Gabriel Culbert & Agung Waluyo: HIV Research in Indonesian Prisons

Dr. Gabriel Culbert is an Assistant Professor in the College of Nursing at the University of Illinois Chicago and Dr. Agung Waluyo is the Directorate of Community Engagement & Empowerment at the Universitas Indonesia. Gabe and Agung describe how they met in Jakarta in 2003 and how their research partnership has developed since then. Agung reflects on what it was like to learn about drug use and the HIV epidemic after a sheltered childhood, recalls being warned that he could be sent to jail for doing stigma research focused on Indonesian healthcare providers, and shares how he navigates conversations about politically sensitive research with government officials. Gabe describes the reasons why the HIV epidemic became concentrated in prisons in Indonesia, questions why Indonesia has one of the highest HIV mortality rates despite having the largest universal healthcare system in the world, and envisions an expanded role for nurses in HIV prevention and treatment. Valerie and Carly nominate Gabe and Agung to be poster children for international research partnerships.

Read more about Agung’s work here: http://staff.ui.ac.id/agungwss
Read more about Gabe’s work here: https://nursing.uic.edu/profiles/gabriel-culbert/

Transcript

Valerie: 0:13

I'm Valerie Earnshaw.

Carly: 0:14

I'm C arly Hill.

Valerie: 0:15

And this is Sex, Drugs and Science. Today's conversation is with Drs. Gabriel Culbert and Agung Waluyo. Gabe is an assistant professor in the College of Nursing at the University of Illinois, Chicago,and Agung is the Director of Community Engagement and Empowerment at the Universitas Indonesia.

Carly: 0:34

Just as a warning, guys, you are going to hear a little bit of traffic in the background of this podcast.

Valerie: 0:40

Yeah. So Agung was joining us from halfway around the world. He's joining us from Jakarta, and Jakarta actually ranks in the top 10 cities sometimes per year for traffic and congestion. So you can certainly get, you know, those traffic noises in the background, but we hope that you enjoy the episode, nonetheless. All right. Gabe and Agung, thanks for joining us today. And I thought that we might start by hearing a little bit about your origin story. So Gabe, you're in Chicago, in the US, and Agung you're in Jakarta, in Indonesia. So we were hoping that maybe you could tell us a little bit about how you met each other.

Gabe: 1:34

Sure. I, I met Agung in 2003, and we always laugh about the fact that it's been 15 or 17 years since we met. I had the opportunity as a undergraduate in nursing to travel overseas to study the nursing research process. And so I was really lucky at that time. The National Institutes of Health had a program that provided support for undergraduate nurses in the United States to travel to a, a host site internationally to learn firsthand and up close what the nursing research process looked like. And so my mentor came to me in the spring of 2003 and she said,"Gabe, do you want to go to Malawi, Chile, or Indonesia?" And I said,"Well, let's see, Indonesia is about, about as far away as you can get from Chicago,". And so I said,"How about Indonesia," and knowing nothing about the country or the culture, I think I had seen a few movies on in my youth that had peaked my interest in, in Indonesian history. I said,"Well, let's go with Indonesia,". And programs like are incredibly important for developing scientists. And I get a lot of students who come to me and they want to learn about research. And so they're, they're very interested in methodology and statistics and making sure that they ask the right research question and that they have the tools to answer those questions. And I try to help them and guide them. And, and, and I think all of those things are important to learn, but what will sustain your interest? What has sustained my interest over the long haul and what I'm talking about as a 20-30 year career is not the statistics and methodology, although it becomes interesting later on what sustains your interest are those human connections and those early experiences that are, that become part of who you are and your identity. And I went to Indonesia in 2003. Dr. Waluyo, Agung was my mentor. And I'm not sure that I produced the most interesting or, or well conducted research project, but that was not really the point. I had a wonderful time and I met wonderful people. And the dean at that time, Ellie, who was the Dean of Nursing at the University of Indonesia, which is the largest nursing program in the country made sure that I had a variety of experiences that would, that left an indelible impression on me. I, I, I had the opportunity to work with nursing students and faculty in Jakarta, had the opportunity to go to Bali and be parts of, be part of workshops and seminars there. And so when I came back to the United States, I had had this really rich experience. And it was many years before I returned to Indonesia, but those experiences left a real impression on me. And so here we are 17 years later. And I, I think of Indonesia as my second home. I've immersed myself in the language and the culture, my family lived there for a year in 2013. And so it's, it's, it's a building process. And so now when I talk to students about kind of their, these first forays into global health research, I say, don't underestimate the importance of hanging out and spending time with people, and enjoying ice cream on the side of the road and doing things that will, that really sustain your, your interest in your engagement with a site, throughout the rest of your life. I think Agung may w ant t o talk about that a little bit. He has a sort of a funny story about when we met at the airport.

Agung: 6:00

Yeah, well, before I, telling about that moment, actually, area of HIV is not my area of interest in teaching or research in the beginning, but since, in typical hospital, the word for taking care of HIV patients is put side by side with a patient with cancer or oncology cases. So, by the time I have to supervise the students, then the students have the opportunity to see and taking care of them. Although in the beginning, they are scared because they don't know anything about HIV. So I was trying to make them understand, although that was 2002 or 2001, I, I see that HIV is still a very scary disease, like COVID-19 right now. So, uh, everyone tried to, uh, see the patient from the windows, not, some of them, like precision, uh, not trying to touch the patient so important. So, and then when professor Ellie was having postdoc in UIC, uh, when she returned back to Indonesia, her duty was to make an initial, a working group of HIV/AIDS, research center. And then, um, before she can expand more on that dream and, uh, suddenly she received email from Dr. Michael Laurie that one of the students of UIC would come and do some internship or something or, and research activity. So since I'm the only person in the faculty of nursing who deal with the patient of HIV, then I was appointed to become a mentor of Gabe. So that is the, the start and the, of the insights person, including all of the activity A to Z, including picking, picking him up in the airport. And I didn't expect to see a very tall, uh, white people wearing a hat, with a backpack, enjoying the, uh, hot chocolate of Dunkin Donuts in the airport. So, at the beginning, I, I holding the paper written name of Gabriel Culbert UIC, since probably gave it an expect to see me as a person who would pick him up in the airport. So it's just passing through, but then I'm sure that this is the kind that I have to pick in the airport. Because he is the only, we call it bully, like the white people in the building. So I'm just like,"Hey, I'm sorry, are you Gabriel Culbert?" Because yeah, I do that. We start to have a chat and finally, the dropping to the, we call it what hotel gate, right? It's like some small house for international guests located in central Jakarta. So that is the, at the beginning. And then, and I didn't know that that is become my first step stone to the world of HIV research area.

Speaker 3: 10:53

And then from that the year, then I start to have a workshop conducted by a School of Public Health UIC where Dr. Levy was the host. It was about the drug, uh, drug users and HIV/AIDS, like, like, uh, introducing about HIV AIDS and the relation to the users. So that, from that year I start to, I didn't, I didn't expect that, I have to deal with, or listen to the topic of drug users because I, uh, I'm like a person who really, a house boy or homeboy, like never go out for something like, exploring new things. I enjoy staying at home and just accompanying my parents to go out and just a nice boy of the house. So when I listened to that topic, I was like, wow. It was a really new topic. And, yeah, I, I start to learn a new things, including, uh, how the police officer try to use them as a source of money because when the drug users starting to have methadone and when they have a urine test and the result is positive of using, um, drugs or something. And they put in jail were supposed to stay put in the rehabilitation process...when, uh, the, the family give policemen the money and they transfer to the rehabilitation process. So, so that is the, the start, how I met Gabe at the beginning.

Valerie: 13:27

Well, I would give you an A plus right there, because, you know, just in terms of mentorship that you're schlepping over to the out, schlepping over to the airport, because especially, you know, traffic in Jakarta was that like a full day affair to go get Gabe from the airport?

Agung: 13:43

Right. Right.

Carly: 13:45

And then you show up and the guy's drinking Dunkin Donuts hot chocolate, that was the real stand out there.

Valerie: 13:53

And it's hot in Jakarta.

Agung: 13:55

It is, it is. I think it's still in the, in the building of the airport. So the air can air condition. Uh, yeah.

Valerie: 14:05

We'll forgive him a little bit. Oh, this is really interesting to learn a little bit more about you both. So Agung it sounds like, you know, when you're describing your background that you, you grew up a little bit sheltered, maybe is how I might describe it. But now you're doing all of this work related to HIV, drug dependency, stigma. So how did, h ow did both of you, and you've already talked about this a little bit, but start focusing in on this area. What got you interested in it?

Agung: 14:43

Uh, starting with me first, probably I choose when I choose, my topic for my dissertation, since I knew the timeframe of international students, uh, I only have like maximum four years, doing my research and the scholarship also maximum four years then. Telling to myself that I have to do research where it's related to the, uh, healthcare workers related to the people living with HIV. So, when I read a few things about nurses and HIV things, most of them telling about stigma. So since there is no study conducted on that time in 2007, a study about stigma from the nurses, then I stick on that idea. And whenever I got into the classroom of PhD study, when the faculty asking me, Hey, you, Agung, what is your research interest? And I keep telling that I'm going to do assessing the level of stigma of the nurses. And I didn't expect that when I choose the place of collecting data from four different hospitals affiliated from different religions. But on that time, I was thinking that, I think if we see if, if the hospital affiliation, I may, I may, collect some of the data like they are different, but I didn't expect that the difference is because of the religious background. I start to understand what I'm doing, when I was, asking by the IRB in faculty of medicine in University of Indonesia. They warned me that you can be put in jail if you're still doing this study. And I didn't understand what they are, telling me. But this professor telling that, you know, the, the result would be the nurses from this hospital have higher stigma compared to the others, or Muslim nurses can have higher, stigma compared to the other nurses in the hospital. But on that time, my ego was so high and I say that if you are not allowing me to do this rearch in your hospital, fine, I have one of the received three IRB approvals approvals from three different hospitals. So thank you very much for allowing me to sending this proposal in front of you. And after that, among them, they are mumbling and say, no, no, no, we are not telling that you cannot do that research in our hospital. But we try to ask you to change a little bit in some of the question and blah, blah, blah. Oh, in that case, I do the change that I have to change the topic of the stigma measuring on the nurses in your hospital. I cannot do that. And finally, I can collect data on that, that hospital, although it was like at the end of last week, I stay in Jakarta because I can only be collecting data in Jakarta like two months that is programmed from the eighth trip in my age. So the day at the end of collecting, done, then I flew back to Chicago. So, from that, from that data, uh, just realize after like one or two years, I graduate and return back to Jakarta. And Gabe starting to have his postdoc program. And when, you know, like we were, having a discussion on how to start a Gabe's research on his postdoc, in the meantime, because of a very long time of waiting approval from many ministries, you can tell a complete story about that experience. But meanwhile, that Gabe asking me"Agung, what do you want me to help you? You helped me a lot,". And I say,"Well, I still have my raw data of my dissertation that has not been published,". And Gabe said,"Oh, how about we see the data? And we can have a discussion,". And from that gives you"Agung, you have a very good data and you can there's this. And, Oh, well, why don't we just like, start to writing up?" And I say,"Okay, fine,". I just remember sometime we have a discussion of the afternoon. Actually Gabe you stayed in a very spooky hotel that time, really, many, many faculty say that sometime the night they can see, you know, like ghosts or something, but, yeah, lucky Gabe and his family didn't see anything unless. Unless small snakes when they have a, you know, a small walk in the morning, I believe. So, so, so that is the very start, um, you know, connected to the very sensitive study then. If you asked me, how can I do some study on the prison? That is because of Gabe's proposal. I remember like a week before I leave Chicago, I'm just like this one to say goodbye to Gabe and have a chit chat, but then the chit chat is so interesting because Gabe say"Agung, don't you, do you know about the issue of recent in America, and I believe the problem in the United States have the same in Jakarta or even more interesting. Do you want to work together research in Jakarta, based in Jakarta? And I said yes, although on that time, I was thinking. Okay, Gabe. I just want to go back home,". But I didn't expect that, that crazy idea, it happens finally. So when, like in 2011, Gabe start to send me email and us, uh, many information about our condition of prison in Indonesia. And just like I, I try to help you, the things that I know. So, uh, I'm sorry if I cannot give you complete data or the data that you expect me to share. So that is the situation. When, when Gabe start to ask me to represent him presenting our proposal or Gabe's postdoc proposal in from of the Ministry of Research and Technology, I, that was the first time for me stepping on that ministry building. That was so huge we'll pack with the...army from the United States because Gabe's schedule was put in the same date and the same time with the idea of doing research from the army. They are going to try to find the skeleton of the army from the World War II, that it in, Island of Celebas. And on that time, they, they, they talk about the project as if there is nothing, there is no, no one in the building, uh, representing of United States person or researcher, but from, from their discussions, uh, they say like, we have to be very careful with the United States researcher because they might collect something valuable from our country. So we have to protect blah, blah, blah, blah, blah, blah. So I was like, so scared when Gabe's name was called. And, and they asked, is there any represent from Indonesian art? And I just raised my hand, I and I said, Oh, okay. You, you didn't expect me just sitting next to them when they talk about the study of the army. So, uh, yeah, uh, Gabe gave his presentation. And then when the discussion coming and they are trying to use Bahasa Indonesia, and, uh, they stop, presentation of Gabe. And they asking me with some questions that, yeah, I, that is my very first valuable experience. Never have that, that kind of activity before. So, I'm so lucky, although at the same time, it's so scary. I never expected to have that kind of meeting before. Yeah,

Valerie: 27:04

Well, Agung, that's pretty incredible. I mean, for you to go from your dissertation proposal, when you're talking about what you're going to do, and folks are like, well, you might go to jail for this, and then you do it anyway. That's incredible all the way up to sort of advocating, you know, for this research partnership at that sort of higher level. That's really, that's really intense. I would have to say. Yeah, but I feel like I've got like a million questions now. So first off, Gabe, everyone wants to know if that house actually was haunted that you stayed in, and then also, you know, to follow up with the same idea, how did you get interested in all of these issues related to HIV drug dependency, stigma?

Gabe: 27:48

Well, I'll just comment briefly on the ghost issue and that's you know, Indonesia is often referred to as the largest Muslim majority country in the world, and that that's true. There are the most numerous followers of the Islamic faith, but Islam is layered over many other religions and some, one of those is Animism. And so certainly there's the belief that spirits reside in inanimate objects. And so, you know, I always take that into consideration when I'm, when I'm walking through the natural world in Indonesia. I want to back up a little bit. I think I'm going is maybe not doing justice to the, the the work that, that, the risks that he took to carry out the work that he was doing. Agung was sponsored through an National Institutes of Health fellowship to come to the United States. So kind of building on what we talked about earlier, Agung was my mentor for many years. And then I said, Agung, why don't you come get your PhD in the United States? And so he took a huge, ah, he took a huge risk by doing that. He left his family, he left his country, he left his position. Ge left a very good job at the World Health Organization in Indonesia with no, with no promise of a payoff. And he came to the United States and he did a dissertation looking at stigma towards people with HIV that was being enacted by healthcare providers. So that right there is risky because you're really, you're, you're putting healthcare providers under a microscope and you're saying, what is it that you do? Or you don't do that contributes to the perpetuation of this disease? Then his findings. We said, well, let's look at things like knowledge does knowledge affect stigma. Does the degree of religious involvement affect stigma? While we're at it, let's look at whether Catholics and Muslims enact stigma differently. And by way of background in Indonesia, there's many types of hospitals. Some of those hospitals are public institutions. Some are run by Islamic religious centers. Some are run by Catholic or Protestant religious centers. So hospitals look very different in Indonesia in terms of their institutional affiliations. Well, what Agung found was that, um, people who were, uh, nurses who were practicing in Islamic hospitals on average, endorsed more stigmatizing attitudes towards people with HIV. And this is where Agung was getting pushed back. And I think he immediately saw the risks of coming forward with this sort of data in a country where the, the ministry of religion, um, has significant sway over public policy and is very influential within government. And this may be something that we're unaccustomed to in the United States. But if you're going to say things about religion in Indonesia, you have to take into consideration the fact that, um, the ministry of religion and in general, in, in people's daily lives, religion is incredibly important. And there's not the same distinction perhaps between the public sphere and the private sphere that, that, that might allow some of those comments to pass. But what's interesting is because of these risks, we said, well, let's look at the data a little deeper. And so we started to dig in a little bit and we found something interesting, which was that it wasn't so much that nurses were coming from Muslim hospitals or Catholic hospitals. It's that Catholic and Protestant hospitals tended to be more diverse in terms of who they hired. So in a Muslim hospital, you're more likely to be practicing alongside another Muslim nurse. And so we can think about the normalization of attitudes and things like this, but where we landed with this was that it wasn't so much that these were Muslim hospitals or public hospitals. It was that public and Catholic hospitals tended to employ a more diverse array of students. So you can think about any work setting anywhere in the world. If you're practicing next to people whose opinions and hopes and fears may look a little different than your own, you're, you may be more tolerant. And so, in, in a way, the risks that we had to think about in terms of publishing or disseminating, this information actually led us to scrutinize the data further, which led to these insights about maybe it's diversity in the workplace that's really driving this. And, and subsequent to this, Dr. Waluyo has continued this line of research recently with 500 healthcare providers in three different parts of the country. And again, we're seeing a similar pattern is that people who are practicing in more diverse workplace settings are on average endorsing fewer stigmatizing attitudes. So that's one thing I wanted to touch on. The other thing is back in 2003, Agung and I weren't aware of what was happening with the HIV epidemic in Indonesia.

Valerie: 32:47

Okay.

Gabe: 32:47

Neither one of us understood what was going to happen during the next 10 years. And so, as we were getting our PhDs, and we were forming ideas about what we wanted to do, and the HIV epidemic in Indonesia was becoming one of the least well controlled epidemics in the world. So that by, by 2013, Indonesia had been singled out by the United Nations. U h, the joint United Nations Program on HIV AIDS known as UN AIDS, had singled out Indonesia as one of the countries where mortality and HIV incidence, o r the number of new cases, had increased. And that this was in contrast to most other countries in the world. And so Indonesia's HIV epidemic had started out in people who inject drugs, and because of the punitive drug laws i n Indonesia, those people were disproportionately being incarcerated. I read one estimate that a third of all, people who inject drugs in Indonesia had gone to jail or prison. And as a result, the, t he prison population swelled tremendously over the seven year period that we were, we were becoming researchers. And so the epidemic was u nfolding a nd in, in really devastating ways, while both of us were getting up to speed as researchers. So that by 2013, the Australians, the Dutch, several other governments had invested heavily in HIV reduction in Indonesia, and with a special focus on prisons because they knew what was happening or not happening there. And so I'll, I'll give a little bit of background on that. Indonesia has the eighth largest prison population in the world. That's because it's a huge country. The incarceration rate is actually far lower than the mean incarceration rate for the world, which is about 145 per a hundred thousand. Indonesia only incarcerates about 78 per a hundred thousand. So the incarceration rate is incredibly low, not even close to the United States, which incarcerates about a quarter of all the world's prisoners.

Valerie: 34:56

Wow.

Gabe: 34:57

Nevertheless, because of the punitive drug laws, Indonesia's prisons tend to concentrate, tend to incarcerate people who are at risk for HIV and, and the majority of whom are people who injected drugs. More recently, as we have seen a shift away from injectable opioids towards amphetamine type substances, we've seen increasing incarceration or among gay men. Why? Because club drugs, stimulants, ecstasy, those kinds of things tend to circulate in the club circuit. And so it was striking to me to go back into the prisons and in 2015, and to see that there was sort of this older generation of men who had injected heroin, and that was their pathway into prison, but then also, younger gay men who were being drawn into the prisons because they were being, they were being singled out in police raids and other police. In Indonesia, there's sometimes vigilante groups that will raid nightclubs. And that will result in, in young gay men being incarcerated. But we see it history repeating itself, right? The, uh, the, the drug, the drug market has shifted. It's shifted towards another population where, that is at risk for HIV gay men. And now we're seeing them in the prisons as well. Well, there's a, there's, there's a, there's a global discourse on what to do about this. Incarceration is probably the, the, the, the least productive way to address an epidemic. Incarcerating people who have, who have a disease is, is tremendously counterproductive to reducing the spread of infection. We knew from second hand information, some of it done in collaboration with the Indonesian prison authority and, and AusAID, which is sort of Australia's version of USA ID, that there was drug use in the prisons. And when we went in, in 2013, certainly we, we saw evidence of this as well. It wasn't just that the prisons were incarcerating people at risk for HIV or living with HIV, but then people were renting needles. They were sharing syringes and, and there was, there was an increase in drug use that happened when people were in prison because the boredom, being in contact with other people with substance use disorders. So that by the time they left prison, they had been exposed to, they had been exposed to HIV and other bloodborne pathogens like hepatitis C. And so a very, a recent study that looked at people who inject drugs in Jakarta found that incarceration was the single most important risk factor for the acquisition of drug resistant HIV. And so Agung and I looked at each other and we were like, this is what we've been saying. So these prisons are extremely high risk settings. And we also see this in the former Soviet Union, Malaysia and other countries where incarceration is sort of the national strategy for dealing with people at risk for HIV.

Valerie: 38:19

People at risk of HIV right type policy...

Gabe: 38:22

Right. T he, the war on drugs, the one drugs has really resulted in prisons being one of the main places where people with HIV are diagnosed and first offered treatment. And when we went and we found 77% of the men with HIV had been diagnosed in prison. Half of them during the current prison term. In the U S it's 1%.

Valerie: 38:45

So does that mean that they're not testing enough outside of prisons?

Gabe: 38:50

That's exactly right. It represents a failure to kind of connect with these men in the community. And Indonesia, I should back up and mention here though, that at the same time, Indonesia has been ahead of many other countries in terms of its public health response in the community. So Indonesia embraced a harm reduction model early on. But the, the drug policy was sort of working against that. I should also mention here that Indonesia in, in many respects is ahead of other countries in terms of public health in prisons. And so often when we read about Indonesian prisons in the media, it's often proceeded by the word notorious. I often I challenged someone once I said, I, I challenge you to find a news article about Indonesia prisons, where the word notorious is not used. Yeah. I think a lot of journalists use it reflectively cause they're like, they've never been to an Indonesian prison, but they know they have a reputation.

Valerie: 39:49

Our prisons are niche notorious. I feel like in the States, like not only at our, like our system that incarcerates so many people, but then like, you know, we've got all this, like Mister on like Shawshank and like Riker's Island and we've got, so.

Gabe: 40:04

Well, there's a whole mythology around prisons. And I get that, like when I talk to people about what I do, one of the first questions they ask is like, well, everybody's having sex in prisons and everybody's using drugs in prisons. And sort of, they have these, these, these beliefs that a lot of them are from, you know, watching Oz or other, you know, Shawshank Redemption. And, some of that fits with reality to the extent that we understand reality in these spaces. And some of it doesn't, doesn't fit so well with, with, with the things that we've seen and the things that we've heard. One of the, when we started working in prisons in 2013, it was really a, it was really just a long shot. As, as Agung mentioned, we had to go in front of several panels of government representatives and kind of make the case that this was important work and that we could be trusted to be good collaborators over the longterm. And I think that our relationship has gotten better and better. A couple of years ago, the University of Indonesia signed the first memorandum of understanding with the National Prison Authority, and that has led to service teaching and research. And that to me indicates an openness and a willingness to, to, um, to serve the interests of people who end up in prisons and jails and to bring expertise from outside to inform policy and practice. So we're very, very enthusiastic about that. Um, and we have maintained a balance and I think we've done a good job about being candid with the scientific community and with our, our readers, people who are interested in our research about what we're finding while at the same time, not being sensationalist or misrepresenting in any way what's happening and to provide a balance of the good and the bad. As an example of, of a public health measure that Indonesia has implemented, they have methadone for the treatment of opioid use disorder in the prisons. Now it's probably not reaching as many people as it should. But you'll find many prison jurisdictions in the United States that don't even have methadone. It's not even an option. And this is a who essential medicine. This is not a, a, a, you know, this is a mainstream treatment for opioid use disorder, and we don't have it in...

Valerie: 42:48

Many decades...

Gabe: 42:50

Right. It's been around. Safety is very well established. Efficacy is very well established. So I think when we talk about Indonesian prisons, we have to think about, we have to look for the bright spots and kind of see what's happening well, and who are championing, w ho, w ho, who is it that's getting behind these initiatives, and then connect with those people and say, what could we do better? Or what could we do more of if we had additional inputs? And so we've, we've identified some of those champions and we've built up a network of, of, of scientists and practitioners in Indonesia to try and move some of these projects forward.

Valerie: 43:31

I feel like the idea of champions comes up a lot in research. I remember doing work in hospital settings with pregnancy, and it was the same thing. You know, if we can find those champions in these spaces, then we can really do nice interventions here. And talk about this. I'm curious just about what the experience is like for someone to be, diagnosed with HIV. And then Carly and I were having a conversation earlier, we were really curious about, what's it like if you, once you are diagnosed with HIV in a prison setting, what's it like to start accessing medication? Or maybe if you have an opioid use disorder, what, what's it like to start accessing methadone? Sort of, what, what does that process looks like? Look like for someone who is in a prison in Indonesia or in Jakarta?

Gabe: 44:20

Let me start out by talking about what I think it's like in the United States. This is what I, this was my dissertation work. Most people with HIV in prison in the United States knew their status before they were incarcerated. Some are diagnosed in prison in jail. But most of those who are currently in a prison or jail knew their status beforehand. So the issues for that individual are, do I disclose my status? Do I tell a guard? Do I tell the, the first doctor or nurse that I see that I'm on treatment and that I need my treatment? If I do, what are they going to be the costs? And so we found in a few cases that in the United States, your HIV status can sort of be used as a weapon against you by, by correctional officers or by the other inmates. And so prisons are very hierarchical. You, there's a, there's a pecking order. And someone with HIV is as it is, it occupies a very low status on that pecking order. At the same time, people are looking for support in prison. One of the first things that they, what I heard many men say is that when they got into the jail and they were in the holding cell, one of the first things they were trying to figure out is, how do I protect myself in this environment? And so that more immediate threat supersedes considerations of am I going to miss my pills today? Maybe I've heard people tell me, I just don't open up my, I just go off my meds when I'm in jail. Cause if I'm only there for 30 days, I'd rather go off my meds, than take all the social risks associated with disposing my HIV status. And it interferes with their ability to, to develop the kinds of support or protection that they need in order just to get through that first 30 or 90 days.

Valerie: 46:20

That big sacrifice.

Gabe: 46:22

Yeah, that's a big sacrifice to make. Especially if you see the treatment i s something that you're going to be doing your whole life and maybe being off meds for 30 days is not going to hurt your health. That's an, that's sort of a choice that the individual makes now in Indonesia, where many men are being diagnosed during the current prison term, they're coming in, probably with the understanding that drugs led them to be incarcerated. Maybe starting to think, is this becoming a problem for me? Maybe the inklings of do I, do I have a drug use problem? There is not the same level of discourse around addiction a s a mental illness in Indonesia. So in all likelihood, many people are thinking of this as a moral failing. O kay. I failed my God. I failed my family. I failed my religion. Okay. So a lot of guilt, a lot of shame. And then at some point, either a few weeks or a few months into incarceration, they take a blood test and the doctor says you have HIV. Now in Indonesia, if you tell someone they have HIV, the first association is death sentence. Why? Because it is still largely a death sentence in Indonesia. Indonesia has one of the highest mortality rates from HIV of any country in the world. Now the central paradox that has driven my research is how could that be in a country that imports or produces its own antiretrovirals and has the largest universal h ealthcare system in the world. So in the United States, we typically say, well, you know, the reason the medicine doesn't get into people's m ouths is because we have such a botched healthcare system. In other words, it's health system issues. And we say, gosh, if only we had universal healthcare, if only we c ould get drug prices down. Well, Indonesia did both of those things and it did them early. It did them before most other countries. SBY, one of the past presidents, authorized domestic production or importation of like eight HIV medicines and HIV activists w ere celebrating this a s like, look what Indonesia has done. They really they're really ahead of the curve in terms of taking concrete actions to address the epidemic at the, at the structural level, by making these medications. ART is free of cost in Indonesia, right? A few years ago, a bottle of a triple a cost, a thousand dollars in the United States. And a lot of that was b orn by the insurance company, but in Indonesia, antiretroviral therapy is free and healthcare is universal. Now, once you start to dig and peel back the layers there's hidden costs and things like that, nevertheless, I, we're just starting to understand how it is in a country with universal h ealthcare and free antiretroviral therapy. You can have extraordinarily high mortality rates. And, and up until the last few years increasing incidents, incidents h as started to go down in the last few years, not by much, but some of this is making a difference.

Valerie: 49:45

So that's, that's so interesting because this really brings up the, you know, some of the issues of context that we all struggle with. I mean, if you were to run these studies in the States, or, you know, I've done some work in South Africa around access issues and, and these like healthcare related factors, the system, the systemic factors and, and especially cost comes up all the time. Okay. So, so what are some of the, um, so what are some of the reasons that lead to people not then accessing or taking their medication, especially in prison settings?

Gabe: 50:26

Well, in the prison, although many of them are diagnosed and offered antiretroviral therapy in prison. The, until recently the guidelines said that ART should be set aside for people who have compromised immunity who have, who have depleted immunity like 350 CD4 cells. Now who changed the guidelines based on several large global studies. I think most countries are now saying, treat everybody. There is a, there's a delay to ramping the healthcare system up. I mean, when you say, when you say not everyone's eligible for treatment now, there's, there's all these cost considerations, there's supply chain considerations. So part of that is just a lag in getting things up to speed. Another issue is that when, when we think of medicine, it's something we take when we don't feel well. When, when we feel like we need medicine to help us get better. And for many people with HIV will not experience symptoms until a very advanced stage of illness. So in Indonesia, as in many countries, it may be hard to convince someone to start lifelong therapy or commit to lifelong therapy when they don't feel particularly unwell. The problem is that in Indonesia, there's also a lot of tuberculosis, and the prisons are 400% over capacity. You will often have 20 men in a cell, and they will take turns sleeping because they there's literally enough, not enough floor space for everyone's body to fit down at the same time. And so these are conditions that are, that are very conducive to transmission of TB. Then you add to that, that anywhere between one and 14% of the prison population is immune compromised. These are conditions for explosive tuberculosis outbreaks. So it's very important that that, that, that people are being started on antiretroviral therapy in prison. Also, they're using some of the regimens that are in use are a little bit older. And so they have like a worst side effect profile. And some of the side effects are very undesirable. And so people may say, but I really don't want to do that. Some of it may have to do with things like health literacy, or how much people are really able to absorb and understand information that they're getting about this new treatment that they're supposed to be taking, and then the stigma. So if you have to take HIV medicine in prison, that means you have to line up once a week and go to a pill line. And it's possible that you're going to be identified as someone who has HIV, and that that's going to change where you are in the pecking order. We've also found that prisons are very busy environments in Indonesia. People are working, um, they're working for other inmates doing their laundry, preparing food. I think I went in thinking, well, everyone here just has a, a ton of free time. Right? And we would have people come in and they would say, you know, I've only got 10 minutes to talk to you, and then I need to get back to work. And so they may have schedules where they just don't feel like they want to be coming to a clinic every day.

Valerie: 53:53

So you're, you're from this kind of formative research that you did learning about the situation you, you currently have two different interventions that are up and going that you, you both are collaborating on. So one is an adherence intervention to get and it has the best name Athena, which is my favorite. I think, you know, intervention tagline out there, but one is to get people to essentially take their medication, to kind of get over these barriers and to continue to take their medication as they, after they leave prison. Right. Cause I think that some of your work together has shown that people are at risk of, of dying due to HIV related complications in the two years after they leave prison. And then the other line of research that you've been working on is a partner notification study to help people once they have been diagnosed. And so many people are diagnosed in presence to help them notify folks in the communities. So this is, this just strikes me like a lot of work you're doing together. And we were wondering kind of what it looks like for you to, to keep this, this research together, up and going on, on the sort of day to day basis, but Gabe in Chicago and Agung in Jakarta. And I don't know if you guys have like done the geography, but it feels like, you know, you could probably like go directly through the globe to get to each other.

Gabe: 55:22

That might be faster.

Carly: 55:24

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

Valerie: 55:27

Yeah. So what does this look like for you t o what's the ins and outs of working together from halfway around the globe? Is t hat a lot of like late night or early morning phone calls and...

Gabe: 55:40

Late night, early morning phone calls, there's no substitute for, um, people in, in, in Indonesia who are a hundred percent trustworthy and reliable and, and, and excellent with communication and decision making. Agung has taught me a tremendous amount over the last 10 years about speaking diplomatically and engaging with people in a way that they will be receptive to. I think one of the most amazing things to me about Indonesian culture, if I can generalize for a minute is the, the value that they place on, on engaging people in respectful relationships and ensuring that when two people walk away from a conversation that they both feel like they have their esteem intact and that they want to continue working with this person. And so as someone steeped in kind of American culture, you know, I will often say things in a way that for maximum impact or what I consider to be maximum impact or to, to make my, my message as forceful as possible and what Agung has taught me and just living there has taught me is that that's the quickest way to a dead end often. And so in, in conversations with stakeholders, like if we're immediate, if we're at a meeting with the director general of corrections or, um, someone in one of these ministries, I think I'm doing a better job. I have a long way to go, but I'll often probably wisely lit Agung take the lead and, and, and model how those conversations are supposed to go and trying to understand what it is that, that you're, you're the person that you're conversing with, what their what's in their mind and kind of, what are they hoping to walk away from this conversation with.

Valerie: 57:46

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

Gabe: 57:50

Well, the actually, not every important person in the ministry of connectional have that a way of, you know, or even in ministry of health, but in general. Yeah. They, they tends to, say to everyone not we can solve the problem of this station, but, you have to know that I am sitting in this position. So I have my own goals. Some of them are keeping the position or they are going to have a promotion to the higher position. So sometime if we endorse with the idea of decreasing the spread of HIV in the prison, they, they know that as their, daily jargon, but they are not... Sincerely put that as their, they are going to achieve that, but more on, how this activity is seeing, excellent in front of the boss.

Agung: 59:40

So, even we are facing a very high position in the ministry of correction. Sometime they have also the higher, uh, position that, uh, observing them. And, now I'm sitting in the position of the Director in University of Indonesia, then I'm more understand that, among the hierarchies they are seeking of surface or they are seeking of, of place and from their, their stuff. Like I have, my boss, up there. Although I'm the one working on that job, uh, from day to night, uh, A to Z, but the credits should be put on my boss name. So I think that it's also, happens in ministry of a correction where, where, when they talk to us, me and Gabe, they are not talking with our project. They are talking with the idea, how can I use this activity to boasting, uh, my name or my position in front of my boss. So sometime I have to be, you know playing political nicely accepted among them. So like when we when Gabe is sending the proposal in English, and then when this was, seems like a bit allergic of like forcing the result of this study, so implemented and blah, blah, blah. Seems like they, they are not happy with that sentence. So I'm telling that this can be, endorse of what, one of the, uh, achievement of your, KPI, um, you know, KPI, right? Yeah. So when you help us at the same time you achieve the goal of your ministries. So we have to bring that idea in terms of, to make them understand not always the, what they do is only pleasing their boss, but they have to be, they have to play smart. They have to work smart by helping us, and in doing this research in order to achieving that goal, their goals. So that is, if you are asking whether Gabe is noticeable about this situation, uh, since they, they, uh, the situation of facing the, the person is changing, it depends on who are sitting there. So I, I think Gabe is more, I think now it's, more, aware and understand compared to it at the beginning of 2010, when Gabe showing me, uh, around four or five ID card from each ministries. And Gabe asking me"Agung, if policeman stopped me, which ID card that I have to show?" And I cannot answer that question, because that is only like, when you are coming to this ministry, they give you this ID card, you come to this ministry, they, they give you this ID card. So, uh, the policeman will, they don't care about that ID card. They only ask your passport and yeah, that's all. So that, the ID card is only to show them that they have the authorities to give or not give the approval. That's all.

Valerie: 1:04:55

You know, Agung, it just, I'm really struck by the breadth of mentoring here. I mean, it sounds like, I mean, you, you probably also deliver like a, uh, some pretty advanced training in social psychology to gave here along the way, too. You know, I did have one more question, which is that I was really curious, to get your, on how nursing fits into the bigger picture of HIV prevention and treatment and prisons. But maybe also more generally since you're a nursing PhD, and now you're on the faculty at a school of nursing?

Gabe: 1:05:30

Sure. Well, I think with HIV as with any global health concern that we have to, we have to utilize all the tools that we have. And globally nurses are underutilized. When we take into consideration their training, their distribution, their professional code of ethics, their ability to interact with patients over 90% of patient care in the world is delivered by nurses. And I nurses are like the sleeping giant of the healthcare system. Studies now from sub Saharan Africa showed that nurses with the right training can provide HIV care at the same level as physicians and achieve higher rates of patient satisfaction. If we look back to the 1800s in the U S nurses were the pioneers of doing home visits for tuberculosis care. And so I think nurses for a long time have just intuitively recognized that it's not enough to be in a clinic and wait for patients to come see you, that you have to go out there in the community. You have to build trust, you have to do epidemiologic surveillance. You have to understand, I mean, nurses are out there and they're, they're doing ethnography, they're doing epidemiology, they're doing psychosocial care. They're caring for the needs of the whole patient, but in many parts of the world, including the United States, um, there's been a tension between physicians and nurses for dominance of the healthcare system. And we see this in things like the contracts that nurses have to enter into, to subordinate themselves, to physicians when prescribing certain medications. The development of physician's assistants came about in the 1960s because nurses refuse to subordinate themselves to physicians. So physicians said, fine, we'll just, we'll come up with our own nurses. We'll call them physician assistants. And we see even now with prescriptive authority that physician assistants got out ahead of nurses because they had that, that, that relationship with physicians. But I may have mischaracterized that a little bit. And I think some of that had to do with people coming back from the Vietnam war and needing to enter into healthcare positions. But anyway, the, in Indonesia, for example, nurses, are nurses are numerous they're distributed throughout the country in a decentralized healthcare system. That includes lots of local mosques or community health centers. And community health centers are sort of the, the, the primary care hubs for the healthcare system. So that's where you go, if you have the sniffles or if you need reproductive health information. It's also where a lot of HIV treatment is being delivered and, and methadone is also being done at the level. So nurses are, and you and the university of Indonesia was the first program in the country to start training nurses at the clinical scientist level. So at what we would think of as the nurse practitioner level. However, it wasn't until I think, 2014, okay, that they had their first nurse practice act. So nursing has not been codified in the same way that it has been in the United States. And the roles, the legal protections, the responsibilities, the licensing issues, all those are starting to get sorted out in Indonesia, but it's in a framework where physicians still want to control the decisions. And so we've seen things like nursing has not had a seat at the table. When they build new hospitals, nursing gets put under physicians instead of having its own department. And these control issues are important because if, if you see a ceiling in your profession, then it discourages people from aspiring to do the best that they can. And that's everything from clinical practice to research. And so, as a result of this kind of the ceiling, that's put on nurse practice and nurse research, nurses are not doing everything that they're capable of. Who does that really hurt? Well, the patients.

Valerie: 1:09:49

Yeah.

Gabe: 1:09:50

Right.

Valerie: 1:09:50

Absolutely.

Gabe: 1:09:51

So like prescribing an antiretroviral therapy is, can be done using an algorithm now, right. More complicated decisions always need to be pushed over to a specialist, but physicians already do this. They don't make decisions that are out of their training. They refer it to a specialist. And so why aren't we doing, especially only 17% of people with HIV in Indonesia receive lifesaving therapy. One of the lowest rates of art utilization in the world. And again, if the is free, so why is it not getting it to the bodies of the people that need it? Part of that probably has to do with a bottleneck effect of limited numbers of physicians. I was told once by an infectious disease specialist, that there's eight infectious disease specialists for the country of Indonesia. This is the fourth most populous country in the world.

Valerie: 1:10:44

Wow.

Gabe: 1:10:44

And I know two of the eight p ersonally. So in addition, in addition to increasing the number of physicians that t hey're graduating and Indonesia has always done a really good job of moving people out, into practice settings, where they're likely to have an impact they don't have, they don't have probably the same degree of brain drain a nd people going into specialties where t hat are very lucrative, but are not going to have a significant public health impact of being in fact, up until a few years ago, all physicians who graduated h ave had to have some service or practice i n, in what would be considered kind of a, a lower resource or a community setting. So that's always been a priority, but the same needs to happen with nursing, where we're, where we are. We have the legal framework and the regulatory framework that supports them, practicing all the knowledge and talent that they have. And that would include things like initiating antiretroviral therapy and people monitoring them. A big part of what we do is when people get out of prison, they simply need somebody to be checking in with them and finding out how are you doing, how is this going? Let's have an honest conversation about why it's difficult for you to take the medicine, and what can we do to help you overcome these obstacles? And so that seems straightforward enough. If t here a re issues like, well, I have, I, you know, maybe this person has g enotypic resistance. Like the medicine just isn't working for them anymore. That's a really important problem. You want to catch it early. And yes, it needs to be referred up to a specialist, but we can think of nurses and probably a lot of lay health workers who could go and do the kinds of things that would make a huge difference in the course of this epidemic. In t he l ast, in the study, in the study that I'm referencing from Vietnam, Indonesia, and Ukraine, a quarter of the Indonesian, HIV infected Indonesian, people who inject drugs h ad drug resistance. This means the first line medication, the free medication no longer works. So not only is this bad for that individual who will now have to switch to a more aggressive therapy or a different therapy, think about the ripple effects through the healthcare system. This is a middle income country that through bold action and, and resource allocation has managed to provide ART for free. Now, they're looking at a second wave of drug resistant infections. I t's because in large part because there weren't health workers out in the places where t hey were needed to monitor people who were receiving therapy to make sure that they were able to consistently take those treatments.

Valerie: 1:13:19

Definitely seems like nurses can be a big part of the solution.

Gabe: 1:13:22

Nurses can fill these gaps.

Valerie: 1:13:24

Yeah. As the, as the daughter of a nurse, I totally am with you on that. And Agung, if you could sort of raise, if you could wave your magic wand, what would you have nurses doing, um, in Indonesia for HIV prevention and treatment?

Agung: 1:13:41

Well, I actually, I still have faith that although it's not really easy to implement, then the idea of empower community nurse to do the job. We are now, have for your presser from ministry of misdemeanor, ministry of health, where beforehand we still have the nurse, uh, for, uh, some certain hospitals. Now, for type a or type A, we have, the head off nurse, in the directorate, uh, the type B, C, D there is no nurse on directorate. So, I, I would like to offering my hands to those community, nurse specialists or community nurse who are working in public health center to embrace that become one of their job. And if they can, if evidence that their work can improve the quality of life, people living in, uh, HIV in the prison or after they released that probably, they, help district center. A decision maker and make that job become of their, uh, authority to, to do. And when they have the authority to become all the insurance person for, uh, caring people, living with HIV in the prison or in the community, then they seems like to have another option to be, receive attention from the decision makers in the ministry or a district officer, so, uh, yeah, it's... Now we are not really easy to, to work, uh, in the environment where, everyone tried to, uh, like Gabe said, under supervision or under the medical or medicine. So it's, yeah, it's... If we have to, uh, if we act too vocal, like we yell too much to the ministry of health... Then they, they built a thicker and higher wall where we cannot climb and get through that wall. But then with the help of the nursing associates, uh, with the president of nursing associates, senior associates, as we have now, uh, they asked us to, uh, act calmer. So the ministry see us not as a trend or... They feel threatened because of the nursing voices are made not really feeling comfort in their comfort zone. So we try to play nicely with them. Uh, but, uh, at the same time, we try to use the opportunity to, to be improve and show the government that nursing can do something for the nation. And also, uh, in the future, we, we expect that the local government or the district health officer may give incentive for the nurses who work in the prison and the community better while we, they caring for people.

Valerie: 1:18:36

Well Agung I feel like if anyone has the social skills to navigate this and you to, to change, it's probably you, so that's great, that you know, you're on it. And you've got this collaboration with Gabe to, to keep it going too. I've been so super grateful for the opportunity to work with you both and to learn from your boat from you both. And we're really grateful for your time today. It's been really neat to bear witness to what I think is a really special and a really effective collaboration. So, yeah. Thank you so much for all the work that you're doing, and thank you so much for spending some time to come on the podcast with us. We really appreciate it.

Agung: 1:19:22

Thank you.

Gabe: 1:19:23

Thank you, Valerie.

Carly: 1:19:37

Wow. So what a great conversation, and I just love that, you know, right off the bat, these guys, you know, Agung starts in about his experience, you know, with the work and where he got a little bit of feedback and that, you know, he thought maybe it was uncomfortable because he grew up a little bit, maybe sheltered from, you know, these things that are happening, um, and, uh, you know, at his home, and that Gabe just stops and says like, no, no, like you're not doing yourself justice. The work that you're doing is, you know, or at the time, especially really controversial. And, you know, you really had to stick your neck out on the line in, you know, sorta like fight for, for what you believe in. And that's why, you know, you felt that way. And I just thought it was like, honestly, like just the cutest thing that here are these, you know, they're not just two scientists at this point. And that's really, I think what that first part highlights is that these are two humans that are like, you know, in it for the full human experience, you can tell that they have such like a genuine relationship outside of the science world. And I just love that, that, that's how, you know, we got to start off this conversation.

Valerie: 1:20:45

Yeah. You can tell they're buds. Yeah. And yeah, no, I think it's really interesting. Cause if we had only had Agung on the call, because often we're only interviewing one scientist, then we wouldn't have had this other perspective from Gabe to say, no, no, no, hold on a sec, like, right, this was a really intimidating and challenging situation for you to be walking into. And so that was super interesting and neat to be able to, to, to learn by talking to both of them together.

Carly: 1:21:17

Right. And I feel like that's mirrored throughout the whole thing too. It's just like that they both have, you know, bring to the table such, you know, seemingly radically different upbringings and perspectives and like cultures that are just like coming together in such a wonderful way and obviously, you know, really meaningful and impactful way. So yeah.

Valerie: 1:21:37

Do you know what I mean? Yeah, it makes me think back to the conversation we had in our very first episode with Carmen Logie about how what's good ways to do international research and, and, you know, Agung and Gabe just seem like the ideal way to do international research. Like they are partners right in their work. And I know Gabe is always, you know, thinking about Agung. And, you know, it's, it just seems like that isn't, that's an equitable research research partnership for just two people who happen to live like halfway around the world.

Carly: 1:22:16

Right. Exactly. Yeah. That was just so, so neat to see.

Valerie: 1:22:20

Yeah. It was really neat. It's a, it's a great research partnership. And I think, you know, when Gabe talked about going and living in Indonesia for a w hile, with his family during the interview that was facilitated, I believe by a Fogarty award. Right. And so F ogarty a wards sometimes a re designed to try to really facilitate these l ike partnerships and relationships. So in some way I feel like these two could be like a poster, you know, the poster children for the type of award.

Carly: 1:22:53

Yeah, absolutely. Totally agree.

Valerie: 1:22:56

Yeah. Well, the research assistants had a few questions that they thought might be useful about background information to kind of contextualize some of the science that ongoing and Gabe were talking about. So they wanted a little bit more information on like on HIV in Indonesia.

Carly: 1:23:18

Right.

Valerie: 1:23:19

So I thought it'd be useful to know that the HIV prevalence, uh, which is the percentage of the population that's estimated to be living with HIV is 0.4% in 2018 is what I found from UN AIDS. And I wanted to compare that to the US. We're at 0.3%. So it's actually super close. And then if we keep kind of going down the line, HIV testing though is, at 51%, which basically means that they estimate that about 51% of people who are living with HIV have been tested for that and know that they are living with HIV. So that's actually kind of striking because it means that almost half or 49% of people may not know that they're even living with HIV, which is really, hard to think about because, or, you know, sad to think about. Because as soon as you know, that you're living with HIV, you can access medications that are going to help you live a long and healthy and lovely life. But if you don't have access to those medications, you're going to get sick a lot sooner and die faster. By comparison in the United States, it's about 14% of people with HIV are estimated to not have been tested. And so don't know that they're living with HIV. So that's actually, so that looks quite different. So number of people are about the same, but the people who, the number of people who know that they are living with HIV is smaller in Indonesia. And then if we look even further, if we think about, if you're living with HIV, are you accessing treatment? In Indonesia, it's about 17% of adults with HIV who are accessing medication. So that becomes a quite small number. Um, interestingly UNH it's like all those cells were blank for the youth, for the US and, um, so I couldn't find that specific number to be a good comparison point, but in the US 64% of people living with HIV received some sort of care in 2016, 53% of people living with HIV had a suppressed viral load, which would suggest that they are probably on a medication that is suppressing the amount of HIV virus that's circulating through their blood. So, you know, we might say that, you know, 17% of folks in Indonesia are receiving medications, whereas in the US that's actually it's much higher. So that's a big difference. Yeah. There are 30 countries that make up 89% of the world's new HIV infections. They're called fast-track countries by the UN AIDS. And they're usually prioritized for our HIV interventions and both the US and Indonesia are on, are on that list. So, um, so yeah, there's, I think important work to be done in both of these places in both the US and and Indonesia, um, to try to do better on some of these statistics for sure.

Carly: 1:26:35

Right. Absolutely. And I think it's cool, you know, it's not great that we're both on the fast track, but how great that we have these two people from both of those places that are working on the same issue, you know, to get there.

Valerie: 1:26:46

Yeah, I think, yeah, absolutely. That's right. The other thing that the RAs wanted to dig into a little bit is, um, incarceration. So why what's the situation here about HIV and substance use and, and prisons essentially. So what I thought I'd highlight here is that Indonesia is one of a handful of countries in which there's sort of this like confluence, or I don't know if it's like a tornado of substance use disorders, um, and, and specifically injection drug use and heroin. And then also HIV spreading among people with substance use disorders. And then third laws that are sending people with those substance use disorders are people who are injecting drugs to prison. So essentially what you end up with is a lot of people who have injected drugs or who have substance use disorders. And then who also have HIV who are landing in prison. And so Gabe actually talks about this a lot. Like he writes about this a lot in his work, and he draws parallels between Indonesia and maybe Russia and some other countries where you have these things happening all together. And I think it's really interesting because the US is also experiencing this opioid epidemic. I mean, we also have, um, a lot of substance use disorders, and then we also have a war on drugs, which means that a lot of people who use drugs or who have substance use disorders also end up in prisons here. But our HIV epidemic looks a little bit different. And I think, you know, one of the interesting things that happens in the US but doesn't happen everywhere is some of the delivery of what people call harm reduction strategies. And so, you know, in the earlier years of the HIV epidemic, they began things like needle exchange programs, where people who are injecting drugs can bring in their used needles and change those out for sterilized needles. And they found that actually just letting you know, just letting people change out their needles has been a really fantastic public health strategy to reduce HIV among people who inject drugs. And so that's, I think one of the, maybe, probably one of many differences between, you know, the US and other places. It was, it was interesting. I don't know, Carly, if you were at this meeting. When I first got to Delaware, I went down, uh, to an HIV consortium meeting, which is this really cool umbrella group, where our local stakeholders come together and talk about issues related to HIV in our state. And there was as amazing a guy there from public health who is just kind of like losing his mind about how we didn't have a syringe exchange van going to southern Delaware. And, you know, despite the fact that we know that we have like an, an issue with injection drug use down there as a result of the opioid epidemic. So when I first got here, that was one of my first things that I was learning about Delaware is that A we need, we need some more spread out harm reduction in the state, but then also we had these really cool advocates who were like.

Carly: 1:30:28

Right. I was just going to say, yeah, in special shout out to the HIV consortium for, you know, all their work with that. Cause they, they now have one, right?

Valerie: 1:30:37

Yeah. They had, there is a van that now goes down there and, um, which is excellent because there's such good data showing that when people can switch out their needles that they do and that helps to prevent the spread of HIV. So that's really great. All right. A big, thank you to the Stigma and Health Inequities Lab at the University of Delaware, including Alyssa Leung and McKenzie Sarnak. And I would just like pause and say a huge, thank you to McKenzie. She's been working with us for several weeks and we haven't gotten a chance to thank her yet. So huge thanks to her. This episode was researched by Saray Lopez and the episode was edited by Kristina Holsapple.

Carly: 1:31:19

And as always thanks to City Girl for the music. And as an update this week, why don't you guys follow us on Sex, Drugs Science on Instagram, that's Sex Drugs Science without the and.

Valerie: 1:31:31

And thanks to all of you for listening.

Speaker 4: 1:32:09

[inaudible].