1:30:46

can switch out their needles that they do

1:30:49

and that helps to prevent

1:30:51

the spread of HIV. So that's really great. All

1:30:55

right . A big, thank you to the

1:30:57

Stigma and Health Inequities Lab at the University

1:30:59

of Delaware, including Alyssa

1:31:01

Leung and McKenzie Sarnak. And

1:31:03

I would just like pause and say a huge,

1:31:06

thank you to McKenzie . She's been working with us for several

1:31:08

weeks and we haven't gotten a chance to thank

1:31:10

her yet. So huge thanks to her.

1:31:12

This episode was researched by Saray

1:31:15

Lopez and the episode was edited by

1:31:17

Kristina Holsapple.

1:31:19

And as always thanks to City Girl for the music.

1:31:22

And as an update this week, why don't you guys follow

1:31:24

us on Sex, Drugs Science on

1:31:26

Instagram, that's Sex Drugs Science without

1:31:29

the and.

1:31:31

And thanks to all of you for listening.

1:32:09

[inaudible] .