>> From the Library of Congress in Washington DC.
[ Silence ]
>> I would like to welcome Lucy Suddreth,
our Chief of Support Operations for the Library of Congress
and she will be introducing our distinguished speaker.
So, without further ado.   >> Good morning.

Glad to see those of you who have joined us so far and welcome
as well to today's health forum.
I'd like to actually start by thanking though Dr. Charles
and Paul Martin and really the entire health services staff
for their continued support and making sure that we are aware
about important health issues and say not only relate to us
but to the greater community.
Today's forum is especially an important informational session
as the incidence of HIV/AIDS within the District of Columbia area is
at three times the national average.
Early diagnosis of HIV has a good prognosis given the current advanced
and treatment protocols and that's why awareness is so very critical.
We're especially pleased to have with us today a renowned position
in her own right, Dr. Mandefro, an Ethiopian-American physician,
medical anthropologist and public health researcher.
She currently serves in the faculty
at George Washington University School
of Public Health and Health Services.
Dr. Mandefro has worked with HIV-infected
and affected communities domestically
and internationally for more than a decade.
She doesn't look that old, does she?
During her internal medicine residency
at the Montefiore Hospital, she founded the nonprofit TruthAIDS,
focused on improving behavioral health literacy among
vulnerable populations.
This work is featured in a full length documentary film on HIV/AIDS
and Aftrican-American women entitled "All of Us" which premiered
on Showtime Networks in 2008 for World AIDS Day
and was recently featured at the Library by Health Services.
Her interest in improving public health
through media was also the focus of her work
as a Robert Wood Johnson Health and Society Scholar
at the University of Pennsylvania.
Dr. Mandefro was recently a White House Fellow
in the Obama administration, or I should say
with the Obama administration
where she co-authored the first Joint Veterans Affairs
and Department of Defense Mental Health Summit report
and recommendations confronting America's 21st century responses
to the psychological needs of returning service members
and veterans and that too is touching all of us.
She currently serves as an adviser in the Strategy Group in the Office
of the Secretary of Veterans Affairs with a focus
on behavioral health policy and health disparities
and she is their representative
to the federal interagency health equity team.
Dr. Mandefro also continues her international work as a member
of the board of directors
for the reproductive health organization in gender health.
She received both her undergraduate and medical degrees
from Harvard University and a Master of Science in the Public Health
of Developing Countries from the London School of Hygiene
and Tropical Medicine as a Fulbright Scholar.
Here at the Library, we set a high mark for acquiring, preserving
and providing access to knowledge and we're pleased
to have this position with us here today to share here knowledge.
Please join me in welcoming to the Library of Congress Dr. Mandefro.
[ Applause ]
>> Wow, that was quite an introduction.
Thank you for that and thank you for all of you.
It's a treat and it's a real honor and pleasure to come speak here.
I've been in communication with your staff and Jean [phonetic]
in particular for over a year now I think, going back
and forth, so I'm very excited.
I also have to point out my father is in the back row
and he never gets a chance to actually see me speak.
[Applause] So that's my dad in the corner.
I actually grew up in this area, so for me,
coming back to DC was a totally unexpected thing
and a very good thing, this is home for me, so it means even more.
Today, I'm gonna be talking to you about awareness but first I'd
like to talk to you about disparities because that's
where the bulk of my research is and I think to understand awareness
and to talk about it, we have to understand the epidemic kind
of from the top view level so that's where I'll be starting.
Is there a problem with my mic?   Can you guys hear me?

>> We can hear you.   >> Okay. I just wanna make sure.

[ Inaudible Remark ]   [ Laughter ]

>> Thank you.
So, I'm gonna start the presentation by just thinking
through what the epidemiology of the epidemic actually looks
like in the black community which is where I've done most of my work.
I've also worked in Kenya, South Africa and Ethiopia.
And I'll touch a little bit on global disparities but I kind
of wanna focus top level on what those numbers are
because I think it very much sets the frame
for what limits of awareness are.
I'll be using CDC data slide, so all of this is on the CDC website.
I'm also using a couple of slides from Dr. Valerie Stone
at the Harvard Medical School
who very kindly shared some of her slides with me.
I'll talk a little bit about women of color and youth
because lately I've been thinking a lot about the issues of youth.
It's kind of a different piece for different reasons.
I actually for a short time was an adolescent medicine physician
at Children's Hospital Philadelphia and got a first hand look
at what those issues were and wanted to mention that.
And towards the end I'll talk about kind of treatment disparities
but really asking some questions
about what the future of all of us means.
So, without further ado, this is a history of the epidemic.
This is AIDS diagnosis from 1985 to 2008 and the two things to kind
of walk away from this slide if you'll notice is
that we expanded the case definitions for HIV at about 1993
and that led to the expansion of AIDS cases.
And then in 1996, that's when we started to have medicine.
So you'll notice this decrease right here is right around '96
when we got the antiretroviral therapies
and that slowed the progress of HIV infection moving into AIDS.
And so that's why you see the dip in the curve.

Now, AIDS diagnosis amongst adolescents and adults by race,
you'll note the changing distribution
since the beginning of the epidemic.   I don't know how to use this yet.

Okay. So this yellow line used to be very much a white epidemic
in the beginning and then with time it has risen.
So this changing of distribution,
these colors will stay relatively consistent through the slides
with the pink or purple representing African-Americans.
Then from about 2005 to 2008,
AIDS or HIV infection actually became the largest,
the largest percentage of that diagnosis
about half the population was in African-Americans,
so we've been here with this epidemic since at least 2005.
In terms of even what the epidemic looks like in the district,
it's mostly an African-American--
disproportionately African-Americans with HIV diagnoses.
Now, when you subdivide this data a little differently,
you'll see actually that this disproportionality holds
across subgroups.
So when you're looking across all cases of women,
you'll notice 64 percent of women that HIV infection from 2005
to 2008 were actually also African-American,
66 of those infections when you look at it by heterosexual contact.
And then one of the most disturbing to me when you look at of the kids,
it's 13-- 13 and under 66 percent of those kids are black.
Okay, so this is kind of the milieu that led to "All
of Us" for me as a researcher.
Just by show of hands, how many of you have seen the film?
Just so I know.   Okay, so it's about half and a half.

Thank you.   Great. Thanks.

So when I made that film, I was a first year resident
in the South Bronx and I had just come back
from South Africa and Ethiopia.
I had completed my master's work and I was trying to get my head
around what the epidemic looked like in the inner city.
My clinic was very much situated--
it was actually the poorest urban congressional district in New York
and the clinic was called the Comprehensive Health Care Clinic
in the South Bronx.   It's a-- Montefiore is a hospital

of Albert Einstein's College of Medicine.
And so these numbers were very much my reality,
kind of thinking through the epidemic.
Now, this pie chart here illustrates the distribution a
little differently.
The one on the left is the distribution of diagnosis by race
and ethnicity and then the one on the right is the total population.
Actually in the film I do an exercise like this with the girls
and one thing I'd like you to note is the pink actually
or purple here is the black population so, you know,
makes up 14 percent just in 37 states
if you take it as a total population.
But when you look at the burden of infection, 52--
sorry about that, 52 percent of the infection.
>> Now, when you slice the data up differently and you just look at men
and women, it continues to be disproportionate.
So on your right, 13 percent compared to 46 percent.
And the other color is just to-- the yellow color is the white population
and the green color is the Latino population.
And then when you get to women, this number in particular was kind
of what sparked my research.
You know, black women make up 14 percent of the population
of these 37 states but actually 67 percent of the disease burden.
And when you have such a disparity, it has to make you pause, right?
I mean, you have to pause at the very least
and start thinking, what is it?
What leads to such disproportionalities?
Especially in a country that's so powerful,
so fully resourced, you know.
And you know, in my idealistic kind of eyes at that time, this is now--
God, it's been 6 years since I started that film project,
maybe almost 7 years, you know.   There are doctors there.

You know, there are clinics available.
What is going on?   How do these numbers persist?

And you know, it's 7 years later, I can't tell you the answers are
that much clearer to me but I do know that part of what we have
to do is look at it a little differently and try
to unlearn some things we've learned.
That's that.
I'd like to also talk to you about rates of infection.
So up until this point I've been showing you kind
of individual numbers, individual diagnoses, but in public health,
in epidemiology, we also talk about race, right?
Which gives you kind of the idea of how fast the epidemic is growing.
It's also referred to as incidence and it's basically looking at,
you know, the number of people who developed a disease over a period
of time divided by the population numbers, okay?
So these are rates and when you start looking at the rates,
this gives you an idea of how fast it's growing.
For African-- this is for men, it's 131 compared to a baseline
in the white population of 16 and that's about 8 times higher
than for whites and 2.5 times higher than for Latinos.
Now when you look at the same--
now mind you, these numbers are from 2008 and once again, it's 37 states
from the CDC surveillance database.
Once you look at women, we have a rate of 56 compared to 2.9
and that's about 19 times higher.
So this disease is 19 times more efficient spreading in the lives
of black women, and that was really the backdrop to "All of Us" for me,
especially as a primary care physician in a clinic
that was giving, you know, free ARV medication.
The whole kind of ethos behind my primary care residency,
and so jewel of a program was really community-based efforts.
So, these statistics kind of flew in the face of all of that
and I was trying to very much make sense of them.
So, when you look at this distribution,
they actually don't have the District of Columbia up here,
annoyingly, but you'll realize that there are hot pockets of infection
in the epidemic even as of today.   And why this is important is more--

the epidemic today is a question of density.
It's kind of like where you live.
If you live in a pocket, your behaviors,
it doesn't matter how high risk they are, you're kind of in trouble.
And trying to message around that is actually a very difficulty thing.
So there's a demographical distribution
to the epidemic that's also a challenge
for communication in my personal opinion.
So that said, let's transition a little to the epidemiology of HIV
and women's lives because that's where I focused.
You know, the film was shot in New York City and when you look
at these same numbers, what you realize is there are actual
geographic variations.
Geographic variations is something, it's like a buzz word in healthcare.
We talk about that a lot but there's also kind of geographic variations
of wellness and in these pockets of infections
and what you'll notice is HIV's been particularly bad
in the northeast followed by the south.
The south's epidemic is actually catching up very quickly,
but what you'll note is there's actually less--
well, this Montefiore, you know that northeast epidemic,
New York State has had a bad situation,
especially for the black population for a very, very long time,
which is probably why that film was shot there.
This is probably the most important data slide in a way, compared--
for the film "All of Us"
because what this slide shows you is it color codes the transmission
categories for HIV, so this is particularly important
because when it comes to our federal dollars and spending
on prevention programs, we actually tend to do it
by transmission categories.
So, if you look at the color codes, you have injection drug use
and then you have heterosexual contact,
and then you have other for women.
Okay? Now, I'm not sure what other means but when you look at blacks
and you look at Latinos and you look at whites,
there's a disproportionate rate of heterosexual contacts.
So in women's lives, that's kind of what it represents, right?
And that's why I delved into those issues
of interpersonal relationships with the film, and why I think thinking
through relationships and messaging around relationships is a very,
very important awareness message.
We haven't gotten that part quite right yet, and I think it's
because we don't have enough messengers telling it
in different ways and we'll kind of delve into that.
But, you know, this struck a chord.
And it struck a chord in me also because anthropol--
anthropologically, if you think about it, then well 75, 84,
and 87 percent isn't that different across the races.
But when you start looking at who dies from HIV,
it's not quite that equal.
So that was the other piece of what I wanted to talk to you about.
Now, when you start splitting up the data by age,
it actually gets even more extreme.
So if you look at risk, heterosexual contact,
you'll notice in the older age group, it's about 79.
You get younger and younger.
In the young group, it's 90.5 percent of cases come
from heterosexual contact, young girls having sex
between those ages oftentimes with men who are older than them.
And that from the jump sets up a very difficult power dynamic
and it's something that I thought we didn't talk enough about.
It's partly why at the end of that film I started going into schools
and I still speak in schools and try and get people
to think, think about this issue.   So what does these all mean?

Relationships matter, they matter a lot, you know,
and it seems like such a simple, simple thing to say but sometimes
when a risk factor is so around you, what happens is you don't see it
and I genuinely think that's kind of what we've done
with HIV perceptions and risk.
It's something that we kind of all take for granted.
Interestingly enough, in the developing world literature,
actually in the global health literature,
there were test statistics that showed this that in some countries
for example, marriage was a risk factor, what do you even do
with a statement like that, right?
I mean seriously, so do you stop getting married?
You know, that's not the solution but it makes you really grapple
with the things that we usually don't talk about
or the assumptions we make, you know.
In some cultures you can't say no to your husband
or in some cultures there's a disproportionate amount of violence.
I'm actually working on a film right now, an amazing story about a woman
in Ethiopia who got married too young
and was abducted into marriage.   There are situations in the world

where vulnerable populations don't have as much choices.
And so thinking through the context of relationships
and the social conditions
that actually produce risk is a great deal of what I do right now.
I think the other important thing to think
about is people always are making decisions.
You know, humans are social.
We make these important decisions actually about our relationships,
our wellbeing within the context of these--
these interpersonal relationships.
And then it also begs a very disturbing question
which I kinda hinted at which is, okay, risk is the same across all,
why are some people dying more.
And, you know, that question is kind of the unanswered question
in "All of Us", in "All of Us".
You know, you can't put everything in a film but it's certainly the one
that broke my heart the most because as you know
in the film I lose one of my patients.
And you know, we build this grand case.
It's about all of us but the truth is not all of us die.
And delving into what leads to that disproportion,
excess risk of death is something I've kind of devoted the next stage
of my career too and think about.
By the way, this is not supposed to be relatively informal,
so if I say anything or you have questions,
please feel free to stop me.
I actually prefer interactive presentations as opposed to one
on one, me talking at you.
So, that said, I wanna talk a little bit about losing Tara Stanley
because that was the turning point for me as a physician,
as a researcher and it's also I think the facts
that gets misrepresented most often
which is the HIV/AIDS mortality difference.
So I wanted to review a couple of slides with you about that.
So this is the mortality rates by race and ethnicity for women
and you'll notice the rate once again for black women is 25.7
as compared to a baseline of 1.2.   This is 20-- 21 times as high.

This is even more disproportionate than the slides I showed you
about diagnosis and infection, okay?
So what this tells you that even in this day and age,
now this slide is dated as of 2007, but even in this day and age,
when we have antiretroviral therapies, we have these clinics,
there are portions of the population that are dying
at extremely high rates that are just into-- not tolerable.
>> And thinking through why is, you know,
if I had more time we could also delve into treatment disparities
because I think part of it is not everyone has the same kind
of access.
You know, we legislate HIV medications on a state basis.
I don't know if you guys have heard of ADAPs,
AIDS Drug Assistance Programs, but a lot of states now have waiting lists
for those kinds of things.
And one of the things we know is if you have ADAP and access
to medication, it actually ensures that you get on treatment.
Valerie Stone has actually done great research
on treatment disparities but I think that's part of the story.
So, HIV Aids has higher mortality rates in minorities as a whole and--
even in 2006, the death rate in African Americans is
at least 10 times higher.
So, these next two slides just show you this is again rate--
deaths of person for all total.
So, when you look at this, men and women combined,
the rate is 31.3 percent as compared to 3.2 percent.
And when you look at these trends in age adjusted annual rates of death,
this is kind of like the big, the big picture.
You see this-- the same kind of line, the blue line.
This one, I'm just realizing, I think my slides got changed.
I'm like, oh, I'll go with it.   [Laughter] My slides got changed.

This is the difference by men and women.
This just shows you the disproportionality
and once again based on race, on death rates.
And this is the slide actually I was looking at.
What's interesting about this-- thinking through differences
and mortality rates is actually the regional variations
because what you'll notice, have you ever heard this tag line lately
that's been, you know, health is where we live, learn, and play?
I mean they say this a lot now to talk about social determinants,
but this idea that your zip code actually determines more
about your-- more about your health and anything else, okay?
And to me, that's been one of the biggest struggles
when it comes to awareness.
Communicating that is a very hard thing to do if you think about it.
When you're doing individual risk counseling,
how do you talk about that?
You know, move out of your neighborhood?
You know, and so I think that's actually the challenge of some
of this data but what this data shows you if you look at the north,
east, south and west, these are the death rate--
the death rates are the blue lines and there's actually--
it matters more for black populations where they live,
it depends more actually on-- on the mortality rate difference.
There's less variation.
So if you look at these bars in the other-- in the other regions,
for other race groups, there actually is not as much difference.
You see how different it is between the northeast and the south
for this blue line and from the south and the west?
So it matters even more.
And we actually know that from literature just even
in the international context that the more vulnerable you are,
the more these social factors actually end
up amplifying your risk and producing risk.
And the same is true in-- in the states, in the United States.
So this gives you just overall, you know, HIV.
When you look at the numbers from 87 to 2006, it's been a leading cause
of death actually, in the top 10 for all populations
when you look at the age by 25 to 44.
So, we have unintentional injury as the number one, cancer number two,
heart disease, suicide number four.
I wanna pause there because I think the other hugely underdressed,
and this is the other thing that hit me over the head in the film
that I didn't really get to delve--
delve into is the issue of mental health.
I mean I think mental health, I mean it's a large,
to a large degree what brought me the government and it's--
it's definitely why I ended up at the VA because I wanted to work
on this issue and think about this issue,
but it's a hugely underdressed epidemic.
And I actually think, for the future of HIV prevention,
one of the most important things we have
to do is integrate mental health efforts.
Because we already know when you start to delve
into treatment disparities, for example who takes the ARVs or not,
what some of the studies has shown is if someone has depression,
we know for a fact they won't or they take it less.
So I think we have a couple of like co-occurring epidemics going on
and it's very hard to tease some of the stuff
out when you think about it.
Violence, drug addiction, mental disorders and HIV are all jumbled
up certainly in the places where I practice,
which is the South Bronx and Philly.
And then the other thing, we still have a long way
to go with this homophobia.   I think that's the other issue.

In the adolescent clinic that I was--
I was working in in Philadelphia it was mostly, you know,
young men who have sex with men and black.
It was a different population from what I was taking care
of in the Bronx which was mostly women and I was just--
you know, they broke my heart.
So many people had been kicked out their homes for coming out.
And you know once you're on the streets,
it's an entirely different ballgame when it comes to risk,
much harder to protect yourself for a lot of-- a lot of reasons, not--
least of [inaudible] material, you know?
And we'll talk about kind of the resources and the, you know,
basic needs that people need to take care of first before they can sit
down and think about health.
Because although I've devoted my life to health and although all
of you guys I'm sure have an interest in health,
what I have learned working with the regular folks is they're not
thinking about it often, you know?
So, one of the things that makes prevention
such a challenge is you have to sit there and try
and increase people's thresholds, like try to make them see things
that are not quite a problem yet.
That's difficult with any behavior let alone,
I'm someone who's negotiating adolescents or someone
who doesn't know, you know, where-- where their next meal is coming from
or if they have, you know, a shelter over their heads that night.
So, I think we have to be a lot more realistic when it comes
to our awareness efforts and I-- lately I've been talking about,
you know, prevention is kind of about a tactile thing almost in--
and capturing people's imaginations which is why I think all of us
to a certain degree hit, right?
I mean it was just really trying to--
to get people to understand this is a lot more
than the didactic information we give you at the-- at the clinic.
You know, this is about your life and how you choose
to live it and what terms.
The environment sometimes deals-- deals you.
So, that said, this statistic, when I started residency,
this statistic bothered me.
I was like this is my age group, what is going on.
Does not, you know, like what--
and actually, the thing that disturbed me even more was I went
to Montefiore, which is like this bastion for social justice
and health if anyone knows about it.
It's had the oldest department of social medicine and there were all
of these HIV researchers and I went to the top and I was like,
"Do you know the statistic?"   And she didn't.

And that-- that's when I paused.   I said, "Okay, what's going on?

You know, what's going on?"
Now, when there are disparities like these and there are millions
of dollars were pumping into a system, millions of research grants
at what you're doing and we're still not going anywhere.
You have to take a step back and say, "Okay, what are the obstacles?"
Something is creating a blind spot.
I don't know what it is but something has to be, otherwise,
how can for, you know, HIV is turning 30 in June--
June 5th of 19-- 1981, June 5th, the first case that diagnosed an MMWR.
So we are crossing a threshold, but what do we have
to show for it, you know?
And really grappling with this issue,
how can it be the number one cause of death in this group?
That's more than anything what led to the film "All of Us"
and I at that point had done a master's
in medical anthropology and--
and I had looked at the same issue in Ethiopian women.
I actually worked with the International Center for Research
on Women and wonderful Ethiopian researchers
at an institute called Miz-Hasab Research Center in '97
and I did that on a Fulbright.
And when I was in London doing this work, I was basically looking
at HIV positive women's diaries, okay?
So my work was they had gone to Ethiopia and collected all
of these data with HIV positive people's experiences.
The data had been coded and transcript and you know,
coded and I was dealing with like the text, what does it mean.
And so I wrote this-- I had-- wrote this dissertation's thesis on--
on this experience of being HIV positive in Ethiopia
and at the time I met a filmmaker named Emily Abt
who was in London with me.
And you know, she approached me, she was like, "Look,
you're work lends itself so well to film,
you should really consider it."
Because I was looking at stories all day, never really thought about it.
But when I got back to the-- to the Bronx, so I keep-- decided to--
at that point I came back, I finished medical school
and I told dad, "Okay, I'm going to residency."
He had a slight heart attack 'cause he thought I wasn't but I--
I did end up going to residency.
She had returned to New York herself and had her--
was starting her own film company,
and so that's how this partnership happened.
And the reason why I stopped to--
to pause and tell that story is because I think awareness
in HIV is gonna take a lot of unlikely partnerships actually.
And it's kind of one of the things as professionals
that we are not trained to do so much.
We do not know how to talk across disciplines very well.
And when you start to kind of unpack why these numbers are, what they are
or you go back to what I mentioned about abstraction analysis,
what are creating blind spots, you realize there's actually a lot
of silos that we all live in.   I don't care what you do.

We tend to think of it.
And the more training you get, the more siloed you will all get
and you start to develop these blind spots.
So, I truly think one of the things we need to do is a lot
of this interdisciplinary work.
So, you know, at this point I had come back from Ethiopia
but what I didn't realize at the time was that experience had quite--
had given me very powerful vocabulary and a framework
to start thinking through context, okay?
>> So I wanted to pause here and at least mention
to you the global disparities because when you look
at the numbers, it's kind of humbling.
You know, up until this point, we've been talking about this.
Okay, this is data from the UNAIDS Program.
Now, all the slides and CDC data I've been talking about has been
on less than 1 million people.
When you take the epidemic and you start looking at it by country,
this is Sub-Saharan Africa, okay?
This is the line for 2002, 12.5 million people and at that point--
a number of women, sorry, 12.5 million women and 13.5 by 2004.
So, I went from this-- I went from this experience
with my master's work to thinking about it
but let me tell you the determinants are actually not dissimilar.
The determinants are actually very-- very same.
It's similar.   It's just a question of magnitude.

What HIV did on the African continent was just unmask the fact
that there wasn't a public health infrastructure at all, you know?
That there wasn't care, and when you look at the same kind of issues
in urban centers, people are still not plugged into care, you know?
It's just a question of magnitude.
So in-- you know, in a kind of ironic way thinking
about that extreme setting,
I personally think actually help me see what was going on better
in the South Bronx and at least made me aware in a different way.
So, if these determinants are what it's about
and I fundamentally think what HIV teaches you more
than anything is it tries to tell you this so--
this story about social determinants.
Lately, we talk about this a lot.
You know, the Robert Wood Johnson Foundation has done a lot
of great work around developing language for social determinants,
so this idea of where we live, learn and play.
Thinking through, okay, how do you communicate about this,
but I think the other story tells you is the story
of access to care, right?   The story of access to care,

and this is certainly in the global epidemics.
Post 2000 and on, the whole movement have tried to get treatment
to Africa and struggling with-- with that was all about that story.
This is a very difficult subject though I think to communicate
about one-on-one when you're talking about risk counseling so, you know,
contextual-- although contextual influences determine health outcome,
I don't think we've been quite as savvy about figuring out how
to integrate that in our prevention messaging.
So this is-- this slide is one attempt
and it really-- it captures our problem.
How do you communicate about this web?
I mean seriously, look at it, right?   [Laughter] This is-- this is a slide

from of my favorite nonprofits called Advocates for Youth.
They produce great, great stuff and this is their slide
on understanding disparities and HIV epidemic, has such social
and cultural forces lead to unequal risk
for African-Americans and blacks.
And for those of you can't read, so what this bucket say,
and we can really talk about each one of these
for an entire presentation on their own, right?
So mistrust of the healthcare system,
delayed diagnosis and/or treatment.
I personally think this is very huge actually.
People still-- we know from the WIHS study,
which is the Women's Interagency HIV Study,
it is our largest natural kind of history study
of HIV infection in America.   It's based on six different sites.

We know from WIHS that about 28 percent of women who meet criteria
for treatment do not get in, okay?   Treatment disparities are huge,

so delayed diagnosis is the other issue.
A great deal of people still don't get tested.
In fact, I mean, over half of the infections, I believe it was
in 2007, were spread by people who were HIV positive
who just didn't know it, you know?   So testing is still a huge issue.

The CDC changed their recommendations a few years ago
to make it a mandatory thing so we could mainstream it.
So you go to your primary care doctor, you get tested,
you know, everybody once a year.
The other buckets, unemployment and underemployment, right?
People need material resources.
People need economic security before they can start thinking
about health.
This is not a complicated science, right?
The other-- the other boxes are increased risk of HIV and STIs.
One of the relationships we know is
if you already have one sexually transmitted infection,
it makes it easier to transmit HIV because you have--
for women, you have vaginal shedding, sloughing.
But-- so if you have undiagnosed STIs,
that's another kind of baseline reason.
If you're not accessed into care, if you're not plugged into care,
more likely to have that.
Unprotected sex, obviously huge, huge issue.
I mean condoms, condoms, condoms.
But my problem with talking about unprotected sex, if we're gonna talk
about unprotected sex, we have to talk about domestic violence
in the same sentence and we do not make that distinction enough.
On this slide I think violence is one of these circles, if not,
that's probably the one that I would put up the highest.
And why I say that is one of the things that blew me away
in my research in the South Bronx,
and I'm writing a book all-- about all of these.
I just needed time to think about it,
is the alarming statistics around sexual assault.
And at that point in my life, I had done a lot of public health work.
I don't think it ever came up in my curriculum, ever.
And I-- you know, I went to great institutions.
The number's in the United States just so you're familiar with them.
So this is why sometimes when people just leave this entire discussion
about condoms and unprotected sex, I really--
I think it's irresponsible actually because to the truth
of the matter is, on a population level in America,
if you take the definition of child sexual abuse which is penetration
to molestation, it is one in three girls
that have had this experience by the age of 18.
One in three, that is a huge population risk factor.
And this number is not just black women.
This number is across all races for women.
It's also a number that holds substantially well when you look
at the population variations between countries.
So talking about unprotected sex without also saying actually
for some women, it's just not a choice.
They're forced, you know, they're beat into it, they're raped.
That's a very common reality.
The other statistic to keep in mind is sexual assault.
In the context of interpersonal relationships,
it's one in four, okay?   That's also alarmingly high.

So one in three and one in four, that's the reality of what a lot
of these women are dealing with.
And if you notice, for those of you watched the film, I--
that was Tara's story, right?   I mean that's what killed me.

I just never thought about it, you know?
And in my own, thank God, naivety, but I haven't had that experience
and it's very hard to imagine if you haven't had that experience,
what that experience can mean.   It's actually been studied.

One of the researchers-- you know, when I made this film,
I had a lot of, you know, I decided who I got to interview and one
of the researchers was Gail Wyatt, who's a renowned researcher
on domestic violence issues.
And it's kind of why I wanted to talk to Gail in particular was
to help me understand what is it about risk.
And in the film, she articulates it quite beautifully.
She's like, "We know what happens to women once they get raped."
They tend to look like promiscuous women or they tend
to realize what Tara said was, "I couldn't say no to my father,
so how can I say no to other people."
These are really heavy issues to try and unpack in any kind of way.
And what we do in Medicine often or what we do in research is we kind
of leave it out of the sample or don't talk about it.
And I think those are the different ways that we start to create silos
and blind spots to the reality
of what the epidemic is in these communities.
As difficult as it is to confront those realities,
we need to at least talk about them
because the good news is I actually think there are some things we
can do.
There's-- there are things to be done for traumatized patients,
but you need to recognize the traumas operating.
So, sorry to go on a soapbox on that issue but it's--
I just think it's so important, it's so often ignored.
Then the other boxes, drug and alcohol abuse,
unstable neighborhoods, poverty, races and historical
and modern inequities, concurrent partnerships,
one of my favorite terms in the literature.
Concurrent partnerships, people who are sleeping
with multiple people at the same time.
[Laughter] That's what that means and we do that a lot.
Okay? And it-- it's reality, okay?   It's a reality.

And the irony, there's actually a wonderful book written
by Dr. Epstein [phonetic] called, oh gosh, of course I'm blanking.
This book came out a couple of years ago.
Oh, Why the West is Losing the Fight against HIV or something
like that on the continent.
And she illustrates these beautiful studies on concurrent partnerships,
especially in developing countries.
And anyone wanna wage your guess, why would it matter more there?
Because one of the things that has always--
the literature has always shown is that, you know,
even though HIV/AIDS is more prevalent in Africa,
it's not because Africans are having more sex than everyone.
I mean that we know that's actually not the case.
There're a lot of other issues around access under diagnosis
of STIs but importantly, also these casual relationships
where people are having transactional sex for money,
you know, for security for their kids.
>> One thing we know, women will do whatever they need
to to make sure their kids are fed.
You know, those kind of realities are actually very common
when you look at it on a population level across--
across-- across countries.
So, back to the original question you guys pose me, where are we now
and what are the limits to awareness.
How do you communicate about this in any kind of efficient way?
You know, how do you say, okay,
we're gonna allocate these many dollars to this web.
An anthropologist in the '80s,
Merrill Singer developed the term called a syndemic saying actually
HIV has all of these synergies.
It's not an epidemic, it's a syndemic and in his, you know,
his analysis with substance abuse, violence in particular
and HIV were almost impossible to separate out.
So, it's a challenge to our funding system.
Like if you think about how we allocate our--
our dollars, how do you-- how do you allocate risk like these?
And that's the challenge.
How do you even communicate about it?
You know, even in the film,
when you're telling these individuals narratives of triumph,
it has a tendency to slip into the individual responsibility trap too,
too often sometimes.
I mean sure there's a certain amount of responsibility that people need
to have in terms of controlling what they can, but what happens
when you literally have no control.
What happens when you're in a situation like Tara was?
You know, where you're in an abusive relationship with no door out.
And I think being modest about those limits for all
of us is one of the take home points.
We can't put it all on condoms.   We do that way too often.

Condoms are a very important part but it's a piece and we need
to remember that it's a piece.
I think microbicides are huge, and thank God for the trials that came
out of Venice that were done in South Africa.
For those of you who aren't familiar with microbicides, what it is,
is a chemical combination.
Usually a gel that women can insert in their vagina as a cream
to protect them from HIV.
So then the condom discussion is no longer even in the room.
To me, that would be the sure shot way,
female controlled prevention technology.
We needed it yesterday, you know.
And there has been far too longer the delay.
The-- that's also part of the story.
So, a few thoughts on HIVs and I'm talking too much.
Do you have any questions?   Any questions at all?

Yeah.
>> I would just like the say in the early--
even late '80s, advertisement was a key,
especially with CDC [inaudible] educating
and I think that did help--   >> You're right.

>> -- the community at that time.
And that may be why it went down because of the education.
But somehow, it didn't reach our community.
>> I agree with you.
I think and I'm glad you mentioned that.
You-- you set me up lovely for what I'm about to say about the youth.
There are competitive messages in society that compete
with what I'm trying to tell my patients in-- in the office.
And that we are being outcompeted bar none.
I mean to me this is kind of the issue.
People do not realize that, you know, they leave my office
and then they go back out into that world.
They go back out into the South Bronx and they deal
with abusive boyfriends and they deal with, you know,
misogynistic images, they deal with all kinds of crazy situations.
How do you compete with that?
You know, and I used to always say, you know, the environment is,
you know, really kicking our butts right now to tell you the truth.
That's why one of the things at least,
the Black AIDS Institute is actually doing I think some
of the most cutting edge work around this issue in particular.
They actually have a campaign right now called greater than--
we are greater than aids-- greaterthan.org.
You should go to it.
You should check it out, greaterthan.org.
It was a partnership with the Kaiser Family Fund Foundation.
They launched it towards the end of last year, but you know,
it's been running and this is really trying to get back to your point
of this issue of educating the community,
especially the black community in ways that are positive,
messages that are embracing.
Why all of us worked is we were talking about love.
You know, how come in the four-letter word
that you will never hear in an HIV technical meeting,
unless I'm speaking.   I promise you.

That's my opening line all the time.   Can we say the word you guys, love.

>> Love.   [ Laughter ]

>> It's a four-letter word that doctors are very uncomfortable
to deal with, researchers even more so because, you know,
we equate emotions with irrationality.
>> But that's part of the person and you have
to deal with the whole person.   >> That's right.

That's right.
But honestly, we are trained and I mean, I'm--
I'm in the middle of a PhD believe it or not, but--
we are trained to think that stuff out.
It's part of why I love anthropology so much.
It was the only discipline where I could live it in legitimately
and not worry about being called, you know, whatever by other people.
It was a big enough discipline and it's very intolerant
of boundaries which I love.   [Laughter] So, yeah.

[ Inaudible Remark ]   >> Eligible men.

[ Inaudible Remark ]   >> Yeah.

>> They were still in school.   >> Yeah.

>> And then I see all these back and forth.
And then I, and then I talked to another, she was a--
my young sister-in-law and I just, I couldn't see them but when I talked
to her and she was having a continuous affair
with this young woman but then when the boyfriend came out of jail,
she was having sex with him as well.
And I was just so worried about it and trying to tell her [inaudible].
>> Yeah, I hear-- I hear the mom in you.
>> [Inaudible] the violence with the violence
with the boyfriend coming [inaudible] and seeing.
And I said, "Why are you still having this affair
with this young woman?"
She is around the same age, maybe be 19, 20.
She said, well, she works.
She's-- she's very-- she just need a lot of--
she just shows me a lot of love and attention to my [inaudible].
>> Yeah, right, right.
>> And I said, but then he comes out and he beats you up
and the police are [inaudible] you're gonna call him in,
what's going on?   >> Right.

>> And she said, well, because-- because I--
I love him and he's my daughter's father.
I just-- I couldn't just see anybody.
>> Yeah, no.
It's-- it's hard to wrap your head around.
You are right.   [ Inaudible Remark ]

>> Oh absolutely.   I mean, literally.

[ Inaudible Remark ]   >> Yeah.

>> [Inaudible] true meaning of love.   >> Yeah.

[ Inaudible Remark ]
>> Yeah, we need an emotional curriculum with this stuff.
You know, it's funny we leave it-- we--
we get educations and everything else and then we kind of pretend
to figure this part out and it doesn't always work, you know.
It doesn't always work.
You-- you touch on two points that I talked about on the film.
This issue of sex ratios is-- is real in the black community of terms
of incarceration as the other soapbox I usually get
on in addition to violence.
What incarceration did in Black America was create single family
homes, okay.
We've created single family homes and we've maintained it.
And what happens is sexual networks change when you do that.
We know for a fact that that happens.
So, it's another contextual influence that's as important as far
as I'm concerned to-- to think about in terms
of producing what produces risks in these populations, you know.
So, when you have single people who are not in marriages,
we know they tend to have sex with more people.
You know, if you're in a monogamous marriage situation,
you tend to hopefully stay with your partner.
More likely than not.
Sometimes that's not the case either but the point is we already know.
So, that's where the incarceration piece.
The other piece that incarceration does is, you know,
people get right in jail.   Lots of things happen in jail.

We already know that the HIV prevalence rates
in jails are much higher than the normal community and a lot of places
like where I was-- you know, in the Bronx, you know, Rikers,
there was a whole door out of Riker's Island and then back
to the South Bronx and then back to Riker's Island.
And so, that's in of itself another cycle.
In a lot of these communities, that creates those hotbeds.
Remember that regional map that I was showing.
>> New York actually did this beautiful study where they--
they overlapped the topic, boroughs of incarceration with the HIV map
and it was almost a one to one fit in terms of, you know,
maintaining the odds of infections in those populations.
So, I mean, how do you communicate about that one?
How do you take on that one?
So, let me-- let me get through a couple of these slides.
And, you know, the challenging questions to think about with kids
and with-- with young people is how do you prevent new infections
when you don't even know you're at risk.
So this idea of, you know, young people are invincible.
And, you know, part of adolescent development is I am invincible.
That is literally part of--
that kind of psychological trajectory that you're doing.
So trying to message around or trying to get them to think
about vulnerability is a difficult thing to do at that stage.
This idea of competing messages that, you know,
how do you sustain a behavioral effect.
So, even if you gave-- gave them the counseling, even if they've gone
through the trainings and they've gone through the workshops,
how do you maintain that effect in an environment that is difficult.
I think a couple of the things you have to do obviously talking
about healthy relationships, what they mean
and I think the most important one starting with yourself first.
You know, having this discussion, it's really actually interesting.
The teen pregnancy literature is fascinating and the things
that we've learned, you know,
sometimes I don't even think we should call it sex education.
It's actually knowing yourself education for lack of a better word
because some of the things that we know that delay pregnancy
or delay sexual debut, you know, how the--
the age at which you first try are things
like public service at a young age.   Who would have thought?

Or things like for girls, being involved in team sports.
Or, you know, the other school attachment.
How-- how proud you feel about your school.
How connected you feel about an identity outside
of the one society gives you.
These are very tricky things to try and wrap our head around
yet when we think about sex education,
we don't look at that literature.
We kind of boil it down to abstinence,
are we talking about sex.
And sometimes, really, it's about age appropriate information
about development and who you are.
So, I almost feel like we need to kind
of repackage what we're talking about.
I think once again, addressing dating violence
and sexual assault is huge.
Dealing with mental health, you know, issues of beauty,
eating disorders, all of these things are kind of stumbled
or rolled up in one ball when you're dealing with adolescents.
They're going through a lot of these stuff.
And then, last but not least, behavioral communication skills.
And you know verbal art is what I call it.
You need to learn how to-- to command yourself through words.
Because oftentimes when you think about how all
of these discrimination happens, how power balancing happens,
all of these things revolve around censorship
and how you censor yourself without necessarily even knowing it.
Failing to articulate your own stories
to someone else does it better than you
and you kind of go with that script.
So, I think communication is actually huge piece
of this story as well.
The other things to think about, you know, youth by definition are
at risk for longer period of time.
So, the interventions that we have have to be even more robust,
offered in even more voices, offered in even more places just
because of the time variable.
The social environment as I was saying
in an adolescent's life is a hugely competitive force.
How do you create health-seeking behaviors and that kind of setting,
especially when it's outcompeting you?
This next slide is-- is one way to think through it.
You know, if the kid is in the middle thinking through this more,
you know, what I call mainstreaming prevention,
it's about thinking what touch points people have in their lives.
Young people come across all kinds of touch points, right?
I mean they have families, peers, which is kind of their enablers
that sets influences around kind of social conditions.
But you know, teachers, police department, someone mentioned, huge,
huge unused population as far as I'm concerned.
I've actually given HIV a domestic-- HIV trainings to police cops
and they're so receptive in a way
that I had never imagined that they would be.
I think the other group we ignore are parents.
I've had so many fathers reach out to me, so many mothers reach
out to me saying, look, you know, I know I'm missing this point,
how do we do this better.
I think it's a hugely underused population.
Largely because people assume no one wants to--
that they wouldn't go there, but actually I think they would.
Providers, you know, the court systems.
Guidance counselors, these are the kind of places that we actually need
to offload our discussions of HIV risk too.
I mean, they could come to me anytime as a doctor.
They can come to their primary care providers, whoever they are.
But, actually these people see them much-- much more often than I do.
And that's just the reality of the situation.
So, thinking through what we have to do
to offload some of these discussions.
And you know, some-- some great work is being done on the city level.
In Philly there were great community-based programs.
The question is scale, right?
How do you take something from a city level and then move it up,
kind of getting it in the water, much harder, harder issue to tackle.
And then employers, you know, I-- I love occupational health lately
because it's-- it's a really interesting space.
It's another interesting space to think through how
to broaden this discussion about health and how
to create ownership about it.
As we go through, you know, the implementation of our, you know,
huge healthcare reform legislation, you know, occupational health
and wellness is a huge part of it.   People spend a lot of time at work.

And-- and therefore, you kind of got to meet people where they are at.
It's actually very powerful sight to think
through what behavior reduction, even behavior change can look like.
There's a lot of behavioral wellness type initiatives
that are now being funded, you know, wellness at work initiatives.
This is part of the continuum for HIV risk reduction
because I really think it starts here, right.
Although we make this debate about sex, we make it about all of this,
you've got-- it starts here.
It starts with you, your relationship with yourself,
conversations about worth, what your limits are,
what your boundaries are.
And that kind of discussion is an emotional health discussion.
You know, it's-- it's an internal one that you have
to start and start sooner.
I think these are the other organ-- oh, there was a hand, go ahead.
>> Yes, the [inaudible] that I've got from watching all of those
when you took and you took what was happening 'cause you may not be able
to identify with your case studies--   >> Yeah.

>> So when you had that meeting at the home with your sister's friend
and talked about their emotional dealings with relationships
and flipping that emotional dynamic of unprotected sex means love
and 'cause that's-- I mean that-- that went home to me and I met
and talked to my girlfriends about that doesn't do that.
That you always use condoms, and you automatically think, oh,
he loves me because he didn't use protection,
and you have to value yourself and say, I don't want unprotected sex.
>> That's right.   >> That's right.

>> That's right.
And if you notice, I mean those are really the--
my friends and I said in the film,
very privileged, very educated women.
And it really boils down to kind of have you stopped
to think about it, you know.
That's why I think even what you've said about pulling her aside
and saying, wait a minute, why?   That-- that starts the journey.

You know, so sometimes a lot of this stuff is so basic
that we just miss it and we don't give ourselves the time or space.
I think the best HIV risk production happens
or counseling happens with your friends.
Hands down bar none.
They know you like no one else so they're meters are a lot higher
and you can't lie to them in the same kind of ways.
You feel comfortable enough to share what you are doing.
You know, as a doc, even you know I try to be very extra nice, you know,
people, there is a power dynamic there.
People don't always share.
Even you know with Tara, it took her a while
to trust me enough, you know, to do that.
Trust takes time to build but there're a lot of relationships
that already have it which is also why I think the other part,
very powerful part is in the film, when I go into the schools
with Chevelle, Chevelle's imparting wisdom
to those girls was talk to your mother.
How often do you hear that for an HIV prevention message?
I mean do you ever, have you ever heard that actually?
And it's so true.
I actually think health starts at home.
It starts at home.
And there is actually a lot of disturbing literature
that I didn't have time to go into.
It depresses me and so and I don't present it often
but the ACE studies, Adverse Childhood Event studies,
if you have time, go over this, this literature.
It's disturbing how much gets determined between zero
and 5 in terms of your life outcomes.
How much you've seen the stressors with, you know--
and the more adverse events you hav,
the more correlation you have with chronic diseases.
Later on, poor health making decision,
so much gets determined at home first, you know.
So, having those conversations with your--
with your siblings or your parents is actually a very productive space
that we often don't use.
So, the other thing to think about, youth service organizations.
This is an easy place to mainstream HIV awareness efforts.
There's actually a lot that are already doing it.
I work with one in Philadelphia that I love.
Very, very low-hanging fruit that I think we can do working
with schools and college campuses.   I teach at UW.

There are tons of student groups there
that are constantly looking for activities.
I think that's another easy place to mainstream awareness and take it--
take it outside of doctor's offices.
Obviously, primary care providers to the degree
that we can make HIV a routine thing,
not necessarily stigmatized disease or activity
which has been its history for a very long time.
And then targeting young people who dropped out.
You know, once you drop out of school,
a lot of things get determined for you, a lot.
And I really didn't appreciate that enough either or think
through that enough until I started seeing what was happening to some
of the kids I was taking care of in Philadelphia.
>> So these are leverage touch points.
These are places where HIV awareness is not happening enough
or low hanging fruit as far as I'm concerned
for taking HIV awareness to a larger scale.
So, the future, a couple of words about the future.
So, what does this all mean?
You know, I've told you a story about context,
and as an anthropologist that's actually what I study, you know.
How do social influences, how does culture, how do the conditions,
the milieu that we live everyday determine what happens to us
in addition obviously to the structural things, you know,
like where you live and what you have access to.
This is actually a quote from a very wonderful physician
who was the leader of the health and human rights, really the founder
of the health and human rights movement,
Jonathan Mann who is no longer with us, passed away,
but I had the good fortune
of actually having him as a college professor.
He kind of changed my life at a very young age.
But one of the things he would teach is that, you know,
public health difficulty
in addressing the indisputably predominant social determinants
of health status is exacerbated by a lack
of a coherent conceptual framework for analyzing social factors,
societal factors that are relevant to health.
The social class approach, while useful, is clearly insufficient.
Public health action based on social classes often simply accusatory
and it raises but cannot answer the question, what must be done.
In this sense, poverty as a root cause of ill-health is both evident
and paralyzing to further thought and action.
I wanted to at least end with this because I think, you know,
finding this language about how to talk about actions has everything
to do with social barriers.
Health disparities, not only HIV ones or kind
of inextricably linked with social barriers.
These barriers include violence, discrimination based on sex, race,
gender, and/or sexual orientation, you know,
stable housing relationship-- should have said unstable housing,
unequal access to care, unemployment,
economic disempowerment, and poor education.
This is the milieu of social barriers that most--
most people face in their lives and this is--
this is what contributes to health disparities.
So, what barriers do is they increase vulnerability.
They-- they keep people even more vulnerable.
And what I've learned is there are limits to vulnerability.
This is a definition also by Jonathan Mann and Daniel Tarantola
from a book called "AIDS and the World II".
And it says vulnerability is the conversed concept of empowerment.
By vulnerability, we mean the extent to which individuals are capable
of making and affecting free and informed decisions about your life.
So, living your life on your terms.
A person who is generally able to make free
and informed decisions is least vulnerable, empowered.
The person who is ill informed or does not have the ability
to make informed decisions freely and carry them
out is the most-- is the most vulnerable.
And where we are now in 2011 is not that dissimilar
from where we were many years ago in the epidemic.
The most vulnerable are the ones that would get kicked
with social barriers the hardest.
And until we can fix that equation, we're not getting anywhere.
I think part of what confronting social barriers means,
and I alluded to this earlier is it requires thinking out of the box.
It really requires interdisciplinary approaches, unlikely partnerships
and leadership, and social entrepreneurship.
Each one of these are presentations on--
in of themselves but I think examples that I've talked to you
about and thought through, I continue to use film
and I think it's a wonderful medium to try
and teach people and reach people.
I mean this-- this film was aired on Showtime for 2 years
and I can't tell you-- I mean I couldn't respond enough
to people fast enough.
I still have a long list but when I walked away with this, okay,
it's in the water, you know.
And I think we need more efforts like that, you know.
I'm still a researcher.
I don't think of myself actually as a-- as a filmmaker.
I think of myself as a public health researcher and a physician.
I just used it.   It's a tool for me.

And so, right now, I'm working on a film, two films,
one on race in America called "Outside the Box".
The second one on violence in Ethiopia
and women's lives called "Oblivion".
And I continue to encourage scholars and educators and anyone
who is really interested in teaching people at, you know, meeting people
where they're at to use, use films and use kind
of these innovative health literacy efforts through media.
I think the other things we-- we can do which I've talked to you
about is, you know, offloading health, offloading health
into the places where it actually happens.
So, community schools, workplaces, even conversations like these.
Like right now, what we're doing right now.
If we could do this more often at a more regular interval,
you would be surprised at what happens, right?
These small changes add up.   You can start to accrue scale.

Because remember that main theme of what I-- what I was saying,
societal, there is a lot of competitive forces, right?
Well, you know, the messages that we're trying to impart
to the people we're teaching gets drowned
out by all these other voices.
So, to the degree that you can start to build up some--
a model, a [inaudible] model where some of the stuff gets repeated over
and over again, I think it would do a lot of good.
I also really think health starts at home.
So, thinking through how
to use parents a lot more effectively than we have.
I know I've talked to them, I've met many wonderful parents
through this whole initiative and it's actually something
that my nonprofit is actually thinking a lot about.
Okay, what can we create for parents that make it all a little easier?
The other thing is we need new messengers.
You know, she was-- the woman who introduced me is joking about my age
and this one I'm like [inaudible] we need people like half my age.
We need people even younger.   We need to recruit new messengers.

They do not have enough opportunities.
Young people do not have enough opportunities to teach us.
And you would be humbled if you gave them a chance.
It's something that I've learned over and over again.
There is actually an overwhelming talent brewing.
There're a lot of HIV educators that are very young, very articulate
that I've met and if we could just give them a stage and get
out of their way a little, I think it would be wonderful.
And I think they are the most effective at talking
to their own peers about these messages.
So, we need a lot more messengers, you know.
You don't have to be a doctor.
You don't have to be HIV positive to talk about HIV.
And I think people need to be comfortable enough to own that.
The epidemic, you know, the activism and advocacy
around HIV very much came out of the leadership
out of HIV positive people and I think that's--
that's wonderful and they continue to be a very important voice.
But I think there is room for other voices and I think it's important
for people to take on this battle even if they are not positive.
Chances are with the numbers being what they are, I'm sure someone
in your life is, you know.
The other thing is the difficult conversations to your point.
The woman who spoke in the front row, you know, stopping someone
and saying, wait a minute, what was that about in your own peer circle.
You know, you obviously have to have these relationships
and feel comfortable enough to do it.
But you know, challenging difficult conversations take a bit of courage.
They take, you know, some courage and-- and that's what we need.
They're also uncomfortable.
>> I think this is so good that you're here and your educating us
but the information that you're giving us and--
through the questions and comments that other people make,
we can go back in maybe a small circle of people that we know--
>> Sure.
>> But we're gonna share it with those people
and those people will share it with more people
and that's what has started to take down the ugly face of AIDS and, oh,
I don't wanna talk about it and you know, put it in the corner somewhere
and hide it away when it really needs
to be right there in front of our face.
You know, so we could face that and move on.
>> And thank you for saying that.
And I think I have one more slide, I thought I was at the end.
I just wanted to pause.
There are some great things that have happened.
Leadership is the other thing we need
for confronting social disparities.
I mean America finally has a national AIDS strategy.
This is so huge, you guys.   We haven't had one forever.

So, we-- we finally released the National HIV/AIDS Strategy last year
and if you haven't read it, read it, there's a role for you in it.
It's on-- it's online, aids.gov.
The other thing that HHS just released last week
which was huge is the federal government's first ever plan
to eliminate health disparities.   We have never done this before.

This got released 2 weeks ago.   That's also on the website.

It's called the National Partnership for Action.
I sit on the Federal Health Interagency Health Equity Team.
Very, very exciting things that are happening and, you know,
really room for involvement from people who wanna get involved.
So, I wanted to-- to leave you with that and that's it.
So, thank you for inviting me.   If there's any questions.

>> Thank you.   [ Applause ]

>> This has been a presentation of the Library of Congress.