DR. ROBERT GAROFALO IS A DIRECTOR OF ANN & ROBERT LURIE CHLDREN'S HOSPITAL OF CHICAGO GENDER SEXUALITY HIV PREVENTION CENTER AND ATTENDING PHYSICIAN AT ANN & ROBERT LURIE CHILDREN'S HOSPITAL CHICAGO WHERE HE DIRECTS ADOLESCENT YOUNG ADULT HIV PROGRAM. ADDITIONALLY HE'S ASSOCIATE PROFESSOR OF PEDIATRICS AND PREVENTATIVE MEDICINE AT NORTHWESTERN UNIVERSITY'S FINEBERG SCHOOL OF MEDICINE, DR. GAROFALO RECEIVED HIS BS FROM DUKE UNIVERSITY IN BIOLOGICAL PSYCHOLOGY. HIS M.D. FROM NYU SCHOOL OF MEDICINE AND HIS MPH FROM HARVARD SCHOOL OF PUBLIC HEALTH. HE COMPLETED A PEDIATRIC RESIDENCY CHILDREN'S HOSPITAL PHILADELPHIA AND A FELLOWSHIP IN PEDIATRIC ADVOCACY AT BOSTON'S CHILDREN HOSPITAL. HE'S A NATIONAL AUTHORITY ON LGBT HEALTH ISSUES, ADOLESCENT SEXUALITY AND HIV CLINICAL CARE AND PREVENTION. FORMER PAST PRESIDENT OF THE GAY AND LESBIAN MEDICAL ASSOCIATION. IN 2010 DR. GAROFALO SERVED AS COMMITTEE MEMBER FOR THE NATIONAL ACADEMY OF SCIENCES OR INSTITUTE OF MEDICINE COMMITTEE ON LESBIAN GAY BISEXUAL AND TRANSGENDER HEALTH ISSUE AND RESEARCH GAPS AND OPPORTUNITIES. DR. GAROFALO AND OTHER FACULTY AND STAFF OF THE CENTER SHARE COMMITMENT TO CLINICAL TRAINING PROTEGESNAL EDUCATION AND HENTORSHIP OF TRAINEES FROM MULTIPLE HEALTH PROFESSIONS TO IMPROVE HEALTH OF MARGINALIZED ADOLESCENT AND YOUNG ADULT POPULATIONS. DR. GAROFALO IS CO-DIRECTOR OF COMPASS, A GENDER AND SEXUAL DEVELOPMENT PROGRAM AT LURIE CHILDREN'S. THIS PROGRAM IS THE FIRST COMPREHENSIVE PROGRAM SERVICE FOR GENDER NON-CONFORMING CHILDREN AND ADOLESCENTS IN THE MIDWEST. PLEASE HELP ME WELCOME DR. ROBERT GAROFALO. [APPLAUSE] >>PROFESSOR: GOOD AFTERNOON. THANKS FOR HAVING ME. THAT WAS A LONG INTRODUCTION NOT WRITTEN BY ME. I'M A ADOLESCENT PHYSICIAN. I WOULD START OFF BY TELLING TWO STORIES. ONE IS ABOUT MYSELF, MAYBE MY BACKGROUND SINCE YOU GUYS ARE POST BACKS MIGHT BE HELPFUL OR INTEREST PING BECAUSE I DIDN'T TAKE -- INTERESTING BECAUSE I DIDN'T TAKE A TRADITIONAL CAREER PATH IN THAT I WENT TO UNDERGRADUATE AND THEN WENT TO MEDICAL SCHOOL BUT THEN FELL OFF THE GRID. SO I BECAME A WAITER ACTUALLY FOR A YEAR BECAUSE I FINISHED MY RESIDENCY IN PEDIATRICS AND I WAS LIKE I COULDN'T REMEMBER WHY I HAD DONE THIS IN THE FIRST PLACE BECAUSE IT SEEMED LIKE SO DISTANT WHEN YOU HAVE BEEN WORKING LIKE SO HARD SO I DECIDED THAT I WOULD JUST BE A WAITER FOR LIKE A YEAR. WHEN I WAS IN BOSTON WAITING TABLES, THIS YOUNG MAN WHO IS ALSO A BAR BACK FOUND HIMSELF HOMELESS AND HE WAS TELLING ME ABOUT A HOMELESS SHELTER FOR HOMELESS AND KIDS. I WOULD BE UP FOR VOLUNTEERS THERE. YOU GUYS CAN HEAR ME, RIGHT? OKAY. SO THEY WERE LIKE OH, WE CAN HIRE YOU IF WE HAD SOME MONEY. I WAS LIKE YOU DON'T NEED TO PAY ME, I'M WAITING TABLES, I CAN JUST VOLUNTEER LIKE TWO DAYS A WEEK. AND WITHIN SIX MONTHS THAT JOB TURNED INTO A HARVARD FELLOWSHIP POSITION. IT WAS SO WEIRD. BUT I NEVER SAW MYSELF WANTING TO GO BACK INTO LIKE ACADEMIA AT ALL BUT I WAS LIKE -- I WAS WORKING IN THIS CLINIC ONE DAY AND IN WALKS THIS WOMAN AND SHE HAPPENED TO BE THE HEAD OF THE DEPARTMENT OF PEDIATRICS AT HARVARD, BOSTON CHILDREN'S. SHE WAS LIKE WOULD YOU BE WILLING DO A FELLOWSHIP YOU CAN DO THIS SHIT YOU'RE DOING HERE, BUT IT WOULD BE WITH A LITTLE KICK AND MONEY. SO I WAS LIKE OKAY. COOL. AFTER I FINISHED THAT FELLOWSHIP I ALSO WAS LIKE I'M NOT REALLY SURE SORT OF WHAT I WANT TO DO AND SO I DECIDE TO COME DOWN HERE. I WORKED FOR SENATOR KENNEDY ON THE RYAN WHITE HEALTHCARE LEGISLATION. SO I WAS A LEGISLATIVE AID FOR SENATOR KENNEDY IN D.C. FOR TWO YEARS AND HE WAS THE PERSON THAT CONVINCED ME TO GO BACK. HE WAS LIKE YOU CAN STAY AND THIS MIGHT BE SOMEWHAT RELEVANT FOR MAYBE SOME OF YOU, HE'S LIKE YOU CAN STAY HERE IN D.C. AS AN M.D., NEVER HAVING LIKE FORMED APPROXIMATE EXPERTISE IN A CLINICAL AREA AND YOU WILL BE MUCH LIKE MANY OTHER POLICY WONKS ALL OVER WASHINGTON D.C. THAT CONTRIBUTE. BUT HE'S LIKE IF YOU REALLY WANT TO MAKE A REAL DIFFERENCE IN YOUR COMMUNITY OR A REAL DIFFERENCE, YOU NEED TO GO BACK TO WHERE YOU WERE AND P BECOME A CLINICAL EXPERT IN AN AREA AND THEN COME BACK AND DO POLICY AND EFFECT POLICY AND THEN YOU'LL BE SOMEONE THAT'S LIKE DIFFERENT AND SOMEONE THAT CAN EFFECT CHANGE IN A DIFFERENT WAY. BECAUSE THERE AREN'T THAT MANY M.D.s THAT CAN DO POLICY PIECE AS WELL AS CLINICAL MEDICINE. SO I THINK THAT WAS THE BEST ADVICE I EVER GOT. AND I DID GO AND SORT OF BEGAN A CAREER IN HIGH RISK ADOLESCENT MEDICINE AND DOING ADOLESCENT HIV WORK. AND THE LAST CAREER TWIST FOR ME BECAUSE I WAS A CLINICIAN, I WAS DOING WORK FOR LGBT YOUTH AND HOMELESS AND HIV POSITIVE YOUTH, I WAS THE BIGGEST DRAIN ON ANY BUDGET MY CLINIC CAME UP WITH. IT WAS EXPENSIVE TO PAY A DOCTOR AND KEEP IT FUNDED. SO I WAS LIKE HOW DO I GET MYSELF FUNDD? SO I WAS LIKE I'LL BECOME A RESEARCHER. SO LIKE MADONNA, I REINVENTED MYSELF AGAIN AT THE RIPE OLD AGE, NOT THAT OLD BUT AND I DECIDED TO PURSUE A CAREER THAT WAS A BALANCE BETWEEN CLINICAL MEDICINE AND RESEARCH. I THINK A LOT OF PEOPLE WILL TELL YOU, YOU MAY HAVE ALREADY HEARD THIS WHICH I HATE WHEN PEOPLE SAY THIS, THAT YOU HAVE BE A GOOD CLINICIAN YOU HAVE TO DO CLINICAL WORK, IF YOU WANT TO BE A GOOD RESEARCHER YOU HAVE TO DO RESEARCH. YOU CAN'T DO BOTH. I THINK THAT'S THE BIGGEST BUNCH OF CRAP I HAVE HEARD. I DON'T THINK RESEARCH I'M GOING TO PRESENT YOU IS THE MOST SOPHISTICATED ON THE PLANET BUT IT'S FUNDD BY THE NIH SO IT AIN'T SO BAD. IT'S ALSO VERY GROUNDED IN THE COMMUNITIES THAT I WANT TO SERVE. SO I WANTED TO GIVE YOU THAT BACKGROUND FOR WHEN I TALK ABOUT MY RESEARCH. IF YOU HAVE QUESTIONS ABOUT WHY I TOOK SOME OF THOSE CHANCES LET ME KNOW. THE ONE THING I WOULD SAY TO Y'ALL IS STUDENTS SOMEWHERE ALONG THE PROCESSES DON'T BE APARADE TO TAKE CHANCESES. BECAUSE PEOPLE ARE GOING TO TELL YOU ALL THE TIME THAT LIKE IF YOU JUMP OFF THE GRID IT'S HARD TO GET BACK OR IF YOU GO WORK IN THE COMMUNITY, YOU CAN'T WORK IN ACADEMIA, IT'S A BUNCH OF CRAP, NONE OF IT IS TRUE, FOLLOW YOUR HEART. DO WHAT IS INTERESTING TO YOU. I CAN DO RESEARCH IN LIKE ASTHMA OR DERMATOLOGIC CONDITIONS BECAUSE I KNOW HOW TO DO RESEARCH. WOULD I BE THAT INTO IT? PROBABLY NOT BECAUSE THEY DON'T FLOAT MY BOAT. SO LIKE PURSUE THE THINGS THAT INTEREST YOU AND DON'T LET PEOPLE TELL YOU YOU CAN'T TAKE CHANCES BECAUSE YOU CAN. THAT'S THE END OF MY STORY. THE OTHER STORY IS THAT OUR HOSPITAL UP UNTIL RECENTLY WAS NAMED CHILDREN'S MEMORIAL HOSPITAL. ANYONE HERE FROM CHICAGO? HAVE YOU HEARD CHILDREN'S MEMORIAL HOSPITAL, RIGHT? NOW IT'S THE ANN AND ROBERT -- NOT THE, IT HAS TO BE ANN AND ROBERT H. LURIE CHILDREN'S HOSPITAL CHICAGO. YOU CAN'T SAY THE AND YOU CAN'T USE THE WORD AND BETWEEN ANN AND ROBERT. IT HAS TO BE THE AM PER SAND OTHERWISE YOU'RE SCOLDED. THAT'S WHAT HAPPENED WHEN YOU HAVE $100 MILLION TO GIVE TO THE HOSPITAL. SO ANN LURIE, SHE'S FABULOUS, DON'T GIGGLE. SHE'S GREAT. SHE GAVE $100 MILLION TO THE HOSPITAL BUT THE BEST PART IS SHE USED TO BE A PEDIATRIC NURSE. AT CHILDREN'S MEMORIAL. AND SHE RUNS AN HIV CLINIC TO THIS DAY IN RURAL KENYA. I'M SURE SHE FLIES HER PRIVATE JET THERE SO SHE'S GOT TO GET PROPS FOR THE PRIVATE JET BUT SHE TO THIS DAY AS A NURSE RUNS A CLINIC FOR HIV INFECTED CHILDREN IN RURAL KENYA. SO THAT'S LIKE MY KIND OF PHILANTHROPIST. SO IF YOU'RE NOT ALREADY BORED I'LL MOVEN TO MY TALK WHICH WILL BORE YOU IF THE STORIES DIDN'T. SO I'M GOING TO TALK ABOUT UNDERSTANDING HIV RISK IN YOUNG MEN WHO HAVE SEX WITH MEN AND YOUNG TRANSGENDER WOMEN. I UNDERSTAND YOU GUYS DID A LITTLE READING AROUND WHAT THE WORD TRANSGENDER AND SOME OF THE COMPLEXITY HIV RISK THAT MY TEAM WROTE IN TRANSGENDER WOMEN. SO THAT'S A GOOD -- AND FEEL FREE TO RAISE YOUR HAND, INTERRUPT ME, THIS IS FOR YOU. AS YOU CAN TELL I'M RELATIVELY LAID BACK AND CAN HANDLE IT IF YOU SCREAM OUT A QUESTION OR TWO. I START EVERY LECTURE WITH HIV WITH THIS SLIDE. I DON'T WANT TO DATE MYSELF BUT I WAS A TEENAGER LIVING IN NEW YORK CITY AT THIS TIME IN 1981 SO YOU CAN KIND OF FIGURE OUT MY AGE. BUT THIS WAS THE PHASE OF AIDS IN 1981. I ACTUALLY REMEMBER THIS NEWSPAPER ARTICLE OR THIS PARTICULAR STORY LINE THAT RAN IN THE NEWSPAPERS IN NEW YORK CITY AT THE TIME. AND IT WAS CANCER IN THE GAY COMMUNITY. THEY DIDN'T EVEN KNOW WHAT HIV WAS AT THAT POINTE IN 1981, THEY DIDN'T ISOLATE THE VIRUS. WHAT THEY SAW IN 1981 WAS A GROWING NUMBER OF CASES OF VERY UNUSUAL CANCER THAT HAD PREVIOUSLY ONLY BEEN SEEN IN MEN OF MEDITERRANEAN WHICH IS CALLED CAPACESES SARCOMA, WHICH RARE IN THE HIV FIELD. IT ALSO HAPPENED IN IMMUNOCOMPROMISED PEOPLE SO THERE WERE CROPS OR CLUSTERS OF OMEN IN URBAN CENTERS LIKE NEW YORK, SAN FRANCISCO, MIAMI, LOS ANGELES THAT PRESENTED WITH CAPASES SARCOMA SO THERE BECAME THE NOTION THIS WAS JUST CANCER IN THE GAY COMMUNITY. IT WEPT FROM THIS NOTION TO SOMETHING CALLED GRID OR GAY-RELATED IMMUNE DEFICIENCY. SO THERE ARE THERE WERE ALL THEE THINGS BEFORE ANYONE MENTIONED THE WORD AIDS OR HIV. IN FACT FROM A POLITICAL STANDPOINT THERE WAS A LOT GOING ON BACK THEN AND IF YOU WANT TO WATCH A GOOD HISTORICAL PERSPECTIVE YOU CAN WATCH AND THE BAND PLAYED ON. ANGELS IN AMERICA IS ALSO REALLY GOOD. BUT RONALD REAGAN WAS THE PRESIDENT AT THIS POINT, LIKE DID NOT MENTION, DIDN'T UTTER THE WORD HIV UNTIL 1985. EVEN THOUGH WE KNEW HIV WAS AN ENTITY AS EARLY AS 1982, 1983, AND THE HI COMMUNITY TO THIS DAY -- HIV COMMUNITY TO THIS DAY LARGE EXTHE TENT I HEARD RACHEL MADDOU TALK THIS ABOUT THIS LAST NIGHT AT HOME. STILL BLAME RONALD REAGAN FOR NOT ACTING AS PROACTIVELY AS HE COULD HAVE TO PREVENT WHAT HAS BECOME A NATIONAL CRISIS. SO THAT WAS 1981. THEN IN 1986 THESE WERE THE HEADLINES WE BEGAN TO THE SEE. THIS WAS THERE WAS A HOPE WERE WE ABOUT TO SEE THE END OF AIDS. WHAT HAPPENED IN 1986 WAS ADVENT OF MULTI-DRUG ANTIRETROVIRALTHER P BY OR WE USED TO CALL HART OR HIGHLY ACTIVE ANTIRETROVIRAL THERAPY. WE DON'T USE THAT TERM WE JUST USE ANTIRETROVIRAL THERAPY, IMPLICIT WE'RE TALKING MULTIPLE DRUG REGIMENS BUT UNTIL 1986 WE DIDN'T HAVE A THAT OPTION FOR CHILDREN FOR INSTANCE BORN BEFORE 1996 OR EVEN ANYONE THAT WAS AFFECTED THEY WERE PUT ON SEQUENTIAL MEDICINES, ONE AT A TIME. WHICH WE NOW KNOW WOULDN'T WORK. BUT THERE WAS THIS IDEA IN 1996 OF WE FINALLY FIGURED OUT DID WE -- DID WE FINALLY HAVE THE CLUE THAT WAS GOING TO MEAN THE END OF HIV OR AIDS? WE KNOW THAT WASN'T THE CASE AND WE'RE LEFT HERE IN 2013 WITH LIKE IS AIDS OR HIV SOMETHING WE'RE GOING TO LIVE WITH FOREVER? WE KNOW FROM DATA COMING OUT OF MOSTLY EUROPE THAT THE LIFE EXPECTANCY NOW FOR PEOPLE THAT GET DRUGS IS -- CAN BE NORMAL. PEOPLE NOW WHEN THEY'RE -- WHEN THEY DIE OF HIV-RELATED DISEASE IT TENDS TO BE THE THINGS OTHER PEOPLE DIE FROM, HEART ATTACK, STROKE. PEOPLE AREN'T DYING ANY MORE, NOT ANYONE BUT THE MAJORITY OF PEOPLE AREN'T DYING FROM CAPASES SARCOMA OR PNEUMOSIS AT THIS PNEUMONIA, THINGS WITH WE USED TO TALK ABOUT ALL THE TIME WHEN I WAS A MEDICAL STUDENT. WHEN I WAS A STUDENT IN NYU IN 1990, 91 AND 92, I DID MY SUBINTERNSHIP AT THE MAP HAT TAN VA WHICH WAS A NIGHTMARE FRANKLY. BUT THEY WERE FOUR ENTIRE FLOORS OF THE HOSPITAL DEDICATEED TO PEOPLE THAT HAD HIV IN PATIENT HIV WITH IMMUNOCOMPROMISED. TWO FLOORS WITH PEOPLE THAT BOTH HAD HIV AND TB. SO YOU CAN THINK ABOUT LIKE NOW WE'D WALK INTO A HOSPITAL AND YOU WOULD BE HARD PRESSED TO FIND A PATIENT. AS HIV. IT'S BECOME A BIG ISSUE IN MEDICAL EDUCATION IN SOME WAYS BECAUSEe GET THE EXPOSURE TO LIKE HIV THEY MIGHT HAVE OTHERWISE. SO ANYWAY, I THINK EVEN THOUGH WE WANT TO CONTINUE TO APPROACH PREVENTION, PRIMARY PREVENTION IS AN IMPORTANT THING, I'M A PROMEANT OF PRIMARY AND SECONDARY PREVENTION. SOME PEOPLE ARE LIKE WELL IF IT'S NOW LIKE A CHRONIC ILLNESS WHY DO WE HAVE TO CARE SO MUCH ABOUT HIV PREVENTION? BECAUSE IT IS LIVING WITH HIV ANY EASIER THAN IT WOULD BE TO TRY TO PREVENT IT? IT'S STILL A VERY PREVENTABLE DISEASE AND AS SOMEONE ACTUALLY HI POSITIVE HIMSELF, IT ANOTHER A DISEASE UP LIKE ANY DISEASE KNOWN TO MAN IN THE SENSE IF YOU HAVE CANCER, YOU HAVE SICKLE CELL DISEASE OR YOU HAVE CYSTIC FIBROSIS OR GOD FORD BY P TB OR ANYTHING, IT'S IMPLICIT THAT YOU'RE GOING TO HAVE THE LOVE AND SUPPORT AND -- OF YOUR FAMILY AND FRIENDS AND EVERYBODY IN YOUR SOCIAL NETWORK. STILL TO THIS DAY THE IT'S FUNDAMENTALLY UNTRUE AND WE START TALKING HIV. THAT'S A DYNAMIC THAT I THINK SHOULD BE RELATIVELY EASY TO CHANGE BUT IT'S WEDDED IN THIS 30 YEARS OF HISTORY THAT'S CLOAKED IN SECRECY AND STIGMA AN SHAME. SO IT'S WITH THAT SORT OF THAT I MOVE ON TO WHAT I THOUGHT OF YOUR EDUCATIONAL OBJECTIVES MY OBJECTIVES TO TRY TO TEACH YOU SOMETHING, TO UNDERSTAND A LITTLE BIT ABOUT THE EPIDEMIOLOGY OF HIV RISK AND HIV AMONG U.S. ADOLESCENTS AND YOUNG ADULTS TO LEARN OR UNDERSTAND CONTEXTUAL INFLUENCES RELATED TO HIV RISK SPECIFICALLY RELATED TO THE HIGH RISK GROUPS THAT I DO THE MOST WHICH IS YOUNG MEN WHO HAVE SEX WITH MEN OR TRANSGENDERRER YOUTH MOSTLY TRANSGENDER WOMEN. AND TO LEARN ABOUT SOME POTENTIAL APPROACHES, SOME OF THE NIH FUNDED WORK THAT WE'RE DOING IN YOUR UNIT. IN TERMS OF EPIDEMIOLOGY, I PULLED THESE OFF THE CDC WEBSITE AND YOU CAN FIND THESE, THEY'RE EASY TO GET ON THE WEB. BUT YOU CAN SEE OF ALL THE TRANSMISSION CATEGORIES MALE TO MALE SEXUAL CONTACT OR MEN WHO HAVE SEX WITH MEN CONTINUE TO BE THE ONLY CATEGORY WHICH THERE ARE RISING RATES OF HIV STILL TO THIS DAY, IF IF YOU BROKE THAT DOWN BY AGE, IT'S REALLY IN THE YOUNG MSM RANGE, 16 TO 29. THAT'S CONSISTENT ACROSS GEOGRAPHIC AREAS OTHER THAN ACTUALLY IN THE SOUTHEAST PORTION OF THE UNITED STATES WHERE YOUNG WOMEN CONTINUE TO BEAR SIGNIFICANT BURDEN OF INFECTIONS BUT IN OTHER PARTS OF THE U.S., THOUGH WE FOUGHT, I SPENT MY CAREER PRIOR TO MEDICINE AS THIS COMMUNITY ACTIVIST. WE FOUGHT FOR YEARS TO SAY THIS ISN'T A GAY DISEASE, I OOH E NOT IT CAN AFFECT EVERYONE BUT WE PAID PRICE FOR THAT BUT IT STILL IN MANY WAYS IS A GAY DISEASE AND DESERVES SOME ATTENTION TO BUT IF YOU LOOK AT SUBSAHARAN AFRICA OR OTHER PARTS OF THE WORLD IF ASPECTS OF THE EPIDEMIC AREN'T CONTAINEDDED IT CAN BREAK THROUGH AND TRANSMISSION CAN OCCUR ACROSS MANY DIFFERENT DEMOGRAPHIC GROUPS. I'LL FOCUS MY ATTENTION ON YOUNG GAY MEN AND TRANSGENDERRER WOMEN BECAUSE THAT'S WHEY DO THE MOST OF. YOU CAN LOOK AT RACIAL ETHNIC BREAK DOWN IN KIDS 13 TO 19 OR YOUNG PEOPLE AGE 20 TO 24. THE PIE GRAPHS ARE SIMILAR HERE. THE DISTINCTION HERE IS YOU CAN SEE THAT WHY WOULD BLACK OR AFRICAN AMERICAN PEOPLE REPRESENT ABOUT 14% OF THE U.S. POPULATION, THEY REPRESENT 55 TO 60 IN SOME CASES 70% OF THE CURRENT HIV EPIDEMIC. SO THAT'S NOT JUST A DISPROPORTIONATE BURDEN, THAT IS LIKE PUBLIC HEALTH MAYHEM IN MY OPINION IN MANY COMMUNITIES. THIS IS IS SOMETHING THAT NOW I THINK IN THE PAST FOUR OR FIVE YEARS HAS BEGUN TO GET PEOPLE'S ATTENTION. THIS SHOULD HAVE GOTTEN PEOPLE'S ATTENTION A LONG TIME AGO. AND WE NEED TO DO INCREASED WORK IN COMMUNITIES AND THINK ABOUT WHAT ARE SOME STRUCTURAL THINGS IN BLACK OR AFRICAN AMERICAN COMMUNITIES LIKE RELIGIOUS ORGANIZATIONS THAT WE CAN TAP INTO TO HELP. WE HAVE A PAPER THAT'S COMING OUT IN A COUPLE OF MONTHS THAT FOCUSES ON RELIGION AS A PROTECTIVE FACTOR IN THE LIVES OF YOUNG GAY MEN WITH HIV. SOME THINK OH, WELL, THEY'RE GAY AND THEY CAN BE RELIGIOUS. PEOPLE ARE MULTIPLE IDENTITIES, JUST BECAUSE THEY'RE GAY DOESN'T MEAN THEY CAN'T BE ITALIAN OR A JEW. OR BLACK. OR HAVE OTHER -- OR BE A WRESTLER OR A TENNIS PLAYER. PEOPLE HAVE DIFFERENT IDENTITIES AND WE NEED TO LOOK AT THE VARIOUS IDENTITIES IF WE WANT TO CAPTURE HOW WE'RE GOING TO MAKE INROADS AROUND PREVENTION BECAUSE WE HAVE HAD A HARD TIME CRACKING 40 TO 50,000 NEW INFECTIONS OCCUR EACH YEAR.pt„ THIS IS MY FAVORITE PIE GRAPH, THOUGH IT'S KIND OF SAD, WHAT I LIKE ABOUT THIS GRAPH TO SOME EXTENT SPEAKS TOEN ARTIFACT THAT FOR MANY YEARS MISLED THE PUBLIC HEALTH COMMUNITY. SO THIS GRAPH, 13 TO 19, 20 TO 24, GREATER THAN 25, THE RATES OF HIV BETWEEN MEN AND WOMEN IN THIS COUNTRY ARE HUGELY DISPROPORTIONATE IN TERMS OF MEN VERSUS WITH WOMEN. IF YOU LOOK AT RISK CATEGORIES WITHIN THE YELLOW AND GREEN PIE CHARTS, YELLOW PIE CHART, YOUNG MEN WHO HAVE SEX WITH MEN OR MEN HAVING SEX WITH MEN ARE THE OVERWHELMING MAJORITY. YOUNG MEN WHO HAVE SEX WITH MEN WHO ACQUIRE HIV OUTNUMBER YOUNG WOMEN WHO GET HIV ACROSS ALL RISK CATEGORIES YOUNG WOMEN CAN GET HIV FROM. IF YOU LOOK AT THE GRAPH FIVE YEARS AGO IT WAS DIFFERENT. ANYONE REMEMBER WHAT THIS LOOKS LIKE FIVE YEARS AGO? YOU GUYS ARE YOUNG. BUT THIS GRAPH PARTICULARLY ON THE -- I DON'T KNOW YOUR LEFT LOOKED LIKE 50/50. SO IT LOOKED AS THOUGH YOUNG WOMEN, P IF NOT OUTNUMBERED YOUNG MEN WAS ABOUT -- STILL WAS ABOUT EQUAL. YOUNG WOMEN BY AND LARGE AT THAT POINT OUTNUMBERED YOUNG MEN. BUT IT ACTUALLY WASN'T EPIDEMIOLOGIC REALITY, IT WAS AN ARTIFACT OF WHAT WE SEE UP THERE WHICH IS NOW YOU SEE 46 STATES AND FIVE U.S. DEPENDENT AREAS. THAT'S BECAUSE THE CDC AND FEDERAL GOVERNMENT DECIDED TO MANDATE THAT ALL STATES REPORT INCIDENT CASES OF HIV TO THE CDC PRIOR TO THAT FIVE YEARS AGO IT WAS VOLUNTARY. SO STATES THAT WERE PROGRESSIVE OR BLUE STATES LIKE ILLINOIS, MASSACHUSETTS AND NEW YORK AND CALIFORNIA, THEY TOOK THIS REAL LIKE ADVOCACY STANCE AROUND TRYING TO PROTECT PEOPLE, THEY WERE AFRAID OF REPORTING, PEOPLE BY NAMES TO THE FEDERAL GOVERNMENT AND NOT WITHOUT REASON. BUT THOSE STATES WHICH HAD LARGE NUMBERS OF INFECTED MSM WERE NOT REPORTING THEIR CASES TO THE CDC YET ALL THOSE STATES IN THE SOUTHEAST WHICH STILL TO THIS DAY HAVE YOUNG WOMEN GETTING INFECTED SO THOSE STATES DOMINATED, IT WAS ABOUT 32 STATES AS OPPOSED TO 46. SO THE ADDITION O THOSE 14 TO 15 ADDITIONAL STATES HAS COMPLETELY CHANGED THE DEMOGRAPHIC. BUT IN SOME WAYS IT CREATED THIS ARTIFACT THAT ALLOWED US, AND I'LL GET TO IT IN MY TALK BUT ALLOWED US TO NOT FOCUS ON YOUNG GAY AND BISEXUAL MEN IN A WAY WE NEEDED TO. WE'RE BEHIND THE 8 BALL NOW. IF YOU THINK OF THE INTERVENTIONS THAT WE'RE GOING TO TALK ABOUT THERE'S NOT A SINGLE PROVEN INTERVENTION FOR YOUNG GAY MEN THAT HAS EVER BEEN SHOWN TO BE EFFECTIVE AGAINST HIV. NOT ONE. NOT ONE IN THE PUBLISHED LITERATURE. THAT'S CRAZY, IF COW THINK HOW LONG WE SHOULD HAVE KNOWN THIS P POPULATION WAS AT RISK. THIS SLIDE SPEAKS TO THAT. SO IF YOU THINK OF YOUNG MSM AND SEX ED, SCHOOL BASED PROGRAMS YOU CAN IMAGINE BEING LIKE HIGH SCHOOL AND YOUR TEACHER STARTS TALKING GAY SEX IN HIGH SCHOOL, NOT THE WAY SEX ED PROGRAMS IN MAINSTREAM HIGH SCHOOLS ARE ORIENTED. SO YOUNG GAY MEN DON'T GENERALLY RECEIVE SEX ED IN A FORMAT THAT IS WITHIN THEIR SCHOOL SYSTEMS OR WITHIN THEIR HOME. THEY'RE ALSO LESS LIKELY TO RECEIVE SEX ED AT ALL DESPITE DESIRE FOR IT AND SEVERAL REVIEWS RECENTLY OF MORE THAN 60 ARTICLES THAT LOOKEDDED AT THE INTERVENTION LITERATURE IN ADOLESCENTS AND YOUNG ADULTS IN THE UNITED STATES AND NOT A SINGLE ARTICLE OUT OF 60 SHOWED A SINGLE EFFECTIVE INTERVENTION AGAINST YOUNG MEN WHO HAVE SEX WITH MEN. PART BECAUSE OF THAT ARTIFACT ON THAT OTHER PAGE SO THE LION'S SHARE OF FUNDING UP UNTIL THE 2006 REALLY WAS WHEN THE CDC HAD AND A HA MOMENT RELATED TO EPIDEMIOLOGY. BUT UP UNTIL 2006 MORE THAN 90% OF THE FUNDING DIRECTED TOWARDS ADOLESCENT HIV WAS DIRECTED TOWARDS YOUNG WOMEN, SCHOOL BASED YOUTH, HOMELESS YOUTH, NONE GOT DIRECTED TO THE POPULATION WE KNOW NOW KNOW, HAS BEEN AT RISK FOR 25 YEARS. SO THAT'S A FAILURE OF THE PUBLIC HEALTH COMMITTEE, IT'S A FAILURE OF THE GAY COMMUNITY. IT'S A FAILURE OF EVERYONE ALONG THE CHAIN. WHY WAS IT A FAILURE? I BELIEVE IT'S A FAILURE BECAUSE THIS IS A INCONVENIENT GROUP TO WORK WITH. BECAUSE IF YOU'RE TRYING TO WORK WITH YOUNG MEN WHO HAVE SEX WITH MEN IN AN ACADEMIC INSTITUTION YOU HAVE TO FACE THINGS LIKE INSTITUTIONAL REVIEW BOARDS LIKE IRBs. SO WHAT'S IT LIKE TO ENGAGE A YOUNG GAY MAN IN RESEARCH MAYBE AROUND HIV PREVENTION WITHOUT PARENTAL CONSENT. THERE'S STILL INSTITUTIONS IN THE NATION THAT WOULD NOT ALLOW IT TO HAPPEN. THEY WOULD ABSOLUTELY INSIST. SO WHAT WOULD IT BE LIKE TO BE A CLOSETED ADOLESCENT YOUNG GAY MAN AND HAVE TO ASK YOUR MOTHER FOR PERMISSION TO PARTICIPATE. THE DYNAMIC DOESN'T WORK. THAT'S ISSUES AROUND CONDUCTING RESEARCH WITH THIS POPULATION THAT ARE TIKI. THOSE IN THE GAY COMMUNITY, THERE'S SUCH A STIGMA AROUND WHAT IT WOULD BE LIKE FOR LIKE AN ADULT GAY MAN TO ADVOCATE FOR YOUNG GAY MEN. THAT'S A PREDATORY STIGMA THAT PREVENTS PEOPLE IN THE GAY COMMUNITY, I THINK REALLY HAVING DONE WHAT THEY SHOULD HAVE DONE FOR MANY YEARS, STEP FORWARD, SPEAK THE TRUTH AND ADVOCATE FOR A POPULATION THAT NOW WE SEE IS REALLY BEING DECIMATED. I DON'TIOUS THAT TERM LIGHTLY WITH INCIDENT HIV INFECTIONS. ONE THING I WANT TO SAY, HIV IS COMPLEX. EN I KNOW NANCY REAGAN ONCE SAID JUST SAY NO TO DRUGS. WE CAN TALK CONDOMS ALL YOU WANT AND I THINK IT'S IMPORTANT TO TALK ABOUT BUT WHAT'S IT LIKE TO BE A YOUNG GAY MAN OR YOUNG TRANSGENDER YOUTH WHO MIGHT NOT KNOW WHERE THE NEXT MEAL IS OR MIGHT BE WORRIED IF THEIR PARENTS FIND OUT ABOUT SEXUALITY THAT THEY'LL END UP ON THE STREET. SO WHAT'S IT LIKE TO TALK ABOUT SAFE SEX OR CONDOM USE WHEN THEY MIGHT BE WORRIED ABOUT ACCESS TO HEALTHCARE, ACCESS TO HOUSING OR BEING VICTIMS OF VIOLENCE OR BULLIED IN SCHOOL. THERE'S BEEN A RASH OF BULLYING CASES AMONG GAY YOUTH ACROSS THE COUNTRY. HOUSING INSTABILITY. ECONOMIC MARGINALIZATION. FOR TRANSYOUTH, THEY'RE MY PEEPS I LOVE WORKING WITH THE TRANSGENDER COMMUNITY. IN PART BECAUSE NO ONE HAS GENERALLY DONE IT WELL AND THEY'RE SO APPRECIATIVE IF YOU LIKE DIVE IN AND REALLY TRY TO HELP THEM. BUT THE COMPLEXITY OF COMMERCIAL SEX WORK AS HIV RISK FOR THIS GROUP IS SO UNDERSTATED. I THINK IT WAS IN THE ARTICLE YOU GUYS SHOULD HAVE READ. OR IF I WROTE THE ARTICLE SHOULD HAVE BEEN. WHICH IS THAT SEX WORK VALIDATES A GENDER IDENTITY FOR THEM THAT IS KIND OF ELUSIVE SO THEY HAVE A HARD TIME FINDING MEN TO DATE OR BE INTERESTED IN THEM AS ROMANTIC OR SEXUAL PARTNERS SO DOING COMMERCIAL SEX WORK IN SOME ODD WAY VALIDATES THIS GENDER IDENTITY THAT THEY'RE DYING TO HAVE EMBRACED. AND IT'S A PATHWAY FOR MANY YOUNG PEOPLE TO ECONOMIC STABILITY, THAT IS OTHERWISE ELUSIVE. THEY CAN'T GET JOBS, THEY HAVE A HARD TIME SEEKING EMPLOYMENT OR MY UNIT AT LURIE WITH SOME OF THE NIH GRANTS I'LL TALK TO YOU ABOUT, WE WERE THE FIRST UNIT TO ACTIVELY TRY TO HIRE TRANSGENDER WOMEN IN OUR -- AT THE HOSPITAL. FROM AN HR PERSPECTIVE IT WAS A TOTAL NIGHTMARE TO TRY TO GET LIKE THE HR TEAM AND HR POLICIES TO WORK FOR THIS POPULATION THAT HAVE NEVER HAD JOBS BEFORE. SO HERE WE WERE, I HAD THIS NIH GRANT WHICH WAS GREAT, IT'S A TWO CITY TRIAL, WE'LL TALK ABOUT IT BUT HAVE TO HIRE TRANSGENDER WOMEN TO BE LIKE RESEARCHERS. WELL, YOU GO TRY TO FIND TRANSGENDERRER WOMEN IN THE COMMUNITY THAT HAVE UNDERGRADUATE DEGREES OR MASTERS DEGREES. IT'S HARD. SO I ENDED UP HIRING WHAT I WOULD CALL DIAMONDS IN THE ROUGH, SOME HAD NEVER HAD A JOB BEFORE. BUT WE HAD TO TRAIN THEM TO BE SORT OF RESEARCHERS TO IMPLEMENT THE INTERVENTIONS WE'RE GOING TO TALK ABOUT. SO I LOVE THAT ASPECT OF MY JOB, WE HAVE SIX TRANSGENDER WOMEN IN MY PROGRAM OF THOSE SIX FIVE HAD NEVER HAD A FULL TIME JOB BEFORE WORKING IN THE UNIT NOW THEY'RE ALL EMPLOYED BY THE NIH OR EMPLOYED BY MY HOSPITAL THROUGH THE NIH. SO I THINK THIS QUOTE FROM A TRANSGENDERRER YOUTH IN MY PROGRAM DURING A STUDY THAT I THINK SUMS IT UP NICELY, SHE WAS 19, THIS WAS A STUDY IN 2003, SHE SAID PREVENTING HIV IN GIRLS IS COMPLICATED. WE NEED JOBS PLACES TO STAY, HIV IS JUST ONE OF MANY PROBLEMS WE DEAL WITH. SO THAT LEAVES YOU WITH THE IDEA OF CAN YOU BEGIN TO MAKE INROADS IN HI WHEN YOU TRY THE TACKLE AND INDIVIDUAL BEHAVIOR OR DO YOU TRY TO TAKE THIS ENDEMIC OR HOLISTIC APPROACH WHICH IS OBVIOUSLY MUCH MORE COSTLY, IT'S DIFFICULT. EACH COMMUNITY IS DIFFERENT, THE SOCIAL REALITIES OF YOUNG TRANSGENDER WOMEN ARE NOT THE SAME AS YOUNG GAY MEN, NOT THE SAME AS HOMELESS THEY MAY OVERLAP BUT THEY'RE NOT THE SAME SO TRYING TO HAVE HOLISTIC APPROACHES CAN BE VERY EXPENSIVE BUT IS IT POSSIBLE TO ADDRESS ONE OF THE PROBLEMS WITHOUT TRYING TO ADDRESS THEM ALL. I DON'T KNOW THE ANSWER TO THAT QUESTION. I TEND TO THINK NO BUT IT'S HARD TO ADDRESS THOSE PROBLEMS, THROW IN MENTAL HEALTH ISSUES AROUND PTSD WHICH IS HUGE IN THIS POPULATION, PARTICULARLY AROUND BULLYING OR SUBSTANCE USE, NOT JUST LIKE THE SEXY SUBSTANCE LIKE METHAMPHETAMINE, I'M GUILTY, I HAVE WRITTEN ARTICLES ON METHAMPHETAMINE. I'LL ADMIT IT'S GOT GRANT MONEY BEFORE, HAPPY TO GET IT BUT WE DON'T TALK ENOUGH ABOUT ALCOHOL. IF YOU WANT TO TUCK ABOUT A SUBSTANCE THAT IS CREATING POOR SEXUAL DECISION MAKING IN THIS POPULATION, ALCOHOL. FOR THE YOUTH THAT ARE USING METH IF YOU USE METH THAT IMPARTS ANOTHER LEVEL OF RISK BUT ON A POPULATION BASE LEVEL STILL ROLE THRIVE FEW PEOPLE USE METH IN PAIR SON TO THE OVERWHELMING NUMBER OF YOUNG ALCOHOL OR ABUSE ALCOHOL SO I THINK SOMETIMES WE GET IT JUMBLED IN OUR HEADS FOR WHAT WE WANT TO FUND FROM WHAT IS SEXY VERSUS WHAT MIGHT HAVE SOME SORT OF PUBLIC HEALTH SIGNIFICANCE. I WANT TO GO BACK, I'M SO GLAD YOU TOLD ME I HAVE UNTIL 6 THOUGH I WON'T KEEP YOU THAT LONG, BUT I CAN TAKE MY TIME. ONE THING I WANT TO TELL YOU ABOUT THESE STUDIES IS SOME PEOPLE THINK IN ORDER TO DO RESEARCH, YOU HAVE TO HAVE MILLIONS OF DOLLARS FROM THE NIH. IT'S NICE TO HAVE MONEY FROM THE NIH. IT'S TAKEN LONG IN MY CAREER TO HAVE IT. BUT EACH STUDY I'LL SHOW YOU U THAT I NOW HAVE NIH MUST BE FOR NOT ONE STARTED WITH A PILOT PROJECT THAT I DIDN'T IMPLEMENT FOR UNDER $1,000 SO I'M LIKE THE K-MART SHOPPER OF LIKE HIV PREVENTION RESEARCH. YOU DO NOT NEED A MILLION DOLLARS TO DO REALLY GOOD RESEARCH, YOU JUST NEED A GOOD IDEA AND INTERESTED PEOPLE, AND I'LL TALK THROUGH HOW WE DID THIS. SO THE TRANSGENDER STUDIES THAT -- I TELL YOU THAT WHEN I GET THERE BUT OPEN OF THE STUDIES I'M GOING TO TAUGHT TALK ABOUT STARTED WITH A PILOT UNDER $1,000. VERY PROUD OF THAT. AS YOU CAN TELL. SO EXAMPLES, WE'RE LUCKY WE HAVE I THINK I HAVE BEEN A PI OF LIKE 8 NIH GRANTS IN THE PAST FIVE YEARS WHICH IS PRETTY COOL. SO WE HAVE A BUNCH OF PROJECTS BOTH PRIMARY PREVENTION, WHICH IS TRYING TO PREVENT THE ACQUISITION OF HIV IN A NEGATIVE POPULATION, THEN WE HAVE SECONDARY PREVENTION PROJECTS WHICH TARGET HIV POSITIVE YOUTH AND THEN WE HAVE ONE PROJECT THAT TARGETS BASIC DATA COLLECTION WHICH IS VERY IMPORTANT IN THIS POPULATION. SO I'M GOING TO GO THROUGH EXAMPLES OF EACH OF THESE JUST TO GIVE YOU A FLAVOR OF WHAT OUR UNIT WORKS ON. WHAT OUR UNIT WORKS ON IS VERY WEDDED IN A COMMUNITY BASED MODEL OF RESEARCH. WE DON'T DO THE MOST SOPHISTICATED WORK. BUT IF YOU ASK ME QUESTIONS ABOUT PHYSICAL ANALYSES, I MAY DRINK A GLASS OF WATER AND PRETEND I DIDN'T HEAR YOU BECAUSE I MAY NOT ANSWER THOSE QUESTIONS. I CAN CONDUCT RESEARCH THAT HAS SIGNIFICANT IMPACT ON THESE COMMUNITIES AND THAT'S SORT OF OUR TEAM GOAL. SO LIFE SKILLS. THIS WAS A STUDY INITIALLY FUNDED BY THE CDC, CURRENTLY A TWO CITY EFFICACY TRIAL FUNDED BY NIMH. THIS STARTED WITH $500, A SONG AND A PRAYER FOR ME BACK IN 2002, OR 2003 REALIZING LIKE NO ONE HAD DONE JACK ON TRANSGENDER WOMEN REGARDS HIV, I GOT $500. WE HAD A BAKE SALE, I SWEAR TO GOD. WE MADE CUP CAKES SOLD THEM AT A LOCAL BAR AND RAISED $500. I ENGAGED THE TRANSGENDER COMMUNITY WITH $500 AND MOTIVATED GRADUATE STUDENT TO COLLECT DATA FOR THREE MONTHS BECAUSE IT'S ALL WE HAD, ALL WE COULD AFFORD, THREE MONTHS TO COLLECT DATA ON PERCEPTIONS OF RESEARCH AND HIV RISK, BLAH, BLAH, BLAH. AMONG TRANSGENDER WOMEN OF COLOR. WE'RE USING A COMMUNITY PARTICIPATORY RESEARCH MODEL. SO I HAD THIS GRATITUDE, WE MET WITH TRANSGENDER COMMUNITY LEADERS AND WE TALKED ABOUT INSTITUTIONAL REVIEW BOARDS AND SELF-ESTEEM MEASURES. THEY WERE LIKE HALF THE TIME THEY WERE BORED TO TIERS BUT THEY HUNG IN THERE WITH US AND BUILT THIS QUESTIONNAIRE. SURE ENOUGH IN THREE MONTHS WE WERE ABLETO RECRUIT 51 YOUNG TRANSGENDER WOMEN OF COLOR. I PARLAYED THAT MEASLY SAMPLE TO THREE PUBLICATIONS IN A MAN OF A YEAR. I HAVE WORKED MY AS OFF TO SELL THAT BABY BECAUSE I WAS LIKE I SAW THAT LIKE THERE WAS GOING TO BE A FUTURE HERE, NOBODY HAD DONE IT. IF I CAN GET MY NAME OUT THERE IN TERMS OF SOMEONE THAT DOES THE WORK WELL, WHEN FUNDING IS AVAILABLE IT WILL BE HARD TO DENY MY TEAM FUNDING. THAT'S WHAT HAPPENED. SO IN 2006 WHEN THE EPIDEMIOLOGISTS STARTED TO SHIFT, THE CDC PUT OUT A CALL FOR GROUND BREAKING INTERVENTIONS. SO WE WROTE THIS PROPOSAL TO DO A GROUND BREAKING PILOT WITH WITH THIS IMMUNITY BASED PARTICIPATORY RESEARCH MODEL WHERE WE HAD YOUNG TRANSGENDERRER WOMEN SUPERVISED BY RESEARCH TEAM, THEY WROTE THE WHOLE INTERVENTION THEMSELVES. SO WE MADE SURE THAT IT WAS GROUNDED IN THE APRIL THEORY BECAUSE THE NIH BEHAVIORAL THEORY. IF THERE'S NOT A THEORY ATTACHED, DON'T STAND A CHANCE OF GETTING FUNDED. SO WE HELPED THEM MAKE SURE THE STUFF THAT WAS GROUNDED IN THEIR SOCIAL REALITIES FIT INTHE BEHAVIORAL THEORY BUT WE LET THEM GO WITH IT. THIS IS THEIR INTERVENTION. WE APPLIED TO THE CDC AND THEY FUNDED IT FOR A TWO YEAR PILOT. I WILL SAY ONCE WE GOT THE AWARD, THE CDC TURNED AROUND, THIS SPEAKS TO INCONVENIENCE OF SAM LING, THEY SAID WE WANT -- SAMPLING, WE WANT TO GIVE YOU THIS AWARD, IT'S A GREAT PROJECT AND WEDDED, THINGS THE CDC CARES ABOUT BUT CAN YOU JUST DO IT 18 AND ABOVE? THEY ASKEDS TO DO THAT BECAUSE THEIR OWN IRB AND THEY WERE AFRAID IRBs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j TEENAGER IT WOULD HAVE BEEN EASIER TO REACH IN MY POCKET AND SHOVE OUT A CONDOM AND PUT IT ON THE TABLE THEN WHAT DO YOU THINK ABOUT USING A CONDOM TONIGHT BECAUSE IT MIGHT BE A GOOD IDEA. THAT'S TOUGH IN A LOT OF SITUATIONS BUT WE DON'T FOCUS ENOUGH ON LIKE NON-VERBAL COMMUNICATION SKILLS WHEN WE TEACH YOUNG PEOPLE. SO SELF-ADVOCACY SKILLS UNEMPLOYMENT HOUSING AN HEALTHCARE, HIV EDUCATION, BLAH, BLAH. WE DID NOT MENTION HIV IN THIS INTERVENTION UNTIL SESSION 4. WHEN WE INITIALLY PROPOSE TO THE CD,C, THEY WERE LIKE WHAT? YOU CAN'T HAVE HIV INTERVENTION THAT DOESN'T TALK ABOUT HIV UNTIL SESSION 4 OF 6 BUT ACTUALLY IT MADE SENSE BECAUSE THERE'S A LOT OF HIV BURN-OUT. FOR SOME OF THESE TRANSWOMEN AS THAT QUOTE TOLD YOU, THEY WERE LIKE YEAH, YEAH, WE WANT TO KNOW ABOUT HIV BUT WE HAVE OTHER PROBLEMS, WE'RE NOT GETTING JOBS OR HOUSING. SO THIS INTERVENTION IS VERY WELL GROUNDED. PARTNER NEGOTIATION SKILLS, ACCESSING RESOURCES. BASELINE CHARACTERISTICS WE RECRUITED 51 GIRLS FOR THIS INTERVENTION, 31% WERE HOMELESS, ALMOST ALL SEXUALLY ACTIVE. ONLY 10% STI DIAGNOSIS IN THE PAST THREE MONTHS, 40% REPORTED NOT USING CONDOMS AT THE LAST INTERCOURSE. ALMOST 30% ALREADY, UNDER AGE 24 ENGAGED IN COMMERCIAL SEX WORK. 63% OR 43% WERE IN JAIL OR PRISON, HAD ENGAGED IN THE CORRECTIONAL FACILITY SO THIS IS A HIGH RISK SAMPLE. THIS IS A VIN DIAGRAM, OF THE 51 PARTICIPANTS 38 ATTENDED ONE OR MORE SESSIONS. OF THOSE 38 ONLY 6 COMPLETED THREE MONTH RETAINED 80% IN THREE MONTHS WHETHER THEY ATTENDED A SESSION OR NOT. WE GOT GOOD FEEDBACK ON THE ACTUAL SESSIONS THEMSELVES. PEOPLE FELT IT HELPED ESTABLISH POSITIVE FRIENDSHIPS WITH WITH OTHER TRANSWOMEN. IF YOU KNOW ANYTHING ABOUT QUESTIONNAIRES THEY ALWAYS ANSWER THESE POSITIVES. THROUGH PURCHASE NICE TO HEAR. IT HELPED UNDERSTAND THINGS BETTER. CREATE POSITIVE GOALS FOR THEMSELVES, YADA YADA. SO THE CRUX WAS IN THE BEHAVIOR SO ON STATISTICAL ANALYSIS THE GROUP OR INTERVENTION GROUP HAD STATISTICALLY LOWER NUMBER OF MAIN SEX PARTNERS AND ALSO HAD ENGAGED IN UNPROTECTED INTERCOURSE AT STATISTICALLY LESS LEVELS THAN -- IN A PRE-POST TEST MODEL. THIS WAS DOWN AND DIRTY, IT WAS A PILOT STUDY BUT WE DIDN'T EXPECT TO ACTUALLY SEE BEHAVIORAL OUTCOMES THAT ARE PREPOST TEST WITH N OF 51. THAT'S A SMALL SAMPLE. SO THIS WAS PROMISING. WE WENT TO NIMH AND SAID HERE WE ARE. YOU NEVER FUNDED AN INTERVENTION FOR TRANSGENDER WOMEN, LET'S DO IT. THE NIMH GAVE US FIVE YEARS WORTH OF FUNDING. IT'S NOW A TWO CITY EFFICACY TRIAL BETWEEN BOSTON AND THE FENWAY IN CHICAGO IT IS A THREE ARM STUDY SO ACTUALLY ONE ARM GETS ROUTINE TESTING AND COUNSELING AND JUST GETS FOLLOWED IN TERMS OF LIKE EPIDEMIOLOGY. ONE ARM GETS THE BROCCOLI INTERVENTION FOCUSING ON LIKE HEALTHY EATING AND TIME MATCHED CONTROL. WE CAN TALK ABOUT DESIGNS IF ANYONE CARED. MOST WOULDN'T BUT IT'S A TIME MATCH CONTROL BETWEEN INTERVENTION ITSELF AND THE INTERVENTION. EACH SITE WILL RECRUIT OVER 200 YOUNG TRANSGENDER WOMEN UNDER AGE 24 OVER THREE MONTH FOLLOW THEM FOR 12 MONTHS NOW, NOT THREE MONTHS. AND THE GOAL IS, I DON'T KNOW IF YOU GUYS HEARD THE TERM DEBBIE, SO THEY'RE -- OH, MY GOD, DIFFUSIBLE EFFECTIVE BEHAVIORAL INTERVENTIONS. YOU GOOGLE DEBBIE YOU SEE THESE ARE INTERVENTIONS THAT HAVE A FORMAL CRITERIA APPROVED BY THE CDC SHOW PROMISE IN VARIOUS COMMUNITIES. THEY'RE BOXED AND SEALED, FUNDED ROLLED OUT IN IMMUNITIES ALL ACROSS AMERICA. THERE IS NOT A SINGLE DEBBIE FOR TRANSGENDER WOMEN, NOT A SINGLE DEBBIE FOR YOUNG GAY MEN. BUT THERE ARE DEBBIES FOR HOMELESS PEOPLE YOUNG WOMEN. SISTA IS A VERY POPULAR DEBBIE EMPOWERMENT, THAT'S ANOTHER ONE. THESE ARE INTERVENTIONS THAT HAVE BEEN SHOWN EFFECTIVE AND OUR HOPE IS THIS WILL BE THE FIRST DEBB WOMEN. MY PEEPS IS ANOTHER NIMH STUDY FUNDED BY THE NIMH A FEW YEARS BACK. THIS TARGETS YOUNG GAY MEN AGE 16 TO 20. THIS STUDY I DIDN'T DO A BAKE SALE. I GOT A THOUSAND DOLLARS FROM MY DEPARTMENT AND WE COLLECTED SOME PILOT DATA WITH THE HELP OF A GRADUATE STUDENT ON YOUNG MEN IN THE AREA AND THEIR EXPERIENCES WITH HIV PREVENTION RESEARCH AND USED THAT SMALL AMOUNT OF FORMATIVE DATA TO WRITE A PROPOSAL TO THE NIMH. YOU'LL SEE WHERE I THINK IT'S AN INTERESTING DESIGN IN A FEW MINUTES. IT'S -- MY PIECE HIV INTERVENTION PREVENTION FOR YOUNG MSM AGE 16 TO 20, YOUNG AGE GROUP THAT FOCUSES ON HARM REDUCTION, IT'S A MANUALIZED CURRICULUM, IT'S THEORY DRIVEN, SOCIAL COGNITIVE THEORY, GROUP BASED. WE USE THE SAME FORMAT SIX SESSIONS ACROSS THREE WEEKS. PRE- AND POST TEST SURVEYS. BUT THE INTERESTING PART, WHAT WE LEARNED IS HIV POSITIVE YOUNG MEN HAVE A LOT TO SAY ABOUT PREVENTION. THEY HAVE A LOT TO SAY ABOUT WHAT COULD HAVE BEEN DIFFERENT IN THEIR LIVES OR EXPERIENCES THAT MIGHT HAVE HELPED OTHER YOUNG MEN LIKE THEMSELVES. SO IN PHASE 1 ACTUALLY WE DID QUALITATIVE INTERVIEWS WITH YOUNG MEN WHO HAD ACQUIRED HIV DURING THE AGES OF 16 TO 21. WE ASK THEM ACROSS VARIOUS FACETS OF THEIR LIFE, WHAT COULD HAVE BEEN DIFFERENT? IF YOU COULD TELL ME, IF YOU COULD HELP ME DESIGN IN HIV PREVENTION PROGRAM, WHAT WOULD IT LOOK LIKE? SO SPEAKING FROM STANDPOINT AFTER FAILURE. SO THAT TYPE OF MODEL HAD NOT BEEN TRIED BEFORE AND THAT REALLY GAVE MY OWN CLINICAL EXPERIENCE. I WAS SEEING HIV POSITIVE KIDS EVERY WEEK. AND I JUST THOUGHT HERE IS A WEALTH OF KNOWLEDGE ABOUT WHAT DIDN'T WORK WITH REGARDS TO PREVENTION OR LIKE WHAT MIGHT HAVE BEEN HELPFUL. EVERY HIV POSITIVE KID REMEMBERS OR THINKS THEY REMEMBER, HAS A NOTION OF HOW HE OR SHE GOT INFECTED. SO WHY DON WE ASK THEM ABOUT WHAT MIGHT HAVE MADE THAT SITUATION DIFFERENT? WHAT MIGHT HAVE CHANGED THE OUTCOME. SO WE USE THOSE QUALITATIVE INTERVIEWS TO WRITE THIS CURRICULUM AND DESIGN SO THE CURRICULUM WAS WEDDED WITHIN THE SOCIAL REALITIES OF THESE YOUNG MEN. SO WE USE IN PHASE 2 WE DEVELOPED A PILOT TEST IN CURRICULUM AN PHASE 3 WE DID A SMALL RANDOMIZED CONTROL TRIAL IN THE CONTROL TRIAL WE RECRUITED 101 YOUNG MSM RANDOMIZED IN THE TWO ARMS. ONE WAS AGAIN, A REALLY ALMOST DREADFULLY BORING TIME BASED, TIME MATCHED CONTROL WHICH WAS ACTUALLY AN ACTIVE CONTROL SO AGAIN, MY IRB, I ACTUALLY KIND OF LIKED THIS THOUGH IT SUCKED FROM A RESEARCH STANDPOINT, WE CAN HAVE DISCUSSION ABOUT CHALLENGES DOING ETHICALLY BASED COMMUNITY RESEARCH AND POPULATIONS THAT YOU KNOW HAVE A NEED. THIS CAME UP IN THIS STUDY AND TEXT MESSAGING STUDY I'LL TALK ABOUT IN A SECOND. HOW CAN YOU IN GOOD CONSCIOUS RANDOMIZE A HIGH RISK GROUP OF YOUNG GAY MEN TO CONTROL? HOW CAN YOU TALK TO THEM ABOUT BROCCOLI OR NUTRITION? THE RESEARCH ARGUMENT IS, WELL WE DON'T REALLY KNOW THAT THE MY PEEPS INTERVENTION IS BETTER THAN TALKING ABOUT BROCCOLI. WE DON'T. WE HAVE NO WAY OF KNOWING. THAT'S A LEGITIMATE RATIONALE. YOU CAN ALSO MAKE THE ARGUMENT SHOULDN'T YOU TRY TO DO SOMETHING? THESE KIDS ARE PRESENTED, SO OUR CONTROL IN THIS ARM, ACTIVE CONTROL BECAUSE WE GAVE THEM HIV INFORMATION IN ALL THE SESSIONS. IT WAS A RELATIVELY DRY POWERPOINT SLIDE SET, IT WASN'T INTERACTIVE THE WAY THE MANUALIZED INTERVENTION, DIDN'T HAVE CUTE LITTLE AVATARS LIKE ON YOUR SCREEN. BUT ANYWAY, SO IT WAS TIME MATCHED AND IT WAS ACTIVE. WHY DO I SAY THAT IS IN SOME WAYS BAD FOR THE SCIENCE? IF YOU THINK ABOUT IT, IF YOU'RE TRYING TO PROVE THAT MY PEEPS IS BETTER THAN BROCCOLI SO TO SPEAK YOU WANT BROCCOLI TO BE DRY AS A BONE AS POSSIBLE. YOU DON'T WANT TO HAVE ANY INTERVENTION AFFECT THERE. SO BY USING AN ACTIVE CONTROL, TEACHING THEM HIV POWERPOINT YOU'RE MAKING IT LESS LIKELY TO FIND THE DIFFERENCE BETWEEN YOUR INTERVENTION. IN SOME WAYS POTENTIALLY SHOOTING YOURSELF IN THE FOOT. THIS IS A PILOT STUDY. AN R-34 FOR THOSE PEOPLE THAT KNOW NIH GRANTS THAT'S A RELATIVELY SMALL GRANTS, THREE YEARS, $150,000 A YEAR. SO WE COULD HAVE BEEN SHOOTING OURSELVES IN THE FOOT REGARD TRYING TO GET THE BIG ENCHILADA GRANT RO-1 THAT TAKES IT TO AN EFFICACY TRIAL. BUT OUR IRB AND COMMUNITY ADVISORY BOARD BUT LIKE YOU WANT TO CALL YOURSELF ETHICAL RESEARCHERS. YOU CAN'T DO IT. YOU JUST CAN'T DO IT. I KIND OF APPRECIATED IT WE HAD DECENT IRRETENTION HERE, NOT GREAT. SO ALMOST 70% I THINK AGAIN, THIS IS A POPULATION WHAT I DISCOVERED YOUNG GAY MEN ARE REALLY LIKE THEY'RE FATIGUED IN TERMS OF TALKING ABOUT HIV. THEY WANT TO TALK ABOUT HIV BUT THEY TALK ABOUT WITHIN THE CONTEXT OF MANY OTHER ASPECTS OF THEIR LIFE. THEY DON'T WANT TO COME TO AN INTERVENTION SO HIV-DRIVEN AND FOCUSED. STATISTICALLY LESS LIKELY TO HAVE SEX UNDER INFLUENCE OF DRUGS OR ALCOHOL, LESS LIKELY TO HAVE UNPROTECTED S UNDER INFLUENCE OF ALCOHOL OR DRUGS, REPORTED FEWER SEX PARTNERS AND FEWER -- SO THERE ARE BEHAVIORAL FINDINGS INCLUDING SOME SIGNIFICANT FINDINGS. WE'RE MOVINGING FORWARD TO GREG THE ENCHILADA RO-1. ONE STUMBLING BLOCK IS IT'S SMALL GROUP BASED. I THINK AS YOU GUYS HOPEFULLY HAVE TALKED -- THIS IS AN HIV ONLY, IT'S ALL RESEARCH. SO ONE OF THE BIG THINGS IN THE HIV FIELD NOW ARE LIKE BIOLOGICAL INTERVENTIONS. SOMETHING CALLED PREP. I DON'T KNOW IF YOU HEARD ABOUT PREP. THERE IS I THINK MORE TREATMENT AS PREVENTION. THOSE ARE TWO BIG BUZZ WORDS IN THE HIV FIELD TRYING TO GET EVERYBODY INTO TREATMENT SO THAT THE COMMUNITY VIRAL LOAD GETS LOWER, TRANSMISSION RATES DECLINE. PREP IS LIKE THE HIV VERSION OF A BIRTH CONTROL PILL WHERE WE GIVE A YOUNG PERSON AT RISK OR ANY PERSON AT RISK HIV MEDICINE EVERY DAY LIKE A YOUNG WOMAN MIGHT TAKE A BIRTH CONTROL PILL IN HOPE OF PREVENTING INCIDENCE RATES OF HIV WHEN UNPROTECTED SEX HAPPENS. SO IT'S NOT RELATED TO THE TIMING OF UNPROTECTED SEX ACT, YOU'RE TAKING IT EVERY DAY REGARDLESS WHEN YOU MIGHT ENGAGE IN SEX. THERE IS CONTROVERSY ABOUT BOTH STRATEGIES. EEL GIVE ANOTHER TALK ABOUT THOSE IF YOU WANT ME TO COME BACK. BUT SO THERE'S A PUSH I THINK AGAINST REAL BEHAVIORAL INTERVENTIONS. SO NOT SURE WHETH9, IT WILL GET FUNDED OR NOT. WHAT I HAVE LEARNED ABOUT THE HIV IS YOU THROW A LOT OF STONE TRYING TO HOPE THAT ONE WILL HIT HAIR TARGET AND GET YOU FUNDED. WE HAVE BEEN LUCKY SO FAR. THIS IS ANOTHER INTERESTING INTERVENTION. AND INTERVENTION IN A GROUP THAT NONE EXIST SO NOBODY IS DOING INTERVENTION WORK WITH 16 TO 20-YEAR-OLDS YOUNG GAY MEN. SO THIS MOVES ME TO OUR TEXT MESSAGING REMINDER, THIS GOES INTO OUR SECONDARY PREVENTION TALK. THIS IS A STUDY OF LOOKING AT A TWO WAY TEXT MESSAGING SYSTEM TO HELP HIV POSITIVE YOUNG PEOPLE TAKE THEIR MEDICINE. YOU'RE LIKE OH MY GOD THAT MAKES SO MUCH SENSE. SOMETIME IT IS SMARTEST RESEARCH COMES WITH SIMPLE STRAIGHT FORWARD APPROACHES. THERE'S ALSO OF TALK ABOUT DESIGNING LIKE APPS AND VERY FANCY MEDICATION MONITORING DEVICES. BUT OUR APPROACH IS WOULD A SIMPLE TEXT MESSAGE REMINDER MAKE A SIGNIFICANT DIFFERENCE? THIS CAME OUT OF MY OWN CLINICAL EXPERIENCE WITH THESE KIDS TELLING THEM TO SET ALARMS ON THEIR PHONES, IF THEY THEY CARRIED iPHONES SET AN ALARM. BUT PEOPLE DON'T GENERALLY USE THE ALARMS AS MUCH AS TEXTS ARE UBIQUITOUS. LIKE EVERY YOUNG PERSON IS TEXTING. SO THIS STUDY, WE DID WITH WAS UNDER $1,000, MOSTLY BECAUSE (INDISCERNIBLE) AT PENN NOW WAS ABLE TO TALK TO THE COMPANY IN TELECARE TALKED THEM INTO DONATING THE SOFTWARE. SHE CAME TO MY OFFICE ONE DAY, SHE WAS A FELLOW AND SHE SAID I WANT TO DO THIS PROJECT. I WAS LIKE WITH WHAT MONEY ARE YOU GOING TO GET THIS SOFTWARE? I'M GOING TO CALL THE PRESIDENT, CEO OF THE COMPANY AND ASK THEM TO GIVE IT TO US. SURE ENOUGH SHE DID. TWO DAYS AND THEY DIDN'T GIVE US THE PATENT TO IT BUT THEY LET US USE IT FOR PERIOD OF TIME AND WHAT WE DID IS COLLECTED PILOT DATA AND WENT RIGHT TO THE HIV AND GOT MONEY FOR A PILOT. I'M GOING TO GIVE YOU THE RESULTS OF THE PILOT WHICH PRODUCED THREE PAPERS THAT NADIA IS AUTHOR ON. I KNOW THE FIRST PAPER IS IN THE PUBLISHED LITERATURE WITH LESS THAN $1,000 PILOT ON TEXT MESSAGE INTERVENTIONS IN HIV YOUNG PEOPLE. WHY DO WE WANT TO LOOK AT THIS? HIGH LEVELS ADHERENCE OF THESE MEDS ARE REQUIRED FOR OPTIMAL HEALTH. THERE'S A NUMBER OF RISK FACTORS INCLUDING DEPRESSION, STIGMA, SUBSTANCE USE, REASONS COMMONLY PILL BURN, SIDE EFFECTS, STIGMA, PRIVACY, BUT SIMPLY FORGETTING SO THE LAST BULLET IS THE NUMBER ONE REASON WHY YOUNG PEOPLE DON'T TAKE -- HIV POSITIVE PEOPLE DON'T TAKE MEDS. FORGETTING. WE CAN TALK DEPRESSION AND STIGMA AND ALL THAT STUFF WHICH IS HIGHLY RELEVANT BUT THE NUMBER ONE REASON I JUST FORGOT I FELL ASLEEP ON MY COUCH. I WENT OUT TO MY FRIENDS HOUSE, I JUST SIMPLY FORGOT. OUR HYPOTHESIS IS WE GAVE KIDS A DAILY SMS TEXT REMINDER THAT IT WOULD BE FEASIBLE AND ACCEPTABLE, I THINK THERE WAS A LOT OF QUESTIONS AS TO A KID'S CONFIDENTIALITY, WHAT WOULD IT BE LIKE TO GET A TEXT MESSAGE. SO THERE WAS SOME CONCERNS THAT YOUNG PEOPLE MIGHT NOT LIKE THE MODALITY. WE THOUGHT THESE REMINDERS WOULD IMPROVE ADHERENCE. SO OUR ELIGIBILITY CRITERIA, YOU HAVE TO BE HIV POSITIVE BETWEEN AGE 12 AND 29. YOU HAVE TO HAVE YOUR OWN CELL PHONE. THAT WAS AGAIN WHEN YOU WANT TO COLLECT PILOT DATA WE COULDN'T BUY THE KIDS CELL PHONES. MOST DON'T WANT YOU TO BECAUSE THEY WANT THEIR CELL PHONE, THEY DON'T WANT -- UNLESS YOU BUY THEM AN iPHONE, THEY DON'T WANT A JUNKY PHONE, THEY WANT A GOOD PHONE. SO WHAT WE DID IS WE GAVE THEM AN INCENTIVE MONTHLY INCENTIVE TO OFFSET THE COST OF THE TEXT MESSAGES. BUT THEY HAVE TO ACTUALLY HAVE THEIR OWN CELL PHONE AND HAVE EXPERIENCE TEXTING AND ENGLISH SPEAKING BECAUSE OF MEASURES AND THEY HAVE TO HAVE POOR ADHERENCE BUT THEIR OWN REPORT. SO AGAIN, WE RECRUIT PEOPLE FROM JUNE TO NOVEMBER. AGAIN, WE HAD A SHORT PERIOD OF TIME WITH THIS SOFTWARE, SO WE RECRUITED THESE PEOPL IT WAS A SIX MONTH STUDY, PRIMARY OUTCOMES ARE FEASIBILITY ACCEPTABILITY AND ADHERENCE BASED POP SELF-REPORT MEASURESSH THE VISUAL ANALOG SCALE, OR THIS ADHERENCE MEASURE DEVELOPED BY THE NIH OF THE AIDS CLINICAL TRIAL GROUP. WE LOOKED ATTENTION BACK FUNCTION SO IT WAS A TWO WAY SYSTEM. IF THEY TOOK THEIR MEDS, TEXT BACK. IF THEY DIDN'T THEY WOULD GET ANOTHER REMINDER LIKE BEING A PEST. SO WE SEND A REMINDER AT HOUR, AND A SECOND HOUR. WE WOULD STOP AT THAT POINT BECAUSE OTHERWISE WE WOULD BE STALKERS AND YOU DON'T WANT TO BE A STALKER WHEN DESIGNING AN HIV PREVENTION TRIAL. BUT A NUDGE, YES. STALKER NO. FINE LINE. SO THE OUTCOMES WE LOOK AT DISEASE SPECIFIC OUTCOMES LIKE VIRAL LOAD THOUGH THIS WAS A PILOT. WE USE VERY SIMPLE DESCRIPTIVE ANALYSES HEREIN COLLUDING T TESTS WHICH IS -- SO THE WAY IT WORKS, THEY GOT TO PROGRAM THE MESSAGE SO THEY COULD HAVE THE MESSAGE SAY WHAT THEY WANTED. AND PART WAS BECAUSE WE HAD SOME CONCERNS THAT WE HAD A WHOLE SCRIPT. HELPING AROUND THAT, AND RECEIVE THEIR DAILY REMINDER AND GET A MESSAGE ONE AND TWO HOURS LATER WHETHER THEY TAKEN THEIR MEDS. AND THEY HAVE TO TEXT BACK YES OR NO. THIS IS SAMPLE CHARACTERISTICS OF THE PILOT. THIS WORK WAS DONE WITH LESS THAN $1,000. EVERYTHING I'M SHOWING YOU AGAIN BARGAIN BASEMENT RESEARCH. NOT FUNDED BY ANYBODY BUT CUP CAKES AND A GOOD DIVISION HEAD MOST WERE MALE, YOUNG, MEAN AGE MOST WERE AFRICAN AMERICAN OR LATINO. MOST OF THEM HAD ACQUIRED HIV BEHAVIORALLY THOUGH THERE WAS A FEW INFECTED KIDS AND THE MAJORITY GOT THEIR MEDS ONCE A DAY AS OPPOSED TOpJ THE MESSAGE CONTENT, THIS WAS INTERESTING, THE OVERWHELMING MAJORITY DESPITE BEING COACHED BY US THAT IT SHOULDN'T SAY MEDS WANTED THE MESSAGE TO EXPLICITLY HAVE THE WORD MEDS IN IT. I WAS A LITTLE SHOCKING TO ME. I REALLY THOUGHT THEY WANT TO IT SAY DRINK YOUR JUICE OR EAT YOUR COOKIE, MAMA SAYS SOMETHING. I DON'T KNOW BUT THEY ALMOST ALWAYS WANT TO SAY SOMETHING ABOUT THEIR MEDS. SOME SAY THINGS LIKE TAKE YOUR VITAMINS OR HEALTH COMES FIRST. WHATEVER IT IS. SO IT'S INTERESTING THE TALK TO YOUNG PEOPLE WHAT THEY WANTED, THE TEXT TO SAY. SO ALMOST 85% OF THE SAMPLE RETAINED WITH WITH OWN PHONES. ON AVERAGE A KID EACH PARTICIPANT LOST THEIR PHONE TWICE BUT WE WERE ABLE TO -- THAT'S WHAT KIDS DO. THIS IS A CHAOTIC POPULATION BUT WE -- I MEAN, WE STALKED THEM. BUT WE ENCOURAGE THEM WHEN THEY GOT THEIR NEW PHONE TO CALL US BACK WITH A NUMBER AND WE WOULD RESET IT UP BUT THESE -- THE DIFFERENCE HERE, WHY WERE WE ABLE TO HAVE THEM USE THEIR OWN PHONES FOR ADHERENCE STUDY WITH HIV AS OPPOSED TO SAY A STUDY AROUND HIV PREVENTION MESSAGES DELIVERED BY CELL PHONE WHICH I THINK GOOD LUCK. THEY'RE GOING THE LOSE THEIR PHONE, NEVER CALL YOU. WITH ADHERENCE STUDY, WHY DO YOU THINK IT'S EASY TO RETAIN THEM? BECAUSE THEY WANT TO DO WELL. THESE KIDS KNOW THEY NEED TO DO WELL IN ORDER TO STAY HEALTHY. SO THEY ARE MOTIVATED. YOU DON'T HAVE TO LIKE THE BEHAVIORAL MODEL INFORMATION MOTIVATION. IMB. YOU LEARN ALL THE TIME. BULL SHIT IN THIS POPULATION THEY'RE MOTIVATED. THEY GOT SOME INFORMATION, THEY KNOW HA THEY NEED TO DO. THEY HAVE TO CHANGE THEIR BEHAVIOR. IT'S DIFFERENT THAN PRIMARY PREVENTION BECAUSE THESE KIDS ARE MOTIVATED TO DO WELL,On THEY'RE GOING TO GET SICK. MOST THOUGHT IT WAS HELPFUL, IT HELPED THEM TO REMEMBER TO DO REFILLS WHICH IS A MAJOR SOURCE OF POOR ADHERENCE IN YOUNG PEOPLE. 100% FELT THE MESSAGES RESPECTED THEIR PRIVACY, OVER 80% RECEIVED THE MESSAGES. 81% WHICH IS ALMOST EVERYBODY WANTED TO CONTINUE TO RECEIVE THE TEXT AFTER THE STUDY WAS OVER. IN FACT NADIA, GOD LOVE HER WENT TO THE CEO OF THE COMPANY, WE HAVE HIV POSITIVE KIDS USING SOFTWARE, WHAT DO WE DO WITH THEM, THEY WANT TO GET THEM AND THEY SHOULD GET IT FOR FREE. 100% SAID THESE MESSAGE REMINDERS WOULD HAVE BEEN HELPFUL IT'S IMPORTANT TO THINK ABOUT THESE INTERVENTIONS. ABILITY TO ADHERENCE OUTCOMES WITH N OF 21, THE VAS IS THE VISUAL ANALOG SCALE, YOU CAN SEE THE MEAN SCORE ON THE VAS PRE, POST, BASELINE WAS 74% AT SIX MONTHS WAS 93%. SO THE GOLD STANDARD FORWHY MEDS IS 90% OR GREATER. AND WE ACHIEVEED THAT. FOR THE MAJORITY. STATISTICALLY SIGNIFICANT WITH N OF 21. THAT'S A HIGHLY PROMISING INTERVENTION. MESSAGES WERE FEASIBLE AND ACCEPTABLE. THEY WERE EFFECTIVE IN IMPROVING MEDICATION ADHERENCE AND THAT NEEDED A LARGE SCALE RANDOMIZED TRIAL WHICH IS LIKE YOUR FAVORITE BUZZ WORD WHEN YOU COME TO GIVE ANY TALK AT THE NIH. RANDOMIZED CONTROL TRIAL. ONE THING IS THE DATA SAFETY MONITORING BOARD. I DON'T KNOW IF YOU TALKED ABOUT THAT, DATA SAFETY MONITORING BOARD IS A BOARD OF PEOPLE EXTERNAL TO THE RESEARCH THAT HAVE NO VESTED INTEREST IN THE RESEARCH, THAT CAN TAKE A LOOK AT THE DATA AND DECIDE WHETHER A STUDY NEEDS TO BE STOPPED OR CONTINUE THESE PEOPLE ARE ENGAGING IN HIGH RISK SEX MORE THAN CONTROL OR THE INTERVENTIONS A CONTROL GROUP RELATED TO AN INTERVENTION. WELL, MY PATIENT POPULATION, MY IRB AND HOSPITAL SAID YOU'RE GOING TO DO A STUDY OF HIV POSITIVE KIDS WHO TELL YOU THAT THEY'RE POORLY ADHERENT. YOU'RE GOING TO RANDOMIZE THEM TO A CONTROL ARM WHERE THEY GET NOTHING? DOES THAT MAKE SENSE? IT DOES TO THE NIH BECAUSE THEY GAVE MONEY TO DO IT BUT DID IT ETHICALLY MAKE SENSE TO DO THAT. SO WE CHANGED THE RESEARCH DESIGN SO THAT WE GIVE THEM A VIDEO UP FRONT. AND EVERYBODY AT BASELINE GETS A MOTIVATIONAL INTERVIEWING INTERVENTION AT BASELINE BUT THEN THEY GET, IN THIS TRIAL, A TWO ARM TRIAL FOLLOWED OUT A YEAR. THE OTHER THING WE DID TO BE ETHICALLY RESPONSIVE TO THAT CONTROL ISSUE IS WE CREATED A CROSS OVER DESIGN. SO THAT THE PEOPLE IN THE CONTROL FOR THE FIRST SIX MONTHS IF THEY WANTED TO CROSS OVER INTO THE INTERVENTION ARM AND RECEIVE THE TEXT MESSAGES. SO WE HAD ALL THESE CRAZY AND SCIENTIFICALLY COMPLICATED DESIGN ISSUES THAT THE NIH FOUGHT US ON. IN THE SCIENTIFIC REVIEW ALL THESE BELLS AN WHISTLES THAT WE THOUGHT MOST ETHICALLY RESPONSIVE TO THE COMMUNITY CREATED SCIENTIFIC CHALLENGES GETTING PAST REVIEW GROUPS BECAUSE IT WAS COMPLICATED. WHAT WOULD HAVE BEEN EASIEST IS TO GIVE THEM NOTHING. BUT WOULD IT HAVE BEEN ETHICAL? YOU GUYS CAN HAVE A DISCUSSION ABOUT ETHICAL CONSIDERATIONS WHEN YOU'RE DOING HIV PREVENTION RESEARCH. THIS WAS INTERESTING FOR US. WE'RE GOING TO PROBABLY END UP HAVING TO STOP THE STUDY IN PART BECAUSE THE DATA SAFETY MONITORING BOARD IS GOING TO LOOK AND SEE THE INTERVENTION ARM IS DOING BETTER. WHAT WE'LL NEED ADVICE WHETHER WE%g STUDY BUT IT'S DEFINITELY A POSSIBILITY WITH THIS PARTICULAR STUDY. IT IS NOW GOING ON TO A -- ONE THING ABOUT THE THIS STUDY THAT WAS DIFFERENT, THIS WAS BASED UPON FEEDBACK OF HIV POSITIVE KIDS, THEY'RE LIKE WE JUST DON'T LIKE WHEN WE HIT YES OR NO WHEN WE HIT THE BUTTON. IT WOULD BE COOL TO GET POSITIVE OR NEGATIVE FEEDBACK. SO WE WEPT TO URBAN DICTIONARY AND CAME UP WITH LIKE 30 AFFIRMATIVE STATEMENTS LIKE ATTA BOY OR GOOD JOB. IF THEY DIDN'T DO IT THEY GOT A NEGATIVE STATEMENT LIKE AW SHUCKS OR BUMMER. AND WE RANDOMIZED THEM INTO THE SOFTWARE SYSTEM AND THEY LOVE IT. THEIR FAVORITE PART OF THE INTERVENTION, YES, THEY WANT TO SEE LIKE WHAT AFFIRMATION THEY'RE GOING TO GET. IT'S ACTUALLY REALLY -- IT'S BEEN REALLY COOL. I THINK IT SPEAKS A LOT TO THAT DETECTS INTERVENTION ITSELF COULD WORK BUT SOMETHING ABOUT THIS MOTIVATIONAL COMPONENT THAT KEEPS THEM ENGAGED. SO IN THE RO-1 WE WRITE, IT'S A THREE ARM STUDY WHERE THAT'S A CONTROL, AGAIN THE VIDEO AND MI COMPONENT AT BASELINE, THERE'S A PLAIN OLD SIMPLISTIC TEXT MESSAGE COMPONENT. ONE WAY SYSTEM WHICH YOU CAN BUY, THERE ARE COMMERCIAL PRODUCTS THAT YOU CAN GET FOR FREE VERSUS THIS MORE SOPHISTICATED TWO WAY SYSTEM WITH THIS MOTIVATIONAL INTERVIEWING COMPONENT. SO WE'RE DESIGNING MORE SOPHISTICATED STUDY. BUT STUDIES WE'RE DOING IS NOT ROCKET SCIENCE. THIS IS LIKE -- THESE MAKE SENSE, BASED UPON THE KID THAT I SEE. I'M REALLY EXCITING ABOUT THE STUDY. THE JOKE AMONG MY STAFF IS I WOULD BE DOING A TECHNOLOGY BASED INTERVENTION. IF IF I CAN CHECK MY CELL PHONE AND EMAIL AND FACEBOOK, I'M DOING REALLY WELL. BECAUSE I'M SO TECH NOT SAVVY. THIS IS A TRIAL WE TALKEDDED ABOUT. I ALREADY WALKED YOU THROUGH THIS. WE'RE RECRUITING A SAMPLE OF 150 KIDS. PROJECT SMILE, THIS IS FUNDED BY THE NICHD. THIS IS AN EXAMPLE OF THE OTHER WAY AROUND. THIS STARTED AS A RESEARCH PROJECT. I CALL IT RESEARCH BECAUSE SCIENTIFIC AIMS WERE BOGUS. WE WERE PART OF A NETWORK. SO THE ADOLESCENT TRIALS NETWORK, ALL THE SITES HAD TO PARTICIPATE IN THIS LINKAGE TO CARE PROJECT WHICH IS THIS MODEL, INTENSIVE ADs SENT DRIVEN LINKAGE TO CARE APPROACH FOR NEWLY DIAGNOSED HIV POSITIVE PEOPLE. WE COLLECTED LOCAL DATA. OUR SIDE GOT KICKED OUT OF THE THE ATN, WE WERE ROGUE. THERE WAS CUT BACKS AT THE NIH AND THEY COULDN'T HAVE TWO SITES IN CHICAGO. BOTH SITES WERE DOING EQUALLY WELL. SOMEONE HAD TO SUCK IT UP SO WE SUCKED IT UP. WE COLLECTED ALL THIS RESEARCH DATA, ON LINKAGE TO CARE, THIS IS LIKE USING OUTREACH WORKER AND A LOT OF COMMUNITY PARTICIPATORY BELLS AN WHISTLES LINKING KIDS TO CARE. AND OUR DATA WE HAD 1414 PEOPLE THAT PARTICIPATED -- 144 PEOPLE THAT PARTICIPATED IN PROJECT SMILE. 60% LIBBINGED TO PROJECT CARE AND 90% LINKED TO CARE ALSO ENGAGED IN CARE, ATTENDED AT LEAST A SECOND VISIT. OF THAT 57 WE WERE UPPED THAT TO 75% IF WE INCLUDE OTHER BELLS AN WHISTLES. WE LOOKED FOR OPPORTUNITIES TO GO ON THE OPPOSITE DIRECTION HERE. SO PROJECT SMILE, 2013, WE WROTE A PROGRAM GRANT TO THE CHICAGO DEPARTMENT OF PUBLIC HEALTH AND TOOK OUR RESEARCH FINDING AND WE DID RESEARCH INTO PROGRAMS. SO WE ASKED FOR A HOTLINE INITIATIVE. FOUR SITES, THE ATN SITE, THE CONTINUING ATN SITE OUR HOSPITAL, LUIE CHILDREN'S, UNIVERSITY HOSPITAL, AND COMMUNITY HEALTH CENTER ON HALLSTEAD WROTE THE GRANT TO CREATE A CITY WIDE HOTLINE WHERE ADOLESCENTS OR SCHOOL BASED HEALTH CENTERS OR NURSES, IF THEY HAD SOMEONE HIV POSITIVE 24 HOURS A DAY 7 DAYS A WEEK, WOULD HAVE ACCESS TO THIS BELLS AND WHISTLES OUTREACH PEER BASED MODEL TO CONNECT KIDS TO CARE. IT GOT FUNDED. SO NOW YOU'RE 1 OF 4 FUNDD BY THE CHICAGO DEPARTMENT OF PUBLIC HEALTH, THAT'S AN EXAMPLE OF -- AT LEAST OUR PROGRAM TRYING TO TAKE RESEARCH AND MOVE IT BACK TO A PROGRAM ENVIRONMENT. SO THERE'S THIS BACK AND FORTH. YOU CAN -- CAN YOU SEE THAT HAPPENING WITH OUR TEXT PROJECT? SO LIKE ONE THING ABOUT THAT TEXT PROJECT WAS WERE IT TO BE EFFECTIVE DO I WANT A ROLL GROUP ANY MORE? I WANT TO GO TO LIKE HRSA. RYAN WHITE PROGRAMS AND SAY I HAVE GOT THIS GREAT SOFTWARE PROGRAM THAT HELPS KIDS TAKE THEIR HIV MEDS. YOU SHOULD PUT THIS IN EVERY HIV CLINIC IN THE UNITED STATES. FOR ME, THAT'S THE NEXT STEP OF RESEARCH, I DON'T WANT TO DO RESEARCH FOR RESEARCH SAKE. I WOULD BE BORED TO TEARS. I WANT TO DO SOMETHING THAT MAKE AS DIFFERENCE IN THESE IMMUNITIES. SOME OF THESE THINGS CAN HAVING SAID THAT, WE DO HAVE ONE PURELY BASIC DATA STUDY WHICH IS FUNDED BY NIDA CALLED CREW 450. BRIAN MESTANSKI AND I ARE CO-PIs. AND THIS IS BASED ON THIS ENDEMIC THEORY YOU READ ABOUT, IT'S A DIFFERENT ENDEMIC THEORY FOR YOUNG MEN WHO HAVE SEX WITH MEN THAN TRANSGENDERRER WOMEN. THE WAY WE WROTE THE ARTICLE YOU READ RECENTLY WAS FOR TRANSGENDER WOMEN THEIR HOUSING AND ECONOMIC INSTABILITY IS SO INTERTWINED IN THIS ENDEMIC, NOT SO INTERTWINED FOR YOUNG MEN WHO HAVE SEX WITH MEN. BUT WE HAD WRITTEN A PAPER ABOUT THIS THEORY AND YOUNG MSM AND USED IT TO FRAME AN NIH GRANTS. CREW 450, IS -- NOT THE FIRST BUT WELL IT'S THE FIRST DOING IN KIDS THIS YOUNG. LONGITUDINAL COHORT STUDY OF THE PREVALENCE COURSE AN PREDICTORS OF HIV AND STI INCIDENCE IN YOUNG MSM 16 TO 20. SO WE'RE RECRUITING 450 YOUNG MEN WHO HAVE SEX WITH MEN, AGE 16 TO 20 AND FOLLOWING THEM FOR AT LEAST TWO YEARS, HOPEFULLY FOR THE NEXT 10, TO LOOK TO SEE LIKE WHAT ARE FACTORS THAT ARE RELATED TO ACQUISITION OR INCIDENCE OF GETTING AN STD OR GETTING HIV. WHERE THAT'S I THINK IMPORTANT, I JUST FINISHED TALKING ABOUT A LOT OF INTERVENTION WORK THAT HELPS POPULATIONS BUT WHERE I THINK THIS BASIC DATA IS IMPORTANT IS WE LACK A LOT OF FUNDAMENTAL UNDERSTANDING WHAT ARE THE$ WHEN YOU TALK ABOUT YOUNG GAY MEN AND ACQUISITION OF HIV. OUR TEAM BELIEVED THERE WAS FORMATIVE RESEARCH THAT COULD BE DONE THAT COULD HELP PREVENTION FIELD FORWARD. THIS IS AS ESOTERIC AS MY TEAM GETS BUT I DON'T THINK THAT'S THAT'S SEW TEARIC. THERE AREN'T LONGITUDINAL STUDIES OF THESE POPULATIONS. SO WE'RE DOING A -- HOPEFULLY SOMETHING THAT WILL HELP GENERATIONS TO COME. IT USES THIS SAMPLING FRAME CALLED RESPONDENT DRIVEN SAMPLING WHICH IS -- WAS LIKE ALL THE RAGE, ALL THE RAGE, IS IT WORTH A BAG OF BEANS, SOMETIMES IT WORKS, SOMETIMES IT DOESN'T. WHAT IT IS IS INCENTIVIZED SNOWBALL SAMPLING, LIKE YOU GET A GROUP OF YOUNG GAY MEN THAT HAVE SOCIAL NETWORKS INSTEAD OF YOU RYE TRYING TO CREW DOWN TO THE COMMUNITY, YOU GIVE YOUNG GAY MEN A, B, C, THREE COUPONS EACH. THEY GIVE COUPONS TO THOSE THREE FRIENDS AND WHEN THEY COME IN THEY GET THREE COUPONS, SO ON, SO ON. IT'S NOT A BAD WAYOF RECRUITING SAMPLES, IT'S NOT A PARTICULARLY EFFICIENT WAY RECRUITING YOUNG GAY MEN AS IT WOULD BE FOR OTHER TIGHTLY NETWORKED SAMPLES BECAUSE MANY KIDS DON'T HAVE TIGHT SOCIAL NETWORKS. IT WORKED IN GENERAL FOR THE YOUNG BLACK GAY MEN IN OUR SAMPLE WHO I THINK PROBABLY GEOGRAPHICALLY NETWORKED IN WAYS THAT I THINK WHITE MSM IN CHICAGO AREN'T BUT IT DIDN'T WORK FOR ALL POPULATIONS. RDS HAS A CRAZY WAY OF TRYING TO MAKE POPULATION BASED ESTIMATES FROM THE DATA. I'M NOT GOING TO GET INTO THAT BECAUSE I DON'T THINK IT WORKS AND IT CERTAINLY DIDN'T IN OUR POPULATION. BUT WE USE THIS INNOVATIVE SAMPLING FRAME. SO WE'RE COLLECTING THIS DATA. THAT GIVES RUN DOWN OF STUDIES THAT WE'RE DOING. I WANTED TO SORT OF CLOSE, WHAT I BELIEVE IS SOMETHING THAT I'M EQUALLY PROUD OF DOING. THIS IS MY DOG, FRED. THIS WAS HIM AT O'HARE AIRPORT. I DIDN'T TAKE HIM WITH ME THIS TIME, HE'S NOT HIDING HERE. BUT I BELIEVE AS AN HIV POSITIVE PERSON AND SOMEONE THAT DOES THIS WORK THAT I'M SICK AND TIRED OF WRITING TO LIKE THE NIH FOR MONEY. I'M SICK AND TIRED OF BEING BEHOLDEN TO THESE RANDOMIZED CONTROL TRIAL FRAMEWORKS THAT WE KNOW AREN'T ALWAYS ETHICALLY RESPONSIVE. TIRED OF TRYING TO WRITE GRANTS LEFT AND RIGHT, WHEN I KNOW THAT I DON'T BELIEVE THAT THE HIV PREVENTION FIELD IN THE UNITED STATES HAS A VIABLE BUSINESS MODEL. YOU HAVE GONE BACK TO THE SAME PEOPLE TO FUND THE SAME THINGS AND I TH OUTSIDE THE BOX. SO I CREATED THIS CHARITY AROUND MY DOG CALLED FRED SAYS. AND I'M NOT PITCHING THE CHARITY. USING IT AS AN EXAMPLE HERE THOUGH YOU COULD GO TO THE WEBSITE AND SEE THEM WHICH IS RELAUNCHING TOMORROW. THIS IS THE AD. SO FRED SAYS ALL HIV POSITIVE TEENS SHOULD HAVE CARE TO LEAD HEALTHY LIVES. THE GOAL HERE WAS TWO. TO THINK ABOUT HELLO KITTY, THAT CARTOON CAT WITH THE LITTLE BOW, I HATE HER. I'M LIKE IF THAT BITCH CAN HAVE AN EMPIRE SHE'S LIKE IN JAPAN, SHE'S IN EUROPE, SHE'S GOT A TOASTER FOR GOD SAKES. HELLO KITTY HAS A TOASTER. THINK ABOUT IF ALL THE MONEY THAT HELLO KITTY RAISED P IF ALL THAT MONEY WAS ACTUALLY DESIGNED TO GO TO A CHARITABLE EFFORT LIKE HIV. SO I THOUGHT MY DOG IS AS CUTE AS THAT CARTOON COW WITH THE BOW. SO I'M GOING TO CREATE A CHARITY AROUND MY DOG. AND MY OTHER -- STROKE OF GENIUS OR MADNESS DEPENDING WHO YOU LOOK WAS A DOG ON FACEBOOK CALLED BOO. WHO HEARD OF BOO ON FACEBOOK? SO YOU MIGHT BE LAUGHING BUT DON'T LAUGH BECAUSE IT'S SERIOUS SHIT. BOO HAS 7 MILLION FANS ON FACEBOOK. 7 MILLION. NOT 1 MILLION, NOT 2. 7 MILLION. I READ, IT COULD BE LOWER THAT BOO RAISED A MILLION DOLLARS IN 20 MINUTES ON FACEBOOK BY ASKING ALL HIS CRAZY FOLLOWS TO DONATE ONE DOLLAR. HE GOT A MILLION DOLLARS. SO I THOUGHT IF IF BOO, THAT DUMB DOG WITH THE HAT, HE'S GOT THE DEAD EYES. MY DOG IS CUTER THAN BOO. I THINK. BOO HAS BEEN TO THE WHITE HOUSE, BOO IS ON THE TODAY SHOW, SO I THOUGHT WHAT IF BOO, BOO HAS A DOLL THAT'S IN STORES LIKE WHAT IF WE COULD CREATE A SELF-SUSTAINING CHARITY THAT RAISE MONEY AND THEN COULD FUND INNOVATIVE PROGRAMS? SO FRED, HE'S NOT BOO, HE HAS 23,000 FANS ON FACEBOOK. PERHAPS SOME OF YOU ARE FRIENDS WITH HIM ALREADY. I KNOW SOMEONE IN THE AUDIENCE IS, AT LEAST ONE PERSON. WE HAVE DOLLAR MAKES A DIFFERENCE CAMPAIGN. WE ALSO HAVE MUGS AND WE DONE HAVE A TOASTER YET BUT IT'S COMING. WE HAVE PLUSH TOYS AN GREETING CARDS AND T SHIRTS. BUT THE PREMISE WAS REALLY THAT I DON'T WANT PEOPLE TO HAVE TO GIVE A TON OF MONEY IF THEY DON'T HAVE A TON OF MONEY BUT EVEN THAT CARED ABOUT THEIR PET, THE REASON I DID THIS IS BECAUSE FRED ACTUALLY SAVED MY LIFE. WHEN I WAS DIAGNOSED WITH HIV IT WAS PROBABLY THE HARDEST THING THAT'S EVER HAPPENED TO ME. I HAD ACTUALLY HAD CANCER YEARS AGO AS A YOUNG MAN AND THAT WASN'T NEARLY AS BAD AS HAVING TO DEAL WITH HIV BECAUSE AGAIN WHEN I HAD CANCER EVERYONE RALLIED TO HELP ME. MY PARENTS, MY FRIENDS -- WHEN YOU HAVE CANCER, IT'S JUST BY DEFINITION EVERYONE WILL BE OUT THERE SUPPORTING YOU. WHEN YOU GOT DIAGNOSED WITH HIV YOU DON'T KNOW WHO TO TURN TO. YOU DON'T KNOW IF YOUR FAMILY WILL BE SUPPORTIVE OR WHAT YOUR FRIENDS WILL SAY. I GOT LUCKY, IT TURNS OUT THAT MY FRIEND AND FAMILY HAVE ALL BEEN REALLY SUPPORTIVE AND IT'S GREAT BUT IT DOESN'T -- IT'S NOT THAT WAY A REALLY DARK PLACE. THERE'S A VIDEO ON FRED'S WEBSITE THAT TELLS YOU THE STORY BUT FRED GOT ME OUT OF MY OWN HEAD P AND GOT ME TO A PLACE WHERE I FELT LIKE I GOT MISSILELY BACK. WHICH YOU CAN SEE HERE. MY SPIRIT BACK. SO I DECIDE WHAT IF I GIVE PEOPLE A GIFT TO FRED? SO THERE ARE THESE eCARDS ONLINE, IF IF FRED COULD HAVE 7 MILLION FOLLOWS ON FACEBOOK AND–ym THEY EACH SENT ONE FRIEND LIKE A LITTLE eCARD FOR A DOLLAR, I WOULD HAVE $7 MILLION. TO FUND INNOVATIVE PROGRAMS. I PUT THIS UP THERE NOT TO PEDAL FRED OR THE WEBSITE BUT FOR Y'ALL AS YOU'RE MOVING ON FOR YOUR CAREER TO THINK OUTSIDE THE BOX, THINK CREATIVELY ABOUT THINGS THAT YOU CAN DO AND LIKE I REMEMBER WHEN I BROUGHT THIS UP TO MY HOSPITAL, I NEED TO START A NON-PROFIT, LIKE I NEED A HOLE IN THE HEAD. I DON'T KNOW ANYTHING ABOUT BUSINESS, I CAN'T BALANCE A CHECK BOO, WHEN I GO TO THE ATM AND I PUNCH THE CODE AND MONEY COMES OUT IT'S FUNNIEST THING IN THE WORLD FOR ME BECAUSE I DON'T KNOW WHERE IT COMES FROM. I JUST DON'T UNDERSTAND MONEY SO FOR ME TO START A NON-PROFIT IS CRAZY. SO I WEPT TO THE HOSPITAL AND I WAS LIKE I THINK THIS IS A REALLY GOOD IDEA. YOU GUYS SHOULD RUN WITH IT. THEY THOUGHT -- THEY CAME AT ME WITH A STRAIGHT JACKET. THEY THOUGHT I WAS INSANE. BUT NOW IN OUR FIRST YEAR OF OPERATION WITH WE MADE MADE A $10,000 DONATION TO CHARITY FIRST YEAR SO I THINK IT ACTUALLY LIKE THIS IS AN IDEA THAT COULD GET TRACTION. IT'S SO CRAZY IT COULD WORK. BUT THE IDEA IS FOR YOU GUYS AS YOU THINK ABOUT HIV, AS YOU THINK ABOUT EPIDEMIC 30 YEARS IN THERE'S UNANSWERED QUESTIONS AS THERE ARE ANSWERS. IN 30 YEARS THIS EPIDEMIC HAS SEEN THE BIGGEST CHANGES IN PUBLIC HEALTH HISTORY IN TERMS OF COMMUNITY MOBILIZATION, IN TERMS OF MOVING FROM AN AUTOMATIC DEATH SENTENCE TO CHRONIC ILLNESS. BUT IT'S STILL AN ENDEMIC WHERE LIKE A VACCINE OR CURE REMAINS ELUSIVE GOAL. SO THERE'S STILL SO MANY UNANSWERED QUESTIONS. THERE'S MANY UNANSWERED OPPORTUNITIES SO FOR ME LIKE FRED REPRESENTS AN OPPORTUNITY TO DO SOMETHING DIFFERENT THAT'S IN THE ABOUT LIKE WRITEING A SOMEBODY OUT THERE IN DES MOINES WHO HAS A GROUP OF HIV POSITIVE KIDS AND HE WANTS TO WRITE TO ME AND HE WANTS TO GIVE FOOD. I LOVE TO BE ABLE TO FUND STUFF LIKE THAT OR MAYBE SOMEONE HAS AN INNOVATIVE PROGRAM THAT'S NOT A RANDOMIZED CONTROL TRIAL. WITH NO FUNDING FROM FEDERAL GOVERNMENT BUT COOL AND INTERESTING. I WOULD LOVE TO SEE FRED FUND INNOVATIVE THINGS BECAUSE WE HAVE TO BEGIN TO THINK OUTSIDE THE BOX IF WE'RE GOING TO COMBAT THIS EPIDEMIC. SO WITH THAT I'M GOING TO STOP AND YOU GUYS CAN ASK ANY QUESTIONS OR GET THE HELL OUT OF HERE, WHATEVER YOU WANT TO DO. SO THAT'S IT. [APPLAUSE] ANY QUESTIONS? THEY'RE ALL SHELL SHOCKED. THAT MEANS I GIVE A BORING LECTURE IF NO SOMEONE ASKS YES, SIR, >> DO YOU THINK NONE OF THE INTERVENTIONS WERE EFFECTIVE? HOW IS THERE LIKE DID NONE OF THEM (INAUDIBLE) EFFECTIVE OR WHAT ARE YOU MEASURING THAT BY? >> FOR YOUNG GAY MEN? FIRST OF ALL VERY FEW HAVE ACTUALLY BEEN IMPLEMENTED. SO THERE'S ONLY ONE THAT'S ACTUALLY BEEN TESTED WIDELY, IT'S EMPOWERMENT WHICH IS DEBBIE AND IT'S SHOWN TO BE EFFECTIVE IN GAY MEN OLDER THAN AGE 25 BUT NOT ADOLESCENT OR YOUNG ADULT BUT HOW WE DO MEASURE THE EFFECTIVENESS IS IN COMPARISON TO A CONTROL GROUP. WE LOOK AT BEHAVIOR CHANGE. SO LOWER RATES OF UNPROTECTED ANAL INTERCOURSE, IS ONE EXAMPLE. OR LOWER RATES OF HAVING SEX UNDER THE INFLUENCE OF ALCOHOL OR DRUGS, OR I DON'T LIKE USING A LOWER NUMBER OF SEX PARTNERS WHICH IS COMMONLY HELD BEHAVIORAL CHANGE MARKER. THE REASON I DONE GENERALLY LIKE THAT IS BECAUSE IT DOESN'T TELL YOU ANYTHING ABOUT THE CONTEXT OF THE SEX WITH THOSE PARTNERS. IF I HAVE A YOUNG GAY MAN WITH 100 SEX PARTERS BUT USING A CONDOM WITH ALL, THAT'S PROBABLY BETTER THAN YOUNG GAY MEN WITH ONE SEX PARTNER BUT ISN'T USING A CONDOM. THERE'S LITERATURE NOW THAT SHOWS PARTICULARLY IN THIS POPULATION, I THINK THIS WAS TRUE OF -- THAT MY PEEPS INTERVENTION ENWE TALKED TO YOUNG MEN THE OVERWHELMING MAJORITY BECAME INFECTED WITHIN A PARTNER RELATIONSHIP. SO YOUNG GAY MEN DO A GOOD JOB HOOKING UP OR THEY HAVE A TRICK OF REMINDING THAT TRICK OR THEMSELVES TO USE A CONDOMMENT BUT WHEN THEY START DATING SOMEONE, BE IT FOR A WEEK OR TWO WEEKS OR A MONTH OR TWO MONTHS, THERE IS THIS COMPLACENCY AROUND USE OF CONDOM USE AND DISCUSSION AROUND CONDOMS AND SAFE SEX THAT'S TRICKY. MOST YOUNG GAY MEN TELL YOU THEY BECOME INFECTED WITHIN A PARTNER RELATIONSHIP. BUT YOU HAVE TO GAUGE IN A -- TECHNICALLY GAUGE IN A REASON DOCUMENTIZED CONTROL TRIAL -- RANDOMIZED CONTROL TRIAL WITH DIFFERENCES IN BEHAVIORAL CHANGE IN THE CONTROL GROUP, 3, 6, OR 12 MONTHS. >> LIKE TRANSGENDER WOMEN HAVE I GUESS DIFFERENT RISK FACTORS IN GAY MEN LIKE YOU SAID. DO YOU THINK THAT -- AND I HOPE YOUR PROJECTS BECOME LIKE DEBBIE, THEY SOUND GREAT. DO YOU THINK THEY COULD BE IMPLEMENTED OTHER GROUPS LIKE CHILDREN, NOT NECESSARILY IN THE U.S.? >> I THINK THAT'S A GREAT QUESTION. THERE'S A WHOLE FIELD OF SCIENCE AROUND ADAPTATION SCIENCE. IF YOU GO TO THE CDC WEBSITE THEY TELL YOU HOW TO ADAPT INTERVENTIONS FOR OTHER POPULATIONS. IN FACT, I DIDN'T TALK ABOUT THIS STUDY BUT WE ALSO HAD A STUDY FOR YOUNG TRANSWOMEN FUNDED BY THE CDC THAT WE CALL AT THISA, IT WAS SISTA THAT WE ADAPTED USING THE FORMAL FRAMEWORK, SISTA IS FOR AFRICAN AMERICAN HIGH RISK WOMEN AND WE USE THE SAME STRUCTURAL SAME THEORETICAL COMPONENTS IN SISTA AND WE GOT TRANSWOMEN TO ADAPT SISTA FOR THEIR NEEDS. IT LOOKED PRETTY GOOD. IT WAS AN ADAPTATION THAT SEEMED TO WORK. BUT A LOT DEPENDS UPON ADAPTATION AND WHETHER IT WOULD WORK IN ORACLETURES -- OTHER CULTURES, DEPENDS. HOW -- AND THIS IS JUST BUT ONE EXAMPLE, LIKE THE WHOLE NOTION OF COMMERCIAL SEX WORK IS THE COMPLEXITY OF THAT RISK THE SAME FOR TRANSGENDER WOMEN IN OTHER CULTURES THAT MIGHT NOT HAVE THE SAME CULTURAL MORE RAYS OR VALUES AROUND COMMERCIAL SEX WORK. SO WOULD ASPECTS OF INTERVENTION FALL FLAT IN OTHER CONTEXT AND YOU HAVE TO THINK ABOUT THAT. I THOUGHT ABOUT THAT BECAUSE HAWAII IS A GOOD EXAMPLE. HONOLULU APPROACHED ME, IT'S NICE TO BE APPROACHED BY HONOLULU. THEY OFFERED ME A VISITING -- SOMEONE CALL AND SAID WE WANT YOU TO COME DO A VISITING PROFESSORSHIP AND I WAS LIKE OH GOD PROBABLY LIKE IN LIKE NEBRASKA AND I WAS LIKE I DON'T THINK I CAN BECAUSE I'M BUSY. HE SAID HOLD ON LET ME TELL YOU WHERE I'M CALLING FROM FIRST. UNIVERSITY OF HAWAII. I WAS LIKE ALOHA. WHEN CAN I BE THERE? BUT THEY FLEW ME OUT. THEY WANTED TO DO THIS ADAPTATION AND AS IT TURNED OUT THE TRANSWOMEN THEY SAW LIKE BEING TRANSGENDER IN TRADITIONAL HAWAIIAN CULTURE WAS DIFFERENT THAN AFRICAN AMERICAN TRANSGENDER WOMAN IN CHICAGO. SO ASPECTS OF INTERVENTION WERE SALIENT BUT THERE WERE OTHER ENTIRE SESSIONS WHICH NEEDED TO BE GUTTED OR REVISITED OR REVAMPED. THAT'S ALL PART OF ADAPTATION PROCESS. THERE'S A ADAPTATION. >> I THOUGHT THE TEXT MESSAGING STUDY WAS INTERESTING AND I'M GLAD IT SEEMS TO BE WORKING. BUT I HAD A QUESTION ABOUT SUSTAINABILITY OF IT. I DON'T THINK YOU'RE GOING TO BE TEXTING THESE PEOPLE FOR THE REST OF THEIR LIVES. ARE THERE INTERVENTIONS OR OTHER ASPECTS TRYING TO ENCOURAGE PEOPLE TO -- THAT YOU HAVE A SAMPLE THAT ALREADY HAS POOR ADHERENCE, ARE THEY GETTING FROM THIS INTERVENTION SKILLS THAT WILL ALLOW THEM TO IMPROVE THEIR ADHERENCE ON THEIR OWN? >> THAT'S A GREAT QUESTION. FIRST, I WANTED TO ENTITLE, I REALLY WANTED TO I WANTED THE TITLE TO BE ANNOYING BUT USEFUL, TEXT MESSAGE ENTERP SECTIONS. BECAUSE AFTER A WHILE, OH MY GOD THESE MESSAGES ARE ANNOYING BUT THEY'RE HELPFUL. IS SOMEONE ABLE TO DO IT THE REST OF THEIR LIVE? MAYBE. I'M NOT CONVINCED IN THISSER RA OF TECHNOLOGY THAT'S SETTING UP TEXT MESSAGING REMINDER AD INFINITUM IS INPOSSIBLE. I THINK IT MAY BE. I HAVE ONE FOR MY DOG'S MEDICINE THAT I GET ON MY PHONE AS A TEXT MESSAGE REMINDER, NOT EVERY DAY BUT IT'S EVERY WEEK. SO I'M NOT CONVINCED IT CAN'T HAPPEN BUT YOU'RE RIGHT. WE DON'T KNOW WHAT'S THE DOSE WE NEED, IS IT A MONTH, THREE MONTHS FOR IT TO BE LIKE IMPRINTED. SO IN OUR STUDY, AND I GUESS I DIDN'T TALK ABOUT THIS, THE TEXT MESSAGING INTERVENTION STOPS AT SIX MONTHS, THERE'S THAT CROSS OVER SO THE ONES THAT DIDN'T GET INTERVENTION CROSS TO INTERVENTION. WE FOLLOW BOTH GROUPS OUT TO 18 MONTHS. SO WE'LL SEE WHETHER TEXT MESSAGING INTERVENTION, WHETHER THAT DOSE, THE SIX MONTHS, WHETHER THAT'S SUSTAINED OVER TIME. WE DON'T HAVE THE ANSWER TO THAT YET. NO ONE DOES. THAT'S BUILT IN. OTHER INTERVENTIONS WE'LL USE A STRATEGY OF BOOSTER SYSTEMS. SO MAYBE THE INTERVENTION WORKS FOR A WHILE, IT'S SUSTAINABLE BUT AFTER LIKE A YEAR, THEY NEED ANOTHER MONTH. I'M MAKING THIS UP. MAYBE THEY NEED ANOTHER MONTH OF THE TEXT MESSAGING TO GET THEM BACK ON TRACK. EVERY YEAR THEY NEED THEM. NO ONE KNOWS THE TIMING OF THAT DOSE. THOSE ARE IMPORTANT SCIENTIFIC QUESTIONS. THE OTHER INTERVENTION THAT I THOUGHT MIGHT BE INTERESTING IS IF -- WHEN I HAVE KIDS THAT COME IN, THEY GIGGLE ABOUT THE RANDOMIZED LIKE POSITIVE AND NEGATIVE AFFIRMATION. BUT WHAT IF YOU TRY TO TAILOR THAT TO THINGS THAT THEY SAID WERE IMPEDIMENTS TO THEM TAKING THEIR MEDS? FOR INSTANCE, WHAT IF THEY CAME IN AND UPON BASELINE THEY WERE LIKE NO, I DON'T TAKE MY MEDS BECAUSE EVERY FRIDAY NIGHT I GET SHIT FACED WITH MY FRIENDS AND I GET DRUNK AND I FORGET. OR I START SMOKING CRACK ON FRIDAY AND I WAKE UP ON MONDAY. AND I LIKE FORGET. WHAT IF THEY FORGOT THEIR MEDS, THE AFFIRMATION THEY GOT WAS SPECIFIC TO THE ISSUE. LIKE PUT DOWN THE CRACK PIPE. OR DON'T GO OUT TO THE BAR. SO I MEAN WHAT IF YOU COULD TAYLOR IT MORE TO THINGS THEY WERE GOING THROUGH AS OPPOSED TO AW SHUCKS, WOULD THAT MAKE A DIFFERENCE. I THINK THERE'S STILL A LOT OF UNANSWERED QUESTIONS AROUND IT. >> SO I WAS WONDERING ABOUT THE -- I GUESS PEOPLE CONTINUING IN THE TRIAL, THE RETENTION OF PEOPLE. I ALWAYS WONDER WHEN I SEE THAT, EVEN IF IT'S A 10% DROP OUT RATE IF PEOPLE WHO ARE DROPPING OUT ARE PEOPLE WHO ARE INHERENTLY AT HIGHER RISK TO PEOPLE WHOSE LIFESTYLES DONE WORK WELL WITH INTERVENTION, I WONNER IF YOU'VE STUDIED THAT AT ALL OR IF THERE'S A BASELINE UNDERSTANDING OF -- >> THAT'S WHY YOU WANT YOUR RETENTION RATES TO BE HIGH. BUT YOU'RE ASK ASKING GOOD QUESTIONS BUT I THINK THAT'S AGAIN, YOU'RE SUPPOSED TO LOOK AT LOSS TO FOLLOW-UP TO PEOPLE AND SEE IF THERE'S DIFFERENCES AT BASELINE AND THE GROUP THAT DID FOLLOW UP. I THINK THE ONE AREA IN HIV PREVENTION RESEARCH WHERE I'M THE MOST TROUBLED BY USE OF FOLLOW-UP STUFF IS PREP STUDIES. PREP STUDIES, PRE-EXPOSURE PROPHYLAXIS LIKE A BIRTH CONTROL PILL MODEL WHERE YOU TAKE A PILL EVERY DAY. BUT THE STUDIES DONE ON EFFICACY OR FEASIBILITY OF PREP, ONLY ENROLL PEOPLE WHO SUCCESSFULLY MAKE IT THROUGH A BEHAVIORAL INTERVENTION. SO BY DEFINITION TO GET TO THE PREP TRIAL YOU HAVE TO HAVE MADE IT THROUGH SISTA. SO FOR ME IT'S LIKE -- IF YOU CAN MAKE IT THROUGH SISTA, IF YOU CAN COME TO THREE WEEKLY SESSIONS TWICE A WEEK TO TALK HIV YOU CAN TAKE A PILL EVERY MORNING. PART OF ME, DID WE CHERRY BIC OUT, PEOPLE KNEW A GOOD JOB WITH THIS PARTICULAR STUDY BECAUSE THEY CAN COMPLETE. WHY DID WE INCLUDE BEHAVIORAL INTERVENTION? PEOPLE WERE AFRAID WITH PREP IF WE DID NOTHING, IF WE JUST GAVE PEOPLE A PILL AND DIDN'T TEACH THEM ABOUT RISK THAT WHOA, THE FLOOD GATES ARE OPEN AND THEY'LL HAVE UNPROTECTED SEX WITH EVERYBODY THEY PASS ON THE STREET. IT'S CALLED BEHAVIORAL DISINHIBITION. THERE'S A SCIENTIFIC TERM FOR IT. SO THERE'S RATIONALE WHY WE MAKE THESE DECISIONS BUT I THINK YOU'RE RIGHT. WE NEED TO LOOK AT GROUPS THAT DON'T FOLLOW-UP. THAT'S WHY WHEN YOU LOOK AT RETENTION RATES AND FOLLOW-UP RATES WE TRY TO -- EVEN IF PEOPLE MISS EVERY INTERVENTION GROUP WE THEM TO COMPLETE THE LIKE FOLLOW-UP ASSESSMENTS. BECAUSE THAT WAY WE MIGHT HAVE A MORE LIKE NATURAL CONTROL GROUP, PEOPLE THAT DIDN'T GET ACTUAL INTERVENTION ITSELF BUT ABLE TO BE FOLLOWED UP AT THE MEASUREMENT POINTS. IT'S SCIENCE. TRICKY STUFF BUT YOU'RE ASKING A VERY GOOD QUESTION. >> SO THIS IS ABOUT YOUR DYNAMIC THEORY STUDIES AN POLICY. SINCE YOU HAVE EXPERIENCE. SO THERE ARE THESE HIV CRIMINALIZATION LAWS. THERE IS STILL IN PLACE AND THAT WAS ROOTED LIKE THE TIME WE DONE KNOW ANYTHING ABOUT HIV TRANSMISSION, THEY'RE STILL IN PLACE AND I FEEL LIKE -- I THINK IT CONTRIBUTES A LOT TO SOCIAL MARGINALIZATION OF ESPECIALLY FOR LGBT COMMUNITY AND STIGMA. WHAT DO YOU THINK ABOUT THAT? AND HOW CAN WE PROMOTE CHANGE FOR THAT? >> I MEAN, I THINK YOU'RE ABSOLUTELY RIGHT. THINK ABOUT ANOTHER INFECTIOUS -- FOR LIKE TB, WE'RE NOT OUT THERE LIKE ARRESTING PEOPLE FOR COUGHING ON PEOPLE. THERE'S AGAIN A LOT OF STIGMA AND SHAME AROUND THE TRANSMISSION OF HIV FROM EITHER PARTNER. AND IN GENERAL NOT DOING THAT MUCH DIFFERENTLY THAN ANYBODY ELSE DOES. I RUN AN ADOLESCENT MEDICINE PRACTICE SO I SEE STRAIGHT AND GAY KIDS, I SEE -- YOU KNOW, YOU SHOW ME SOMEBODY WHO HAS NEVER IN THEIR LIVES MADE LIKE A MISTAKE SEXUALLY AND I'LL SHOW YOU PROBABLY THE MOST ATYPICAL HUMAN BEING LIKE ON EARTH. WE ALL MAKE MISTAKES. SO THE NOTION THAT PEOPLE SHOULD BE CRIMINALIZED FOR WHAT COULD BE A MISTAKE, I THINK DOES CONTRIBUTE TO SORT OF STIGMA BARRIERS TO CARE FOR PEOPLE TO GET CARE. THAT SAID, THERE ARE THOSE ODD CASES. THEY'RE THE ONES YOU TEND TO READ ABOUT IN THE PAPER OF LIKE THE BUG CHASERS OR PEOPLE THAT WANT TO INFECT OTHERS WITH HIV. THOSE ARE LIKE EXTREMELY RARE BUT THEY CAPTURE THE NATIONAL ATTENTION, WHICH AGAIN SPEAKS TO THE STIGMA AND THE SHAME. THERE'S ACTUALLY ILLINOIS, I'M NOT PROUD OF THIS BUT I'M NOT A LAW MAKER IN ILLINOIS. ILLINOIS STILL HAS THIS REALLY CRAZY AS LAW ON THE BOOKS, IF YOU'RE AN HIV -- IF A HIGH SCHOOL STUDENT TESTS HIV POSITIVE IN MY CLINIC, GUESS WHO I'M SUPPOSED TO NOTIFY? THE PRINCIPAL. I'M SUPPOSED TO CALL THE SCHOOL PRINCIPAL AND TELL THE PRINCIPAL THAT SO AND SO HAS HIV. ARE YOU CRAZY? I MEAN, IT'S LIKE I DON'T KNOW WHERE THESE LAWS CAME F. THE PRINCIPAL AND THE SCHOOL NURSE. SWEAR TO GOD. I WILL SAY I HAVE NEVER DONE THAT AND I HAVE NOT BEEN DRAGGED AWAY IN SHACKLES YET. BUT THERE ARE THESE ANTIQUATED LAWS THAT EXIST THAT GET MANIPULATED. BUT I WILL SAY I HAVE HAD IN MY EXPERIENCE IN 12 YEARS, TWO PATIENTS THAT ACTUALLY BELIEVED WERE RECKLESS WITH REGARD TO THEIR HIV TRANSMISSION. ONE MALE AND ONE FEMALE. AND THEY WOULD KEEP ME UP AT NIGHT HONESTLY; I WOULD BE TROUBLED BECAUSE I JUST WASN'T SURE, WHAT DO YOU DO, CALL OUT THE NATIONAL GUARD? THERE'S NOT MUCH YOU CAN DO AS A PROVIDER. I THINK YOUR POINT ABOUT ALL THIS LEGALIZATION STUFF CONTRIBUTING TO THE MARGINALIZATION AND STIGMA IS SPOT ON. DID THAT ANSWER YOUR QUESTION? NOT SURE HOW YOU GO ABOUT USING THAT TO CHANGE POLICY. I MEAN, I THINK I AT LEAST IN ILLINOIS WE RAISE -- WE RAISE AN ALTERNATIVE BILL TO THAT MANDATORY SCHOOL NOTIFICATION EVERY YEAR. EVERY YEAR I LIVED IN ILLINOIS WE RAISED AN ALTERNATIVE BILL AND EVERY YEAR IT DOESN'T PASS. SO MY APPROACH TO POLICY, YOU JUST GOT TO BE LIKE BELLIGERENT. LOOK AT -- WELL, THERE ARE MANY EXAMPLES. BUT BECAUSE IT'S FAILED TEN TIMES DOESN'T MEAN YOU DON'T TRY THE 11th AND 12th TIME. >> SO LAST WEEK WE READ ANOTHER ONE OF THE ARTICLES THAT WE READ WAS ABOUT THE IDEA OF RISK COMPENSATION SO WHEN YOUTH ARE IN THESE CLINICAL TRIALS THEY TEND TO THINK THEY'RE IN THE EXPERIMENTAL GROUP AND THAT IT'S GOING TO WORK AND THAT COULD BE BAD BECAUSE THEY MIGHT THINK THEY ARE IMMUNE OR SOMETHING. SO I GUESS I WAS TRYING TO -- OR WONDERING WHAT YOU THOUGHT OF THAT AND WHAT YOUR TEAM DOES TO COUNTER ACT THAT. >> I THINK THAT'S REALLY IMPORTANT IN CLINICAL TRIALS WHICH I DIDN'T DESCRIBE. THE MOST CLINICAL TRIAL I WOULD SAY WE HAVE IS THE TEXT MESSAGING WHICH ISN'T REALLY CLINICAL. THEY'RE NOT GETTING THE TEXT MESSAGE SO THEY KNOW THEY'RE NOT IN THE INTERVENTION ARM. THOUGH ACTUALLY ONE OF THE SCIENTIFIC -- ONE PERSON IN THE SCIENTIFIC REVIEW GROUP SUGGESTED THAT (INAUDIBLE) CONTROL WE SEND PEOPLE A TEXT MESSAGE EVERY DAY BUT NOT TIMEED TO THEIR LIKE HIV DOSE. IF WE REALLY WANTED TO -- SO WE LIKE TO SEND RANDOM MESSAGES THAT -- REMEMBER TO TAKE YOUR HIV MEDS BUT NOT TIME TO WHEN THEY'RE SPOTSED TO. AS AN ALTERNATIVE. -- SUPPOSED TO. WHICH I THINK IS INTERESTING. I WAS JUST LIKE I CAN'T BE BOTHERED. I THINK THAT'S A DUMB IDEA. THANKS GOD THEY AGREED. BUT FOR A CLINICAL TRIAL, THAT BECOMES REALLY IMPORTANT. WE DID A STUDY, THIS IS JUST TO USE AN EXAMPLE, WHERE WE WERE DOING EASY ACCESS POST EXPOSURE PROPHYLAXIS SO TAKING THE NOTION OF PREP AND EXTENDING IT TO POST EXPOSURE PROPHYLAXIS. SO LOOKING AT POTTS EXPOSURE PROPHYLAXIS AFTER A NEIDL STICK, IF YOU CAN GET HIV MEDS ON BOARD THERE'S A 90% CHANCE TO PREVENT TRANSMISSION. IN BEHAVIORAL WORLDS, GETTING THAT MEDICINE ON BOARD IS REALLY TRICKY BECAUSE YOU HAVE TO CALL THE DOCTOR, YOU HAVE TO COME IN, GET AN APPOINTMENT. SO WE DID THE PLACEBO VERSUS ACTIVE INTERVENTION ARM WHERE A GROUP GOT ACTIVE PILL, THE OTHER GROUP GOT CONTROL MEDS. IT WAS A PROBLEM FOR ME, I ACTUALLY STOPPED THE STUDY IN THE MIDDLE BECAUSE WHEN I WAS SEEING THE KIDS IN THE CONTROL GROUPS MOST OF THEM STILL THOUGHT THEY WERE O LIKE ACTIVELY IN THE -- DESPITE THE FACT WE EXPLAINED IT TO THEM AND WE DID A CONCEPT FORM, WE HAVE THIS CAPACITY TO CONSENT PROCEDURE FOR ALL OF OUR STUDIES WHERE THEY HAVE TO TELL US BACK ALL THE RISKS AND BENEFITS. SO SO OF ALL THAT IN PLACE STILL IN THIS PARTICULAR STUDY THESE KIDS IN THE CONTROL CHANGE THEIR BEHAVIOR FOR THE NEGATIVE BECAUSE THAT I BELIEVED THEY WERE IN THE INTERVENTION ARM. EVEN IN THE INTERVENTION ARM IT WAS AN UNPROVEN STRATEGY. AS KIDS WERE COMING IN, WE DIDN'T HAVE A DSMB AT THAT POINT BECAUSE IT WASN'T A BIG ENOUGH TRIAL, IT WAS A PILOT. MY OWN TEAM, WE MEET EVERY WEEK. AND WE'D BE RIPPLING OUR HAIR OUT BECAUSE I WOULD BE HEARING THE STORIES. I JUST STOPPED IT AND SAID WE'RE STOPPING THIS STUDY BECAUSE I JUST CAN'T ETHICALLY MOVE FORWARD. BUT YOU'LL BE FACED WITH THAT IF YOU'RE DOING CLINICAL TRIALS WITH THIS GROUP ESPECIALLY IF YOU'RE FORCED TO USE PLACEBO. THAT'S WHAT HAPPENED IN THE PREP TRIALS. SO IF YOU LOOK AT PREP TRIALS MOSTLY WERE IN AFRICA, I THINK I MUST HAVE BEEN AN NIH BASED DSMB SO BIG DSIB FROM THE NIH CAME IN, ALL THE PREP TRIALS ACROSS THE WORLD BECAUSE THE DATA FROM THE FIRST FEW LOOKED SO GOOD THAT THEY FELT LIKE IT WAS JUST UNETHICAL TO CONTINUE TO ENROLL PEOPLE ANYWHERE IN THE WORLD TO GET NOTHING AS PLACEBO, BUT THE ACTUAL PREP INTERVENTION ITSELF LOOKS SO PROMISING. BUT I DON'T HAVE ANY TECHNIQUE THAT I USE. I THINK WHEN YOU'RE WORKING WITH ADOLESCENTS AND I THINK -- THE ARTICLE, I WANT TO READ IT BU CITY BILL IS IN CHICAGO AND I KNOW HER WELL AND I KNOW HER MIND SET AROUND THIS ISSUE. SURE SHE WROTE A REALLY PROVOCATIVE ARTICLE, IT'S TRICKY ISSUE WHEN DEALING WITH ADOLESCENTS. AND PREP IS ONE OF THE EXAMPLES, IS IT ETHICAL TO ENROLL A 16 OR 17-YEAR-OLD IN A PREP TRIAL? LIKE WHO SIGNS OFF ON THAT? THE 16-YEAR-OLD? A PARENT? IF YOU'RE GOING TO GIVE ACTIVE HIV DRUG IS IT ETHICAL TO LET A KID SIGN OFF THEMSELVES? I DON'T KNOW. I THINK THOSE ARE -- THERE ARE MANY UP ANSWERED QUESTIONS THERE. I KNOW THAT THEY DO IT. I THINK STROGER HOSPITAL DOES IT. THEY ENROLL YOUNG MSM IN A PREP TRIAL AND GIVE THEM ACTIVE HIV DRUG WITHOUT PARENTAL CONSENT. I DON'T THINK MY IRB WOULD LET DOUSE THAT. I'M NOT SURE I PERMLY WOULD FEEL COMFORTABLE. IT'S INTERESTING, I DON'T BELIEVE IT'S UNETHICAL. I THINK EACH RESEARCH HAS TO BRING TO THE TABLE THEREIN FEELINGS ABOUT SOME OF THIS SHIT. AND I WOULD ADVOCATE IF YOU DO THIS RESEARCH, I TRY TO DO THIS WITH MY TEAM, TRY TO SURROUND MYSELF WITH PEOPLE THAT CHALLENGE ME EVERY DAY SO SOMETIMES THEY ANNOY THE SHIT OUT OF ME BUT I REALLY WANT MY ASSOCIATE DIRECTOR AND THE OTHER PEOPLE ON MY TEAM TO BE PEOPLE THAT ARE GOING TO TELL METHOI'M LIKE THE PI AND I'M THE GUY THAT BRINGS IN THE MONEY, ROB, YOU'RE ACTING LIKE A JACK AS OR THIS IS WRONG OR -- BECAUSE IF YOU DON'T SURROUND YOURSELF WITH THOSE PEOPLE, IT'S WAY TOO EASY IN ACADEMIA TO SURROUND YOURSELF WITH PEOPLE THAT PAT YOU ON THE BACK AND TELL YOU HOW GREAT YOU ARE. WHEN YOU'RE DOING THIS RESEARCH THAT'S THIS DICEY, I WOULD ENCOURAGE YOU AS YOU MOVE ON IN YOUR CAREER, SURROUND YOURSELF WITH AT LEAST ONE PERSON OR A CADRE OF PEOPLE THAT WILL KEEP YOU HONEST BECAUSE IT'S TOO EASY TO FALL INTO TRAPS. THE MONEY IS SEDUCTIVE, THE PRESTIGE IS SEDUCTIVE, THE ACADEMIC SUCCESS, IT'S ALL SEDUCTIVE. IF YOU DO THIS WORK WELL YOU NEED THE TO KEEP YOURSELF HONEST. MY ASSOCIATE DIRECTOR, SHE'S A YOUNG WOMAN LESBIAN IDENTIFIED. SHE'S GREAT. SHE WOULD HAVE NO QUALMS KNOCKING ON MY FRONT DOOR TELLING ME I'M A COMPLETE JACK ASS. THOUGH SHE DRIVES ME CRAZY, I WOULD NEVER LEE MY JOB BECAUSE I WANT HER AROUND ME AT ALL TIMES. SHES ME HONEST. >> OKAY. IF YOU GUYS DON'T HAVE ANY FURTHER QUESTIONS, THANK YOU SO MUCH, ROB. [APPLAUSE] >> DON'T FORGET TO FILL OUT YOUR EVALUATIONS. TO NATASHA OR YVONNE. THANKS.Ht