>> WELCOME. MY NAME IS LINDA AND I AM A SENIOR SCIENTIST AT THE FOGARTY INTERNATIONAL CENTER AT THE NIH AND FROM THE OFFICE OF FOGARTY AND OFFICE OF SOCIAL SCIENCES RESEARCH I WELCOME YOU TO THE FIRST IN A SERIES OF WEBINARS ABOUT GLOBAL TO LOCAL NOVATIONS. IT'S ENTITLED TRANSFERRING HIV AND STIGMA REDUCTION INTERVENTIONS FROM LOW AND MIDDLE INCOME COUNTRIES TO THE U.S. THROUGH THIS WEBINAR SERIES, WE'LL LEARN ABOUT AND CONDUCT DEEP DIVES INTO INTERVENTION RESEARCH AND DEVELOPED IN LOW AND MIDDLE INCOME COUNTRIES THAT HAVE BEEN OR SHOULD BE TRANSFERRED TO THE U.S. TO ADDRESS SIMILAR ISSUES. THE EXAMPLES PRESENTED IN THE WEBINAR WERE SUBMITTED IN MARCH 2020 IN RESPONSE TO AN NIH REQUEST FOR INFORMATION ON THE TOPIC WHICH WAS SUPPORTED BY SEVEN SPECIFIC CENTERS AND OFFICES. WE WOULD LIKE TO THANK OUR GLOBAL TO LOCAL WORKING GROUPS FOR THEIR TIME AND INTEREST AND GUIDANCE ON THIS PROJECT. OUR GOAL THROUGH THIS SERIES OF WEBINARS AND DISCUSSIONS IS TO ENCOURAGE BOTH FUNDERS AND RESEARCHERS TO GIVE SERIOUS CONSIDERATION TO HOW GLOBAL HEALTH RESEARCH FINDINGS CAN BE ADAPTED FOR USE IN THE U.S. ALTHOUGH GLOBAL TO LOCAL INNOVATION TRANSFER IS NOT NEW, WE HOPE TO INVESTIGATE THE TOPIC DIFFERENTLY BY FOCUSSING ON THE TYPES OF RESEARCH METHODS THAT HAVE BEEN USED SUCCESSFULLY TO EXPLORE ISSUES SUCH AS FEASIBILITY AND APPROPRIATENESS AND ACCEPTABILITY OF A GLOBAL TO U.S. INTERVENTION TRANSFER. NOW, I WOULD LIKE TO INTRODUCE MY FOGARTY COLLEAGUE AND COLLABORATORS ON THIS PROJECT WHO WILL REVIEW THE TOPIC AND GOALS OF TODAY'S WEBINARS. >> THIS IS THE FIRST IN OUR GLOBAL TO LOCAL WEBINAR SERIES. TODAY WE'LL HEAR ABOUT THE SCIENTIFIC PROCESS OF TRANSFERRING HEALTH INTERVENTION INTERVENTIONS THROUGH THE LENS OF FOUR PROJECTS. THEY'LL FOCUS ON STIGMA REDUCTION INTERVENTIONS IN SUB-SAHARAN AFRICA AND HAVE BEEN OR CAN BE TRANSFERRED TO THE U.S. EACH SPEAKER WILL DISCUSS KEY ELEMENTS OF THEIR WORK INCLUDING HOW TO ADAPT INTERVENTIONS AND THE METHODOLOGY AND WHAT IT TAKES TO BUILD SUSTAINABLE STAKEHOLDER AND COMMUNITY PARTNERSHIPS AND FACILITATORS TO CONDUCTING THIS TYPE OF GLOBAL HEALTH RESEARCH. THE SESSION IS BEING RECORDED TO FACILITATE OUR NOTE TAKING. IF YOU'RE AN NIH EMPLOYEE, PLEASE DISCONNECT YOUR NIH VPN IF IT SEEMS TO RESULT IN DELAYS IN THE SLIDE PROGRESSION. SO PLEASE ENSURE VPN IS TURNED OFF. WE ASK YOU REMAIN ON MUTE WITH VIDEO OFF THROUGHOUT THE WEBINAR UNLESS SPEAKING AND USE THE CHAT BOX FUNCTION TO ASK QUESTIONS YOU HAVE FOR SPEAKERS. WE'LL HAVE TWO TIME SLOTS WHERE WE'LL MODERATE Q&A AND GET TO AS MANY QUESTIONS AS TIME ALLOWS. YOU CAN REACH OUT TO ME OR MY COLLEAGUE IF YOU HAVE ANY TECHNICAL DIFFICULTIES AND WITH THAT I WILL TURN IT OVER TO OUR MODERATOR, DR. DIANNE RAUSCH FROM THE NATIONAL INSTITUTE OF MENTAL HEALTH TO INTRODUCE OUR SPEAKERS. >> THANKS FOR ATTENDING AND FOR THE GREAT SET OF SPEAKERS FOR THIS WEBINAR ON A VERY IMPORTANT TOPIC HIV STIGMA. I'M GOING TO INTRODUCE THE SPEAKERS. I'M NOT GOING TO GIVE THE BIOS BECAUSE YOU HAVE THOSE BUT I'LL INTRODUCE THEM AND AGAIN IF YOU DO HAVE QUESTIONS, JUST PUT THEM IN THE CHAT BOX AND WE WILL ADDRESS THEM AS WE GET TO THE Q&A SESSION. SO I'M HAPPY TO INTRODUCE OUR FIRST SPEAKER DR. WILLIAM TIERNEY ON HOME BASED CARE AND ADAPTING AND APPLYING METHODS DEVELOPED IN KENYA TO AUSTIN, TEXAS. DR. TOOIR -- DR. TIERNEY. >> YOU HAVE SEEN THE TITLE OF MY TALK AND I DON'T HAVE ANY CONFLICTS TO DISCLOSE. WHY ARE WE INTERESTED IN GLOBAL LOCAL INNOVATION IS BECAUSE THERE'S MORE SIMILARITIES BETWEEN RURAL AREAS AND LOW-INCOME AREAS AND URBAN AREAS IN THIS COUNTRY AND DEVELOPING COUNTRIES AND IN THIS CASE ELDORET, KENYA AND TEXAS. THERE'S POVERTY CAUSING POVERTY AND TRANSPORTATION AND DIGITAL COMMUNICATIONS, HOME RESPONSIBILITIES THAT PREVENT PEOPLE FROM RECEIVING HELP AND MULTI GENERATIONAL FAMILIES. I'LL FIRST TALK ABOUT HIV-AIDS CARE IN KENYA THROUGH AMPATH ACADEMIC MODEL PROVIDING ACCESS TO HEALTH CARE. IT TO LEVERAGE THE TRIPARTITE TO HELP IMPROVE CARE BUT THE GOAL IS ALWAYS TO LEAD WITH CARE. CARE COMES FIRST AND ALWAYS. AND HERE IS WHERE IT'S LOCATED. AMPATH STARTED ENROLLING PATIENTS IN 2001 AND BY 19 PLUS YEARS LATER ALMOST 300,000 PATIENTS WITH HIV INFECTION HAVE BEEN ENROLLED APPROACHING 200,000 CURRENTLY UNDER TREATMENT AND ALL OF THESE SITES AND MORE IN WESTERN KENYA, MORE THAN 500 SITES AT THIS POINT. MANAGING CARE FOR THIS BROAD A POPULATION AND CONTEXT TAKES AN INFORMATION SYSTEM. TO BE ABLE TO RAMP UP A PROGRAM OF THIS SIZE WE HAVE RAMPED UP A SYSTEM THAT USES FORMS SUCH AS THESE AT THE SITE OF CARE. THEY'RE AT MINISTERED BY CLINICIANS AND FACE TO FACE INTERACTIONS WITH PATIENTS AND THEN WE HAVE A GROUP OF KENYANS ENTER THEM INTO A CLINICAL DATA REPOSITORY SO THEY'RE AVAILABLE FOR CARE MANAGEMENT AND RESEARCH. THESE DAYS IT'S INCREASINGLY DONE ON TABLET COMPUTERS THAN PAPER. BACK THEN THAT'S ALL WE COULD DO. THIS SYSTEM HAS BEEN MADE AVAILABLE PARTIALLY WITH FOGARTY FILING. I WANT TO SAY THANK TO ROGER AND THEIR COLLEAGUES FOR PROVIDING FUNDING AND THESE ARE PLACES AROUND THE WORLD WHERE IT'S BEEN IMPLEMENTED INCLUDING THE UNITED STATES AND THIS IS ANOTHER GAM OF GLOBAL/LOCAL INNOVATION. WHAT WE FOUND OUT IN DELIVERING HIV CARE IS IT TAKES SOCIAL CARE TOO. IF YOU TOOK CARE OF THE MEDICAL THINGS, PEOPLE DIE ANYWAY. THEY WERE OFTEN STARVING AND HAD MANY BARRIERS SO WE HAD TO DEVELOP ENCOUNTER FORMS AND NUTRITIONAL ASSESSMENT, FOOD DISTRIBUTION AND SUPPORT PROGRAMS AND OTHER SUPPORT PROGRAMS AND EVEN OUR FAMILY PRESERVATION INITIATIVE AND THE AGRICULTURAL INITIATIVE AND MICROFINANCE, ETCETERA. ALL THAT HAD TO BE MANAGED TO MANAGE CARE. WE ALSO FOUND YOU CAN'T BREAK THE BACK OF THE HIV PANDEMIC. BY CARING FOR PEOPLE IN SITES LIKE THIS BECAUSE PEOPLE DON'T COME UNTIL THEY HAVE SYMPTOMS AND THEY DON'T HAVE SYMPTOMS FOR THE FIRST 10 YEARS THEY HAVE HIV INFECTION AND CONTAGIOUS. THEREFORE IF YOU WANT TO BREAK THE BACK OF THE HIV PANDEMIC YOU HAD TO GET OUT IN THE COMMUNITY. WE HAD HOME-BASED COUNSELLING AND TESTING AND PEOPLE WOULD GO TO HOMES TO HELP NEEDS ASSESSMENT AND GET A HIV AND URINE PREGNANCY TEST AND GLUCOSE TEST AND IF ANY OF THOSE WERE POSITIVE THE PATIENT WAS REFERRED TO AN AMPATH CLINIC AND 70% TO 80% ONCE REFERRED MADE IT TO THE CLINIC FOR FOLLOW-UP. THE PROGRAM STARTED IN 2007. IN 2014 THIS IS A PICTURE OF THE ONE MILLIONTH KENYAN BEING INTERVIEWED BY THE PROGRAM. BY THE TIME THE PROGRAM ENDED BECAUSE THEY HAD FULLY CANVASSED THE AREA, MORE THAN 2 MILLION KENYANS HAD BEEN INTERVIEWED WITH MORE THAN 98% CAPTURE OF FULL INFORMATION. AND WE HAD TO BE ABLE TO ASSESS HOW THEY'RE DOING AND IF THEY'RE FINE WE GIVE A MONTH SUPPLY OF MEDICATION. WE SHOWED IN THE TRIAL THE CARE WAS EQUIVALENT TO HAVE PATIENTS COMING ONCE A MONTH TO THE CLINIC BUT WE CAN TRIPLE THE CAPACITY BECAUSE MOST THE CARE TOOK PLACE >> IN AUSTIN IT'S THIS GLEAMING WELL TO DO CITY AND GROWING. ALL THAT HAPPENS TO BE TRUE EXCEPT WHERE IT'S NOT. BECAUSE AUSTIN ALSO HAPPENS TO BE THE THIRD MOST ECONOMICALLY SEGREGATED CITIES IN THE UNITED STATES AND THERE'S LARGE DISPARITY OUTCOMES. THIS IS A PICTURE OF TRAVIS COUNTY AND THIS IS LARGE THE LINE THAT SEPARATES THE POORER EASTERN FROM THE OTHER PARTS. YOU SEE THE AREAS OF POVERTY ARE DELINEATED ACROSS THE LINE AND AS YOU MIGHT GUESS IT HAS AN EFFECT ON LIFE EXPECTANCY. IT'S 63 YEARS OF AGE AND IN THE WHITE AREAS ARE 74 TO 81 YEARS OF LIFE EXPECTANCY. CLEARLY THERE'S BARRIERS. I COULD SHOW OTHER SLIDES SHOWING OTHER OUTCOMES BETWEEN THE TWO POPULATIONS. TO BE ABLE TO APPROACH CARE TO THE UNDER SERVED COMMUNITY WE IDENTIFIED ONE CALLED RUNDBERG AND THIS IS THE NEIGHBORHOOD HELP INITIATIVE. IN THIS MODEL FEDERALLY QUALIFIED HEALTH CENTER TAKES RESPONSIBILITY FOR A WELFARE OF A CITY IN THIS CASE RUNDBERG. WE FOCUS ON MEDICAL AND SOCIAL NEEDS AND BEGIN WITH HOUSEHOLD LEVEL ASSESSMENTS THE PROGRAM WE SAW IN KENYA WHERE HEALTH CARE WORKERS ARE THE PRIMARY CONTACTS OF THE HOUSEHOLD ON MEETING NEEDS AND SOCIAL CARE IS DELIVERED BY EXISTING GOVERNMENTAL AND NON-PROFIT ORGANIZATIONS DEDICATED TO MEETING SOCIAL NEEDS. TO DO THIS WE NEED TO CREATE AN INFRASTRUCTURE SIMILAR TO WHAT WE HAVE IN KENYA. THIS DEFINES THE RUNDBERG COMMUNITY OF ABOUT 50,000 PEOPLE. IT'S MOSTLY STABLE AND MOSTLY LATINO. THE AVERAGE INCOME IS $33,000. A QUARTER ARE BELOW THE FEDERAL POVERTY LEVEL AND MOST DON'T HAVE A HIGH SCHOOL EDUCATION. AND UNEMPLOYMENT'S PRETTY LOW POST COVID. THIS WHAT WE OPENED IN POST 2018 AND THIS IS THE MEDICAL DIRECTOR OF THIS PARTICULAR CLINIC. IT STARTS WITH HOUSEHOLD LEVEL ASSESSMENTS WHERE COMMUNITY HEALTH WORKERS GO INTO APARTMENTS AND FREE STANDING HOMES AND ADMINISTER A SURVEY TO HELP CAPTURE INFORMATION INCLUDING WHO PAYS FOR YOUR CARE. AND ONLY HALF THESE PEOPLE HAD SOME KIND OF HEALTH INSURANCE THE COUNTY MEDICAL SYSTEM PLAN OR OTHERS YOU SEE HERE. A QUARTER SAID THEY PAY OUT OF POCKET AND A THIRD SAID I DON'T KNOW. I GUESS IF I GET SICK I'LL HAVE TO FIGURE IT OUT. THEY CERTAINLY HAD SOCIAL NEEDS. MORE THAN A QUARTER WERE THREATENED TO HAVE UTILITY SHUT OFF OR HAD HAD THEIR UTILITIES SHUT OFF AND A QUARTER WERE FOOD INSECURITY AND A THIRD HAD TROUBLE PAYING FOR RENT IN MORTGAGE AND ONE IN NINE WERE SUFFERING FROM DOMESTIC VIOLENCE. HOW DO WE MEET THESE NEEDS? THESE ARE LOCAL ORGANIZATIONS WITH WHOM THE CLINIC HAD ESTABLISHED A PARTNERSHIP AND WE REFERRED THEM TO THESE LOCAL NEIGHBORHOOD ORGANIZATIONS TO HELP MEET THOSE NEEDS. AGAIN, A HEALTH PROGRAM ARE RESPONSIBLE FOR REFERRING PEOPLE. AND WE SCREEN FOR SOCIAL BARRIERS TO HELP. THEY HELP THE PATIENTS NAVIGATE THE HEALTH CARE SYSTEM. PRIMARY AND SPECIALTY CARE IN THE CLINICAL AND WHERE POSSIBLE IN THE HOME. WHY SHOULD A BLOOD PRESSURE FOLLOW-UP BE DONE IN THE CLINIC WHEN IT CAN BE DONE AT HOME. THEY ALSO HELP FAMILIES MEET SOCIAL NEEDS FOLLOWING UP FOR CARE AND SEEING IF THE NEEDS ARE MET. TO DO THIS WE DEVELOPED A DATA PLATFORM. THERE WAS NO DATA EXCHANGE SO WE'RE BUILDING ONE IN CENTRAL TEXAS. WE HAVE BUILDING DATA FROM NETWORKS AND HOSPITALS. STARTING WITH PATIENTS AND THEN PUBLIC ASSISTANTS BECAUSE THEY CAN ORDER THEM TO SEND DATA AND THOSE RECEIVING CARE GET TO NETWORKS AND WE GET DATA THROUGH PROVIDER EHRs, ELECTRONIC HEALTH RECORDS AND FROM THE HOME HEALTH NEEDS ASSESSMENTS AND DATA FROM THE VISITS TO THE SOCIAL CARE PROVIDER TO WHOM WE REFER PATIENTS. SO WHAT CAN WE INCLUDE FROM HAVING IMPLEMENTED THOSE PROGRAMS FROM KENYA AND AUSTIN? FIRST OF ALL, THERE ARE SIMILAR HEALTH NEEDS AMONG PEOPLE IN THE DEVELOPING COUNTRIES. SADLY MORE SO THAN YOU'D THINK. SECOND, LESSONS LEARNED FROM LOW-INCOME COUNTRIES SHOULD BE TRANSLATED INTO CARE IMPROVEMENTS AND OTHER U.S. COMMUNITIES? WHY SHOULDN'T WE GO TO THESE PLACES AND THEY REQUIRE LOCAL CUSTOMIZATION AND ASSESSMENT. THANK YOU FOR GIVING THE ME OPPORTUNITY TO GIVE A HIGH LEVEL OVERVIEW AND HAPPY TO ANSWER QUESTIONS DURING THE Q&A. BACK TO YOU, DIANNE. >> THANK YOU AND THE MILLIONTH PATIENT IS IMPRESSIVE. THE NEXT TALK WILL BE FROM THE UNIVERSITY OF WASHINGTON AND SHE'S GOING TO GIVE US A TALK ON UNITY WHICH IS APPLYING IMPLEMENTATION SCIENCE TO ADAPT STIGMA REDUCTION INTERVENTION IN ZAMBIA AND THE U.S. >> I'LL GO AHEAD AND START. I'LL START WITH A DISCLAIMER THAT I'M NOT AN A -- IMPLEMENTATION SCIENTIST. I'M A CLINICAL PSYCHOLOGIST WITH SOME ORGANIZATIONAL PSYCHOLOGIST TRAINING AND LIKE TO CALL MYSELF AN ASPIRING IMPLEMENTATION SCIENTIST AND I'D LIKE TO TALK ABOUT THE FRAMEWORKS. YOU'RE LIKELY AWARE OF THE NIH MODEL DEPICTED HERE. NOT THE LION. AND I'LL TALK ABOUT THIS WITH UNITY AND THE T2 TIME POINT AND LATER DISCUSS CURRENT EFFORTS TO EXAMINE DELIVERY. OUR DEVELOPMENT EFFORTS WERE MOTIVATED BY DATA ON HEALTH DISPARITIES AND HIV. SO IN THE EARLY 2000s WHEN WE SET ABOUT OUR WORK WITH UNITY, WE NOTED THAT AIDS WAS A LEADING CAUSE OF DEATH FOR AFRICAN AMERICAN WOMEN BETWEEN THE AGES OF 25 AND 34 AND THE AVERAGE RATE WAS 15 TIMES HIGHER THAN HIV INFECTED WHITE WOMAN. SO AT THE SAME TIME WE BEGAN WONDERING WHAT ROLE HIV STIGMA PLAYED IN THE HEALTH DISPARITIES. I ATTENDED THE 2006 INTERNATIONAL AIDS CONFERENCE IN TORONTO AND LISTEN TO THE HIV STIGMA TOOL KIT AND THEY WERE GIVING AWAY CDs WITH TOOL KIT MATERIALS AND ANYONE IN THE AUDIENCE GOT A COPY. I BEGAN TO LEARN WITH THE TOOL KIT DEVELOPED BY THE RESEARCH ON WOMEN AND HAD OVER EXERCISES THROUGH PARTICIPATORY ACTION RESEARCH METHODS. THESE METHODS WERE HELPFUL IN THAT THEY HELPED DEVELOPERS ENGAGE WITH PEOPLE LIVING WITH HIV AND MEMBERS OF COMMUNITY-BASED ORGANIZATION TO CO-DESIGN EXERCISES. SO TO MOVE PEOPLE FROM IDENTIFYING ISSUES TOWARDS ACTION BUT WITH CLOSE ENGAGEMENT WITH THESE STAKEHOLDERS. THE EXERCISES WERE DESIGNED TO BE FLEXIBLE GIVING ORGANIZATIONS THAT USE THE TOOL KIT THE ABILITY TO PICK AND CHOOSE EXERCISES FOR USE. SINCE IT'S INITIAL DEVELOPMENT, THEY HIV STIGMA TOOL KIT HAS BEEN ADAPTED AND USED THROUGHOUT THE WORLD. WE RECEIVED FUNDING FROM THE NIH TO ADAPT THE MATERIAL TO PILOT TEST THE INTERVENTION AND A FEW YEARS LATER WE RECEIVED OUR ONE FUNDING TO DO A FULL SCALE RANDOMIZED CLINICAL TRIAL. WE ENGAGED KEY STAKEHOLDERS AS CLOSE PARTNERS IN THE ADAPTATION. SO WE CONDUCTED FOR FOCUS GROUP DISCUSSIONS AND CONDUCTED INDIVIDUAL INTERVIEWS AND WE FOUND THAT AFRICAN AMERICAN WOMEN LIKED THE IDEA OF A GROUP INTERVENTION AND WE ALSO NOTED THAT AFRICAN AMERICAN MEN WHO WITH WE INTERRED -- INTERVIEWED HAD DISCOMFORT WITH NOT BEING ANONYMOUS AND ULTIMATELY WE CALLED OUR ADAPTATION UNITY AND WAS DESIGNED TO RUN ACROSS TWO CONSECUTIVE AFTERNOONS AND WE USED MECHANISMS OF GROUP DISCUSSION AND ROLE PLAY TO CONDUCT THE WORKSHOPS. ONE KEY ADAPTATION WE MADE WAS WE TOOK ILLUSTRATIONS AND TOOK TRIGGER VIDEOS AND THEY WERE DESIGNED TO STIMULATE DISCUSSION IN THE GROUP. IN THE FIRST COLUMN YOU'LL SEE SOME ILLUSTRATIONS FROM THE ORIGINAL TOOL KIT AND IN THE SECOND COLUMN YOU'LL SEE STILL IMAGES FROM OUR TRIGGER VIDEOS. WE WOULD PLAY A THREE-MINUTE VIDEO SEGMENT AND AFTER A FEW SECONDS OF PAUSE OUR GROUP MEMBERS WOULD EXCITEDLY REACT AND DISCUSS ALL THEY'VE SEEN IN THE VIDEO. AT TIMES THEY WOULD ACTUALLY TALK AT ONCE. THE VIDEO'S STIMULATED QUITE A BIT OF DISCUSSION AND WERE A GREAT RESOURCE FOR US. SOLE WE'LL SEE IF YOU CAN CAN YOU FORWARD TO THE END OF THE SLIDE? AND WITH OUR ONE-FUNDING WE RECEIVED A FEW YEARS LATER WE WORKED ACROSS SIX YEAR TO EXAMINE EFFECTIVENESS AND REDUCING STIGMA OVER TIME. YOU CAN SEE WE EXAMINED UNITY IN A TWO-ARMED TRIAL WHICH PARTICIPANTS RECEIVED COMPARISON INTERVENTION WHICH WAS A GROUP-BASED BREAST CANCER AWARENESS INTERVENTION. WE FOUND STIGMA WAS REDUCED IN BOTH GROUPED AND REDUCED TO BASELINE LEVELS. WE LEARNED TWO THINGS FROM THE WORK. FIRST, STIGMA REDUCTION GROUPS MAY HAVE HAD A GREATER IMPACT IF THEY WERE ONGOING NOT JUST A TWO AFTERNOON WORKSHOP. SECOND, OUR BREAST CANCER AWARENESS INTERVENTION CONTAINED ACTIVE MECHANISM HELPED WITH STIGMA REDUCTION AS WELL. STIGMA LEVELS WENT DOWN AS SOCIAL SUPPORT CHANGES WITH TIME. WE ALSO FOUND STIGMA LEVELS WERE TIED TO VIRAL LOAD AND AS STIGMA INCREASES VIRAL LOAD INCREASES. THIS HAVE THE VIRAL LOAD SLIDE. LASTLY WE FOUND UNITY WORKED DIFFERENTLY ON ENGAGEMENT OF CARE WHETHER THERE WERE POSTTRAUMATIC STRESS DISORDER OR DEPRESSIVE SYSTEMS. UNITY SEEMED TO HELP ENGAGEMENT IN CARE MORE THAN PARTICIPANTS WITHOUT SIGNIFICANT PTSD AND DEPRESSION. PARTICULARLY OUR CLOSE RELATIONSHIP WITH AFRICAN AMERICAN MEN LIVING WITH HIV THEY'RE ROLES ON THE PROJECT AS CLOSE PARTNERS, INFORMANTS, GROUP FACILITATORS AND CONSULTANTS. WHILE I INCLUDED THEM ON CO-AUTHORS ON EARLY MANUSCRIPTS IN FUTURE WORK I'VE WORKED TO INCLUDE AFRICAN AMERICAN WOMEN LIVING WITH HIV AS INVESTIGATORS AS THAT'S BEEN THE TRUE ROLE THEY'VE PLAYED ON THE PROJECTS. IN OTHER LESSONS LEARNED, WE REALIZE WE NEEDED TO WORK AT THE INDIVIDUAL LEVEL AND CO-TARGET SOURCES OF STIGMA IN OUR INTERVENTIONS. WE WOULD DO THAT IN FUTURE WORK BY WORKING AT STRUCTURAL AND COMMUNITY LEVELS AT THE SAME TIME WE'RE WORKING ON INDIVIDUAL LEVELS FOR STIGMA REDUCTION. SO THOSE LESSONS LEARNED LED US TO FOCUS ON DELIVERY ACROSS SETTINGS. SPECIFICALLY WE NOW HAVE SET OUR SITES ON ADAPTING INTERVENTION FOR SIGHTINGS. WE BEGAN LOOKING AT IMPLEMENTATION OUTCOMES OF FEASIBILITY, ACCEPTABILITY AND UPTAKE. WE ALSO LOOKED AT SERVICE OUTCOMES OF EFFECTIVENESS AT THE SAME TIME. KNOW WE'RE SWITCHING GEARS EXAMINING IMPLEMENTATION WITHIN COMMUNITY BASED ORGANIZATION. WE PLAN TO TAKE A LOOK AT STIGMA REDUCING PROGRAMMING INTO HIV SERVICES. WE FOUND IT HELPFUL TO WORK WITH THE EXPLORATION AND SUSTAINMENT OR EPIS FRAMEWORK AND WE HAD INITIAL FUNDING FROM GILEAD WHERE WE LOOKED AT UNITY MATERIALS AND COMMUNITY-BASED SETTINGS. WE'VE AGAIN USED IMPLEMENTATION STRATEGIES OF INCLUSIVITY AND STAKEHOLDERS IN ADAPTATION AND WORKING WITH COMMUNITY PARTNERS IN WHAT SOME IMPLEMENTATION SCIENTISTS CALL MICRO PLANNING EFFORT AND REACHING BOTH MEN AND WOMEN LIVING WITH HIV AND COMMUNITY-BASED ORGANIZATION STAFF MOVING FORWARD. WE KNOW IN THE U.S. THESE DISPARITIES ACCOUNT FOR 49% OF ALL DEATHS OF THOSE LIVING WITH HIV IN THE SOUTH AND IN THE SOUTH WOMEN ACCOUNT FOR 71% OF HIV AMONG ALL WOMEN LIVING WITH HI HIV. OUR CURRENT FOCUS IS LOOK AT HOW THE INTERVENTION MAY BE DELIVERED OPTIMALLY IN THE REAL WORLD IN COMMUNITY-BASED ORGANIZATIONS. WE NAMED THE COMMUNITY VERSION OF UNITY IS UNITY W-O-U-A-T-Y AND WE WORKED WITH DUKE UNIVERSITY INVESTIGATORS WHO LED THE PROJECT AND ENGAGED PEOPLE WITH LIVING IN FOCUS GROUP DISCUSSIONS. WE'VE ALSO ENGAGED WITH STAFF TO MAKE THE ADAPTATION THERE'S BEEN HURRICANES IN SOME CBOs, COMMUNITY-BASED ORGANIZATIONS AND WE START ED AND WE'RE WORKING NOW AT THE MOMENT TO ADAPT OUR INTERVENTION FOR ONLINE DELIVERY. AND WE WANT TO LOOK AT SERVICES PROVIDED BY HIV COMMUNITY-BASED ORGANIZATIONS. WE PLAN TO EXAMINE INTERVENTION IMPACTS ON INTERNALIZED STIGMAS ACROSS PARTICIPANT IDENTITIES AND WE'LL HEAR MORE ABOUT THAT AND WE'RE LOOKING FOR IT TO REDUCE INTERVENTIONAL STIGMAS. OUR AIM IS EXAMINE THE STRATEGIES MAY HELP TO REDUCE STIGMATIZING ATTITUDES AMONG STAFF. IN USING AN ORGANIZATIONAL FRAMEWORK OUR WORK IN SIDE BY SIDE COLLABORATION DEVELOPMENT OF STANDARD OPERATING PROJECTS AND GUIDELINES AND PROMOTION OF ACCOUNTABLE MAY HELP STRENGTHEN OVER ALL SERVICES DELIVERED BY THE COMMUNITY BASED ORGANIZATION. WE HAVE AISLE PEOPLE TO THANK IN THE 4 YEARS WE'VE BEEN WORKING WITH HIV WITH THE TOOL KID WITH UNITY AND THE MOST RECENT ADAPTATION. MANY COLLABORATORS ARE LISTED HERE AND COMMUNITY PARTNERS AND NIH SO THANK YOU. >> THANK YOU VERY MUCH FOR THE GREAT TALKS. I DO WANT TO ASK FIRST IF EVERYBODY WOULD PLEASE GET OFF VPN IF YOU'RE ON IT BECAUSE IT MAY CONTRIBUTE TO THE SLOW MOVEMENT OF THE SLIDES. WE NOW HAVE SOME QUESTIONS. THERE'S BEEN A LOT OF QUESTION AND ANSWER GOING ON IN THE CHAT ROOM WHICH IS GREAT. BEFORE I GET DOWN THERE, I HAVE A COUPLE QUESTIONS HOW DO YOU PAY HEALTH WORKERS AND IS THIS I NEW CADRE OF HEALTH CARE WORKERS THAT NEEDS TO BE ESTABLISHED. >> GREAT QUESTION, DIANNE. IT'S PAID FOR THE PEP FAR FUNDING WE GET. IT'S A GLOBAL FUND AND SPEND HOW YOU FEEL NECESSARY. IF YOU DECIDE TO SPENT IT ON COMMUNITY HEALTH WORKERS RATHER THAN PHYSICIANS OR CLINICS IT'S UP TO YOU. IN THIS COUNTRY YOU CANT GET REIMBURSEMENT SO UNLESS YOU'RE IN A CAPITATED SYSTEM LIKE THE V.A. OR KAISER OR GEISINGER IT'S HARD. LET US DELIVER QUALITY OF CARE WITHIN THE BUDGET BUT LET US SPEND HOW WE WANT AND SURE WE CAN FUND THROUGH NEEDING FEW PHYSICIANS BECAUSE I PRACTICED PRIMARY CARE FOR 25 YEARS AND WAS ON THE 25-MINUTE TREADMILL AND BLOOD PRESSURE FOLLOW-UP AND DIABETES FOLLOW-UP AND THINGS LIKE THAT ARE BETTER DONE IN THE HOME. WE CAN REDUCE HOSPITALIZATIONS AND THEN IF THE MONEY CAN BE KEPT IN PRIMARY CARE IT CAN GO AND WE HAD TO GET MONEY FOR THE HEALTH WORKERS AND WE'RE COLLECTING INFORMATION ON THE AND WE WANT TO CONVINCE THEM TO LET US SPEND IT HOW WE WANT INCLUDING COMMUNITY HEALTH WORKERS. WHEN YOU COME OUT OF MEDICAL SCHOOL YOU'RE READY TO PRACTICE SO THERE'S BROAD TRAINING BUT NEVER WHAT YOU HAVE TO DO. OURS HAD TO GO THROUGH EIGHT WEEKS OF TRAINING AND A MONTH OF INTERNSHIP WITH OUR ADVANCED PRACTICE PROVIDERS BEFORE THEY'RE READY TO GO IT ALSO RAISE THE ISSUE OF SUSTAINABILITY. FEE FOR SERVICE NEEDS TO DIE IN IN ITS PLACE RATIONAL SYSTEMS THAT REWARD CAIRO OPPOSED TO SERVICE. IF YOU PAY FOR A LOT OF PROCEDURES AND DRUGS YOU GET A LOT OF PROCEDURES AND DRUG BUT THEY DON'T NECESSARILY [INDISCERNIBLE] >> I'M GOING GO TO YOU DR. RAO. >> OUR IDENTIFICATION AND ENGAGEMENT WITH STAKEHOLDERS HAD HAD DIFFERENT APPROACHES AND THE RESEARCH FRAME WORKS WE USED SO INITIALLY WHEN WE STARTED OUT WE WANTED TO WORK TOWARDS AN EFFECTIVENESS TRIAL. SO WE BUILT THE INTERVENTION CONSIDERING THAT OUR FUTURE PARTICIPANTS OR AFRICAN AMERICAN WOMEN LIVING WITH HIV WOULD BE KEY STAKEHOLDERS. SO WE RAN A SERIES OF FOCUS GROUPS AND INDIVIDUAL INTERVIEWS WITH THEM. THEN AS WE SHIFTED OUR FRAMEWORKS IN THINKING MORE ABOUT DELIVERY AND ORGANIZATIONS WE'VE HAD TO PULL IN COMMUNITY-BASED STAFF MUCH MORE AND REQUIRED MORE TIME AND EFFORTS IN ENGAGING AND DISCUSSING COMMUNITY BASED ORGANIZATION S AND UNDERSTANDING THE CAPACITIES BEFORE EVEN THINKING ABOUT IMPLEMENTING A PILOT TEST. AND THOSE ACCESSING SERVICES. WITH THE ADDITION OF ORGANIZATIONAL MEASURES WE'VE HAD TO ALSO DISCUSS AND HAVE INFORMAL INTERVIEWS WITH CEO AND COMMUNITY-BASED ORGANIZATION STAFF AS WELL. WE'VE HAD TO SHIFT. THAT TAKES MORE TIME AND ENERGY MORE DIFFICULT TO ACCOUNT FOR IN FUNDING PROPOSAL. WE'VE HAD TO OPEN OUR MINDS AND FIND OTHER WAYS TO JUSTIFY THAT WORK AND WORK WITH GILEAD HAS GIVEN US MORE FLEXIBLE FUNDING TO WORK TOWARDS THOSE COLLABORATIONS OVER TIME. >> DO THE WITH WOMEN APPLY THE THINGS THEY LEARNED TO HELP RESOLVE OTHER TYPES OF HARASSMENT OR UNPLEASANT PERSONAL INTERACTIONS THEY MAY ENCOUNTER IN THEIR LIVES? >> WOMEN BRING IN MANY ISSUES INTO THE GROUPS AND THE MAIN ACTIVE MECHANISM IN UNITY HAS BEEN THE SOCIAL SUPPORT. WHEN THEY TALK ABOUT STIGMA WITHIN THEIR COMMUNITIES THEY MAY FACE DUE TO DEPRESSION THEY USE THE SAME SUPPORTIVE TECHNIQUES IN LIVING WITH HIV STIGMA. THE ONE THING THEY'VE IN THE DONE IS MEASURED STIGMAS TO SEE IF THE INTERVENTION HAS IMPACT ON REDUCING STIGMA ASSOCIATED WITH VARIOUS IDENTITIES AND CONDITIONS. WE ONLY MEASURE HIV RELATED STIGMA REDUCTION IN OUR TRIAL. THAT'S OUR PLAN FOR FUTURE WORK TO MEASURE OTHER STIGMAS REDUCED BY UNITY. >> IN KENYA, I HAVE TO STAY BEFORE WE IMPLEMENT OUR TESTING PROGRAM AND GO TO THE COMMUNITY WITH THE CLINICAL WE PARTICIPATE IN COMMUNITY GATHERINGS WHERE WE GET THE SENSE FOR WHAT THEY LIKE FROM US AND WHAT THEY NEED AND HAVE A SENSE FOR WHAT WE CAN PROVIDE AND THEN WE TALK A LOT OF ABOUT STIGMA AND SOCIAL SUPPORT AND THOSE THINGS GET REPEATED OVER TIME. THAT'S ONE WAY OF SHARING INFORMATION ACROSS A COMMUNITY THAT BLENDS NICELY WITH THINGS IN THE KENYAN CULTURE. THE OTHER THING THAT'S HAPPENED AND YOU CAN'T RAISE YOUR HAND BUT ONE PERSON IN THE AUDIENCE HELPED DEVELOPED THIS THESE MICRO FINANCE GROUPS WHERE UP TO 25 KENYANS, MOSTLY WOMEN, WILL PUT 100 SHILLINGS A WEEK INTO A POT AND MEET ON A REGULAR BASIS AND USE THAT MONEY TO LOAN THEMSELVES TO START BUSINESSES AND BUY SUPPLIES AND SCHOOL UNIFORMS AND THINGS LIKE THAT. WITHIN THAT GROUP THEY INTERACT IN A VERY SOCIAL WAY. INFORMATION SHARING HAPPENS NOT ONLY BECAUSE IT'S AROUND THE HEALTH CARE SYSTEM THEY'RE NOT AFRAID TO TALK ABOUT HIV AIDS, ETCETERA. BUT PROVIDE AS A MEDIUM IN WHICH THINGS OTHER THAN FINANCE CAN BE TALKED ABOUT AND MORE THAN 2500 OF THESE GROUPS ESTABLISHED IN WESTERN KENYA IN THE LAST FIVE TO SEVEN YEARS. >> THERE'S A QUESTION FOR DR. TIERNEY. >> THEY HAVE TO BE ABLE TO ASSESS MEDICAL AND SOCIAL NEEDS. THEY ACTUALLY HAVE PRETTY SIMILAR SKILLS AS I MENTIONED EARLIER. THEY HAVE BROAD AND GENERAL TRAINING AND NEED WE'RE AN ACADEMIC ORGANIZATION, TEACHING IS WHAT WE DO. AT ONE POINT WE WERE THE LARGEST EMPLOYER IN WESTERN KENYA-EVERY ONE OF THEM TRAINED BY US. IN AUSTIN WE SPENT TIME TRAINING OUR COMMUNITY HEALTH WORKERS TO BOTH ASSESS AND MEET MEDICAL AND SOCIAL NEEDS. IN KENYA THE COMMUNITY HEALTH WORKERS HAVE TO KNOW MORE ABOUT HIV/AIDS CARE IN AUSTIN THERE'S MORE LATINO COMMUNITY AND MORE IMMIGRATION ISSUES AND THE LEGAL ISSUES ARE VERY DIFFERENT IN AUSTIN. THEY NEED DIFFERENT KNOWLEDGE BUT THEY BOTH NEED TO HAVE TRAINING BOTH MEDICAL AND SOCIAL HEALTH NEEDS ASSESSMENT AND NOT AS DIFFERENT AS YOU MIGHT THINK. >> THIS IS A QUESTION FOR BOTH OF YOU FOR BUT PROBABLY FOR YOU DR. RAO. HOW DO YOU MITIGATE CONFLICT OF INTEREST WHEN YOU TAKE FUNDS FROM COMPANIES LIKE GILEAD. >> THERE'S PROBABLY MULTIPLE CONFLICTS OF INTEREST INVOLVED. THE MAJORITY OF THE WORK THAT WE DID WITH THE DEVELOPMENT OF UNITY AND THE TRIAL WERE FUNDED BY YOU'RE DEVELOPMENT AND AN RO1 AWARD. THE MODEL OF FUNDING WE HAVE TO WORK WITH COMMUNITY BASED ORGANIZATIONS AND THE ADAPTATION THAT COMES FROM GILL YAD FOUNDATION AND ALSO AND TALKING ABOUT CONFLICT OF INTEREST WITH GILEAD MAKER OF ANTIRETROVIRAL MEDICATIONS AND THE WORK WE'RE DOING, WE'RE PUTTING FORWARD A BEHAVIORAL INTERVENTION THAT DOES NOT USE PHARMACEUTICALS AT ALL AND THE COMMUNITY-BASED SERVICE ARE COMMUNITY-BASED ORGANIZATION ARE PROVIDING BEHAVIORAL NOT CLINICAL SERVICES. VERY SEPARATE KIND OF TASKS. I HOPE THAT ANSWERS THE QUESTION. >> IF YOU WANT TO WEIGH IN ON THAT? >> NO, THAT ANSWER WAS GREAT. >> A QUESTION FOR DR. RAO, BESIDE THE TRIGGER VIDEOS, WHAT OTHER SIGNIFICANT CHANGE WERE MADE TO THE ORIGINAL STIGMA TOOL KIT IN DEVELOPING UNITY INTERVENTION? >> WELL, THE TRIGGER VIDEOS WAS A MAJOR UNDERTAKING BECAUSE BECAUSE WE TOOK VARIOUS SCENARIOS THAT HAD TO BE ADAPTED FOR A U.S. CONTEXT. WE MADE FOUR TRIGGER VIDEOS. WE CHOSE FOUR TO ADAPT. THE BASIC THEMES REMAINED FROM THE HIV STIGMA TOOL KIT IN TERMS OF CONSIDERING WAYS TO HANDLE CERTAIN SITUATIONS VERSUS PASSIVE OR AGGRESSIVE OR SCENARIOS WHERE THERE WERE TENSIONS WITHIN THE FAMILY IN ORDER TO ADAPT MATERIALS WE RELIED ON CONTENT FROM THE WOMEN WE WERE WORKING WITH HIV STIGMA. THE HIV STIGMA TOOL KIT IS SO FLEXIBLE IT ALLOWS FOR PEOPLE TO PICK AND CHOOSE EXERCISES. THE ADAPTATION WAS MORE IN TERMS OF SETTING AND CONTENT AND EXAMPLES RATHER THAN BEING STRUCTURED IN SOME WAY. IT WAS PART OF THE ORIGINAL MECHANISM AND WE UPDATED THEM AND MADE THOSE EXERCISES AND THOSE MECHANISMS PART OF HOW WE ROLLED OUT UNITY IN THE GROIPZ. BY THE WAY, THE HIV TOOL KIT IS STILL AVAILABLE THAT ARE MORE APPROPRIATE FOR GLOBAL CONTEXT AND THE ADAPTATIONS ARE ALSO AVAILABLE ONLINE. >> GREAT, I THINK WE'RE GOING MOVE IT ON THE SECOND HALF AND THERE'LL BE TIME AT TO THE END TO ANSWER QUESTIONS FOR THE WHOLE GROUP. SO OUR NEXT TALK IS FROM THE UNIVERSITY OF ALABAMA BIRMINGHAM AND TALK ABOUT FRESH, ADAPTING AN HIV STIGMA REDUCTION INTERVENTION DEVELOPED IN SUB-SAHARAN AFRICA FOR BIRMINGHAM, ALABAMA. DR. TURN. >> THANK YOU VERY MUCH. THE INTERVENTION THAT WE'RE TALKING ABOUT IS CALLED FRESH WHICH STANDS FOR FINDING RESPECT AND ENDING STIGMA AROUND HIV. THIS WAS ALSO NOT THE ORIGINAL NAME AND THE AFRICAN AMERICAN INTERVENTION BUT SOMETHING THAT CAME UP LOCALLY IN ALABAMA DURING THE ADAPTATION PROCESS. THIS IS AN INTERVENTION THAT FOCUSES ON REDUCING HIV RELATED STIGMA DISCRIMINATION IN HEALTH CARE SETTINGS. THE ORIGINAL INTERVENTION WAS DEVELOPED WITH FUNDING IN FIVE COUNTRIES UNDER THE LEADSHIP OF DR. BILL HOLZEIMER BASED ON INTERPERSONAL CONTACT THEORY AND SOCIAL COGNITIVE THEORY. THE FIRST IS SHARING INFORMATION. WITH THE PEOPLE WE'RE SHARING THE LOCAL HIV RELATED STIGMA AND WHAT'S GOING ON IN COMMUNITIES AND GENERAL COMMUNITY COMMUNITIES THIS WORKSHOP BRINGS TOGETHER WORKERS AND CLIENTS TO PLAN STIGMA ACTIVITIES TOGETHER. AND THE OTHER ASPECT IS COPING THROUGH EMPOWERMENT. THE CLIENTS AND PEOPLE LIVING WITH HIV GET INVOLVED IN SOMETHING WHERE THEY CAN CHALLENGE AND ADDRESS STIGMA DIRECTLY NOT JUST ACCEPT IT OR LIVE WITH IT. IT HAS A REAL EMPOWERMENT PIECE TO IT. WE THOUGHT WE COULD ADAPT THIS FOR THE U.S. SOUTH AND ALABAMA AND REALIZED THE IMPORTANCE OF CONTEXT. WE DID FEEL THE IDEA OF BRINGING CLIENTS AND PROVIDERS TOGETHER TO JOINTLY ADDRESS STIGMA AND HEALTH CARE SEEMED TRANSFERRABLE AND WOULD WORK IN DIFFERENT CONTEXT. WE ALSO REALIZED WHEN ADAPTING FOR ALABAMA THE U.S. SOUTH IS A VERY DIFFERENT PLACE THAN MANY CONTACTS IN AFRICA THOUGH THERE ARE SOME SIMILARITIES BUT OF COURSE OUR HEALTH CARE SYSTEM WORKS DIFFERENTLY. OUR CLIENTS ARE FROM DIFFERENT TYPES OF COMMUNITIES. WE SOCIAL ECONOMIC FACTORS AND WE SORT HAVE DIFFERENT INTERSECTIONAL STIGMA FOR CLIENTS WE NEED TO ADDRESS. WE STARTED TO COLLECT LOCAL DATA TO ADAPT OUR INTERVENTIONS. WE COLLECTED DATA FROM SOME HIV NEGATIVE PARTICIPANTS AND THOSE ENROLLED IN HIV PREVENTION PROJECTS IN NORTHEAST, ALABAMA AND TRIED TO LEARN ABOUT THEIR FEARS OF STIGMA AND VALUES AND ATTITUDES OF PEOPLE LIVING WITH HIV. WE DID A FAIRLY LARGE ONLINE SURVEY OF HEALTH CARE WORKERS IN ALABAMA AND MISSISSIPPI TO FIEND OUT ABOUT THEIR PERCEPTIONS AND VALUES AND ATTITUDES ABOUT PEOPLE LIVING WITH HIV AND ALSO WHAT THEY OBSERVED IN TERMS OF STIGMA AND DISCRIMINATION IN HEALTH CARE SETTINGS AND DID FOCUS GROUPS WITH FOLKS LIVING WITH HIV IN BIRMINGHAM. WE HAD A BIT OF DATA WE COULD PRESENT BACK TO OUR PARTICIPANTS ABOUT WHAT WE'VE SEEN IN TERMS OF WHAT'S GOING ON AT YOUR COMMUNITIES AND FACILITIES. YOU CAN SEE THE DIFFERENCES BETWEEN THE INTERVENTION AS WAS IMPLEMENTED IN SUB-SAHARAN AFRICA AND AS WE ADAPTED IT. IT WAS DEVELOPED AND IMPLEMENTED IN LESOTHO, MALAWI AND SOUTH AFRICA, SWAZILAND AND TANZANIA. THE WORKSHOP HALF HEALTH CARE WORKERS AND HALF CLIENTS. A DIFFERENCE THEY WERE FROM A SINGLE HEALTH CENTER THE DOCTORS AND MAINLY NURSES I HAVE TO SAY IN THE AFRICAN AND DOCTORS AND NURSES GOT TOGETHER AND DID THE WORKSHOP. WHAT WE WERE ABLE TO DO IN BIRMINGHAM WAS GOT CLIENTS AND PROVIDERS FROM DIFFERENT FACILITIES ACROSS THE CITY. THAT WAS A DIFFERENCE. WE AGAIN AND ALSO WE WENT BROADER BEYOND NURSES. SO WE INCLUDED ANY TYPES OF HEALTH CARE WORKERS THAT HAD CONTACT WITH CLIENTS LIVING WITH HIV. SO SOCIAL WORKERS, NURSES, DOCTORS, RECEPTIONISTS, YOU NAME IT. THE CONTENT WAS THE SAME BUT WE ADDED CONTENT THAT SPOKE MORE TO THE BIRMINGHAM SETTING AND I'LL TALK MORE ABOUT THAT IN A FEW SLIDES THE ORIGINAL STUDY HAD QUALITATIVE INTERVIEWS AND QUESTIONNAIRES AT THREE MONTHS PRIOR TO THE INTERVENTION AND ONE MONTH AFTER THEY FINISHED THEIR PROJECTS. WHEREAS IN BIRMINGHAM WHAT WE DID WAS A MUCH SMALLER FEASIBILITY AND ACCEPTABILITY STUDY SO WERE ONLY ABLE TO DO QUESTIONNAIRES RIGHT BEFORE AND AFTER THE WORKSHOPS WITH PARTICIPANTS. WHAT WE ENDED UP DOING IN ALABAMA IN EACH WORKSHOP WE HAD ABOUT 10 TO 15 HEALTH WORKERS AND THE WHOLE RANGE OF HEALTH WORKERS WHO MAY BE DEALING WITH CLIENTS. 10 TO 15 CONSUMERS. THEY'RE JOINTLY FACILITATED BY ONE HEALTH WORKER AND THEY JOINTLY LED THE WHOLE PROCESS. AF ONE AND A HALF DAYS BASED ON FEEDBACK FROM THE CLIENTS IN ALABAMA, THEY DIDN'T REALLY WANT TO DO THIS AFTER THE HEALTH FACILITY OR PARTICULARLY NOT AT A HEALTH DEPARTMENT. THEY HAD SOME NEGATIVE EXPERIENCE WITH HEALTH DEPARTMENTS. WE DECIDED TO DO THE WORK SHOPS IN A NEUTRAL LOCATION WHICH ENDED UP BEING IN OUR SCHOOL OF PUBLIC HEALTH. HERE YOU SEE THE FINAL AGENDA AS DELIVERED IN ALABAMA. I WILL SAY THAT SOME OF THE EXERCISES THAT ARE USED IN THIS INTERVENTION ARE ALSO FROM THE HIV STIGMA TOOL KIT. IT AGAIN SHOWS YOU HOW WIDELY APPLICABLE AND GREAT THE MATERIAL IN THE TOOL KIT IS. WE TALK ABOUT UNDERSTANDING STIGMA AND WE THEN PRESENT THE LOCAL DATA ON STIGMA AND DISCRIMINATION ON ALABAMA. WE HAVE SOME EXERCISES THAT HELP PEOPLE THINK ABOUT THE CAUSES AND CONSEQUENCES OF STIGMA. NOW, WHAT WE DID WAS A SECTION A MODULE ON INTERSECTING STIGMAS AND THAT WAS POWERFUL WE STARTED TALKING ABOUT STIGMA AROUND SEXUAL ORIENTATION, AROUND RACE, AROUND POVERTY, AROUND RELIGION AND THE STIGMA STORIES EXERCISE IS GREAT BECAUSE EVERYONE, HEALTH WORKERS AND CLIENTS ALIKE TELL STORIES AT TIMES THEY HAVE FELT STIGMATIZED OR DISCRIMINATED FROM SOMETHING AS PART OF THEIR IDENTITY. I THINK EVERYBODY HAS A STORY TO SHARE ON THAT AND IT'S A VERY POWERFUL EXERCISE. WE ALSO TALKED ABOUT OUTCOMES OF STIGMA. WE ADDED AN HIV KNOWLEDGE UPDATE BECAUSE BOTH PROVIDERS AND CLIENTS WANT THE LATEST UPDATES ON THE LATEST A.R.T.s AND DELIVERY METHODS AND WHAT'S GOING ON. WE KIND TWEAKED SOME OF THE EXERCISES ON HOW TO CHALLENGE AND COPE WITH STIGMA AND ADDING MORE EMPOWERMENT AND HOW TO ADDRESS AND FIGHT STIGMA INTO THAT SECTION. THEN WE TALKED ABOUT STIGMA REDUCTION STRATEGIES GIVING THEM EXAMPLES BUT ALSO HAVING THEM WORK TOGETHER TO COME UP WITH IDEAS FOR ACTIVITIES TO REDUCE STIGMA IN THE HEALTH CARE SETTING IN OUR OWN COMMUNITY. AND SO AGAIN, THE MAJOR FICTIONS WERE INCLUDING PARTICIPANTS FROM ACROSS THE CITY, BEING IN A NEUTRAL NON-HEALTH FACILITY LOCATION, MAKING THE WORKSHOP SHORTER TO ACCOMMODATE BUSY SCHEDULES AND ADDING THAT TO OTHER SEGMENTS AND FOR THE GROUP PROJECTS TARGETED FOR IDEAS ON REACHING HEALTH CARE WORKERS IN THE REGION. SOME THINGS THAT FACILITATE THE ADAPTATION TO THE U.S. SETTING IS THE FACT THAT STIGMA EXPERIENCES HAVE MANY COMMONALITIES AT THEIR CORE ACROSS THE GLOBE. WHEN YOU TALK ABOUT THE DRIVERS AND MANIFESTATIONS OF STIGMA EVEN THOUGH THERE ARE OFTEN UNIQUE ASPECTS AND DIFFERENT CONTEXTS, THERE'S A LOT OF COMMONALITIES. AGAIN USING THAT LOCAL DATA TO ADAPT THE INTERVENTION AND TO HELP PARTICIPANTS SEE WHAT'S GOING ON IN THEIR OWN COMMUNITIES FACILITATED THE PROCESS. WE ALLOWED NEW CONTENT AND PERSPECTIVES TO BE INCORPORATED BUT KEPT THE CORE PRINCIPLES INTACT OF THE INTERVENTION. WE ALSO -- THIS IS AGAIN TAKING A SYSTEMS APPROACH AT LOOKING AT THE HEALTH CARE SETTING AND HOW THE SYSTEMS CAN BE CHANGED TO REDUCE STIGMA AND SO YOU CAN SEE THE SLIDE FROM THE WOMAN SAYING I HATE ALL HOSPITALS AND DOCTORS, WE KNOW HOW HAVING EXPERIENCE STIGMA AND DISCRIMINATION IN A HEALTH CARE SETTING CAN REALLY CAUSE DEEP TRAUMA AND DISTRESS WITH THE HEALTH CARE PROVIDERS AND SYSTEMS THAT CAN LAST OVER TIME. SO WE KNOW HEALTH CARE SETTING INTERVENTIONS HAVE TO BE ADAPTED FOR DIFFERENT HEALTH CARE SYSTEMS AND HAVE TO RECOGNIZE CLINICS MAY OR MAY NOT BE COMFORTABLE SETTINGS FOR BRINGING PEOPLE TOGETHER FOR ADDRESSING STIGMA BASED ON PEOPLE'S PAST EXPERIENCES WITH HEALTH CARE. WE ALSO NEED TO THINK ABOUT HOW THE HEALTH FACILITY ENVIRONMENT ITSELF MAY CONTRIBUTE TO STIGMA AND DISCRIMINATION. THAT'S ONE OF THE THINGS WE CAN TRY TO ADDRESS. SO THIS WAS AGAIN A VERY SMALL PILOT AND WE DID FIND SATISFACTION THE WORKSHOP WAS HIGH AMONG CLIENTS AND PROVIDERS. PEOPLE WERE REALLY ENGAGED AND EXCITED AND FELT THIS WAS SOMETHING THEY WANTED TO TALK ABOUT FOR YEARS AND SAMPLE SIZES WERE SMALL BUT THERE WERE TRENDS AND HEALTH CARE WORKERS BECAME AWARE THERE WAS STIGMA IN THEIR HEALTH FACILITY AND THE CLIENTS' DECREASED ANXIETY ABOUT TREATMENT AND THAT WAS A SMALL PILOT. SINCE THEN WE RECEIVED CFAR SUPPLEMENT FUNDS ACROSS SIX HIV CLINICS ACROSS ALABAMA AND TENNESSEE. THESE ARE NOT OUTSIDE MAJOR URBAN AREAS. WE'RE TALKING ABOUT THE SMALLER TOWNS AND RURAL AREAS IN THE REGION. WE HAVE COLLECTED BOTH QUALITATIVE AND QUANTITATIVE DATA FROM THOSE SITES AND HAVE PLANS TO FURTHER TWEAK AND ADAPT IT TO THOSE TYPES OF SETTINGS AND HOPEFULLY DO A LARGER TRIAL AT MORE CLINICS ACROSS THE U.S. AND I'M EXCITED WE ALSO RECENTLY HAVE AN HIV FOGARTY SUPPORTED R21 TO ADAPT AND PILOT THE FRESH WORKSHOP INTERVENTION FOR THE DOMINICAN REPUBLIC AND GOING FROM LOCAL TO GLOBAL AND IN THAT ITERATION WE'RE FOCUS ISING ON MEN WHO HAVE SEX WITH MEN AND TRANSGENDER CLIENTS WHO FACE STIGMA IN THOSE SETTINGS. WE'RE EXCITED ABOUT THAT. WE HAVE A HUGE TEAM THAT HAS CONTRIBUTED TO THIS WORK OVER SEVERAL YEARS NOW INCLUDING ALL OF OUR COMMUNITY PARTNERS AND ALL OF OUR RESEARCH PARTICIPANTS AND WE HOPE TO TAKE THIS WORTH FURTHER. THANK YOU. >> THANKS VERY MUCH. THAT WAS GREAT. WE'RE GOING TO TURN OUR LAST TALK FROM THE UNIVERSITY OF WASHINGTON AND THEY'RE GOING TO TALK ABOUT COMMUNITY ENGAGEMENT AND PARTNERSHIP TO IMPROVE HIV STIGMA AND TESTING, ADAPTING AN INTERVENTION DEVELOPED IN SUB-SAHARAN AFRICA TO SEATTLE, WASHINGTON. DR. PATEL, I THINK YOU'RE STARTING. >> THANK YOU, DIANNE. WHAT I WANT TO HIGHLIGHT IS THE WORK IS BEING PRESENTED AND SHOWCASED ON BEHALF OF SO MANY OTHER COLLABORATORS. SOME OF WHOM ARE ON THE CALL [LISTING NAMES] THANK YOU FOR BEING PART OF THE WORK. HARAMBEE LOOSELY TRANSLATES TO BRINGING COMMUNITY TOGETHER AND A WORD AND PHRASE WE DECIDED TO USE TO SYMBOLIZE DIFFERENT MEMBERS OF THE COMMUNITY WITHIN ANY ONE COMMUNITY AND ACROSS THE EAST AFRICAN IMMIGRANT COMMUNITY COMING TOGETHER TO DO THIS WORK IN SEATTLE, WASHINGTON. THE INSPIRATION FOR THIS WORK STARTED WITH A PATIENT THAT I SAW WHEN I FIRST MOVED TO SEATTLE. THIS WAS A 43 OLD FEMALE BORN IN ETHIOPIA WHO IMMIGRATED TO THE U.S. 11 YEARS AGO AND SHE PRESENTED WITH LEFT-SIDED WEAKNESS AND WAS FOUND TO BE NEWLY DIAGNOSED WITH HIV WITH A LOW CD4 COUNT AND PNEUMOSTISTIS IN HER LUNG AND TOXOPLASMOSIS IN HER BRAIN AND TOOK TIME TO RECOVER IN ADDITION TO HER BODY HAVING THE HIV. IT JUST SO HAPPENED I WAS ATTENDING ON THE INFECTIOUS DISEASES SERVICE AT THE TIME WEDGE A COLLEAGUE WHO DOES HOME-BASED WHO DOES WORK IN UGANDA AND I SAID IF WE COULD HAVE DIAGNOSED HER EARLIER RECOULD HAVE CHANGE THE TRAJECTORY OF THIS FOR HER FAMILY AND COMMUNITY AND HEALTH CARE SYSTEM. SHE SAID THAT'S SO INTERESTING. LET'S TALK MORE ABOUT THIS. WE'RE DOING WORK IN KENYA AND UGANDA AND SOUTH AFRICA WE CAN POSSIBLY APPLY HERE. HIV DISPROPORTIONATELY AFFECT D THIS POPULATION AND SOME ARE ONGOING TRANSMISSION OCCUR IN THE U.S. AND NOT ONLY COMING FROM THEIR WERE IN THEIR HOME COUNTRY. THEIR PRESENTATION TO CARE TEND TO BE LATE. AND THEY PRESENT WITH AIDS WHICH IS A LATE PHASE OF THE HIV INFECTION WITHIN THE FIRST YEAR OF BEING DIAGNOSED WITH HIV. HOWEVER, ONCE THEY ARE DIAGNOSED AND RETAINED IN CARE THEIR TREATMENT OUTCOMES ARE GOOD. IN FACT THEY EVEN TEND TO BE BETTER THAN COUNTERPARTS INCLUDING U.S.-BORN BLACK. SO THE KEY HERE IS HOW TO MOTIVATE EARLY HIV TESTING FOR THESE INDIVIDUALS. WE CONCLUDED HIV TESTING NEEDS TO GO WHERE THE COMMUNITIES ARE. AT THIS TIME THERE'S FAIRLY UNIVERSAL TESTING BEING PROVIDED IN OUR EMERGENCY ROOMS AND CLINICS AND OTHER HEALTH CARE SETTINGS. BUT THE PROBLEM HERE YOU CAN IS THAT THESE INDIVIDUALS AREN'T ALWAYS ACCESSING THE HEALTH CARE SETTING AND HAVE MAJOR BARRIERS TO THAT ACCESS. WE SAID WE NEED TO TAKE A COMMUNITY-BASED HIV TESTING APPROACH. AS OTHERS HAVE SHOWN LARGELY IN SUB-SAHARAN AFRICA, WHEN YOU DO THIS COMMUNITY BASED TESTING THERE'S HIGH COVERAGE AND YOU CAN REACH HARD TO REACH POPULATIONS THAT YOU TEND TO IDENTIFY INDIVIDUALS WITH HIV AND HIGHER CD4 COUNTS AND GET HIGHER LINKAGE TO CARE. FURTHERMORE, AS BILL AND OTHERS HAVE MENTIONED ALREADY, WE TOOK THIS APPROACH OF INTEGRATED HIV TESTING MODELS. SO THIS IS FUNDAMENTALLY OFFERING HIV TESTING ALONGSIDE OTHER HEALTH SCREENINGS AND SERVICES. NOT TO BE MYOPIC ON FOCUSSING ON THIS AND TWO OTHER PROJECTS AND STUDIES NAMED SEARCH WHICH DID COMMUNITY HEALTH CARES AND OFFERED HOME-BASED HIV TESTING AS WELL AS ART STUDY WHICH IS SUPPORTED BY MY COLLEAGUE LUANNE WHERE THEY DO HOME OR MOBILE-BASED TESTING IN THE COMMUNITY AND DO ART INITIATION AND THEY GET LINKED TO FACILITIES BUT THAT ISN'T THEIR MODE OF LINKAGE TO CARE AND CONTINUED A.R.T. WE FIND THESE MODELS REFRESHING BECAUSE THEY'RE GOING TO WHERE THE COMMUNITIES ARE. SO IN THE FIRST ITERATION OF THIS WORK CALLED HARAMBEE 1.0 WE DECIDED TO PROVIDE HIV TESTING THROUGH MINI HEALTH CARES. IT WAS A COMBINED RESEARCH SERVICE PROJECT. AS YOU CAN SEE BY ALL THE LOGOS INCLUDED ON THE SLIDE, THERE WERE SO MANY ENTITIES WITHIN NOT JUST THE UNIVERSITY OF WASHINGTON MEDICINE, PHARMACY, DENTISTRY PROGRAMS BUT ALSO BROADER PROGRAMS WITHIN THE SEATTLE, KING COUNTY AREA THAT AGREED TO OFFER SERVICES. IT WAS A MIXED METHODS PROJECT WHERE WE DID BOTH QUALITATIVE AND QUANTITATIVE WORK FUNDED BY THE C IT IS -- CFAR AWARD GLOBALIZING LOCAL RESEARCH. JUST TO SAY IT HELPS TO HAVE THESE TYPES OF AWARDS THAT EXPLICITLY CALL OUT THE ISSUES THIS WEBINAR IS MEANT TO HIGHLIGHT AND HIGHLIGHTING THE PARTNERSHIP AWARD. UNLIKE THE WORK BILL AND OTHERS HAVE SHOWN IN THE SUB-SAHARAN AFRICAN SETTING WE DECIDED NOT TO GO DOOR TO DOOR AND MANY ARE HOUSED IN LARGE RESIDENTIAL COMPLEXES AND WE THOUGHT GIVEN SO MANY ISSUES AROUND IMMIGRATION AND AT THAT POINT WITH THE NEW PRESIDENCY IN THE U.S. WE FELT IT PROBLEMATIC TO KNOCK DOOR TO DOOR. INSTEAD WE SET UP A MINI HEALTH FAIR IN RESIDENTIAL COMPLEXES. WE OFFERED INTEGRATED HIV TESTING INCLUDING NOT ONLY TESTING FOR HIV BUT HYPER TENSION, DIABETES, CHOLESTEROL, OBESITY. SOME OF WHICH REQUIRED A POINT OF CARE FINGERPRINT AND THERE'S DENTAL AND MENTAL HEALTH AND HIGHER EDUCATION AND SOCIAL SERVICES INCLUDING SIGNING UP FOR HEALTH INSURANCE AND CONDUCTED INTERVIEWS. HERE'S PICTURES OF OUR MINI HEALTH CARES FROM 15 TO 20 VOLUNTEERS AND THERE ARE MANY PICTURES OF MEDICAL STUDENTS DOING COUNSELLING AND TESTING AND A PRIVATE ROOM FOR HIV COUNSELLING AND TESTING AND HERE YOU CAN SEE AN ORAL EXAMINE BEING OFFERED. IN TERMS OF OUR RESULTS. WE WERE SURPRISED BUT WE HAD MORE THAN 50% OF UPTICK OF TESTING TO INDIVIDUALS OFFERED AND WE FOUND PREVALENCE OF HIGH COMMUNICABLE DISEASES AND PREVENTION AND DIABETES AND HYPERLIPIDEMIA AND HOWEVER, OUR COMMUNITY PARTNERS ASKED US TO PAUSE AND WE'RE TALKING ABOUT STIGMA DIFFERENT THAN HOW OTHERS HAVE PRESENTED TO DATE. NOT STIGMA OF PEOPLE LIVING WITH HIV OR HEALTH CARE WORKERS BUT NOW THIS IS COMMUNITY WIDE STIGMA THAT ENDS UP BEING THE LARGEST BARRIER TO HIV TESTING. SO HERE'S A QUOTE THAT SHOWS WHILE SOCIAL INTEGRATION AND COHESION IS A POSITIVE FOR SO MANY IMMIGRANT COMMUNITIES TO SURVIVE AND THRIVE IN THIS COUNTRY IT ALSO ENDS UP BEING A BARRIER FOR STIGMATIZING CONDITIONS AND THEREFORE HIV TESTING. SO AS OUR NEXT STEP WE DECIDED WE OF COURSE WERE GOING TO CONTINUE INTEGRATING HIV TESTING INTO OTHER HEALTH SCREENING BUT WE NEEDED TO HIV STIGMA FIRST. THE LESSONS WE LEARNED COMING OUT OF THE WORK WAS THINKING DEEPER ABOUT COMMUNITY PARTNERSHIP. WE PARTNERED FOR THE CENTER FOR MULTI CULTURAL HEALTH WORKING WITH AFRICAN AMERICAN AND AFRICAN AMERICAN COMMUNITIES IN THE SEATTLE AREA. WE PRESENTED A LOT OF THIS WORK TO WHAT WAS NEWLY BUILT COALITION OF ETHIC HEALTH BOARDS BY THE CITY OF SEATTLE. THERE WERE SO MANY QUESTIONS THAT CAME UP ABOUT AUTHENTICITY. WHO ARE WE AS NON-COMMUNITY MEMBERS IN ACADEMIA TO WANT TO DO THIS WORK AND GO INTO THESE COMMUNITIES? AND CAN THE CENTER OF MULTI CULTURAL HEALTH REALLY REPRESENT THESE COMMUNITIES THEMSELVES? WHO IS THE COMMUNITY? THESE WERE SMALL PILOT FUNDINGS. NONE OF WHICH WERE REPNEUM NATED AND ALL THE FUNDING WAS USED FOR THE TESTING SUPPLIES BUT THAT BECAME A STICKING POINT WE WEREN'T OFFERING A LOT OF REMUNERATION FOR PARTNERS TO WORK WITH THIS. WE HAD TO BE MINDFUL OF LARGER INEQUITIES AND THIS WAS PROBLEMATIC IN DOING THE WORK INCLUDING ISSUES AROUND DISTRUST AND MEDICINE AND HEALTH CARE AND HEALTH CARE AND UNIVERSITIES. WHEN I WOULD BE PRESENTING THIS PROJECT PEOPLE WERE ASKING WHAT IS THE UNIVERSITY OF WASHINGTON DOING ABOUT FAIR HOUSING AS LARGE OF THE IMMIGRANT WERE BEING DISPLACED BY STUDENT HOUSING. DO YOU SEE YOU CAN'T OPERATE IN A VAM UME AND HAVE TO TAKE THE LARGER INEQUITIES INTO ACCOUNT WHEN YOU DO THE WORK. WE TRIED TO SHIFT TOWARDS COMMUNITY-BASED PARTICIPATORY WORK WHERE CONTEXT IS TAKEN INTO ACCOUNT AND TAKES INTO ACCOUNT EQUITABLE STRUCTURES IN POWER, MONEY, CAPACITY THE BI-DIRECTIONAL LEARNING APPROACH AND SHARED DECISION MAKING AND WE HIGHLIGHTED PRINCIPLES OF EQUITY, JUSTICE AND SUSTAINABILITY AS WE WERE MOVING ON TO THE NEXT PHASE OF WORK. SO THAT MEANT IMPLEMENTING COMMUNITY PARTNER AS OUR CO-INVESTIGATE ON THE GRANTS WE WERE APPLYING ON. WE COMMITTED TO ENSURING MORE THAN 50% OF THE BUDGET WENT DIRECTLY TO THE COMMUNITIES AND INCLUDED CO-OUR COMMUNITY PARTNERS AS CO-AUTHORS ON PUBLICATIONS. >> THANK YOU. WE PARTNERED WITH OUR COMMUNITY S AND TO IDENTIFY A CULTURALLY ACCEPTABLE APPROACH TO THESE STIGMAS. IN DOING THIS WE CONDUCTED FOCUS GROUP DISCUSSIONS WITH RELIGIOUS LEADERS AND COMMUNITY LEADERS AND LAY COMMUNITY MEMBERS. WITH OUR PARTNERS COME FROM SOMALI AND HEALTH POD AND THERE WERE PEOPLE WHO ARE SPEARHEADING THIS PROJECT AND OUR STUDENTS FROM UNIVERSITY OF WASHINGTON PLAYED AN IMPORTANT ROLE BY PROVIDING SUPPORT TO US. OUR COMMUNITY PARTNERS FROM ETHIOPIA AND COMMUNITY CENTER. [LISTING NAMES] WE CONDUCTED KEY INTERVIEWS AND FIVE FOCUS GROUP DISCUSSIONS. OVER ALL THERE WERE 41 IN THE FOCUS GROUP DISCUSSIONS. SEVERAL THEMES CAME UP FROM OUR ANALYSIS. THE FIRST WAS CONCEPTUALIZATION OF ILLNESS. SO EVEN BEFORE COMING HERE AND WITH ILLNESS IT COMES WHEN IT'S SO SICK YOU CAN IN THE DO YOUR DAY TO DAY ACTIVITIES. SO IF YOU'RE NOT FEELING WELL YOU DON'T GO TO THE DOCTOR SO PREVENTATIVE HEALTH CARE WAS NOT COMMON WHERE THESE COMMUNITY MEMBERS COME FROM. I ONLY COME WHEN YOU'RE SO SICK YOU NEED A DOCTOR'S ATTENTION OTHERWISE IT'S NOT GIVEN A BIG PRIORITY. AND ILLNESSES SUCH AS HIV/AIDS OR MENTAL HEALTH, CANCER, THESE ARE HIGHLY STIGMATIZED ILLNESSES. IF YOU HAVE HIV IT'S ASSUMED YOU'LL DIE THE NEXT DAY. COMING TO THE U.S., THIS THE STIGMATIZED ILLNESSES COME WITH A LOT OF CHALLENGE. AND ENGLISH STATUS AND ENGLISH LANGUAGE% -- AND THEY FEEL WHEN ENGAGING WITH HEALTH CARE ERS THEY MAY NOT BE PROVIDED THE SERVICES THEY NEED IT HAVE OR SO MANY THEY HAVE TO OVERCOME TO ACHIEVE -- >> I WANT TO REMIND YOU YOU'RE TIME IS ALMOST UP AND WE STILL HAVE SOME QUESTIONS. SO IF YOU COULD WRAP IT UP IT WOULD BE GREAT. >> THE COMMUNITY'S FACED SO MANY CHALLENGES THEY FEEL STRONG AND THEY WANT TO BE ON THE DRIVER'S SEAT WHEN IT COMES TO INTERVENTIONS. THEY SUGGESTED THEY WANT TO BE PART OF THE SOLUTION BY IDENTIFYING RELIGIOUS LEADERS AND COMMUNITY LEADERS TO BE PART OF THE SOLUTION. RENA WILL BE TALKING ABOUT THE NEXT PROJECT. >> I'LL BE QUICK. THE NEXT IS IMPLEMENTING HARAMBEE 3.0 USING PROJECT FAITHH FIRST DEVELOPED IN GHANA AND ADAPTED IN RURAL ALABAMA AND NOW WE WILL BE FURTHER ADAPTING FOR SEATTLE AREA INCLUDING NOT JUST CHRISTIAN BUT MUSLIM FAITH AS WELL. AND SO JUST SOME BRIEF REFLECTIONS. THIS IS MORE CRITICAL REFLECTIONS ON OURSELVES. WE FEEL LIKE WE HAVE A LOT OF TO STILL DO. PROJECT BASED FUNDING CYCLES ARE DISRUPTIVE. SO FAR WE'VE BEEN FORTUNATE TO BE FUNDED BY NIH BUT WILL THAT KEEP FUNDING US TO DO THE DURABLE WORK TO BE PRESENT AND WORKING WITH OUR COMMUNITIES AND WE APPLIED FOR AN R01. I'M HOPING WE CAN MOVE TOWARDS A CO-P.I. STATUS. RIT NOW ALL THE COLLABORATORS ARE CO-INVESTIGATORS BUT I THINK WE NEED TO WORK HARDER TO INVOLVE THEM IN CO-P.I.s AND INVOLVE THEM IN GRANT APPLICATIONS AND PUBLICATIONS AND A COMMITMENT TO GETTING MORE THAN 50%. I'D LOVE TO GET MORE FUNDING TO OUR PARTNERS. I THINK WE'RE STILL STRUGGLING WITH BI-DIRECTIONALITY AND NOT ENGAGING WITH ALL THE CONVERSATIONS WHEN THEY TALK ABOUT YOUTH VIOLENCE WE'RE NOT DOING THAT AS MUCH AS I'D LIKE TO AND WANT TO BUILD THE PROJECTS MORE AND MORE WITH THE COMMUNITY. THANK YOU FOR YOUR TIME. >> THANK YOU FOR THE PRESENTATION. I WON'T BE ABLE TO GET THROUGH ALL THE QUESTIONS BULL WE'LL CERTAINLY CONSOLIDATE THEM AND SEND THEM TO THE SPEAKERS AND THEY CAN PROVIDE ANSWERS TO THEM WE CAN GET TO. I WANT TO START WITH A QUESTION THAT IS ACTUALLY FOR BOTH SPEAKERS BUT I'LL START WITH ONE. THERE'S SO MANY COMPONENTS OF STIGMA AND SO MANY DIFFERENT PLACES OR CONTEXTS WHERE DIFFERENT STIGMAS BECOME MORE IMPORTANT THAN OTHER STIGMAS. YOU TALKED ABOUT INTERSECTIONALITY BUT HOW DO YOU DEVELOP AND ADDRESS IT OPERATIONALIZE ADDRESSING STIGMA FROM SO MANY CONTEXTS WITH SO MANY PRESENTATIONS? >> WE SOMETIMES FOCUS IN ON HEALTH CARE SETTING STIGMA BECAUSE IT'S SOMETHING THAT WE FEEL WE CAN ADDRESS. IT'S ALMOST THE EASY LOW HANGING FRUIT THAT WE'RE IN THE HEALTH CARE SETTINGS. WE CAN REACH THESE HEALTH WORKER AND HAVE SOME INTERVENTIONS THAT CAN HELP THEM TO CHANGE. AND THERE'S OTHER EXPERIENCES IN THEIR COMMUNITIES AND CHURCHES AND WORKPLACES. PART OF WHAT WE'RE -- AS WE'RE DEVELOPING THE FRESH INTERVENTION IS WHAT WE ALSO WANT TO DO IS GIVE HEALTH CARE PROVIDERS TOOLS TO HELP CLIENTS DEAL WITH THOSE EXPERIENCES. TO HELP THEM NOT INTERNALIZE THAT STIGMA THAT THEY'RE EXPERIENCING AND TO HELP THEM BUILD RESILIENCE AND SOLIDARITY TO RESIST STIGMA IN THOSE SETTINGS. AND IT'S BROADER THAN THAT. SO WE'RE TRYING TO ADDRESS IT IN THAT WAY. >> DO YOU WANT TO ADD TO THAT DR. PATEL? >> SURE. I THINK THAT'S FUNDAMENTALLY THE WE ARE UP AGAINST IN THE COMMUNITIES WHERE PEOPLE ARE LIVING THEIR LIVES. WE NEED TO THINK OF A WAY WE ENGAGE WITHIN THOSE COMMUNES. IT'S NOT EASY WORK, UNFORTUNATELY. BUT WE'RE TRYING. THERE'S A QUESTION HERE FO FOR EVERYONE OR ALL OF YOU. CAN YOU CLARIFY 50% WENT TO THE COMMUNITIES? HOW WAS THE MONEY DISTRIBUTED? >> IN OUR FUNDING POST FUNDING WENT TO TESTING SUPPLIES, THE CARTRIDGES, POINT OF CARE OF MACHINES AND SO FORTH. THE COMMUNITIES DIDN'T FEEL LIKE THAT WAS REALLY BRINGING THEM A LOT OF VALUE. THE NEXT RATION OF HARAMEE, 2.0 WE MADE SURE IT WENT TO THE COMMUNITY PARTNER ORGANIZATIONS OR OTHER ENTITIES. YOU CAN APPRECIATE 2.0 WAS FORMATIVE WORK SO THEY WERE THE ONES CONDUCTING ALL THE KEY INFORMANT INVIEWS -- INTERVIEWS AND FACILITATORS AND DID THE TRANSLATIONS AND TRANSCRIPTIONS AND ALL THE WORK AND THAT WAS EXPLICITLY REPNEUM RANUPNEUM -- REPNEUNUME RATE RENUMERATED APPROACH AND WE TOOK A LITTLE ROLE. AND MOHAMMAD DID THE TRAININGS FOR THE FOCUS GROUP FACILITATION A AND FOR SOMEONE IN ACADEMIA IT'S BEEN DIFFICULT TO COORDINATE AND BRING COHESION TO THE WORK. THOSE ARE THE SMALL DETAILS. THE WORK WAS MORE MEANINGFUL BECAUSE THE COMMUNITY PARTSS -- PARTNERS TOOK MORE OF A LEADERSHIP ROLE IN DOING ALL THE WORK. >> GO AHEAD. >> WE'VE GIVEN A LUMP SUM TO THE COMMUNITY BASED ORGANIZATIONS AND THEY'VE PAID FOR THE PART OF BUT WE CAN DO MORE TO SHARE THE MONEY AND THE POWER FOR SURE. >> WE'LL CONSOLIDATE THE KEGSES AND PROVIDE THEM WITH TO THE PRESENTERS AND THEN OPEN UP SOME IF THEY'RE WILLING. I DO WANT TO GIVE LINDA A CHANCE TO HAVE A FEW FINAL WORDS BUT BEFORE I GO I WANT TO THANK YOU ALL FOR YOUR ATTENTION AND FOR ATTENDING THIS. IT'S BEEN REALLY FUN. LINDA, THE FLOOR IS YOURS. >> THANK YOU VERY MUCH ON BEHALF OF FOG ARTEE AND MYSELF, I'D LIKE TO THANK AND I'D LIKE TO THANK THE STAFF WHO HELPED WITH THE TECHNICAL ARRANGEMENTS AND ALL THE ATTENDEES WHO PARTICIPATED IN THE WEBINAR. YOU'VE BEEN ACTIVE AND ASKING GREAT QUESTIONS AND THANK YOU SO MUCH. I WANT TO LEAVE YOU WITH SOME IMPORTANT POINTS I LEARNED FROM THE PRESENTATIONS TODAY. FIRST, POPULATIONS IN THE U.S. CAN HAVE SIMILAR BARRIERS TO HEALTH CARE AS THOSE FACED BY POPULATIONS IN LOW AND MIDDLE-INCOME COUNTRIES. THESE BARRIERS SUCH AS STIGMA AND BARRIERS OF POVERTY THAT BILL AND RENA AND OTHERS DISCUSSED CAN BE ADDRESSED BY INTERVENTIONS DEVELOPED WHICH ARE ADAPTED FOR USE IN THE U.S. AND WE HEARD ABOUT THE COMMUNITY-BASED RESEARCH AND IMPLEMENTATION SCIENCE TO LOOK AT THE FEASIBILITY AND ADAPT AGENCY AND WE HEARD WITH THE IMPORTANCE OF INVOLVING STAKEHOLDERS FROM THE START. MANY NEED TO BE PART OF RESEARCH ITSELF AND THEY NEED TO BE INVOLVED THROUGHOUT THE RESEARCH PROCESS TO INFORM THE ADAPTATION AND TO ENSURE SUSTAINABILITY OF THE INTERVENTION. I'M SURE ALL OF YOU HAD YOUR OWN IMPORTANT TAKEAWAYS FROM THE PRESENTATIONS TODAY AND TO THAT END, WE'LL BE SENDING A FOLLOW-UP E-MAIL TO EVERYONE TO GET FEEDBACK ON THE WEBINAR AND FIND OUT WHAT YOU WOULD LIKE TO SEE IN FUTURE WEBINARS ON THE TOPIC AND TO REQUEST IF YOU HAVE RELEVANT GLOBAL TO U.S. RESEARCH EXPERIENCES YOU CONSIDER SHARING THEM WITH US. I THANK EVERYONE FOR PUTTING TOGETHER THIS REALLY AMAZING AND INFORMATIVE WEBINAR AND WE LOOK FORWARD TO SEEING YOU AT FUTURE WEBINARS. THIS CONCLUDES THIS WEBINAR AND THANK YOU VERY MUCH.