Laramie Smith: HIV Medication Adherence

Dr. Laramie Smith is an Assistant Professor in the Department of Medicine, Division of Infectious Diseases and Global Public Health at the University of California, San Diego. Valerie, Carly, and Laramie take a slow walk through Laramie’s early years, including her childhood plans to become a rodeo barrel rider and adversities she faced on her path to college. Laramie shares her experiences working for the Seattle King County HIV Planning Council before graduate school, her dissertation project in the Bronx, and her current intervention work in Tijuana. Laramie and Valerie reflect on the value of qualitative work and some of the participants from whom they’ve learned the most. 

Learn more about Dr. Smith’s work here:  https://profiles.ucsd.edu/laramie.smith

Watch Dr. Smith’s GSBA speech: https://www.youtube.com/watch?v=KlX0VjuwRxg

Transcript

Valerie:

I’m Valerie Earnshaw 

Carly:

I’m Carly Hill

Valerie:

And this is Sex, Drugs & Science 

Valerie: 

Today’s conversation is with Dr. Laramie Smith who is an assistant professor of infectious diseases and global public health at the University of California, San Diego. Laramie’s work focuses on improving health equity among people living with HIV and substance involved communities.

Carly: 

We also wanted to warn you that there are some background noise to this episode. Please enjoy the sounds of Southern California as you listen to us speak with Dr. Laramie Smith. 

Valerie (00:00:04):

Dr. Laramie Smith. Welcome to the podcast.

Laramie (00:00:11):

Oh, well what you can't see are my jazz hands so exciting.

Valerie (00:00:16):

Pretty much. What happens whenever I see you on zoom these days its lots of...

Laramie  (00:00:20):

Yeah. Lots of jazz hands.

Valerie (00:00:25):

So Dr. Smith, we've got like a unique opportunity today. I think more so than some of our other guests, which is to do like a slow walk through the story of Dr. Laramie Smith, because, uh, you know, we know each other pretty well. Some might say (we) are good friends. Um, so I actually, I'm going to take us all the way back to Idaho because Dr. Laramie Smith was born in Idaho and Laramie. I'm really going there. So Laramie is an unusual name too. It's a town though, right?

Laramie  (00:01:00):

It is. It is. So, um, I was born in South central Idaho, if you will. Um, it's a region, I guess. Um, but, uh, you know, where there's potato fields and tumbleweeds, but my name Laramie comes from a town in Wyoming. Yeah. Um, so, uh, yeah, my father rode rodeo, not well, but rode rodeo for, uh, early part of my childhood. And, um, that's in part how I got my name. The other part was, you know, like no one could agree on which, which family name I should get. So no family name. And if I was a, uh, a boy, I was supposed to be named Laramie. And if I was a girl, I was supposed to be named Cheyenne, both towns in Wyoming, supposed to be beautiful areas that my dad loved riding rodeo in. Um, but my mom decided that Cheyenne was a stupid name and she liked Laramie and just named me Laramie regardless. So my dad was confused why I was wrapped in a pink blanket when he first saw me.

Carly  (00:02:05):

That's pretty awesome though

Laramie  (00:02:06):

Yeah. Yeah. If only he knew, like, it was just the, the, the perfect setup for the rest.

Valerie (00:02:14):

So this time in Idaho and your dad riding rodeo, is this, why does this like lay the stage for Laramie being a country music listener? I don't know if many people know this, one of the first times I got into your car, you had like country music blastic. And I was like, huh really?

Carly  (00:02:31):

That's nice but okay.

Carly  (00:02:31):

That was, um, that was partially a function of living in Connecticut. Uh, and, uh, but also a function of, yeah, I did grow up listening to country music, although it was, um, my father was very selected. What was country music and what was, you know, um, using his terms, uh, the druggie hippie music. So anything like out of the Willie Nelson or the outlaw, uh, Renegade, um, string was, was, you know, druggie hippie music and wasn't real country music and anything where there was like, the twang was about to bust your speaker, um, was real country music.

Valerie (00:03:19):

So, I mean then true to true to form with your dad then. I mean, not a big Taylor Swift fan, you know, at least at the beginning or something.

Laramie  (00:03:27):

So he came around, I came around to Taylor when I was running. Um, Oh yeah, because, uh, Taylor Swift and J-Lo have a constant beat that just keep you, you can keep, you can run, you can get some good mileage in, on those beats. So I, you know, I'm not ready to co-sign Taylor, but, uh, but I'll, I'll run to her. Yeah. Right.

Valerie (00:03:52):

All right. So we've got feisty mom kicking out the name, Cheyenne and giving you Laramie. And so you live in Idaho for a few years, but then she decides to move the clan to Washington state, right?

Laramie  (00:04:06):

Yeah. Um, we moved to Washington primarily because I've been in fights all the time, um, on campus, um, access at school and didn't really have any friends. Um, it turns out, you know, that part of Idaho is racist, um, it was really white, really Mormon. And my family was neither. Um, so my mom, Mexican, and, and we were, I guess, Catholic, but we definitely weren't in church. And so both made you like people who, kids who couldn't be my friends, cause I wasn't more, you know, and then there were kids that couldn't be my friend because one wasn't white. And so, um, both things made it okay to be mean, but, but because actually mom, I, you know, learned that I don't, you know, to fight back basically or people just push me around. So I was getting in fights. And then my mom decided that that was not a good thing for my future. And so she was like, you know, she's like, we're moving back to Washington. So she'd lived in Washington before. Um, and, uh, was basically told my dad, you can come with us or not. So

Valerie (00:05:18):

Did they have rodeo in Washington state for your dad?

Laramie  (00:05:22):

Well, they did have rodeo. We moved to Olympia, Washington, so it wasn't super super country there. Um, I thought I was moving to the big city. It turns out now, uh, it turns out small towns slash really happy and fun. Um, but, uh, but it was a big city for me, um, when I first moved there. But, um, my dad didn't ride rodeo by that point because, uh, my mom being as feisty as you, well, if she, if you can call her that, um, I told him, I told him that he needed to stop riding rodeo after he got, you know, punctured by a bull horn.

Valerie (00:05:59):

I feel like that...

Laramie  (00:06:01):

Yeah.

Valerie (00:06:02):

I might tell Bryan character to stop riding rodeo if he was punctured by a bull. So, yeah.

Carly  (00:06:09):

I'm just like, wait a minute. This is getting spicier than I thought, Brian rides rodeo? Is what I thought--

Valerie (00:06:15):

in a hypothetical world.

Carly  (00:06:17):

That man gets more interesting, and more interesting as the time goes on.

Valerie (00:06:22):

I mean, luckily he'll never listen to this so

Laramie  (00:06:26):

I mean I an see, I can see it

Carly  (00:06:29):

At this point. Anything with Brian,

Laramie  (00:06:32):

Maybe some barrel racing. I think he could get into barrel racing, which is something I always thought I would be a barrel racing radio queen that was a little

Valerie (00:06:40):

Already, like 10 minutes in, and I'm learning more.

Laramie  (00:06:45):

It's been like part of my summers. Um, mostly cause I didn't have friends. I went to someone else's, um, during the summer their ranch and when would ride rodeo--I'd ride horses. So they just go up to get on their bare backs on the fence and then just like ride them around the patio or the field. And then I get in trouble cause I would chase the cows. And apparently that's not what you're supposed to do. Um, because they're supposed to be getting fat and not, you're not supposed to exercise them. Also. I, my, I got in trouble because you know, there's stitches. And if I broke the horse hooves, like jumping in properly, then I would be responsible for that horse being killed. So that's that, that killed that during real fast, but for a brief summer period, I really thought that's where my, uh, my life was headed.

Valerie (00:07:34):

Glad you have this backup plan if it's ever required (laughs).

Laramie  (00:07:40):

Cause the other option in life at that point was to be just like a rodeo queen. And that look that looked real boring, but like bracing, the barrels was the only other thing that girls were doing. And I was like, I'd do that. That's fun

Valerie (00:07:51):

Well, let's just tell, thank the universe that you found your way to science. Yeah. I mean, I'm sure you'd be very talented, like being a barrel rider I think. But anyway, you're spectacular. It's science, so

Laramie  (00:08:04):

Yeah. Um, yeah, I don't know that I was that great that, um, getting the horse to go that fast.

Carly  (00:08:09):

this would be a much different podcast though if you'd have stuck with it.

Laramie  (00:08:11):

Queer rodeo queen

Valerie (00:08:19):

So this, so now we're, you know, we've got Laramie living in Washington ages eight plus. So I wanted to get us here in part because I watched your GSBA, um, speech. So if this YouTube video and it's an acceptance speech or not an acceptance, you're their keynote speaker kind of in celebration of this scholarship program that they had. And you talk about your experiences basically like going to college. So we're going to link to it, um, in our show notes, because I watched it this morning and we've been friends for over a and I was like ugly crying. Like to me, I'm a teacher. I'm like, I was like ugly, crying into like all stories I've heard before about ugly tea this morning and you know, probably also for such, such close friends. I can't see you crying without me crying. So like that's also a thing

Laramie  (00:09:13):

I know. I was like, well, that's good. Cause I'm at least I'm not crying alone on that video.

Valerie (00:09:18):

No, everyone who watches it, it's going to be crying right there with you.

Carly  (00:09:21):

I even said to Valerie before this, I was like, this might be the one podcast that gets me to cry and it's not like we haven't had cry worthy material before some people lay down some, some tear jerkers, but I was like, man, this one, this one might be the one,

Laramie  (00:09:34):

Oh man. Stick with me all the emotions.

Valerie (00:09:39):

We're here for it. Okay. So you're 16 and you come out to your parents. Right. And then I, I forget how you phrased it, but you basically said turmoil ensued.

Laramie  (00:09:47):

Oh yeah, yeah. You know? Um, yeah. It wasn't the coolest thing. Uh, um, yeah, so I had grown up, so, so growing up, I had a brother and sister who were also gay and now, and I have to say that, you know, a, in a lot of ways I was raised like, if, if God did not want gay people, he wouldn't have made gay people. That was my mom. That's what she said. Now, now, now saying that and being raised that are two different things or what was one thing and then actually being that was something different. Right? Um, it just, it triggered a lot of like, you know, I think came up against a lot of like, uh, a lot of her mental health issues, but also came up against a lot of cultural things. Right. And, and all the time growing up, the things that I kept coming up against was, you know, I wasn't feminine enough. Right. Like I, I crossed those lines of, um, of what a girl is supposed to, what a lady is supposed to be. Um, you know, wanting to be a barrel racer was one of them, you know, (laughs) like she came with the name Laramie. So listen, I think I might leave the room with her. Um,

Carly  (00:11:03):

my name is Carlisle so.

Laramie  (00:11:07):

You're like, listen about these things. Uh, no. Um, but yeah, so, so, so came out and I had torn, locked a fun if it was it. Um, I think my father had a harder time legitimately dealing with it because he just was like, well, your hope, like how can you ever succeed at anything in life, your life's over? Because, uh, you know, being gay meant that I couldn't get married and it meant that I couldn't have kids. Um, and so for him, from his perspective, like really what else was there left for me in life. And so like, that's hard at 16 having, you know, your dad telling you that. And I laugh now because I was like, I mean, even at 16, I was like, I don't ever want to get married and I don't ever want kids. And so two, those two things have not

Laramie  (00:11:54):

Changed and I'm grateful for that. Um, but, um, but I was just like, wow, that's really, you set a high bar for me. Um, so yeah, so like I was kicked out of the house, you know, here and there, um, for a period of time. And then, and then ultimately the closer I, you know, and, and this is more kind of like a reflection of looking back, but, um, but the closer I got to going to school, the closer I got to going to college, the more things I did to check off those boxes to be like, this is what they say you gotta do to go to college, do this, do this, do this take, you know, was it the SATs? Like, you know, um, it, the worst things got, right? And the more, um, me being , uh, was a problem and was used as a justification for why I was a horrible kid before being gay. I was horrible.

Laramie  (00:12:49):

Well for a bunch of other reasons to, you know, parents,

Laramie  (00:12:54):

Uh, you know, uh, they weren't very, very stable people to begin with, but, uh, you know, but like, so, so yeah, so I got, um, just kind of found myself. I came home from volunteering. Um, so I, you know, was like out volunteering. Got to get into college. So I volunteered in a backstage, uh, concert. Uh, there, it was called the backstage. It was, it was concerts. It was Olympia, Washington. So there's like huge immediate music scene, right? Like, um, you know, uh, it was on the tail ends of the riot girl scene. Um, uptake of Foo Fighters were kind of at that crossover period.

Laramie  (00:13:33):

You know, the gossip was just getting started so early, early (Beth day now). Um, and I'm, I'm there in a ginormous like neon yellow staff security. T-shirt like this tiny, tiny little person. And they're like, for sure and volunteer, we don't know what to do with you. You stand over there. Like, what are you, what kind of security are you actually providing? Right. Concerts for free, um,

Laramie  (00:13:57):

And was going to college is what I told the guys like, I need to go to college. I need to volunteer. Um, I had no idea what, what was really needed to get into college. Only tear a check. Yeah. So it came home from a shift doing that. And, and yeah, my mom was just like, well, we need to talk, sit down at the kitchen tables, sat down with the kitchen table. And, um, she just stared out the window on. My father told me that I needed to find a new place to, to, uh, to live and a new means to take care of myself because clearly I didn't understand what it meant right? To, um, to, to take care of myself. And I didn't respect what my family was doing for me. And I thought I was better than them. And, um, and chose to be, to be gay, right? Was choosing to leave the family to go to school. Um, and those types of things. So just in the morning, literally, you, you can watch the YouTube video for a bloke, um, but you know, left and not, and that was, that was it. And I had to figure out everything else from there. Like I had, you know, literally I had no social security card. I had no birth certificate. I had no, no ID. And it turns out to get one of those things. You have to have one of the other, right. So the phone books, I'm literally looking at the Bureau of statistics, like for Idaho in the phone book and the ladies hanging up on me, she was like, well, why can't you, your family give you this? I was like, they kicked me out. What did you do? Nothing I'm gay click, you know? And you're like, ah, okay, leave that part of the story out next time I call. But like, literally I did nothing, you know, I'm, I don't know how to, I'm not, you know, like everyone's like, what did you do to get kicked out? It was really, it was a wild experience because everyone presumes that you must've done something wrong. And I'm like, my parents are not well people. Um, right. So what do you do?

Valerie (00:15:53):

I, you know, I know this story and watching it this morning. I just, I didn't, I don't think I really had thought through just the logistics of like, yeah, you have no like documentation and now I'm going to apply for college. And then, you know, one thing that you said about that time was, um, I mean, you used this word a couple of times when you were describing it and how humiliated you felt as a, as a kid having to call people and be like, I got kicked out, I got kicked out and you know, repeating this story and like, yeah. That's when the crying got real ugly. Over here in Delaware. You know,

Valerie (00:16:29):

Just, we were talking about this, um, with Ryan Watson earlier this week. I mean, kids at that age, like, don't have, like, all the research suggests, like, you don't really have like your resilience resources yet. Like, you don't have like, like your, like you can even hear in your narrative, like, you're figuring it out as you go. Like, what part of the story do I share? What part don't I share and then like, um, yeah, you just don't yet have like all of your coping strategies for when people are to you about this. You know what I mean? So it's just such a vulnerable moment in time to have something like this happened. One of my favorite, I mean, you have a couple of liners in this talk that we really are in this YouTube video that we really love, but one was that, um, how your best friend's conservative Catholic, Republican parents took you in, which is amazing because then you, you know, you met yeah.

Laramie  (00:17:21):

They did!

Valerie (00:17:21):

Eric's family. So I've never met Eric or Eric's family, but I've heard a lot about them. And that was just, that was really an amazing, um, part of the journey it seams.

Laramie  (00:17:32):

Yeah, no, it wasn't really, wasn't it really, you know, being, being on this side of things and this side of the science and, you know, being, we read about all of the risk factors and all of the, you know, like I, like I have, it was such a clear understanding of how had they not been there in that moment when they were there. Like, I may have still ended up here, but, um, but it would have been a different journey and then it would have, have been a different struggle. So the very fact that they were just like, absolutely not, you have a place to live, it's safe, it's secure, it's stable, you have food, you have, you know, like you focus on your grades, your job is to graduate high school. Your job is to be a teenager. Your job is to go to college. Like that is your job. You do those things. And we take care of everything else I had. I had never had that in my life. Right. Um, so, um, my parents were never, those people, um, you know, everything I had with my parents was tenuous. You know, they, they allowed me to stay in their home.

Laramie  (00:18:39):

They, they, they allowed me to eat their food. They allowed me to, you know, like that was, you know, like that's, that's just the way it was. Right. Like I w I did not belong there ever. Um, and, uh, and so it was, it was, it was wild, but it was a blessing, right. Like, I have to say that like, being kicked out of my parents' house was really hard, but it, uh, you know, it allowed me to experience a different way of living that it was really meaningful. Right. Um, and so they did, yeah. They gave me that kind of, that unconditional love and support. They were like, what is, and it was so awkward. Right. It was so uncomfortable. It was just like, uh, this feels weird. (laughs)

Valerie (00:19:27):

I think it also gave you training. And one of the things that I admire so much in you, which is that you, you kind of let you create family wherever you go, which is like, really amazing. Like, you're you create, um, family within your friendships, which is like really incredible. Like, I feel that way in our relationship, you know, and I know that you have that with other folks. And so from like such a young age, to be able to, that's like an amazing skillset, you know, to develop as is to figure out and, you know, maybe they taught you that as well, but you like learn how to create those relationships with yourself or with other people is really powerful.

Laramie  (00:20:08):

Uh, yeah, I, yeah, no, that's something I really value about, about my life and my friendships and that, you know, like, um, you know, you can, you, you can be born into family, but it doesn't necessarily make it family. Um, and, and when you have those people that, that, you know, support you and love you and bring joy into your life, that it's important to tell those people that, and to let them know that it's appreciated and to, um, and, and, and to give that back. Right. Um, so yeah, I think that, that that's, that is something I very much value about, about my life. And, I, you know, like everybody has wild parts of their lives. My parents were them, uh, was it one of the most wild ones, but, uh, but like, I, yeah, I really value that I have those friendships and that family, that sense of family, wherever I, I land. Yeah.

Valerie (00:21:06):

All right. So, um, little baby Laramie Smith, like us she's 18,

Laramie  (00:21:12):

But I was such a baby dyke . Yeah. Flat top neon flat-top um, you know, that's when punky colors was really a thing, but I wasn't, I didn't have enough money to really do it well (laughs). Um, so, so I'm like this fancy stuff. What is it? This overtone stuff that like people put in and like is vibrant and beautiful. And I don't know whether they keep doing it or it washes out more gracefully. Punky colors does not act, have graceful exit for anybody who remembers this. It turns all kinds of like garbage disposal colors. Um, and you bleached your hair underneath. And so you need to have another color to add or more money to buy different hair dye, which I didn't always have. So, so, yeah, so at times it was, it was beautiful and like vibrant plum and neon purple flattop. And other times it, it was awkward, but a flat top, nonetheless (laughs).

Valerie (00:22:12):

Well, maybe we're going to need to ask, like, dig around with Eric and get some photos of this for our Instagram.

Carly  (00:22:20):

Ah yes can we? I'll make that my homework for the week.

Laramie  (00:22:23):

Oh, he would love that.

Valerie (00:22:26):

All right. So we've got Laramie up at, um, Western Washington university and you're a psych major and American studies major. And then after that, you go down to Seattle King County and you work with our department of public health, and Eric has also moved down to it.

Laramie  (00:22:45):

Yeah, yeah. Yeah. He comes up from Olympia. We have a period where we live in our own shoe box studio apartments on separate floors. I'm on the eighth floor. He's on the third floor.

Valerie (00:22:54):

Perfect. Yeah. And so during this time you're starting to do work with HIV, right. I think maybe you were working with, uh, in our homework, we dug up the national HIV, behavioral surveillance study. Is that right? Or, no, not right.

Laramie  (00:23:10):

I finally landed there yet, but I, I started, um, well working like, uh, uh, social tech. So before I moved to Seattle, so I was doing eight hour adult protective custody in the ER, um, with folks who were considered danger to themselves or others by someone else, um, because of what they had consumed. Um, so that, and then I, and then I worked for women's works and, uh, and that was a big, Whoa, not be part of this system. Um, that, that was horrible. Uh, it was valuable experience, but like, I was like have to compromise too many of my values to keep working here. And I just can't do that. And I just landed a job as an administrative assistant in the Seattle King County, HIV public health, um, as working for the HIV AIDS planning council.

Valerie (00:24:08):

Oh wow! We do a lot of work with our Delaware, HIV planning council, and they're just the best. Like they they're amazing. Like, so in Delaware they coordinate like everybody in the state. So like the hospitals are at the table, the, um, you know, public health is at the table, all of the community-based organizations and then HIV are all there. And they talk about everything from like, what's our state priority in terms of like rolling out, maybe like prep, which is HIV prevention medication all the way to, like, we've got this one person who needs like somewhere to sleep tonight, like they do it all. So what kind of things, I mean, was that similar?

Laramie  (00:24:48):

Yeah. So this was, this was a little ways back. So it wasn't as common to have a lot of, a lot of planning groups had had one that focused on prevention and one that focused on care at that point. Um, uh, the dollars were really siloed. Um, but so the public health department had to be very intentional in bridging those groups. And ours was very intentional in, in bridging that, um, Seattle King County public health, HIV AIDS program is leads the way in so many ways still today. Um, I thought all public health departments were like them turns out. Um, but, uh, but, but yeah, so, so, and, and this was at the time when really there was, um, there was a beautiful protest that was done, um, and orchestrated by our council members around, um, around understanding that per that, that, that prevention means you need to support people living with HIV, being in treatment, staying on treatment.

Valerie (00:25:44):

Oh, wow.

Laramie  (00:25:44):

Prevention and prioritizing kind of prevention for positives, which was not, not a given at the time. Right. That wasn't given at the time. So they staged a coup and we're like, Oh, the prevention dollars need to go to making sure everybody living with HIV has access to carry on treatment--and housing. And I was like 100% and it was like 100% of dollars have to go there. Which of course you can't can't couldn't do. But, um, but it was, it was like one of those things when I'm over there, like typing.

Laramie  (00:26:16):

Um, but, uh, but it was, it was, it was, yeah. So, so that's, that's the era when I was there. Um, and then, uh, then started working on some research, got connected through people that were on the council at university of Washington to different research projects. And that's where I started working with homeless, the street involved youth and the white house, um, uh, and, um, and still worked at public health and then moved into the first cycle of the NHBS um,

Laramie  (00:26:44):

So doing straight re you know, the ecological observations, walking around operation, finding places for where you could recruit people recruiting. It was a high risk heterosexual, um, uh, around doing the interviews, HIV testing, driving the van.

Valerie (00:27:03):

Wow.

Laramie  (00:27:03):

(Driving) The van everywhere, big 30 foot RV, parking it on the streets of Seattle. If you've ever been to Seattle and know about it's Hills.

Valerie (00:27:11):

Yeah.

New Speaker (00:27:13):

Those are skills that nobody at NHS, whether you have

Carly  (00:27:17):

They might now though, they're all listening to this podcast. So they might now know.

Valerie (00:27:22):

absolutely. They're all going to want to know, like what the manual transmission?

Carly  (00:27:24):

That was my first--

Laramie  (00:27:28):

Wait, wait, which was this? No, yeah, no, it's not manual. I still can't.

Carly  (00:27:33):

Wow. That's not that impressive then. That's not such--I'm just kidding.

Laramie  (00:27:37):

I want to see you try it.

Carly  (00:27:39):

I couldn't do that (laughs)

Valerie (00:27:39):

Yeah. This is amazing. So from like pretty, I mean, this is like (your) early twenties, you're getting a real education, a with your job at the council of like the importance of like community engaged work, just generally, it sounds like, like really hearing the voices of what, of, what people living with HIV you think is important. And then letting that guide the priorities, which I feel like people like me who went directly from undergrad to grad student, so grad school, you're just, you like, don't get, so that's very important. And then also, um, I'm hearing, like you're getting some really super valuable, like on the ground, like research experience, like the first research studies that I ran in undergrad, where like, you know, like undergrads sitting at a table, like filling out pieces of paper, and then I like lied to them about their feedback. Right. So like your, your research experience. I mean, maybe you did some of that too, as an undergrad, but your research experience there is like driving around and finding (straighten bud views) and like enrolling them in studies. And that's like, that's really like amazing, you know, research experience to, to have in your like early twenties before you get to grad school. So, so where, where, like along this thread, do you decide, you want to level up and you want to go pursue a PhD?

Laramie  (00:29:05):

Oh, I, that, I decided that in undergrad, that's why I was doing all those things.

Valerie (00:29:12):

Oh got it.

Laramie  (00:29:12):

What do you need to do to get your PhD research? Work on a research project?

Valerie (00:29:18):

Where are the concerts that I should volunteer at to get into grad school? Like local concerts. Yeah.

Carly  (00:29:25):

PHD level concerts

Valerie (00:29:25):

PHD level.

Carly  (00:29:27):

You have to get security for like the stones.

Valerie (00:29:30):

All right. So you, so you were pursuing youth activities cause you knew you wanted to go to grad school

Laramie  (00:29:36):

Yeah. Yeah. The how to go to how to go to grad school for dummies book, literally like it was like list was like, um, and my, uh, my undergrad, uh, I had to, I was really blessed. I had two undergraduate faculty, they were husband and wife, Arlene and Max Lewis. Um, and they, they helped helped me in a car, a friend of mine, Joann lead our own undergrad study, you know, um, uh, looking at the associations between internalized home and negativity and state and trait, anxiety.

Valerie (00:30:06):

Oh wow!

Laramie  (00:30:06):

Ooh, yeah. Uh, entered all that data by hand. Um, but, uh, but they were, they were very honest. They were like, listen, if you want a research career, um, and this, this was all clinical. Um, they were clinical psychologists. They were like, if you're going to get into a competitive program, this isn't enough. And then I was like, okay, but the box said like, they're like, no, you need to work.

Laramie  (00:30:32):

You know, like you, you won't be competitive going up against students who did their training and, you know, um, at, at, at university of Washington or, you know, U Penn or like, you know, a big, a big R1 school. And I get that now. Um, I was at a small liberal arts school, so, so I knew I needed more research experience. And, and, and that specifically why I, you know, I left Bellingham, I did my undergrad and went to Seattle and was applying, trying to get into a research shop. And the only way I could get into it was through the being, uh, the administrative assistant to the planning council. So I was like, okay science stuff! Well, uh, here I am, I'm going to work on all the research projects, but yeah, it was, it was phenomenal, phenomenal experience. And, um, and of course they said, you can only select one to work on. And so I told them both, I selected, theres and worked on it successfully for about a year until they were like, you're working on two studies and public health job, how, you know, I'm like, yeah.

Valerie (00:31:40):

Were you also like, and I get all my exercise dancing every night...

Laramie  (00:31:44):

How every night, six nights a week... (laughs)

Valerie (00:31:48):

I think that's my favorite part of that, that era of Laramie Smith's life. All right. So, but it worked though, because when you went, when you applied for grad schools, I mean, I think you, you applied for both clinical psych and social psych programs if I remember, and you, you know, you had a lot of, you know, great reception there and you end up choosing to go work with one of the like huge BFDs in like HIV, behavioral research.

Laramie  (00:32:13):

Yeah. Yeah. I, Jeff Fisher, I remember when I told people where I was going for grad school, uh, about what was like, Oh, Jeff Fisher and the Fisher brothers at UCONN. And I was like, okay, great. I made the right choice.

Valerie (00:32:32):

So, I mean, Jeff Fisher is a big deal. He came up with like some of our early theories of how, um, information, motivation and behavior, all sort of like combine and impact people's health behaviors, including their like HIV related behaviors. So he's super well known for that, that Seth Kalichman who was on season one has this story where he says that like the Fisher brothers went off into the woods with a piece of paper and like came out of the woods with, they call it the IMB model information, motivation behavior. And it's, it's like my favorite version of that story.

Laramie  (00:33:08):

It's my favorite too. I like, I, I have a mental image of what they look like, you know, in the early nineties going out, um, you know, after having some wine and in my, in my version of the story, they'd have some wine...

Valerie (00:33:23):

Oh 100%

Laramie  (00:33:23):

...and on the back of like a paper plate, we're like, okay. So if we take this from, you know, social cognitive theory, what we know of social cognitive theory and what we know about, you know, TPB and what we know about this, this is, this is really how it goes together and really what's happening.

Valerie (00:33:38):

Yeah. Well, that's pretty much how I'm Stephenie Chaudoir and I came up with the HIV stigma framework. We were like sitting around Panera, like drawing, like on like a soil, you know, soiled napkins, like tea and cookie stains. And we're like, yep, looks right. Let's move forward with, um, yeah. And, and Jeff like, he's got this model, he runs a center. So you, you know, you land in a really great place after this. So maybe you need to like go back and rewrite this, like how to go to grad school for dummies.

Carly  (00:34:14):

Seriously, please.

Laramie  (00:34:18):

Yeah. Right.

Valerie (00:34:21):

So when you're there, so first of all, we meet during grad school. So that's like a very big moment. Sorry. I just thought of the story.

Carly  (00:34:35):

This is where the story really begins. We're editing out everything before right now. We just wanted to ease you into it.

Valerie (00:34:43):

Everything rodeo related, all the rodeo stuff, we're keeping, um,

Laramie  (00:34:48):

slash science labs.

Valerie (00:34:50):

Yeah. So we start, so we start collaborating, um, science festing, but the one story that I really kind of wanted to, to hone in was your dissertation awards. So you apply for funding to, um, basically create your own intervention. And as a graduate student, I was like, Whoa, because you know, for me, I was figuring out, you know, how to study what's wrong, but like the, to, to try to change, it seemed like really intense and really challenging. And even now, like, as a stigma researcher, like, you know, I have a, I had a intervention development grant and I'm doing it. And if I look too closely, if I think too hard at the fact that I'm trying to change stigma, I like freak myself out. And I just have to remind myself that, like, you've got a really good team. It's okay. Cause it's because changing people's behaviors is really hard. And I mean, for us, like now, like changing stigma is really hard. So, um, so you got this grant and you get connected with the Chinazo Cunningham at the Bronx infectious disease physician. And she says that you can collect data, but there's like a stipulation, right?

Laramie  (00:36:10):

Oh yeah. Yeah. So this is where my skills, uh, working multiple research projects and telling both investigators that I was only working there came in, came into play. I had to learn, I had to learn how to relate and be like, all right, I'm going to do what I want to do and find a way to make it work. Right. Because, uh, my, my mentor, and, and now as a graduate mentor, myself, fully respect where he was coming from was like, how are you going to get your PhD and do well, and, and here in Connecticut and go collect data in the Bronx. So he was like, let's, let's get you some funding. So you can pay someone to collect that data for you. And Chiazo was like, no. Uh, if you think that you're going to change behaviors in this patient population, you need to understand what that can look like.

Laramie  (00:37:03):

Right. Don't come at me with an intervention, that says, I'm going to take 15 minutes of the provider's time to talk with the patient to do this, to do that. You know, she's like, no, you have to collect your data. You have to understand what the clinics like, you have to understand what the physicians are. Like, you have to understand like what the patient's lives are like, you have to understand what the environment around the clinic is like, like, you know, right. The ride, the ride, the subway, and like everybody else does. So I did that for years. Um, and, um, the one thing that I will say while I managed to convince, uh, Jeff, that I would be able to success be successful in grad school and collect, uh, my dissertation data in the Bronx. Um, I will say that allowing me to select a topic where I'm finding my participants, uh, literally was defined by people who did not come in for their problem, sitting at a clinic to find those people probably was not the best study design choice for a dissertation,

Valerie (00:38:05):

Not a good exit strategy.

Laramie  (00:38:07):

Yeah. an exit strategy.

Valerie (00:38:09):

I always say that dissertations are like part exit strategy and part like this should be everything you love about science. Like you're super excited about, but the exit strategy really like you have to do it in a year or two. So yeah. That's hysterical about like, I want to study the people who never come in and that's not, that's not good for exit strategy dissertation now.

Laramie  (00:38:32):

No, but it does lead to, uh, designing an intervention that can be delivered right there on the spot, the moment someone steps through that door, that part, and sitting in the clinic and understanding what that was like was invaluable. It really was invaluable.

Valerie (00:38:49):

Yeah. So I would, I would have to ask because, I mean, I remember it, um, because, so you were like living in, you know, living in the city, living in New York, you were taking classes in Connecticut. You were like going back and forth multiple times a week. Like, I remember you would like drive down to new Haven, Connecticut, and you would like take a nap, then jump on the commuter train. That's like an hour and a half or two hours to get to the Bronx from the river, and then you'd go collect your data. Um, so like, that's really, like, that's really challenging while also balancing like everything else you have to do as a grad student. So, so it sounds like, I mean, you just said it was invaluable. So it sounds like though that was worth it. I mean, it was worth the effort.

Laramie  (00:39:36):

Yeah. It, it really was worth it. Um, you know, I, we were talking about like, well, what is it that difference in like changing behavior and, you know, the intervention, it was all, it was a, it's a dissertation. Um, you know, so it was, it was a small feasibility and acceptability, but you know, it, it, it showed promise that the reason I believe that it showed promise and hope to show through future studies that continues to show is because, because of time that was there. And that, that time that was spent on same, like, you know, um, that I'm going, like people are taking on a lot to get in to see their HIV care doctor. It's not so much that they don't care about their, their health. Like oftentimes like their health is very, very important. Um, but there's some big misperceptions around like HIV is not my biggest priority.

Laramie  (00:40:34):

Like look around me, you know, it's not, my biggest priority is hassle to get in and then to wait all day clinic, you know? Um, and, and, and, and then the time for my appointment, I still have to wait for more because that's just how it goes. Even though I know when I get in, there's going to have all the time in the world for me, you know, like it was invaluable. It was invaluable for standing like, you know, um, what, what, how to anchor that intervention, uh, what to anchor it around, what folks priorities, um, were, what based what health priorities were really most meaningful for them may not be the priority that, that, which is coming in to see your doctor every three, every three months. Um, can you try other other priorities to do that? Um, and, and address like other health priorities. It's like, people's like, how did they felt about what they HIV? I think that just, that was, would never have through, had I not been in the clinic and people myself.

Valerie (00:41:41):

Yeah, absolutely. Well, it's funny because I feel like my experiences at that time with that, um, we applied for this now. I think like, it felt like a big grant at the time, but now I'm like, I was a little baby grant. It was a pilot grant. It was like $2,000 to go collect data at our local methadone clinic. So, so Carly, we got the grant, we decided that we're going to do qualitative research. So we're going to do interviews. Laramie is the qualitative trained researcher. And then Laramie was like, peace out, South Africa I'm on my way. No, I'm in Connecticut. I have to collect all the qualitative data.

Laramie  (00:42:23):

You got this Val!

Valerie (00:42:25):

Laramie like tells you like, okay, here's how you do it. And no, I'm driving down to New Haven, you know, with this was very generous, um, generously embedded in my Copenhageners, um, study that he had going on. But it's funny because, um, you know, Carly now collects data at our local methadone clinic. And so when I was first training her now she's like, lapped me like a million times number of interviews that she's done. But I was like, so here's, here's some of the things that happened when I first started collecting data, somebody who like was lighting stuff on fire during an interview. But yeah,

Laramie  (00:43:02):

That seems about right here, your track, or something's getting lit on fire.

Carly  (00:43:08):

But you know what I'm never, I'm never the most boring person at parties anymore. Thanks to Valerie putting me in the methadone clinic because the stories that I have are just like bar none, but it's so true though. Like in fact, I can think of a million different stories of like things that I would never have known how to navigate. Had I not been in there and like, or different barriers, like even, you know, with our HIV study, but I like it, you know, the barriers to care that like these providers, aren't thinking about like, no one in that care community is even like aware of. And it's like, you know, as you get through all these layers, it's like, yeah, no shit you're not coming to get your medicine because you have, you know, a thousand other, but until you're like, actually in it, boots on the ground, you don't see it.

Carly  (00:43:43):

You don't have the luxury, you can write about it, you can do it. You know what I mean? But it's so true.

Valerie (00:43:49):

Yeah, absolutely. I mean, like some of those conversations too, like are the things that have motivated me to make the jump from just understanding stigma as a problem to wanting to do something about it. So one of the, in one of the participants in our study, he was really young. He was probably like 18 and, you know, he was really short. He gave us like, no good data in the interview. It's just like, yes, no, yes, no. But then that's it. And I said, okay, so do you have any additional questions for me? And he asked me like, okay, well, yeah. Um, when are they gonna accept me again? And I was like, who? And he's like my family, like when will my family accept me again?

Valerie (00:44:31):

I just, like, I always remember that. And, um, you know, I'm sitting there as like a researcher and I'm like, all right. I don't know, like I have no skills for this, but I mean, it's really like, it's that? And it's also the like showing up at the HIV planning council and they're like, yeah, no , stigma's really bad. Um, so what do we do about it and how do we get, what do we do with the families to get people to accept? Or how do we reduce the stigma? Or one time somebody asked me like, okay, so when I experienced discrimination, how can I make it so it hurts less. Oh my God. I like, almost like cried at this community meeting. And I was like, I don't know, like social support coping, like, um, but, but you don't get there and you don't like, without those experiences, I would probably just have really settled into like, okay, let's keep measuring how bad it is and seeing how bad it is and measuring how bad it is being.

Laramie  (00:45:32):

Yeah, yeah. Yeah. I mean, as the guy, young, young twenties been living with HIV two years interviewing him, um, and it was, Oh, I go to all of my HIV care appointments. I just don't always make it in the clinic door. What, what do you mean? Well, sometimes it just gets too much and I it's my stop and I just can't get off my stop because I just can't believe that I have this and you know, like what it's doing to my life. And you're like, Oh, Oh, right. Like, Oh, like, so it's not enough for like me to give you a calendar and a reminder, like you're on the bus, you're on that Metro, you spent that money. It's about like, how do I manage those feelings about living with this, this life changing diagnosis? Um, that was just like, well, that's not in any of the books I've read.

Valerie (00:46:35):

Would you characterize that as information or motivation? Like which one?

Laramie  (00:46:40):

Um, I, it turns out, you know, it's, um, it's, uh, it's, uh, motivation and behavioral skills. It's skills to manage the aspects. Oh, you live with HIV is, is what, what came out of those data. But, but that's, that's just like the, that's the, the interview that, that I'm like, I know exactly why I'm seeing this result. Like in the structural equation model. I know what I saw. I saw it and I saw it in their response. I saw like, when I asked these group of questions, the entire demeanor of the interview shifts, right? Like, and, and people like, Oh, no, one's asked me about that before. The reason I knew to ask is because I had a long conversation with someone who shared with me, like how they go to every, they just don't always make it through the clinic door. And, and, and, and, and other examples related to that, about what that looks like. And you're like, okay, people have the functional skills, but then there's some, there's some, some other places that we can maybe lend a little, little support, we'll give it to you for the wind.

Valerie (00:47:51):

I mean, there's a reason to Chinazo has one of these like super fancy mentorship awards. She's, you know, she's funded by the National Institutes of Health to spend half of her time mentoring people. And she has, is worth every penny of that mentorship.

Laramie  (00:48:06):

Yeah. 100%. I hope her program officer hears this.

Valerie (00:48:14):

All right. So, you know, after Connecticut sad news bears you road trip over to, um, UCLA university of California at San Diego for Post-doc I say sad news bears. Cause I still remember your car packing up and you're like driving away from my apartment complex, like lots of, yeah.

Laramie  (00:48:35):

Wagons, West journey

Carly  (00:48:37):

Running. Were you running after Laramie's car? Like, no wait.

Laramie  (00:48:41):

Yeah. My dog was perched out the window. Like, so being like by Val by Katniss

Valerie (00:48:48):

Yeah. Katniss is my dog. And she is here. I just want to say for this podcast, as she's like back in the fan section, just yeah.

Laramie  (00:48:56):

Good, I'm Kat's biggest fan. So I'm into this.

Valerie (00:49:01):

All right. So you landed at UCFC and we wanted to pick your brain about, um, you know, you do like a million projects there, so you, you did a post-doc there now, you're faculty there. Um, so we went in to pick your brain about some of the work that you're doing in Tijuana, because it's a, you know, it's a unique context and an intervention that you have been working on there. So could you tell us like a little bit about, um, Tijuana and what, and why should we be studying and looking about looking at HIV and the context of Tijuana Mexico?

Laramie  (00:49:35):

Oh, yeah, for sure. I'm going to pause one, two, three seconds and close my front door. Cause (Laramie's dog) has come in. She's just done with her sun time. Perfect. Awesome. So, um, so yeah, I was really excited to come to UCLA for my post-doc very sad, um, to be leaving you, um, behind, uh, but, um, but excited to be back on the West coast and, and in particular, um, the, uh, the work that was being done in, in Tijuana was something that I had followed. Like, I don't know if you remember in grad school, we had like the chip Brown bag series where like, like, like the top HIV researchers would come through and present on their research. And every year I submitted (Stephanie Strackley's) name, I had, you know, like just reading heart with the work she was doing with people who inject drugs into Tijuana and that, um, and the intervention work that we're doing with females, uh, sex workers into one. And I was just like, like this, this is, this is a group that really gets it. Like, this is a group that's really connected to the community. This is a group who, you know, um, it really tapped into a lot of what I knew from my, my own ex you know, childhood and growing up. But then also my experience working on that in the social detox and whatnot of like, like is horrible. And we treat people who use drugs so bad and like, and it's just so accepted and we need to, you know, like we need to, we need to do better. Um, we need to do better in terms of science. We need to do better in terms of just being human beings we need do better. Um, and, and I really valued the work that they, they did with the, the, these, um, populations into one and knew that they had a post-doc that T-32 postdoc down here. Um, and so they were doing a lot of primary prevention work. Right. Um, but that my work had focused on, uh, second secondary prevention or engagement and Karen, no one was really working on that side of things. And so I was like, huh,

Laramie  (00:51:45):

Huh I don't know, but we could compliment each other very well. Um, you know. I definitely didn't sound that confident. I was just like, please, um, I really would love to come and, and, and expand, you know, cause before that, like the work that I had done had been clinic-based right. And, and, and, and it's clinical based work is very important, but you know, there's a lot that can be done and be supported for folks who aren't getting into that clinic door for a lot of other reasons. And, uh, can we create more low threshold, you know, access to services, um, and, and interventions that, that don't require people to jump through all of the system level hoops, you know, to, to prove that they're deserving of, of healthcare. Um, and, and, and so that's the work that I really, you know, had the opportunity to get connected with and, and, and develop here in, in San Diego, which, you know, as, you know, from having visited is 20 minutes North, uh, we're, where I live is literally 20 minutes from, from the border. Um, and I hop on a trolley and I get off at the, at the border and I walk across the border and I'm in the, the, you know, Tijuana, Mexico which is the area where, uh, where there's a lot of drug and sex tourism, um, and, um, and, and, um, and delicious food I've been to one of, by the way, has the best food scene. Like, and I'm not just talking like tacos, like I'm talking like all of the foods, like all of the foodie foods are there and it's phenomenal. Um, so, you know, go for the drug and sex tourism stay for the food.

Valerie (00:53:28):

That's going to be the catch line.

Laramie  (00:53:30):

They should fund my research

Carly  (00:53:32):

Undergrads, put that on a quote tile, please.

Laramie  (00:53:38):

Uh, but, but yeah, so, you know, like basically if you go and visit you, you step right into, um, where, where the HIV epidemic has hit Tijuana one of the hardest and, and, um, and, and, and, um, and, and folks like the way people are treated, right. Um, uh, like the, the, the difference in the access to resources and the, the, the pervasive nips of structural violence by, um, by the police and the legal system is just, it, it, it's, you're, you're stepping into another world. You're, you're literally walking over a line and step into another world. And, and, um, despite the fact of having a national health care system, right. Um, and having a safety net healthcare system, the hoops that people have to have to go through it in order to access it. And then, then the way that they're treated, you know, if they, if they do use drugs, um, it's, it's a better use of their time. People tell you it's better use of my time to go die in the street to be left, to die in that, that, you know, um, because there's just such high stigma, um, about where you wanted me to tell you about the car.

Valerie (00:54:55):

Yeah. No, you were curious, you know, as to why? Yeah. We just didn't know anything about it. So I'm curious as to why is it important to do research there and to figure out interventions to support people there? And I think that's like super. Yeah.

Laramie  (00:55:09):

Yeah. So one of the first projects they did coming in as a post-doc, um, with, with Stephanie was, you know, they've been doing all of the, you know, decades of like a primary prevention research with, with key populations, right. Um, with people who inject drugs, women engaged in sex work, and they're part of their primary partners. Um, um, and, uh, you know, um, men who have sex with men and transgender women, and, you know, the age of people, it's rates, you know, higher in these groups compared to the general population. And, um, and so I looked at all the data among those and, and, and, and was like, okay, well, what does the character-scape look like? What does the treatment landscape look like in these populations? Right. So it is the across these different studies done in these populations. And, you know, there's the medical limitations there, but it was a way to take us a snapshot of, of what it looks like. Um, and, you know, and less 4% were on treatment,

Valerie (00:56:14):

Less than 4%, one, two, three, four, Oh, they're just dip it. So to put them in a little bit context, so primary prevention is trying to prevent people from becoming infected with HIV. Secondary prevention is Laramie more so focuses on, or, you know, the cascade of care is, you know, once people are living with HIV, how can we keep them in care? Um, and we call it secondary prevention sometimes because as we learned with Ingrid cats, if you get people on their medication and they stay on their medication, their viral load is so low in their body that they can't like pass HIV on anyone else. And, uh, like our goals in the world established by like, you know, the UN is to get what, 90%, 95% of people living with HIV

Laramie  (00:57:09):

Cumulatively at 73%, if you do 90 times, 90 times 90, but,

Valerie (00:57:15):

Okay. So, but still to get 70% of people, um, like on their HIV, on HIV meds and stay, you know, staying on HIV meds. So that is wild. I mean, in Delaware, it's like in the eighties that, I mean, they do really well in Delaware and DE does amazing that's because in part, I mean, just, yeah, the team,

Carly  (00:57:39):

I want to work with Valerie for the rest of my life, except for, if anyone listening at the HIV care here, anyone working at Christiana Care wants me. That would be the only time I think I'd leave. They are just so amazing.

Valerie (00:57:50):

Oh, yeah. they're amazing.

Valerie (00:57:53):

4% is... That's like almost nobody that,

Laramie  (00:57:56):

Right. Right. So that, so what that means across all of those studies with key populations, anybody that, that, that tested, um, you know, uh, HIV positive, um, that, that, of those that knew their status, but of those had said they had talked to a doctor about their HIV. We're not even talking strict retention metrics. And then we're currently taking ART at some point in their course of the study, right? Like they're their last reports that they were taking 4%, 4%. And, you know, this is well that, that, that, and then that tells us something about when we calculate our care cascades basis off the hospital records and, you know, our denominators a little different. And then when we calculate it off people who are not entering the healthcare system at all, uh, the denominator is a little different. Um, and so that, you know, the analysis though really pointed to that, that there is free HIV care in Tijuana. There is the doctors are great, and the people will tell you that the, that they, they, they really liked their HIV doctors when they can get to it. It's 25 kilometers outside of the zone and forte, uh, where most people living with HIV live. Um, but I think staff figured out it's like a four hour bus ride on the transit system. Um, you know, people don't have cars and if they do, who's going to expend that, that money or social capital getting a ride out there. Um, and so they'd set up a, um, uh, basically a very primary kind of like satellite clinic, um, in, uh, needle exchange called Pravin Casa. Um, and so their primary function was to serve as a needle exchange needle, syringe exchange, um, in the zone and art day, um, and do HIV prevention work. And then they had like a really rudimentary, you know, um, basic primary healthcare clinic where physicians provided basic primary care STI screenings and then would connect, um, that originally were supposed to be through iPads, but usually ends up being over the phone with the HIV care, uh, providers, 25 kilometers outside to be like, Hey, we have your patient here.

Laramie  (01:00:01):

We've done the basic workup. We've done this. We'll try to get them in to get their labs because they still had to go all 25 kilometers in to get labs drawn so that they could have their meds prescribed. Um, so there's still some barriers there, but then they were also given permission to help, um, distribute meds for locally. Right. And so we worked with this, this, uh, this needle exchange to develop connection is psychedelics healthy connections.

Laramie  (01:00:29):

Yeah. Um, um, with, with, Elieen Pitpitan

Laramie  (01:00:33):

Um, who, who, uh, Valerie knows we all went to grad school together. Um, and so I leaned and I worked to develop this intervention together, where it was, um, basically putting peer navigators in the needle exchange. Um, and, um, and where they conducted peer empowerment sessions or one on one had one-on-one conversations to be like, what are your challenges? What are your priorities? How do we get that a little bit closer to coming in, coming here to see your doctor here at the needle exchange? How do we get that a little bit closer to taking your meds, getting you back on meds had a little bit closer once on meds too, and then more often during the week. Right. And so that ended up being things like pill boxing ended up being a really, but, but also, you know, knowing, knowing what the environment's like, and that people are often picked up by the police stuff stolen is thrown away, parked there in tenuous relationships with their partners, their stuff can get shot pills stolen. Um, so we were like, Ooh, just pill box. Got it out out 30 days of meds. And you know, you're out a couple of days and then we'll get you reconnected because that's, that's the other thing part of the medications are free, but, uh, there's no refills if you lose your meds or they get stolen or the police. Wow. So, yeah. So those kinds of things like those, you know, you have to think through how do you support be pain in this, uh, in the structural environment that is really not habitable, forced care. Um,

Valerie (01:02:21):

So peer navigators, again, may not be familiar. That's essentially linking someone who is living with HIV, um, with, you know, another person who's living with HIV, but may not be going in to see their Dr. May not be taking their medication. So these are the folks that you want to intervene to get them, um, on their meds. So, and then it sounds like what's really neat about this intervention is it's like it's responsive to and recognizes that the folks who aren't engaged with Cara, as we say, they're, they have like lots of different needs. And so it sounds like what's going on then is that the peer navigator is helping to like, figure out, well, what's going on here. And then like, here's like the toolbox of solutions that we have and what, what can we link you up with? Because, you know, Ingrid, katsu also studies, you know, adherent like linkage to care.

Valerie (01:03:15):

So you know, that first step of getting involved in care and then staying on your medication and, and keeping coming into your doctor, she said, and I really love this. She's like everybody, like, if you're not, if you're not engaged, you're struggling, but everyone's sorta like struggling in a different way. So we need to like figure out how people are struggling in different ways and then be responsive to that. Um, and so the peer leader is like super smart because, you know, these are people who have successfully done it and then can be a role model or a social support, or kind of, yeah.

Laramie  (01:03:50):

It's really important in this context is the just peers that they were't just peers living with HIV. They were peers with HIV who had lived experience, who injected drugs. If someone engaged in sex, someone who was a sexual, you know, a man who has sex with men, a gay man, like, so they understood, right. It is like to, to live at those intercepts, um, and to HIV and, um, and bolt have that connection. So, I mean, he, you know, there were, there were definitely participants that were like, I know you tell me if I take my meds, I got to keep taking, I'm not ready for that yet. Right. So I've learned that, and I know I'm not ready for that yet, but I keep coming back because I've made that social connection. And there's someone who gets me, that's really fast so that in and out, but, you know, while at the same time, maybe you can't even start your meds because you don't have an ID cause that got stolen and you need an ID in order to get back on your health, you get your health insurance reactivated so that you can get in to see your doctor so that you can get it to get your labs so that you can get in to get your HIV medications.

Laramie  (01:04:58):

Right? But if I have that social relationship with someone who understands me, who's cheering me on, who's not judging me. Right. And we're talking about like kind of paternalistic health, you know, healthcare system in general. Right. Um, like it made, it makes the difference. So, so while we may not have seen everybody in this population, get in the intervention and get on beds and get virally suppressed, we saw a movement in the context of, of all of those structural and social things that needed to be navigated of people staying connected and, and moving slowly towards that direction.

Valerie (01:05:42):

Now I want to talk about (Nick DNAs since you sell movement) and then being connected.

Laramie  (01:05:49):

Oh, I need a jump for that. Yeah.

Valerie (01:05:51):

Yeah. Um, so that's awesome. So the results of the intervention were, it sounds like they were pretty promising cause this was another like small pilot intervention. Yeah. So let's see if people like it, if it, if it suggests that it could work. So it sounds like there was some, some little signs that, that it's working.

Laramie  (01:06:12):

Yeah. Yeah. And, and what we saw, it definitely worked better for folks who had less substantial substance use. Right. But I'm also, when we look at the notes, like the empowerment session notes and reasons for people saying I'm not ready, um, for my medications, like I'll keep coming to see the doctor, but I'm not ready for, that was a sense of, deservingness tied to internalize drug use stigma. And that I, I don't, I don't deserve this because I'm that horrible person. I still do these things. And so that really spoke to a need that, um, that we need to, you know, while we may be able to get movement in some populations, other populations, we need to rethink where we're starting. Yeah. And how, again, back to how are we addressing drug use stigma? How are we addressing internalized stigma? How are we addressing anticipated stigma? Um, and, and I get all of the arguments about like, don't always put the onus and the focus on internal stigma, but at the same time, if that's where you are, like, you're gonna, you have meds right here where you can take them, but you don't feel deserving of that. Give that to someone else who deserves to live. Like, that's your comment? You know, like that's not our starting place. Meds is not our starting place.

Valerie (01:07:39):

I struggle with a lot of this, like, um, you know, we've, you know, we've looked at these data like internalized stigma, like that feeling of, I'm not, I'm a bad person because of, of this thing. And it could be, it could be my drug use. It could be my HIV. It could be because I'm gay like that, that internalized stigma is, is such a barrier to like so many health behaviors. And so I totally agree. Like, I really struggle with, with that idea, like, if we're going to intervene in stigma, the answer is really less interviewed in all of the stigma, but like, you know, I'm like people are on fire, we've got to put out the fire. Like, you know, this internalized stigma is preventing people from walking through the door and we do need to change our policies and to do so much, but like, we need to get people to feel good about themselves and like, they're worth it. Yeah. It's hard.

Laramie  (01:08:33):

So, um, so for those, those students who are listening, always collect qualitative data, and there you go, that would never come through in your checkbox. I mean, we collected the quantitative data too. Don't get me wrong. But I'm just saying like that, like the, the, the notes in those empowerment sessions really spoke to, Oh, this is what's holding the, holding it up. This is why we're not seeing this movement in this part, portion of the population,

Valerie (01:09:01):

Thinking of your advice, uh, graduate students and other people doing research. I mean, I don't, we've kept you so long chatting. We've got to let you go eventually, I suppose. But, um, you are so gifted with community engaged research, and it sounds like it goes back to your roots, you know, working in public health in that, um, you do a really good job. I think, like talking with your local community about what their research priorities are and how to reflect that in the work that you're doing. I mean, we have like, you know, we have standing meetings and you'll, you're, you'll come in to those, like, in, you're like all a flutter, because you had a great community meetings or like going to talk about data and it's boring. But I was wondering, like, why do you know if you could share some of your thoughts on, like, why is connecting with communities like doing community engagement when you're doing research important? And then do you have any like, tips for people on how to do it?

Laramie  (01:10:03):

Yeah. That's such a good question. Yeah. I think that this tie, what, this ties back a lot of ways to, you know, Chinaza's point, you got to understand people. So whether, you know, whether it's sitting in that, understanding the clinic environment, all of the players, and that really it's the charge nurse that runs things talks about the thing done. Right. If you want something systems, don't go to the MDs, you know, like, you know, it really, it it's about being, being willing to say, I don't know. Right? You don't know. I don't know how I put on an intervention clinic. Yeah. Oh gosh. I'm going to learn. I'm going to learn. I don't know how I can, you know, get someone who is, um, living with HIV and injecting multiple times a day, (take)HIV meds. I'm gonna, I'm gonna listen, I'm going to, I'm going to shut up and watch. I'm gonna listen. I'm going to learn. And I'm going to ask what priorities are, because if we can come in with all of our public health prior and all of our NIH priorities, and if the only ones those priorities met to nothing is fucking changing.

Carly  (01:11:35):

Yup

Laramie  (01:11:35):

Right? But if I can say NIH is about this, program, officer listens to it. I also care about exhibit a, um, but my community really cares about B and what they really need and what they really want is B how do I make A work B? Because then your target thing, that's meaningful and in to an individual. And if it doesn't have personal or value to them, why should I bother my time aside from taking your money to participate in your study? And that's cool too, because we all got it. We all got to eat. Right. But, uh, but like, you know, like what if it, if it doesn't connect meaningful to you, if it doesn't function in a way that your clinic functions or life functions, then all are really fun ideas that aren't really going to add any value to the communities value too. Yeah.

Valerie (01:12:41):

Laramie. We're so glad that you're out there.

Carly  (01:12:46):

Ah yes

Valerie (01:12:47):

We've got to let you go about your amazing research. I mean, we're four hours ahead of you on the East coast, right? So you've got several more hours of sciencing ahead of you today to do.

Laramie  (01:12:58):

Yes, I get to advise patients' science grants now. Okay.

Valerie (01:13:05):

Uh, Laramie, you're one of the absolute, most hardest working, most passionate and dedicated scientists like in the entire field of sex and drugs, science of HIV research. And, um, it's such a pleasure and, you know, to work with you and it's even better to have you as a friend, although I hope that not everyone calls you up, trying to force friend you, after this...

Carly  (01:13:28):

They will! they will

Laramie  (01:13:30):

I'm better friender than I am being forced friended. I'm just going to say that.

Carly  (01:13:36):

I know I will

Valerie (01:13:42):

You know,-you're really a private person. I think this is a good thing to mention. Like you're really a private person. And so to share and be so generous, but talking about some of your early life experiences, I bet like a lot of people know you and just, and don't know any of that. And so I would just want to thank you for, for sharing that with our listeners. And I'm just, I really hope that there's like a little baby Laramie Smith out there. Who's hearing it. And who realizes that, you know, because you did, she can too. So thank you for sharing that.

Carly  (01:14:17):

Thanks Laramie.

Laramie (01:14:17):

rock on. Yeah.

Valerie:

So, Carly, in this episode we talked a lot about Laramie’s origin story, her personal background.

Carly:

Some would argue not enough, but yes.

Valerie:

(laughs) Yeah, yeah, it’s never enough on the science origin story, that’s true. And we did that because part of out goal is to really share stories of scientists. So, who are they? Why do they study what they study? How did they become this PHD Rockstar? I do feel in this particularly episode we didn’t talk enough about Laramie’s science (laughs) the very big research she is doing. We are super grateful that she did open up to us because Laramie is a rather private person and you wouldn’t necessarily know that listening to this podcast, but she really is. 

Carly: 

Right? Yeah, and it I super appreciated her sharing that part of her life with us, but regretfully didn’t get to that giant RO1. I think we touched on it briefly, but not nearly enough.

Valerie: 

Yeah, so if folks listened to season 1, especially we talked about this type of grant when we were talking about Kim Nelson’s work. An RO1 is a research grant that’s sponsored by the National Institute of Health. Basically, they are big deal grants. They are very big grants. They are doing very big, important, science—they’re a lot of money. What we want to highlight for you is in this, to you know fact-check or debrief you is—what a big deal grant that Laramie is doing and lift up the amazing science she’s doing. Her big deal grant is to study how intersectional stigma, which we’ll come back to I promise, is related to HIV prevention among Latinx men who have sex with men. HIV prevention being wearing condoms when having sex, maybe getting HIV tests, or maybe taking pre-exposure prophylaxis which is that pill you can take to prevent HIV. And then men who have sex with men basically being gay men although we have this conversation with another guest which you’ll hear about next week where we talk a lot about language. 

Valerie: 

That’s basically what she’s studying. How do different forms of stigma relate to people engaging in these sort of-like HIV prevention behaviors. 

Valerie: 

One thing I want to highlight is that doing intersectional stigma research is really hard. 

Carly: 

I was going to say, can we go back to that…what is that? 

Valerie: 

Intersectional stigma research is basically studying stigma associated with multiple stigmatized characteristics or multiple stigmas all at the same time. I’m like using my hands over here like you can see me, which you can’t, I’m making a lot of circles (laughs). 

Carly: 

It’s all circular, I can assure you. 

Valerie: 

So think about it, studying stigma associated with just sexual orientation has all of its own challenges. You have to figure out what kind of stigma, when is the stigma happening, maybe from whom. What Laramie is doing in this study is that she is also adding in other forms of stigma that people might be experiencing. Maybe stigma not only associated with one’s ethnicity, being Latinx, but also sexual orientation, maybe immigration…maybe other things. Once you do that, once you say this isn’t a study just about one type of stigma it’s actually a study about all of these different types all together, it becomes really complicated in terms of well how do you think all of those things relate to each other? How do you measure it? Do I want to measure all of these things separately? Do I want to give you a measure about of how much stigma you experience associated or related to all of those separate identities? Or do I want to mash it all together somehow?  There’s just a lot of questions that you need to answer as a scientist to figure out how to do it and this is an area of research that is rapidly evolving. People are basically (now) figuring out how to do it. Laramie is really one of the pioneers in the HIV stigma research space who’s thinking creatively about solutions for how to do it essentially. 

Carly:

That…is so…cool 

Valerie: 

Yeah, it’s really hard 

Carly: 

Yeah, that sounds really hard but it also sounds absolutely fascinating to, to look at all of those different factors, just the fact that the NIH was like ‘hey good thinking, here’s all of this money, yeah go for it.’ I can’t wait to see what that ends up being, what that looks like. 

Valerie:

So that’s one layer of complication, and then there’s another layer of complication in the study which is that she is taking a “social network approach” which essentially means she’s taking a much deeper dive on to how relationships are shaping experiences of stigma then we normally do in our stigma research. A normal stigma scale will ask someone “how much have people discriminated against you in general in the last month” and the person might say “not a lot” or “a little bit.” Laramie’s study, in what we call a social network approach, asks “how did all the people in your life treat you in the last month?” So, they would say, “how did your neighbor treat you, how did your best friend treat you, how did your mom treat you, how did your boss treat you, how did your coworker treat you?” To me that feels really important as a stigma researcher because I can imagine that people are going to care a lot more, maybe be heard a lot more if their mom or best friend discriminates against them versus their neighbor who they don’t really like anyways. 

Carly: 

Yeah, their coworkers (laughs) 

Valerie:

(laughs) Their pod—

Carly:

Their (podcast) co-host 

Valerie: 

Their co-host, or whatever this thing is that we’re doing. 

Valerie:

Anyways, in taking all of this additional relationship data she is getting a much more nuanced take on how stigma works. This is like a complication cake of science. It’s essentially a dual layered looking at intersectionality, which again is experiencing stigma associated with a lot of different things, and then also taking the social network approach, which again is really doing a deep dive on how relationships shape stigma in a much more nuanced way then we usually do. It’s a really important project, it’s really at the cutting-edge of stigma research and in addition to her potential as an excellent barrel rider (laughs) 

Carly: 

(laughs) Right? The plot twist is that Laramie ended up being a really bad-ass cowgirl anyway and pioneering the world of science you know? Metaphorically speaking, but she still nailed it. Her childhood dreams.

Valerie: 

Yeah, we’re really grateful she took that science route. 

Valerie:
 Thanks to the Stigma and Health Inequities Lab at the University of Delaware for their help with the podcast, including Saray Lopez and Mollie Marine. Also, thanks to Kristina Holsapple for her editing skills, 
  
  Carly:
  Thanks to city girl for the music, and as always be sure to check us out on Instagram @Sexdrugsscience, and be sure to stay up to date with new episodes by clicking subscribe 

 Valerie:
 And thanks to all of you for listening.