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A Shot in the Arm Podcast
AIDS 2060 Ep 01 - Lessons from the Frontlines: San Francisco
01:04:24
This is the first episode of AIDS2060, a special multimedia mini-series of podcasts and Substack articles devoted to understanding what is needed to bring the HIV epidemic under control, how long that will take, and why the world has been unable to do so to date, notwithstanding overly ambitious public commitments that questionably are not rooted in science and hide the real threat HIV poses, even today.
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- [00:00]
A
Foreign. Hello, I'm Ben Plumley, host of A Shot in the Arm Podcast and welcome to AIDS 2060, a new project of A Shot in the Arm Media, a series of long form podcasts and short clips unashamedly asking what has gone wrong with the global HIV and AIDS response? Does it matter? And if so, what do we need to do to fix it? Because yes, we have lost track and yes, it does still seriously matter. HIV is most certainly with us and while we have some crazy exciting biomedical innovations, we still have no cure. There are currently 40.8 million people living with HIV, of which only 31.6 million are on HIV treatment and there are 1.3 million new infections per year. It's not a good place to be in and last year the US sent the world into septic shock with its sudden ill conceived and then partially retracted deep cuts to its global HIV investments, particularly through pepfar, decimating the CDC and NIH and showing to us all the depth and reach of its influence for good or evil. A shout out to Emily Bass sub stack, which monitors all of this very closely and we strongly recommend you follow her. Well, I'm fed up of hearing that old truism that out of adversity comes opportunity because we, instead of innovating, may be actually left with no more than making do or getting by. But in the spirit of optimism, let's imagine what action, innovations and investments we will make and face up to the challenges imagined and unprepared for that we will face over the coming decades. Now some of this is already happening in so called recipient countries and communities. There's no dates that really at this point in the epidemic makes sense to aim for. But for the sake of clickbait and social media short attention spans, let's pick a date totally arbitrarily 2060 where we can listen, learn and make some informed attempt at predicting what the world will be like if we act promptly and smartly. July sees the Global AIDS Conference AIDS 2026 meet in Rio. What will HIV be like 24 years from now when we meet, as we most likely will for AIDS 2060? And what's the aspiration we need to inspire us, say, the final grand plenary presentation to close out AIDS 2060 coming from the last person on earth ever to be infected with hiv? What must we do now to make that have happened by then? So the first piece of AIDS 2060 is a podcast taking us to San Francisco, one of the earliest epicenters of hiv, to meet frontline clinicians, communities and healthcare workers as they navigate an epidemic that is fundamentally different to the one that emerged in the early 1980s. How are today's HIV warriors doing? What are the challenges that they're facing and what are their views of the future? Well, let's find out with Lance Thoma, Daniel o', Neill, and Tatiana Moatan from the San Francisco Community Health Center. So, yes, as you know, I am extremely skeptical about internationally made targets. They beg for failure. I don't think there's one we've ever actually met internationally. We have ending AIDS as a global health crisis by 2030. We have getting to zero. We had, I don't know if we still have it, the AIDS free generation. So as we look at the future, why not start from where we began in San Francisco? And we're not in the late 70s, early 80s. Now here we are in 2026 with a clinic that is at the forefront, really, of providing treatment, holistic care and HIV prevention services to the most marginalized in San Francisco. Now, you all know it because, as you know, I'm the board chair, the San Francisco Community Health center. And I'm thrilled that we are joined by three superstars of the organization. Lance Thoma, the executive director. Welcome, Lance.
- [04:52]
B
Thank you.
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A
CEO. You are not executive director anymore. You'd think I'd get that right. I'm also joined by Dan o', Neill, the chief medical officer of the centre. Welcome to A Shot in the Arm. Dan, it's great to have you here.
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C
Glad to be here.
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A
And last and by no means least, Dr. Tatiana Moatan, who is head of both policy and human resources. You have the most incredible typing. What is it again?
- [05:22]
D
Chief Strategy and workforce office.
- [05:24]
A
Yeah, thank you. And all three of you have done the most remarkable work in HIV over the last few years. As I've seen it close hand and it made so much sense for us to start here. And my opening question really, is AIDS 2030? Do we think we are going to reach December 31, 2030, and AIDS ceases to be a public health crisis of public concern? I'd love to find out from all of you, but maybe, Lance, I could start with you?
- [06:05]
D
Sure.
- [06:05]
B
Well, first off, thank you so much, Ben. So proud of your leadership here at our health center and just grateful that you are always including the work of our health center in these important conversations. So AIDS 2030?
- [06:26]
A
No, we're not.
- [06:27]
B
I mean, you know, I believe in being aspirational. I get it. And I do think there was a moment when we could envision an end to the AIDS epidemic. Ending HIV in San Francisco especially. And we were, we still are so engaged in all of that, but not at all by 2030 considering what has happened over this past year and all of the progress that is coming undone, policies, departments, programs, funding. We are set back years and it's going to take so much effort to get back on track. So no, and I believe we still need to be aspirational, so we still need to think about how we get back on track and reset and then dream again about what is possible for our communities so that we learn from what's going on and we leap forward when we get through this ailment.
- [07:36]
A
And I think for the three of you, I want to come back to this concept of leaping forward. Dan, as a chief medical officer, any hope in hell of ending AIDS as a public health threat by 2030?
- [07:50]
C
I think globally, nationally, no. I'm more hopeful about San Francisco on the heels of UNAID setting out their Getting to Zero initiative. I think around 2013 or so. San Francisco on the heels of that, set up their initiatives based on prep expansion, based on rapid start of treatment and other re engagement strategies of which we're well integrated in and have done quite well. And the numbers show it too, about a little over 300 new infections, new HIV incidents when our Getting to Zero program started. And it would more than halved that to about 140 or so in recent years with a recent uptick. Again, I'll be interested to see how this past year and all the deep budgetary cuts to all of these different programs and those three prongs really bears out as the data comes out in the next couple of years. I think we have locally the political will that has more than waned, certainly entirely gone away at the national level and the real numbers globally too. The 160 some thousand estimated new deaths just from the funding cuts to USAID as of Last February, about 16,000 or so more of those being children. That has implications, not obviously sadly, for the people who will lose their lives, but the communal viral load will potentially increase. And so what I'm getting at is that it's not just the infrastructure that is so easy to cut and go away when someone now shows up back to their clinic to try to get their HIV pill that they no longer can. There's now no clinic, no staffing. You cannot flip that switch back on come the next generation. This will as it's made inroads to all different departments. My brother's in the State Department.
- [09:55]
A
Those with the jobs still, no.
- [10:00]
C
But when we sat with them in this almost Orwellian context in the basement of the State Department. And he and his colleagues were looking over their shoulders telling us of the things to come and what may happen to usiad. It was scary to see that those diplomatic relationships that have taken years, that trust, the fact that the erosion of all of that allows for nefarious governments and other people to come in that will take generations to rebuild. So certainly not 2030 or beyond. But locally I'm more hopeful that we have the political will and the willingness to step in and sustain those programs to maybe meet that goal in the not too distant future.
- [10:50]
A
And here's another example of the glass being half full right in the way that you approach Dan. How many patients does the Community Health center in San Francisco have these days? Because it's increased significantly?
- [11:04]
C
Yes, for our clinical medical functions proper, we have somewhere between 1 to 2000. More broadly, we see about 5,000 unique patients a year and we have heavy intensive touch with those patients. A large portion, about a third or so, are street medicine, are marginally housed and about a third, a fourth to a third are gender diverse trans. But more broadly, through our very robust case management programs outside of medical and the FQHC functions of dental and behavioral health, we reach much further and and wide and the breadth of who we touch in the surrounding Tenderloin neighborhood. I believe over 26,000 encounters we had this past year.
- [12:02]
A
It's an important point to make because the center is not dealing with, how shall I say this? Rich Agaz in the Castro. With health insurance, we're dealing with the hardest to reach populations.
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C
Yeah, most FQHC directors will argue we have the most challenging complex patients, but we really do, I would say. Recently I met with a number of other medical directors and CMOs within the LGBT community and we were able, long overdue, to kind of compare our different populations. And though ours is orders of magnitude smaller in some respects, the complexity more than makes up for it. And it takes that kind of intensive intervention to really get people from A to B those resources and the wraparound case management services that we have is really what's needed to for our HIV patients get us to zero. That re engagement of going out and actively being able to find people on the street to deliver their long acting injectables is something unique about us. And other health centers are interested in that. To really shift course into these brand new interventions that have incredible potential for these hard to reach populations. But in order for us to get to zero, we need to reach these hard to reach populations.
- [13:35]
A
To make that happen. We'll come back to that again with some of the innovations that you've shown. I mean, Tati, you are now, you're a regular on the show now. No getting away from it. In fact, one of the most popular episodes last year with a lot of questions coming back to us online and DMs about your experience, but also the center's experience. Because if there's anywhere where you're going to be able to tell whether you are going to be able to bring the epidemic under control, it's going to be here in the tenderloin at the Community Health center.
- [14:15]
D
Absolutely. And I'll say, just as Dan and Lance outlined, absolutely no. And that saddens me to say that. But when we're thinking about getting to zero, it was always a coalition strategy and we could never get to zero. And I've echoed that for over a decade now, that we can never get to zero until all populations and persons are centered at the table. And when we're thinking about how close, I'll say that, how close we were to reaching that, and particularly here in San Francisco, it showed that it was possible. When you have these coordinations and then the entrance of new biomedical interventions and long acting injectables, these types of things were moving us forward. But I will venture to say that our trans population, population community that I am myself a part of, is the canary in the coal mine. According to CDC's own data, 2 out of 4 black or brown transgender women are either living with or at risk for contracting hiv. That in and of itself is not a margin. That is a public health emergency. And then when we're looking at the assaults and attacks politically and the shifts that are occurring to trans populations, how could we ever say that we will get to zero when there is an entire population that this administration is attempting to erase as we know it? And in the absence of that, what I often say is that those numbers don't go away. Those infections don't go away. They don't just magically disappear. They're forced to the margins. And now we're not having folks who are engaging in care and getting tested. And I would also venture to say that one of my fears is that we will experience an entire generation of people who are not medication resistant and that couples and compounds all of the complications that we're experiencing in this continual fight to get to that place. But as we are sitting now, no. And the sad thing is that even after this administration, because this is not what we think in that Context, this is not just one singular shift. This is something that is emblematic in a culture to all of us, that this cannot sit in the seat of being at the behest of political changes. Because all of that trust that is built within communities, like Dan talked about getting folks to even get tested, we have to honor, particularly for communities of color, the medical mistrust and distrust that exists within our communities. And so after this administration or this shift has a redirection, it's not going to be a reactivation of trust that takes time to rebuild. And so when we're thinking in that context, sadly enough, no, we will not.
- [17:13]
A
Well, I think we're all aligned on that then. And it's a horrible place to align on, isn't it? But I think there is, if we look to the sort of broader longer term agenda, there's still a sense, and you hear this in the cognoscenti from Washington and the AIDS movement a little bit, saying, oh, we can find this way of working with this administration and if we do that and there is a change of government, whichever, there will have to be at the end of. Well, I say there has to be at the end of 2028, but who knows? But we will never be able to go back within a 2, 3 year period with what was destroyed in the space of months. And so one of the things we're going to have to look out for are the steps that we can take now, but a strategy at the domestic level with health and Human Services, that's going to take, I would guess, at least a decade to get us back to where we were. And the reason I say that is simply that the attacks have been so comprehensive on every aspect of our work. You mentioned getting to zero, and I want to put this again to the three of you. One of the things that the administration has done quite spectacularly has basically been to disband surveillance and monitoring in most of the globe. And because the US Was the heavy investor in the AIDS response, they wanted people to use their own reporting mechanisms. So damned if you do, damned if you don't. But I don't understand how we can be talking about a getting to zero agenda when nationally, are we reporting HIV infections in the way we should? Are we reporting the kind of challenges and risks that people are facing in case they become a greater risk of HIV.
- [19:12]
C
I hearken back to when I first started in D.C. and their head of HIV and infectious disease, Dr. Shannon Hayter, came in and she really revolutionized the program. And it started with surveillance. There were some exposes that were done before her time, but she came in and when we could finally collect the data and show around that time that 1 in 20 DC residents was HIV positive, just merely living in DC, it was a risk factor. We could move towards a sixth vital sign being HIV check in every healthcare setting. That is the starting point and it is deliberate. Clearly, if we're going to make the data harder to gather because funding certainly follows where the data shows. And so as to why it's been impossible to include gender data on a lot of these granddaddy national health surveys for years and years and such a fight to even get any LGBT health data because the funding will not follow if you do not collect it. So I think that is a deliberate strategy and it's something we certainly need to push at back on and find our own local and state level mechanisms for collecting that data. It's why internally here, for gender affirming care data, we have surveys to demonstrate the question that we know if people engage in gender affirming care, does it improve their quality of life measures and survival and all of that.
- [20:58]
A
Oh my God, you should have been at Dr. Oz's meeting with medical society just happened recently to look at the effectiveness of gender affirming care. But a question, I guess, and I will put it to you, Dan, is that. You have. We have no mechanism out here on the west coast of doing adequate surveillance of HIV services. Now we could perhaps join, as you know, we joke about with Oregon and Washington state, maybe New Mexico, to have some sort of cohesive regional whole. But the national approach to surveillance has been completely eradicated. And if you look at the international side, the only use of US funding is for pregnant mums and kids. And so vast groups of people most at risk and living with HIV are excluded from what is in service. And again, it speaks to the elimination of different groups of people. Can't believe we're saying that in the mid-2020s in the United States, but that is what we're saying. What does this mean from a policy perspective, Lance? I mean, how the hell do you manage and lead an organization whose primary mission are these communities? And the entire run could be pulled away from you at any time.
- [22:38]
B
That's a lot that you're posing. You know, I think to lead an organization through this moment is an unbelievable, unbelievably challenging task because it is. We're connected globally, so we can't ignore what's happening around the globe because we know that that is going to inform and we inform there's this, there's always this bilateral transfer of knowledge and experience and sharing. And so with that getting cut off and then knowing that, what do we have in our control? That's what I'm always thinking right now.
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C
How do we fight?
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D
Where do we fight?
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B
Where do we position our resources so that we can do the pushback against all of the erasure around our trans communities, our immigrant communities, the DEI initiatives that are all about communities of color. It's about caring for the health and wellness for communities of color. And so, you know, we have to figure out, and that's what we're doing right now is, is doing our best to focus at a national level, at a statewide level, at a local level, so that we can preserve as much as we can so that when we get to that next place of hope and a different administration where we are able to then reset. What I always think is that even in the hardest moments now, we need to be thinking about creating the systems of care, the spaces of care, the relationships of care that we never had in the first place. We are in this moment and we've been in this moment because our healthcare system was not built for people who were struggling with housing. It was not built for immigrants and undocumented folks. It was not built for trans folks and queer folks. And so we really need to think about how do we create a system that is for the communities that we care most about and really, really be true to that.
- [25:01]
A
But you're not thinking you can achieve that by say, the first two years of the next administration. This is going to be a long term strategy and there's something there that you say that I think is really interesting. And I've picked up or pushed the International Aid Society on what I think is a, a marvellous initiative that they've done and which will be the theme of AIDS 2026 in Rio this year. And it is basically focuses on, you know, reform, get ourselves together, rebuild and then rise. And the rebuilding is not necessarily about trying to replace what we had. It's an opportunity, a long term one, almost like a modern New Deal, if you like, to get the kind of services.
- [25:52]
B
And we're doing that here at San Francisco Community Health Center. That's what I'm most excited and proud about, is we are innovating with our communities. And that's what I always have believed, that we can't do it on our own. Healthcare providers and systems don't know how to do that unless we are engaged, truly engaged. And it's the infrastructure of trust that we have built over years and it takes years to engage those communities.
- [26:20]
A
See these structures, these structural obstacles are ones that are going to take decades to overcome and address. I know it's very, very frustrating on the international level. So we're looking at a policy perspective and a leadership perspective of a long term agenda. And I'd love to come back about how touchwood there is a sensible administration after the chaos and corrupt administration to look at what are priorities and then how do we get ourselves in there to make sure we are not forgotten. But Dan, one of the things that I found quite interesting since you've been at the center is the way in which with everybody, you all have created innovation out of biomedical innovation and you've created innovation in service delivery. So I'm probably not breaking any board confidences, but I do recall a time when you were saying that the potential of long acting injectables as therapies and as prevention technologies were things that were really exciting to you given our population, given homeless clients who might, you know, whose marginally housed space in a car park could be erased and moved by the city. But people are able to come back and know that their records in here, they're not dealing with missed drugs. Tell me how that worked because I think that's a really interesting way of thinking about the implementation opportunities of new biomedical advances.
- [28:04]
C
Yes, certainly. I think the broader context around HIV and the question of PREP and particularly long acting injectables is one of acknowledging the question it was raised when I was meeting with the previous medical directors. Has PREP been a slam dunk? Well, there has been over the past, since its advent in 2012, decreases in new incidents of HIV, part of which we can potentially attribute to PrEP, in addition to those other prongs of re engagement strategies and getting folks into treatment and reducing the community virus.
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A
Don't forget the dapiverine ring.
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C
Yes.
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A
Yvette will kill me if I don't mention the dupivirine ring. So I've done it.
- [28:49]
C
Oh, okay, okay. But, but, but, but what we found is that particularly within certain populations and per the CDC unhoused and black and brown folks, lat in particular. So if you look at the CDC data around folks who are eligible, which can be defined in a variety of different ways for benefiting from a PREP intervention, whether oral strategies are long acting injectable, a little over 30% of folks have access to that intervention. Right. But if you break that down further around close to above 95% of white people who want PREP get prep. Right. When it comes to black people, probably in the teens, around 13% who want PrEP, get prep Latinx, somewhere in between around a fourth of what white people can in the way of access, around 20 to 25%.
- [29:50]
D
Right.
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C
So we're seeing that those populations actually aren't getting it and in youth 18 to 24.
- [29:57]
D
Right.
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C
Aren't getting it. Right. And so when the next new prep rolls around, it's not just making sure that white CIS men who have resources and commercial insurance get the next best thing, but really making sure those new interventions that we have strategies to make sure they have access. So to the unhoused folk and the data that we've captured in the tenderloin neighborhood, of which we're right in the center of over half of the city's unhoused live here, this is the epicenter of the opioid or fentanyl epidemic.
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D
Right.
- [30:32]
C
We found in the past year half of the folks that are unhoused, living on the streets, their belongings were swept away. Of those, half of those who were swept, their medical supplies, whether medication was also swept away. And of those whose medical supplies were swept, only 10% got them back. So that could have been their prep medication that is otherwise at threat for being stolen or their HIV drugs. Right. So enter long acting injectables. We've known this, but there's a clear opportunity there. And the number of folks who we've struggled with adherence challenges because they're trying to find a place to stay may be struggling with addiction, other competing priorities, or have food insecurity and needing to find a meal over where they're going to get their meds now can just get a shot. The ability to come in and access our services through walk in in the community living room, get harm reduction suppl and a hot meal and the street medicine can either see them there or we know when they're due and we know where they are out on the street and administer their injection there. And remarkably, on the heels of Ward 86, Monica Gandhi, though off label giving a lot of these long acting injectables for treatment for people who have relatively high viral loads, we have strategies and remarkably have been able to get a lot of those unhoused folks who are not undetectable undetectable because they get their injection and other wraparound resources from us. So that's an example how long acting injectables in the folks that are the hardest to reach really can turn the corner on reducing that communal viral load, on preventing new infections and this overlaps so much with the challenges around access to Latinx and black and brown folks as well. Where I think more broadly the LGBT health services community needs to not just move along the next best thing in prep, of which there's a whole suite of exciting things that are coming down the line, not just in terms of long acting injectables, but weekly pills and other interventions.
- [32:54]
A
I'm glad you mentioned those because in one of the worst case scenarios that we're thinking about for an AIDS 2060 conference is that there have been no new innovations in therapies and prevention technologies since the early 2000 and 30s that the pipeline sort of dries up. We've got good enough drugs that make the market stable. They're all going to be moving to off patent generic availability in the medium term. So that's HIV covered. How do you think of or what advice would you give to a young researcher starting their career now wanting to work for one of these research institutes or a pharma company on HIV research? There's nothing there, is there?
- [33:57]
C
I don't know about that. I think where we are with new proof of concepts kind of foraying into long acting injectables, that is a seismic shift of where we've been and
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D
general
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C
practitioners, internists who want to get into HIV. It's fearful because you see this list of 30 to 50 different drugs, not understanding that once you're in it, it's much more simple and really you're dealing with. Speaking of about 10 to 20 medications that you are rearranging in different ways to take care of certain side effects to simplify or streamline a regime, originally it was getting from multiple pills to one and then limiting the various side effects and then the certain long term effects. Right now in combining long acting injectables in various ways, some of the long acting medications, like the capsid inhibitor Lenacaprevir, the way you initiate it, you combine it with long acting oral tabs and the injections to get you up very quickly to the protective levels or treatment levels where you need to be. So we can take those pills and potentially combine them in various ways. But there are now a whole new classes of HIV drugs. When I was in my training there was about 4 to 5. Now we're approaching 10. The new translocation inhibitors. I'm happy to go back to my whole life cycle of HIV and find the new places they're inserting the CAP inhibitors. Before that, yeah, you had your classic four Proteus inhibitors which are kind of being Phased out.
- [35:44]
B
Yeah.
- [35:45]
C
Integrase inhibitors and then the NUCs, the non NUCs and the nukes and entry inhibitors and now we have some additional classes. So looking at how we can creatively recombine these and get around adherence challenges a la what I just described, the way long acting injectables help the unhoused with other competing priorities I think is the way to where we're thinking about it. And even now with lenacaprevir in the pipeline, a once yearly intramuscular injection is in earlier trials is a very encouraging approach. I would though framing it as a vaccine, given all the anti vax sentiment right now might not be the best strategy. The notion that you could go in for your flu shot and your other
- [36:31]
A
immunization seasonal preventative or your therapeutic.
- [36:35]
B
Yeah.
- [36:35]
C
Would be a remarkable shift. So I'm hopeful and I do think it's, it's interesting. Infectious disease and particularly antibiotics is very challenging when you have medications that are one off but HIV drugs right now there is incentive there to invest in ways that in other realms of infectious disease where it's a limit of time frame, it's still now a, a chronic medical condition.
- [37:03]
A
So that assertion that we may not be looking at anything more beyond the mid-2030s is probably a bit pessimistic. You're a bit more optimistic. I am. But then the challenge Tati comes to getting it to the people who need it.
- [37:19]
C
Exactly.
- [37:19]
A
You know the whole point of a shot in the arm podcast, it's about innovation in health and equity in health. What is the point of innovation if there's no equity, if it doesn't reach the people who need it? And this is not something we have been good at. So what gives us Eddy optimism that we might be able to do something different, begin to do something different when the political chess pieces rearrange themselves?
- [37:49]
D
And I think that that's an important distinction. One that this cannot hinge on one political party or one political shift. That when we're talking about these and things in the context, what we're talking about are infrastructure. And so when we're looking at infrastructure, I utilize this health center as a model because I've been singing the song to a lot pharmaceutical companies for the past year, particularly with the emergence of these new biomedical interventions that we have to also consider some of those psychosocial factors. And for SFCHC treating and utilizing whole person care, integrated care. Because what we're looking at are not one sided, one faceted people. We're looking at this and approaching it from that multi layer, multifactorial approach where we are making those considerations, because I can't begin a conversation with a trans person about their HIV care and treatment if I'm not seeing them and affirming them in their gender. And so when we are approaching it from that way, we are treating the whole person housing, all of these social drivers, because we've moved away from that whole social determinants. What we're looking at are the social drivers and addressing tell unaids that they
- [38:57]
A
need to know we've moved away from social determinants. Okay.
- [39:00]
D
It's one of those things. As a health center, we've just undergone our process of actually putting it into paper, our theory of change and speaking to who we are. And one of the things that was most resonant was that whole person approach. And so when I look at that, as I said, utilizing us as a model. Absolutely. But that has to be something that is a part of the conversation.
- [39:23]
A
And the model that you operate is really cost effective. It's, as we say in England, it's as cheap as chips. You know, it's something that ought to be rolled out. And I've seen an interesting dynamic which I think gets us again to the sort of future agenda that I've seen. Lance, you do it at international conferences, conversations with Africans and Asians around the way they approach, particularly community health workers and how the community is brought in to be part of the service provision. And I think there is a conversation to be had there. So if we look tati at the agenda over the Next, let's say, 20, 20 years, we'll give you that. To what extent are you optimistic that some of these structural questions can be addressed? How likely is it, do you think that we will be able to get access in black and brown communities to prep at the same sort of levels that we're seeing in whites?
- [40:34]
D
And again, going back to our model, but also when I think of it in that way, one of the things that I say that this, this moment has called us back to what it is that this movement really was about, like the entire movement of HIV and AIDS and ending the epidemic was a radical movement. And for us, what we're seeing, even in this moment, for us as organizations and being in coalition with our partners, has been this resource pooling and building of networks that we have not seen since the beginning of the AIDS crisis. And so in that, how folks are responding even on a global level gives me that much hope. And so getting back to some of those foundational things that we Know, as a part of this movement that one, we're all in connection, that two, this is not a singular person issue. This is not moving away from those targeted populations when it's like all of the people that are impacted by HIV and AIDS are a priority. And so in that reimagining and reconceptualizing how we even talk about HIV and AIDS in and of itself, because it has done a disservice to sit in these rooms where we're making these guesses about communities without ever having conversations with folks and inviting folks to be a part of those changes that are happening and shifts that are occurring within their own health care. And so utilizing empowerment as an intervention. And so looking ahead to 20 years, as I said, I find hope in some of those drivers of folks from the beginning of this epidemic that said, you are worth fighting for and we're not going to stop fighting until the death of that. And so in that I am pleasantly optimistic that we will see, yes, differences and changes and as I said, as a landscape, because even when you said like we, I had to make the differentiation when we're talking about the we as a landscape, but we as a health center, we're already doing these things. And so we've seen that. And just like you said, with what we have, you know, of course, yes, much as we had more, we could do more, but utilizing what it is that we've had and finding and being creative in that even just like some of the intervention, homegrown interventions that we created here have impacted health keep for
- [43:01]
C
folks, if I may, just as to to underscore what Tati was saying, that there's the silver lining is there's an opportunity here, a hard reboot reset on how we approach how we do this work and a return to community during previous years under a certain administration of greater prosperity. I think we were more on autopilot, relatively speaking, where when now it's crisis of times of intense scarcity. We're really having to draw on each other and be creative and really rethin think how we rebuild this again to your point, Ben, not just replace everything back again, but do it better this time. And there was a quote in the last meeting of the medical directors. I don't know who to attribute it to, of wanting to not put a good crisis to waste. That's right. That we need to kind of get to the front lines and fight right now and be in a battle or war.
- [44:02]
B
Right.
- [44:03]
C
Lance had voiced to us how it felt when those executive orders came down. A year ago that we felt this odd, you know, we've been in crisis before, but that our own government, while we're in the trenches, is firing at us each day and there's some new fresh hell every morning that we wake up to. And to be in that continual sense of disgust about like what we've become is frustrating, yes, but also empowering. That we need to do this right and better this time as we rebuild and recreate our community like they did in the 1980s, but certainly again in new way.
- [44:43]
A
And I think a key component of that, we're going to have to do better at connecting the domestic with the international. I honestly don't see any difference in issues. I know that for many years that kind of argument would be received with, you know, would go down like a fart in church, to put too fine a point on it. But the idea that a country as rich as the United States has development challenges as much as India or South Africa. And the reality just really hits you when you become involved in an initiative in a center like the Community Health Center. So again, so we can probably look to some progress on some of the structural obstacles. I'm going to hold on to that because I've just not been able to see that. But the AIDS movement itself in the United States, do you think it's fit for purpose? I mean, here's an example and I can say the provocative, but provocative thing. You know, we've had this issue over the last few years of AIDS organizations coming out of the Castro of the well off gay white men. And the leadership of our AIDS organizations has reflected that. Here at the Community Health center we have something different and we see that beginning to churn across the country. But Lance, you must be up, you know, impersonal to this. Are you optimistic that we're going in the right direction there?
- [46:29]
B
When I think about community, I have so much faith in our community. And we were talking about it from the 80s, the resilience of community and the community having to take care of its own because the government then wasn't taking care of us then. But what we have learned since then, I think is that the queer community can't do on, do it on its own. We're not, we don't exist in a bubble. We, the movement of HIV doesn't exist in a bubble to whole person care. We have to acknowledge the intersectionality of our lives. So it's not just about hiv, it's not just about health care, it's about civil rights. It's about also Women's reproductive rights, that the movement, what we've learned from that right now, the attacks on abortion, that now is the attacks on trans folks and gender affirming care. We need to connect the dots. And you know, the other what I'm thinking about too is my role as board chair of nmac.
- [47:40]
A
What we have, just tell us where
- [47:42]
B
nmac, the National Minority AIDS Council. So when we produce, you know, we organize the US Conference on HIV and AIDS and the HIV Biomedical Summit and you know we, we do a lot of national work alongside many of the other national HIV organizations. But we've learned at NMAC and enacting is that we have to build coalitions across movements because we need to support each other and we can't do it in isolation. And so that, that's some of the infrastructure that we are building now at nmac. But not just at nmac, we're doing it within the queer community and across organizations, national organizations, state equality organization, LGBTQ community centers throughout the country. So I do think there's a groundswell of figuring out what's possible in the broadest coalitions that I think we are really focused on right now. And that's what will get us to this next place of truly engaging communities that have been struggling and marginalized and vulnerable and forgotten. And if we don't learn from that and we don't do better this time than you know, then we've truly lost hope. But I do believe we're doing this.
- [49:02]
A
I get what we have to do. I guess my skepticism is that we won't actually do it. And so looking again at this longer term agenda, how long do you think it's going to take for that kind of integration, coalition building with other health priorities? Do you see that as a priority for the next five, 10 years? Is it going to be something that again we're going to be not really seeing results until more the middle of this century?
- [49:37]
B
I, I don't know about the timelines. How I look at it to me is like we gotta use every moment and not stop. We need to continue to do the data collection, the surveillance reporting infrastructure. We need to continually disaggregate data for communities or else we will, we will all be forgotten. We have to keep on doing that now so that, that when we are able to start seeing the impacts, that it's not just impacts for white people or it's not just impacts for rich people. It's actually we have to move together so we are really seeing an equitable progress and that that's now, we need to do that now. So if we can do that now, then, then I. Then I'm hopeful that the timeline. We can move that timeline up my.
- [50:30]
A
So I love hearing that. It takes me back to an issue that we had in the UN in the early 2000s, and that is how the hell do you maintain momentum over an emergency issue? How do you manage an emergency over the long term? It's sort of a contradiction in terms. And I just, I think if any movement can do it, it's the HIV movement, but it's damn difficult.
- [51:00]
D
And I think the challenge is also just going with what Lynce was just talking about, even the term of intersectionality. And Dr. Kimberly Crenshaw, when explaining that, and she says that if you cannot see a problem, you cannot fix a problem. And what we're talking about, even seeing CDC erase everything pertaining to trans people from their entire compendium where we're experiencing CDC and proposal $10 billion in cuts to HIV prevention. And so when you're thinking about that, it's a compounding issue as it pertains to entire populations of people like you're just. Because you say as a function of an institutional body that we're going to erase this population. The population doesn't go away. They're still there. We are a whole people, living and breathing. And even more so, just coming from the perspective of myself being a soldier, a veteran of the military, what we are experiencing is not something that I myself can even conceptualize, because here it is, I'm being fired on by my own government. And so there's. Anything that this moment has taught us is that even our reliance as a movement upon governmental funding has had to shift. We've had to shift a mindset. And so just like what you're saying, if there is any movement that can continue that momentum and harness that power, because, like what Lance was talking about, what we have discovered is that is the power of the people in this moment. It has been community that has shown up for community. It has been community leaders who have stepped up and said, even us as a health center, no, this population in this community is worth fighting for. And in that, if that makes us more of a target for these same people, we are prepared to face that. That because these communities that we have built trust with, that we have invited in, or that they have invited us into these spaces to actually address some of the issues that they're facing that are impacting their way of life, that they themselves are worth centering. And so on the one side, yes, it is an awakening and it is one of those ice bucket moments that I have to wake up and say, this is. This is it. But as we talked about even on the last podcast, that these issues are not just representative of this administration. It is something that is longstanding that we have to address. And if we come out on the other side of this moment in time having those same mindsets and thought processes, we will do ourselves in this movement a disservice. Because what we're seeing is that, no, we cannot rely or put all of our trust even in the response. What we have not seen are other sectors, in particular even within the pharmaceutical sector, who have said we're going to step up, because the reality is that they cannot alone fill that gap.
- [53:57]
A
Now, what you're describing could very easily come from a community leader who is trying to get into some of these, these U.S. department of State conversations with countries over memoranda of understandings that would enable their countries to get significantly less, but at least some PEPFAR funding. And you are essentially repeating what they say, which is, we have to build our community presence. We have to make sure we are there again. I mean, and if there's one thing that does give me hope and optimism, it is that, well, the populists can try and break up the world According to Orwell's 1984, you know, spheres of influence, but the communities won't. And we have to make sure that the dialogue that you are having is a dialogue that's connected with the very same dialogue that Lilian Letiso in Kenya, the head of LVCT Health, is having. What Imelda Mahaka in Zimbabwe, the Pangea Zimbabwe AIDS Trust is having. These are precisely the conversations that are happening now and we can get ahead. So I realize that we are up against the end of this podcast. I would love to have continued this conversation for significantly longer, if it's okay. I would love to be able to come back to you later in the project. Perhaps we with other representatives from around the world who are doing similar or maybe profoundly different things to you, but let's stick with this totally arbitrary figure of 2060. The conference has actually come back to San Francisco, who knew it. And Lance and I are in our third teenage years, our third teenage era at 2060. Good God, I don't even want to think about that. So, so what's happiness for you? What would be like the one big announcement that would come from this earth shattering AIDS conference?
- [56:07]
D
I would say infrastructure. The infrastructure, not just infrastructure from building it, but Infrastructure that in and of itself supports that very same infrastructure. And I know that's like around talking in rounds but what I am saying is that once it is built that we have shown that we can operate it from a space of self sufficiency. And in that because what you describe even just prior to that is that those conversations on a global level are happening. I attended and this is the second year a global convening of community partners and myself I'm always centering the fact that within these conversations I have first person lived experience. And so I'm not just advocating from a space of saying these populations. No I am the population population. And so when we're connecting with sisters of trans experience in Thailand who their entire funding came from PEPFAR and so figure talking to them and understanding how they are figuring it out and bringing back those best practices because what we're seeing even in the threats from the executive orders and providers having to now choose do I go with with the science because that's what's being attacked and make having to make the choice do I treat my patient over what is being proposed as you will be jailed for providing this care. And that is not something that a provider should ever have to sit in the seat of. And so in that bringing back as I said those best practices and creating those referral networks that legally will not be supported. And so in that that that infrastructure that has been built and it is up and running but it is connecting
- [57:51]
A
all of us and it's sustainable that's globally and we're look and we're running it ourselves not what about you Dan?
- [58:01]
C
For me it's not so much did we was there a cure discovered? I think there, there will have been one by then but how we responded to it and you know I think about the advent of, of of penicillin and it wasn't so much the discover all know and credit to fleming.
- [58:21]
B
Yes.
- [58:21]
C
But Dr. Flory and others who work with Merck to get penicillin over to the US and develop it and really make it accessible to the masses is what really revolutionized medicine at the time. And I think that we use HIV and how we've had to really rebuild and bring everyone together in a way to address the syndemic of HIV around gender inequality, poverty, addiction, all of these things that we don't want to talk about that HIV has forced to the surface and really moved us moved humanity along. And so it's less so about HIV and where we are with it and the rolling out of potential cures and the true end of the epidemic, but what we've learned about it as to how we approach the challenges around climate change and those other same syndemics of poverty and food scarcity and housing and the like. So I think that we're more reflecting and learning from the story of HIV and I think that will be the value of 2060, the international AIDS conference, or what I would like to see.
- [59:50]
A
Yeah, so we have the sort of sustainability and structural responses, the integration with others. And of course, the climate agenda is inevitably going to be increasingly overwhelming as we sit here boiling in San Francisco at the end of March for temperatures that should be. I don't know what. Lance, final word to you. We're in our wheelchairs at the bottom of the conference hall. What do we want to see?
- [60:20]
B
You know, I building upon my amazing colleagues here, it would be a conference of celebration of community. It's to have black and brown trans people from around the globe, folk, drug users, immigrants, folks who are claiming that we have. That they are. They're not just seen, but they have been embraced. They are part of. Of the solutions that have been created by 2060 for that to be front and center. That we have all of these key populations that we have been advocating and fighting for who are actually running the show at that point and claiming whatever victories because it is their victories. And that there is an excitement and hope because we have done collectively what we needed to do to do right by the communities that has brought HIV to where we are. We know it's impacted the least and the most oppressed of us. So to then provide power and to give power to those folks who have been so long oppressed and to feel that they have agency and are creating the next, the next, whatever that Next is beyond 2016, that would be. That would be an achievement that I would be proud of.
- [61:58]
A
I mean, I feel inspired listening to the three of you.
- [62:01]
B
We got you to hope and optim. Yes, we are.
- [62:03]
A
Yeah, Hopey carry thing going on there. But I noticed that none of you said, oh, well, we will have ended AIDS. We will have ended HIV as a public health crisis by AIDS by 2060. That I think is going to require more reflection on my part. But it is interesting that the things that you are talking about, the three of you, are structural interventions for the long term. And the response to AIDS requires us to be in it for the long term. Well, lance Toma, Dan O' Neill and Dr. Tatiana Mourtain, thank you all three of you very much. This has been hugely helpful.
- [62:50]
D
Thank you. Thank you, Ben. Yes, always.
- [62:54]
A
Well, that's it for the first episode of Age 2060. If you've got any comments or suggestions, please leave them below or visit our website, our YouTube channel, or our Spotify, Facebook and LinkedIn pages. We really want to hear from you. We're all in this together, so like and subscribe wherever you download your podcast content. A big thanks to Lance, Dan and Tatiana from the San Francisco Community Health Center. And thanks also to our director and producer, Erica Spera from A Shot in the Arm Media. Thank you for your attention to this matter.
- [63:36]
D
Sa.