Gabriel Culbert & Agung Waluyo: HIV Research in Indonesian Prisons

Dr. Gabriel Culbert is an Assistant Professor in the College of Nursing at the University of Illinois Chicago and Dr. Agung Waluyo is the Directorate of Community Engagement & Empowerment at the Universitas Indonesia. Gabe and Agung describe how they met in Jakarta in 2003 and how their research partnership has developed since then. Agung reflects on what it was like to learn about drug use and the HIV epidemic after a sheltered childhood, recalls being warned that he could be sent to jail for doing stigma research focused on Indonesian healthcare providers, and shares how he navigates conversations about politically sensitive research with government officials. Gabe describes the reasons why the HIV epidemic became concentrated in prisons in Indonesia, questions why Indonesia has one of the highest HIV mortality rates despite having the largest universal healthcare system in the world, and envisions an expanded role for nurses in HIV prevention and treatment. Valerie and Carly nominate Gabe and Agung to be poster children for international research partnerships.

Read more about Agung’s work here: http://staff.ui.ac.id/agungwss
Read more about Gabe’s work here: https://nursing.uic.edu/profiles/gabriel-culbert/

Episode Transcript

Valerie (00:13):
I'm Valerie Earnshaw.

Carly (00:14):
I'm C arly Hill.

Valerie (00:15):
And this is Sex, Drugs and Science.
Today's conversation is withDrs.
Gabriel Culbert and AgungWaluyo.
Gabe is an assistant professorin the College of Nursing at the
University of Illinois,Chicago,and Agung is the
Director of Community Engagementand Empowerment at the
Universitas Indonesia.

Carly (00:34):
Just as a warning, guys, you are going to hear a little
bit of traffic in the backgroundof this podcast.

Valerie (00:40):
Yeah.
So Agung was joining us fromhalfway around the world.
He's joining us from Jakarta,and Jakarta actually ranks in
the top 10 cities sometimes peryear for traffic and congestion.
So you can certainly get, youknow, those traffic noises in
the background, but we hope thatyou enjoy the episode,
nonetheless.

(01:14):
All right.
Gabe and Agung, thanks forjoining us today.
And I thought that we mightstart by hearing a little bit
about your origin story.
So Gabe, you're in Chicago, inthe US, and Agung you're in
Jakarta, in Indonesia.
So we were hoping that maybe youcould tell us a little bit about
how you met each other.

Gabe (01:34):
Sure.
I, I met Agung in 2003, and wealways laugh about the fact that
it's been 15 or 17 years sincewe met.
I had the opportunity as aundergraduate in nursing to
travel overseas to study thenursing research process.

(01:58):
And so I was really lucky atthat time.
The National Institutes ofHealth had a program that
provided support forundergraduate nurses in the
United States to travel to a, ahost site internationally to
learn firsthand and up closewhat the nursing research

(02:20):
process looked like.
And so my mentor came to me inthe spring of 2003 and she said,
"Gabe, do you want to go toMalawi, Chile, or Indonesia?"
And I said,"Well, let's see,Indonesia is about, about as far
away as you can get fromChicago,".
And so I said,"How aboutIndonesia," and knowing nothing

(02:43):
about the country or theculture, I think I had seen a
few movies on in my youth thathad peaked my interest in, in
Indonesian history.
I said,"Well, let's go withIndonesia,".
And programs like are incrediblyimportant for developing

(03:04):
scientists.
And I get a lot of students whocome to me and they want to
learn about research.
And so they're, they're veryinterested in methodology and
statistics and making sure thatthey ask the right research
question and that they have thetools to answer those questions.
And I try to help them and guidethem.
And, and, and I think all ofthose things are important to

(03:25):
learn, but what will sustainyour interest?
What has sustained my interestover the long haul and what I'm
talking about as a 20-30 yearcareer is not the statistics and
methodology, although it becomesinteresting later on what
sustains your interest are thosehuman connections and those

(03:47):
early experiences that are, thatbecome part of who you are and
your identity.
And I went to Indonesia in 2003.
Dr.
Waluyo, Agung was my mentor.
And I'm not sure that I producedthe most interesting or, or well

(04:09):
conducted research project, butthat was not really the point.
I had a wonderful time and I metwonderful people.
And the dean at that time,Ellie, who was the Dean of
Nursing at the University ofIndonesia, which is the largest
nursing program in the countrymade sure that I had a variety

(04:33):
of experiences that would, thatleft an indelible impression on
me.
I, I, I had the opportunity towork with nursing students and
faculty in Jakarta, had theopportunity to go to Bali and be
parts of, be part of workshopsand seminars there.
And so when I came back to theUnited States, I had had this

(04:55):
really rich experience.
And it was many years before Ireturned to Indonesia, but those
experiences left a realimpression on me.
And so here we are 17 yearslater.
And I, I think of Indonesia asmy second home.
I've immersed myself in thelanguage and the culture, my

(05:15):
family lived there for a year in2013.
And so it's, it's, it's abuilding process.
And so now when I talk tostudents about kind of their,
these first forays into globalhealth research, I say, don't
underestimate the importance ofhanging out and spending time
with people, and enjoying icecream on the side of the road

(05:39):
and doing things that will, thatreally sustain your, your
interest in your engagement witha site, throughout the rest of
your life.
I think Agung may w ant t o talkabout that a little bit.
He has a sort of a funny storyabout when we met at the
airport.

Agung (06:00):
Yeah, well, before I, telling about that moment,
actually, area of HIV is not myarea of interest in teaching or
research in the beginning, butsince, in typical hospital, the

(06:26):
word for taking care of HIVpatients is put side by side
with a patient with cancer oroncology cases.
So, by the time I have tosupervise the students, then the

(06:46):
students have the opportunity tosee and taking care of them.
Although in the beginning, theyare scared because they don't
know anything about HIV.
So I was trying to make themunderstand, although that was
2002 or 2001, I, I see that HIVis still a very scary disease,

(07:19):
like COVID-19 right now.
So, uh, everyone tried to, uh,see the patient from the
windows, not, some of them, likeprecision, uh, not trying to
touch the patient so important.

(07:41):
So, and then when professorEllie was having postdoc in UIC,
uh, when she returned back toIndonesia, her duty was to make
an initial, a working group ofHIV/AIDS, research center.

(08:08):
And then, um, before she canexpand more on that dream and,
uh, suddenly she received emailfrom Dr.
Michael Laurie that one of thestudents of UIC would come and

(08:28):
do some internship or somethingor, and research activity.
So since I'm the only person inthe faculty of nursing who deal
with the patient of HIV, then Iwas appointed to become a mentor

(08:50):
of Gabe.
So that is the, the start andthe, of the insights person,
including all of the activity Ato Z, including picking, picking
him up in the airport.
And I didn't expect to see avery tall, uh, white people

(09:16):
wearing a hat, with a backpack,enjoying the, uh, hot chocolate
of Dunkin Donuts in the airport.
So, at the beginning, I, Iholding the paper written name

(09:37):
of Gabriel Culbert UIC, sinceprobably gave it an expect to
see me as a person who wouldpick him up in the airport.
So it's just passing through,but then I'm sure that this is
the kind that I have to pick inthe airport.

(09:59):
Because he is the only, we callit bully, like the white people
in the building.
So I'm just like,"Hey, I'msorry, are you Gabriel Culbert?"
Because yeah, I do that.
We start to have a chat andfinally, the dropping to the, we

(10:22):
call it what hotel gate, right?
It's like some small house forinternational guests located in
central Jakarta.
So that is the, at thebeginning.
And then, and I didn't know thatthat is become my first step

(10:47):
stone to the world of HIVresearch area.

Speaker 3 (10:53):
And then from that the year, then I start to have a
workshop conducted by a Schoolof Public Health UIC where Dr.
Levy was the host.
It was about the drug, uh, drugusers and HIV/AIDS, like, like,

(11:28):
uh, introducing about HIV AIDSand the relation to the users.
So that, from that year I startto, I didn't, I didn't expect
that, I have to deal with, orlisten to the topic of drug

(11:50):
users because I, uh, I'm like aperson who really, a house boy
or homeboy, like never go outfor something like, exploring
new things.
I enjoy staying at home and justaccompanying my parents to go

(12:13):
out and just a nice boy of thehouse.
So when I listened to thattopic, I was like, wow.
It was a really new topic.
And, yeah, I, I start to learn anew things, including, uh, how

(12:36):
the police officer try to usethem as a source of money
because when the drug usersstarting to have methadone and
when they have a urine test andthe result is positive of using,

(12:58):
um, drugs or something.
And they put in jail weresupposed to stay put in the
rehabilitation process...when,uh, the, the family give
policemen the money and theytransfer to the rehabilitation
process.

(13:19):
So, so that is the, the start,how I met Gabe at the beginning.

Valerie (13:27):
Well, I would give you an A plus right there, because,
you know, just in terms ofmentorship that you're
schlepping over to the out,schlepping over to the airport,
because especially, you know,traffic in Jakarta was that like
a full day affair to go get Gabefrom the airport?

Agung (13:43):
Right.
Right.

Carly (13:45):
And then you show up and the guy's drinking Dunkin Donuts
hot chocolate, that was the realstand out there.

Valerie (13:53):
And it's hot in Jakarta.

Agung (13:55):
It is, it is.
I think it's still in the, inthe building of the airport.
So the air can air condition.
Uh, yeah.

Valerie (14:05):
We'll forgive him a little bit.
Oh, this is really interestingto learn a little bit more about
you both.
So Agung it sounds like, youknow, when you're describing
your background that you, yougrew up a little bit sheltered,
maybe is how I might describeit.
But now you're doing all of thiswork related to HIV, drug

(14:28):
dependency, stigma.
So how did, h ow did both ofyou, and you've already talked
about this a little bit, butstart focusing in on this area.
What got you interested in it?

Agung (14:43):
Uh, starting with me first, probably I choose when I
choose, my topic for mydissertation, since I knew the
timeframe of internationalstudents, uh, I only have like
maximum four years, doing myresearch and the scholarship

(15:06):
also maximum four years then.
Telling to myself that I have todo research where it's related
to the, uh, healthcare workersrelated to the people living
with HIV.
So, when I read a few thingsabout nurses and HIV things,

(15:34):
most of them telling aboutstigma.
So since there is no studyconducted on that time in 2007,
a study about stigma from thenurses, then I stick on that
idea.
And whenever I got into theclassroom of PhD study, when the

(16:05):
faculty asking me, Hey, you,Agung, what is your research
interest?
And I keep telling that I'mgoing to do assessing the level
of stigma of the nurses.
And I didn't expect that when Ichoose the place of collecting

(16:32):
data from four differenthospitals affiliated from
different religions.
But on that time, I was thinkingthat, I think if we see if, if

(16:53):
the hospital affiliation, I may,I may, collect some of the data
like they are different, but Ididn't expect that the
difference is because of thereligious background.

(17:14):
I start to understand what I'mdoing, when I was, asking by the
IRB in faculty of medicine inUniversity of Indonesia.
They warned me that you can beput in jail if you're still

(17:40):
doing this study.
And I didn't understand whatthey are, telling me.
But this professor telling that,you know, the, the result would
be the nurses from this hospitalhave higher stigma compared to

(18:06):
the others, or Muslim nurses canhave higher, stigma compared to
the other nurses in thehospital.
But on that time, my ego was sohigh and I say that if you are
not allowing me to do thisrearch in your hospital, fine, I

(18:29):
have one of the received threeIRB approvals approvals from
three different hospitals.
So thank you very much forallowing me to sending this
proposal in front of you.

(18:50):
And after that, among them, theyare mumbling and say, no, no,
no, we are not telling that youcannot do that research in our
hospital.
But we try to ask you to changea little bit in some of the
question and blah, blah, blah.
Oh, in that case, I do thechange that I have to change the

(19:16):
topic of the stigma measuring onthe nurses in your hospital.
I cannot do that.
And finally, I can collect dataon that, that hospital, although
it was like at the end of lastweek, I stay in Jakarta because
I can only be collecting data inJakarta like two months that is

(19:42):
programmed from the eighth tripin my age.
So the day at the end ofcollecting, done, then I flew
back to Chicago.
So, from that, from that data,uh, just realize after like one

(20:06):
or two years, I graduate andreturn back to Jakarta.
And Gabe starting to have hispostdoc program.
And when, you know, like we were, having a discussion on how to
start a Gabe's research on hispostdoc, in the meantime,

(20:30):
because of a very long time ofwaiting approval from many
ministries, you can tell acomplete story about that
experience.
But meanwhile, that Gabe askingme"Agung, what do you want me to
help you?

(20:51):
You helped me a lot,".
And I say,"Well, I still have myraw data of my dissertation that
has not been published,".
And Gabe said,"Oh, how about wesee the data?
And we can have a discussion,".
And from that gives you"Agung,you have a very good data and

(21:11):
you can there's this.
And, Oh, well, why don't we justlike, start to writing up?" And
I say,"Okay, fine,".
I just remember sometime we havea discussion of the afternoon.
Actually Gabe you stayed in avery spooky hotel that time,

(21:33):
really, many, many faculty saythat sometime the night they can
see, you know, like ghosts orsomething, but, yeah, lucky Gabe
and his family didn't seeanything unless.
Unless small snakes when theyhave a, you know, a small walk

(21:58):
in the morning, I believe.
So, so, so that is the verystart, um, you know, connected
to the very sensitive studythen.
If you asked me, how can I dosome study on the prison?

(22:20):
That is because of Gabe'sproposal.
I remember like a week before Ileave Chicago, I'm just like
this one to say goodbye to Gabeand have a chit chat, but then
the chit chat is so interestingbecause Gabe say"Agung, don't

(22:40):
you, do you know about the issueof recent in America, and I
believe the problem in theUnited States have the same in
Jakarta or even moreinteresting.
Do you want to work togetherresearch in Jakarta, based in
Jakarta?

(23:03):
And I said yes, although on thattime, I was thinking.
Okay, Gabe.
I just want to go back home,".
But I didn't expect that, thatcrazy idea, it happens finally.
So when, like in 2011, Gabestart to send me email and us,

(23:31):
uh, many information about ourcondition of prison in
Indonesia.
And just like I, I try to helpyou, the things that I know.
So, uh, I'm sorry if I cannotgive you complete data or the
data that you expect me toshare.
So that is the situation.

(23:54):
When, when Gabe start to ask meto represent him presenting our
proposal or Gabe's postdocproposal in from of the Ministry
of Research and Technology, I,that was the first time for me
stepping on that ministrybuilding.

(24:17):
That was so huge we'll pack withthe...army from the United
States because Gabe's schedulewas put in the same date and the
same time with the idea of doingresearch from the army.

(24:38):
They are going to try to findthe skeleton of the army from
the World War II, that it in,Island of Celebas.
And on that time, they, they,they talk about the project as

(25:11):
if there is nothing, there isno, no one in the building, uh,
representing of United Statesperson or researcher, but from,
from their discussions, uh, theysay like, we have to be very
careful with the United Statesresearcher because they might

(25:31):
collect something valuable fromour country.
So we have to protect blah,blah, blah, blah, blah, blah.
So I was like, so scared whenGabe's name was called.
And, and they asked, is thereany represent from Indonesian

(25:57):
art?
And I just raised my hand, I andI said, Oh, okay.
You, you didn't expect me justsitting next to them when they
talk about the study of thearmy.
So, uh, yeah, uh, Gabe gave hispresentation.

(26:18):
And then when the discussioncoming and they are trying to
use Bahasa Indonesia, and, uh,they stop, presentation of Gabe.
And they asking me with somequestions that, yeah, I, that is

(26:40):
my very first valuableexperience.
Never have that, that kind ofactivity before.
So, I'm so lucky, although atthe same time, it's so scary.
I never expected to have thatkind of meeting before.

(27:03):
Yeah,

Valerie (27:04):
Well, Agung, that's pretty incredible.
I mean, for you to go from yourdissertation proposal, when
you're talking about what you'regoing to do, and folks are like,
well, you might go to jail forthis, and then you do it anyway.
That's incredible all the way upto sort of advocating, you know,
for this research partnership atthat sort of higher level.

(27:25):
That's really, that's reallyintense.
I would have to say.
Yeah, but I feel like I've gotlike a million questions now.
So first off, Gabe, everyonewants to know if that house
actually was haunted that youstayed in, and then also, you
know, to follow up with the sameidea, how did you get interested
in all of these issues relatedto HIV drug dependency, stigma?

Gabe (27:48):
Well, I'll just comment briefly on the ghost issue and
that's you know, Indonesia isoften referred to as the largest
Muslim majority country in theworld, and that that's true.
There are the most numerousfollowers of the Islamic faith,
but Islam is layered over manyother religions and some, one of
those is Animism.

(28:08):
And so certainly there's thebelief that spirits reside in
inanimate objects.
And so, you know, I always takethat into consideration when
I'm, when I'm walking throughthe natural world in Indonesia.
I want to back up a little bit.
I think I'm going is maybe notdoing justice to the, the the
work that, that, the risks thathe took to carry out the work

(28:31):
that he was doing.
Agung was sponsored through anNational Institutes of Health
fellowship to come to the UnitedStates.
So kind of building on what wetalked about earlier, Agung was
my mentor for many years.
And then I said, Agung, whydon't you come get your PhD in
the United States?
And so he took a huge, ah, hetook a huge risk by doing that.
He left his family, he left hiscountry, he left his position.

(28:54):
Ge left a very good job at theWorld Health Organization in
Indonesia with no, with nopromise of a payoff.
And he came to the United Statesand he did a dissertation
looking at stigma towards peoplewith HIV that was being enacted
by healthcare providers.
So that right there is riskybecause you're really, you're,

(29:14):
you're putting healthcareproviders under a microscope and
you're saying, what is it thatyou do?
Or you don't do that contributesto the perpetuation of this
disease?
Then his findings.
We said, well, let's look atthings like knowledge does
knowledge affect stigma.
Does the degree of religiousinvolvement affect stigma?
While we're at it, let's look atwhether Catholics and Muslims

(29:35):
enact stigma differently.
And by way of background inIndonesia, there's many types of
hospitals.
Some of those hospitals arepublic institutions.
Some are run by Islamicreligious centers.
Some are run by Catholic orProtestant religious centers.
So hospitals look very differentin Indonesia in terms of their
institutional affiliations.

(29:57):
Well, what Agung found was that,um, people who were, uh, nurses
who were practicing in Islamichospitals on average, endorsed
more stigmatizing attitudestowards people with HIV.
And this is where Agung wasgetting pushed back.
And I think he immediately sawthe risks of coming forward with

(30:18):
this sort of data in a countrywhere the, the ministry of
religion, um, has significantsway over public policy and is
very influential withingovernment.
And this may be something thatwe're unaccustomed to in the
United States.
But if you're going to saythings about religion in
Indonesia, you have to take intoconsideration the fact that, um,

(30:39):
the ministry of religion and ingeneral, in, in people's daily
lives, religion is incrediblyimportant.
And there's not the samedistinction perhaps between the
public sphere and the privatesphere that, that, that might
allow some of those comments topass.
But what's interesting isbecause of these risks, we said,

(31:01):
well, let's look at the data alittle deeper.
And so we started to dig in alittle bit and we found
something interesting, which wasthat it wasn't so much that
nurses were coming from Muslimhospitals or Catholic hospitals.
It's that Catholic andProtestant hospitals tended to
be more diverse in terms of whothey hired.

(31:21):
So in a Muslim hospital, you'remore likely to be practicing
alongside another Muslim nurse.
And so we can think about thenormalization of attitudes and
things like this, but where welanded with this was that it
wasn't so much that these wereMuslim hospitals or public
hospitals.
It was that public and Catholichospitals tended to employ a

(31:42):
more diverse array of students.
So you can think about any worksetting anywhere in the world.
If you're practicing next topeople whose opinions and hopes
and fears may look a littledifferent than your own, you're,
you may be more tolerant.
And so, in, in a way, the risksthat we had to think about in
terms of publishing ordisseminating, this information

(32:04):
actually led us to scrutinizethe data further, which led to
these insights about maybe it'sdiversity in the workplace
that's really driving this.
And, and subsequent to this, Dr.
Waluyo has continued this lineof research recently with 500
healthcare providers in threedifferent parts of the country.
And again, we're seeing asimilar pattern is that people

(32:26):
who are practicing in morediverse workplace settings are
on average endorsing fewerstigmatizing attitudes.
So that's one thing I wanted totouch on.
The other thing is back in 2003,Agung and I weren't aware of
what was happening with the HIVepidemic in Indonesia.

Valerie (32:47):
Okay.

Gabe (32:47):
Neither one of us understood what was going to
happen during the next 10 years.
And so, as we were getting ourPhDs, and we were forming ideas
about what we wanted to do, andthe HIV epidemic in Indonesia
was becoming one of the leastwell controlled epidemics in the
world.
So that by, by 2013, Indonesiahad been singled out by the

(33:10):
United Nations.
U h, the joint United NationsProgram on HIV AIDS known as UN
AIDS, had singled out Indonesiaas one of the countries where
mortality and HIV incidence, o rthe number of new cases, had
increased.
And that this was in contrast tomost other countries in the
world.

(33:30):
And so Indonesia's HIV epidemichad started out in people who
inject drugs, and because of thepunitive drug laws i n
Indonesia, those people weredisproportionately being
incarcerated.
I read one estimate that a thirdof all, people who inject drugs
in Indonesia had gone to jail orprison.
And as a result, the, t heprison population swelled

(33:53):
tremendously over the seven yearperiod that we were, we were
becoming researchers.
And so the epidemic was unfolding a nd in, in really
devastating ways, while both ofus were getting up to speed as
researchers.
So that by 2013, theAustralians, the Dutch, several
other governments had investedheavily in HIV reduction in

(34:17):
Indonesia, and with a specialfocus on prisons because they
knew what was happening or nothappening there.
And so I'll, I'll give a littlebit of background on that.
Indonesia has the eighth largestprison population in the world.
That's because it's a hugecountry.
The incarceration rate isactually far lower than the mean

(34:39):
incarceration rate for theworld, which is about 145 per a
hundred thousand.
Indonesia only incarceratesabout 78 per a hundred thousand.
So the incarceration rate isincredibly low, not even close
to the United States, whichincarcerates about a quarter of
all the world's prisoners.

Valerie (34:56):
Wow.

Gabe (34:57):
Nevertheless, because of the punitive drug laws,
Indonesia's prisons tend toconcentrate, tend to incarcerate
people who are at risk for HIVand, and the majority of whom
are people who injected drugs.
More recently, as we have seen ashift away from injectable

(35:19):
opioids towards amphetamine typesubstances, we've seen
increasing incarceration oramong gay men.
Why?
Because club drugs, stimulants,ecstasy, those kinds of things
tend to circulate in the clubcircuit.
And so it was striking to me togo back into the prisons and in
2015, and to see that there wassort of this older generation of

(35:44):
men who had injected heroin, andthat was their pathway into
prison, but then also, youngergay men who were being drawn
into the prisons because theywere being, they were being
singled out in police raids andother police.
In Indonesia, there's sometimesvigilante groups that will raid

(36:05):
nightclubs.
And that will result in, inyoung gay men being
incarcerated.
But we see it history repeatingitself, right?
The, uh, the, the drug, the drugmarket has shifted.
It's shifted towards anotherpopulation where, that is at
risk for HIV gay men.
And now we're seeing them in theprisons as well.

(36:28):
Well, there's a, there's,there's a, there's a global
discourse on what to do aboutthis.
Incarceration is probably the,the, the, the least productive
way to address an epidemic.
Incarcerating people who have,who have a disease is, is
tremendously counterproductiveto reducing the spread of

(36:50):
infection.
We knew from second handinformation, some of it done in
collaboration with theIndonesian prison authority and,
and AusAID, which is sort ofAustralia's version of USA ID,
that there was drug use in theprisons.
And when we went in, in 2013,certainly we, we saw evidence of

(37:14):
this as well.
It wasn't just that the prisonswere incarcerating people at
risk for HIV or living with HIV,but then people were renting
needles.
They were sharing syringes and,and there was, there was an
increase in drug use thathappened when people were in
prison because the boredom,being in contact with other

(37:34):
people with substance usedisorders.
So that by the time they leftprison, they had been exposed to
, they had been exposed to HIVand other bloodborne pathogens
like hepatitis C.
And so a very, a recent studythat looked at people who inject
drugs in Jakarta found thatincarceration was the single

(37:54):
most important risk factor forthe acquisition of drug
resistant HIV.
And so Agung and I looked ateach other and we were like,
this is what we've been saying.
So these prisons are extremelyhigh risk settings.
And we also see this in theformer Soviet Union, Malaysia
and other countries whereincarceration is sort of the
national strategy for dealingwith people at risk for HIV.

Valerie (38:19):
People at risk of HIV right type policy...

Gabe (38:22):
Right.
T he, the war on drugs, the onedrugs has really resulted in
prisons being one of the mainplaces where people with HIV are
diagnosed and first offeredtreatment.
And when we went and we found77% of the men with HIV had been
diagnosed in prison.
Half of them during the currentprison term.
In the U S it's 1%.

Valerie (38:45):
So does that mean that they're not testing enough
outside of prisons?

Gabe (38:50):
That's exactly right.
It represents a failure to kindof connect with these men in the
community.
And Indonesia, I should back upand mention here though, that at
the same time, Indonesia hasbeen ahead of many other
countries in terms of its publichealth response in the
community.
So Indonesia embraced a harmreduction model early on.

(39:13):
But the, the drug policy wassort of working against that.
I should also mention here thatIndonesia in, in many respects
is ahead of other countries interms of public health in
prisons.
And so often when we read aboutIndonesian prisons in the media,
it's often proceeded by the wordnotorious.
I often I challenged someoneonce I said, I, I challenge you

(39:36):
to find a news article aboutIndonesia prisons, where the
word notorious is not used.
Yeah.
I think a lot of journalists useit reflectively cause they're
like, they've never been to anIndonesian prison, but they know
they have a reputation.

Valerie (39:49):
Our prisons are niche notorious.
I feel like in the States, likenot only at our, like our system
that incarcerates so manypeople, but then like, you know,
we've got all this, like Misteron like Shawshank and like
Riker's Island and we've got,so.

Gabe (40:04):
Well, there's a whole mythology around prisons.
And I get that, like when I talkto people about what I do, one
of the first questions they askis like, well, everybody's
having sex in prisons andeverybody's using drugs in
prisons.
And sort of, they have these,these, these beliefs that a lot
of them are from, you know,watching Oz or other, you know,

(40:26):
Shawshank Redemption.
And, some of that fits withreality to the extent that we
understand reality in thesespaces.
And some of it doesn't, doesn'tfit so well with, with, with the
things that we've seen and thethings that we've heard.
One of the, when we startedworking in prisons in 2013, it

(40:51):
was really a, it was really justa long shot.
As, as Agung mentioned, we hadto go in front of several panels
of government representativesand kind of make the case that
this was important work and thatwe could be trusted to be good
collaborators over the longterm.
And I think that ourrelationship has gotten better

(41:17):
and better.
A couple of years ago, theUniversity of Indonesia signed
the first memorandum ofunderstanding with the National
Prison Authority, and that hasled to service teaching and
research.
And that to me indicates anopenness and a willingness to,
to, um, to serve the interestsof people who end up in prisons

(41:41):
and jails and to bring expertisefrom outside to inform policy
and practice.
So we're very, very enthusiasticabout that.
Um, and we have maintained abalance and I think we've done a
good job about being candid withthe scientific community and
with our, our readers, peoplewho are interested in our

(42:02):
research about what we'refinding while at the same time,
not being sensationalist ormisrepresenting in any way
what's happening and to providea balance of the good and the
bad.
As an example of, of a publichealth measure that Indonesia
has implemented, they havemethadone for the treatment of
opioid use disorder in theprisons.

(42:24):
Now it's probably not reachingas many people as it should.
But you'll find many prisonjurisdictions in the United
States that don't even havemethadone.
It's not even an option.
And this is a who essentialmedicine.
This is not a, a, a, you know,this is a mainstream treatment

(42:46):
for opioid use disorder, and wedon't have it in...

Valerie (42:48):
Many decades...

Gabe (42:50):
Right.
It's been around.
Safety is very well established.
Efficacy is very wellestablished.
So I think when we talk aboutIndonesian prisons, we have to
think about, we have to look forthe bright spots and kind of see
what's happening well, and whoare championing, w ho, w ho, who
is it that's getting behindthese initiatives, and then

(43:11):
connect with those people andsay, what could we do better?
Or what could we do more of ifwe had additional inputs?
And so we've, we've identifiedsome of those champions and
we've built up a network of, of,of scientists and practitioners
in Indonesia to try and movesome of these projects forward.

Valerie (43:31):
I feel like the idea of champions comes up a lot in
research.
I remember doing work inhospital settings with
pregnancy, and it was the samething.
You know, if we can find thosechampions in these spaces, then
we can really do niceinterventions here.
And talk about this.
I'm curious just about what theexperience is like for someone

(43:54):
to be, diagnosed with HIV.
And then Carly and I were havinga conversation earlier, we were
really curious about, what's itlike if you, once you are
diagnosed with HIV in a prisonsetting, what's it like to start
accessing medication?
Or maybe if you have an opioiduse disorder, what, what's it
like to start accessingmethadone?
Sort of, what, what does thatprocess looks like?

(44:15):
Look like for someone who is ina prison in Indonesia or in
Jakarta?

Gabe (44:20):
Let me start out by talking about what I think it's
like in the United States.
This is what I, this was mydissertation work.
Most people with HIV in prisonin the United States knew their
status before they wereincarcerated.
Some are diagnosed in prison injail.

(44:41):
But most of those who arecurrently in a prison or jail
knew their status beforehand.
So the issues for thatindividual are, do I disclose my
status?
Do I tell a guard?
Do I tell the, the first doctoror nurse that I see that I'm on
treatment and that I need mytreatment?
If I do, what are they going tobe the costs?

(45:01):
And so we found in a few casesthat in the United States, your
HIV status can sort of be usedas a weapon against you by, by
correctional officers or by theother inmates.
And so prisons are veryhierarchical.
You, there's a, there's apecking order.

(45:23):
And someone with HIV is as itis, it occupies a very low
status on that pecking order.
At the same time, people arelooking for support in prison.
One of the first things thatthey, what I heard many men say
is that when they got into thejail and they were in the
holding cell, one of the firstthings they were trying to

(45:45):
figure out is, how do I protectmyself in this environment?
And so that more immediatethreat supersedes considerations
of am I going to miss my pillstoday?
Maybe I've heard people tell me,I just don't open up my, I just
go off my meds when I'm in jail.
Cause if I'm only there for 30days, I'd rather go off my meds,
than take all the social risksassociated with disposing my HIV

(46:09):
status.
And it interferes with theirability to, to develop the kinds
of support or protection thatthey need in order just to get
through that first 30 or 90days.

Valerie (46:20):
That big sacrifice.

Gabe (46:22):
Yeah, that's a big sacrifice to make.
Especially if you see thetreatment i s something that
you're going to be doing yourwhole life and maybe being off
meds for 30 days is not going tohurt your health.
That's an, that's sort of achoice that the individual makes
now in Indonesia, where many menare being diagnosed during the

(46:44):
current prison term, they'recoming in, probably with the
understanding that drugs ledthem to be incarcerated.
Maybe starting to think, is thisbecoming a problem for me?
Maybe the inklings of do I, do Ihave a drug use problem?
There is not the same level ofdiscourse around addiction a s a

(47:06):
mental illness in Indonesia.
So in all likelihood, manypeople are thinking of this as a
moral failing.
O kay.
I failed my God.
I failed my family.
I failed my religion.
Okay.
So a lot of guilt, a lot ofshame.
And then at some point, either afew weeks or a few months into

(47:27):
incarceration, they take a bloodtest and the doctor says you
have HIV.
Now in Indonesia, if you tellsomeone they have HIV, the first
association is death sentence.
Why?
Because it is still largely adeath sentence in Indonesia.

(47:47):
Indonesia has one of the highestmortality rates from HIV of any
country in the world.
Now the central paradox that hasdriven my research is how could
that be in a country thatimports or produces its own
antiretrovirals and has thelargest universal h ealthcare
system in the world.

(48:07):
So in the United States, wetypically say, well, you know,
the reason the medicine doesn'tget into people's m ouths is
because we have such a botchedhealthcare system.
In other words, it's healthsystem issues.
And we say, gosh, if only we haduniversal healthcare, if only we
c ould get drug prices down.
Well, Indonesia did both ofthose things and it did them

(48:28):
early.
It did them before most othercountries.
SBY, one of the past presidents,authorized domestic production
or importation of like eight HIVmedicines and HIV activists w
ere celebrating this a s like,look what Indonesia has done.
They really they're really aheadof the curve in terms of taking

(48:48):
concrete actions to address theepidemic at the, at the
structural level, by makingthese medications.
ART is free of cost inIndonesia, right?
A few years ago, a bottle of atriple a cost, a thousand
dollars in the United States.
And a lot of that was b orn bythe insurance company, but in
Indonesia, antiretroviraltherapy is free and healthcare

(49:11):
is universal.
Now, once you start to dig andpeel back the layers there's
hidden costs and things likethat, nevertheless, I, we're
just starting to understand howit is in a country with
universal h ealthcare and freeantiretroviral therapy.
You can have extraordinarilyhigh mortality rates.

(49:31):
And, and up until the last fewyears increasing incidents,
incidents h as started to godown in the last few years, not
by much, but some of this ismaking a difference.

Valerie (49:45):
So that's, that's so interesting because this really
brings up the, you know, some ofthe issues of context that we
all struggle with.
I mean, if you were to run thesestudies in the States, or, you
know, I've done some work inSouth Africa around access
issues and, and these likehealthcare related factors, the
system, the systemic factorsand, and especially cost comes

(50:08):
up all the time.
Okay.
So, so what are some of the, um,so what are some of the reasons
that lead to people not thenaccessing or taking their
medication, especially in prisonsettings?

Gabe (50:26):
Well, in the prison, although many of them are
diagnosed and offeredantiretroviral therapy in
prison.
The, until recently theguidelines said that ART should
be set aside for people who havecompromised immunity who have,
who have depleted immunity like350 CD4 cells.

(50:47):
Now who changed the guidelinesbased on several large global
studies.
I think most countries are nowsaying, treat everybody.
There is a, there's a delay toramping the healthcare system
up.
I mean, when you say, when yousay not everyone's eligible for
treatment now, there's, there'sall these cost considerations,

(51:08):
there's supply chainconsiderations.
So part of that is just a lag ingetting things up to speed.
Another issue is that when, whenwe think of medicine, it's
something we take when we don'tfeel well.
When, when we feel like we needmedicine to help us get better.
And for many people with HIVwill not experience symptoms

(51:32):
until a very advanced stage ofillness.
So in Indonesia, as in manycountries, it may be hard to
convince someone to startlifelong therapy or commit to
lifelong therapy when they don'tfeel particularly unwell.
The problem is that inIndonesia, there's also a lot of
tuberculosis, and the prisonsare 400% over capacity.

(51:55):
You will often have 20 men in acell, and they will take turns
sleeping because they there'sliterally enough, not enough
floor space for everyone's bodyto fit down at the same time.
And so these are conditions thatare, that are very conducive to
transmission of TB.
Then you add to that, thatanywhere between one and 14% of

(52:18):
the prison population is immunecompromised.
These are conditions forexplosive tuberculosis
outbreaks.
So it's very important thatthat, that, that people are
being started on antiretroviraltherapy in prison.
Also, they're using some of theregimens that are in use are a
little bit older.

(52:39):
And so they have like a worstside effect profile.
And some of the side effects arevery undesirable.
And so people may say, but Ireally don't want to do that.
Some of it may have to do withthings like health literacy, or
how much people are really ableto absorb and understand
information that they're gettingabout this new treatment that

(53:00):
they're supposed to be taking,and then the stigma.
So if you have to take HIVmedicine in prison, that means
you have to line up once a weekand go to a pill line.
And it's possible that you'regoing to be identified as
someone who has HIV, and thatthat's going to change where you
are in the pecking order.

(53:20):
We've also found that prisonsare very busy environments in
Indonesia.
People are working, um, they'reworking for other inmates doing
their laundry, preparing food.
I think I went in thinking,well, everyone here just has a,
a ton of free time.
Right?
And we would have people come inand they would say, you know,
I've only got 10 minutes to talkto you, and then I need to get

(53:42):
back to work.
And so they may have scheduleswhere they just don't feel like
they want to be coming to aclinic every day.

Valerie (53:53):
So you're, you're from this kind of formative research
that you did learning about thesituation you, you currently
have two different interventionsthat are up and going that you,
you both are collaborating on.
So one is an adherenceintervention to get and it has
the best name Athena, which ismy favorite.
I think, you know, interventiontagline out there, but one is to

(54:17):
get people to essentially taketheir medication, to kind of get
over these barriers and tocontinue to take their
medication as they, after theyleave prison.
Right.
Cause I think that some of yourwork together has shown that
people are at risk of, of dyingdue to HIV related complications
in the two years after theyleave prison.

(54:39):
And then the other line ofresearch that you've been
working on is a partnernotification study to help
people once they have beendiagnosed.
And so many people are diagnosedin presence to help them notify
folks in the communities.
So this is, this just strikes melike a lot of work you're doing
together.

(54:59):
And we were wondering kind ofwhat it looks like for you to,
to keep this, this researchtogether, up and going on, on
the sort of day to day basis,but Gabe in Chicago and Agung in
Jakarta.
And I don't know if you guyshave like done the geography,
but it feels like, you know, youcould probably like go directly

(55:20):
through the globe to get to eachother.

Gabe (55:22):
That might be faster.

Carly (55:24):
Yeah.
Just going to say might be afaster flight doing it that way.

Valerie (55:27):
Yeah.
So what does this look like foryou t o what's the ins and outs
of working together from halfwayaround the globe?
Is t hat a lot of like latenight or early morning phone
calls and...

Gabe (55:40):
Late night, early morning phone calls, there's no
substitute for, um, people in,in, in Indonesia who are a
hundred percent trustworthy andreliable and, and, and excellent
with communication and decisionmaking.

(56:02):
Agung has taught me a tremendousamount over the last 10 years
about speaking diplomaticallyand engaging with people in a
way that they will be receptiveto.
I think one of the most amazingthings to me about Indonesian
culture, if I can generalize fora minute is the, the value that

(56:25):
they place on, on engagingpeople in respectful
relationships and ensuring thatwhen two people walk away from a
conversation that they both feellike they have their esteem
intact and that they want tocontinue working with this
person.
And so as someone steeped inkind of American culture, you

(56:50):
know, I will often say things ina way that for maximum impact or
what I consider to be maximumimpact or to, to make my, my
message as forceful as possibleand what Agung has taught me and
just living there has taught meis that that's the quickest way
to a dead end often.
And so in, in conversations withstakeholders, like if we're

(57:13):
immediate, if we're at a meetingwith the director general of
corrections or, um, someone inone of these ministries, I think
I'm doing a better job.
I have a long way to go, butI'll often probably wisely lit
Agung take the lead and, and,and model how those
conversations are supposed to goand trying to understand what it

(57:33):
is that, that you're, you're theperson that you're conversing
with, what their what's in theirmind and kind of, what are they
hoping to walk away from thisconversation with.

Valerie (57:46):
Agung, has Gabe gotten better at this over the years?

Gabe (57:50):
Well, the actually, not every important person in the
ministry of connectional havethat a way of, you know, or even
in ministry of health, but ingeneral.

(58:15):
Yeah.
They, they tends to, say toeveryone not we can solve the
problem of this station, but,you have to know that I am
sitting in this position.

(58:36):
So I have my own goals.
Some of them are keeping theposition or they are going to
have a promotion to the higherposition.
So sometime if we endorse withthe idea of decreasing the

(59:01):
spread of HIV in the prison,they, they know that as their,
daily jargon, but they arenot...
Sincerely put that as their,they are going to achieve that,

(59:27):
but more on, how this activityis seeing, excellent in front of
the boss.

Agung (59:40):
So, even we are facing a very high position in the
ministry of correction.
Sometime they have also thehigher, uh, position that, uh,
observing them.
And, now I'm sitting in theposition of the Director in

(01:00:03):
University of Indonesia, thenI'm more understand that, among
the hierarchies they are seekingof surface or they are seeking
of, of place and from their,their stuff.

(01:00:27):
Like I have, my boss, up there.
Although I'm the one working onthat job, uh, from day to night,
uh, A to Z, but the creditsshould be put on my boss name.

(01:00:55):
So I think that it's also,happens in ministry of a
correction where, where, whenthey talk to us, me and Gabe,
they are not talking with ourproject.
They are talking with the idea,how can I use this activity to

(01:01:19):
boasting, uh, my name or myposition in front of my boss.
So sometime I have to be, youknow playing political nicely
accepted among them.

(01:01:39):
So like when we when Gabe issending the proposal in English,
and then when this was, seemslike a bit allergic of like
forcing the result of thisstudy, so implemented and blah,

(01:01:59):
blah, blah.
Seems like they, they are nothappy with that sentence.
So I'm telling that this can be,endorse of what, one of the, uh,
achievement of your, KPI, um,you know, KPI, right?

(01:02:21):
Yeah.
So when you help us at the sametime you achieve the goal of
your ministries.
So we have to bring that idea interms of, to make them
understand not always the, whatthey do is only pleasing their

(01:02:47):
boss, but they have to be, theyhave to play smart.
They have to work smart byhelping us, and in doing this
research in order to achievingthat goal, their goals.
So that is, if you are askingwhether Gabe is noticeable about

(01:03:16):
this situation, uh, since they,they, uh, the situation of
facing the, the person ischanging, it depends on who are
sitting there.
So I, I think Gabe is more, Ithink now it's, more, aware and

(01:03:42):
understand compared to it at thebeginning of 2010, when Gabe
showing me, uh, around four orfive ID card from each
ministries.
And Gabe asking me"Agung, ifpoliceman stopped me, which ID

(01:04:06):
card that I have to show?" And Icannot answer that question,
because that is only like, whenyou are coming to this ministry,
they give you this ID card, youcome to this ministry, they,
they give you this ID card.
So, uh, the policeman will, theydon't care about that ID card.

(01:04:30):
They only ask your passport andyeah, that's all.
So that, the ID card is only toshow them that they have the
authorities to give or not givethe approval.

(01:04:54):
That's all.

Valerie (01:04:55):
You know, Agung, it just, I'm really struck by the
breadth of mentoring here.
I mean, it sounds like, I mean,you, you probably also deliver
like a, uh, some pretty advancedtraining in social psychology to
gave here along the way, too.
You know, I did have one morequestion, which is that I was
really curious, to get your, onhow nursing fits into the bigger

(01:05:19):
picture of HIV prevention andtreatment and prisons.
But maybe also more generallysince you're a nursing PhD, and
now you're on the faculty at aschool of nursing?

Gabe (01:05:30):
Sure.
Well, I think with HIV as withany global health concern that
we have to, we have to utilizeall the tools that we have.
And globally nurses areunderutilized.
When we take into considerationtheir training, their
distribution, their professionalcode of ethics, their ability to

(01:05:54):
interact with patients over 90%of patient care in the world is
delivered by nurses.
And I nurses are like thesleeping giant of the healthcare
system.
Studies now from sub SaharanAfrica showed that nurses with
the right training can provideHIV care at the same level as

(01:06:17):
physicians and achieve higherrates of patient satisfaction.
If we look back to the 1800s inthe U S nurses were the pioneers
of doing home visits fortuberculosis care.
And so I think nurses for a longtime have just intuitively
recognized that it's not enoughto be in a clinic and wait for
patients to come see you, thatyou have to go out there in the

(01:06:37):
community.
You have to build trust, youhave to do epidemiologic
surveillance.
You have to understand, I mean,nurses are out there and they're
, they're doing ethnography,they're doing epidemiology,
they're doing psychosocial care.
They're caring for the needs ofthe whole patient, but in many
parts of the world, includingthe United States, um, there's

(01:07:00):
been a tension betweenphysicians and nurses for
dominance of the healthcaresystem.
And we see this in things likethe contracts that nurses have
to enter into, to subordinatethemselves, to physicians when
prescribing certain medications.
The development of physician'sassistants came about in the
1960s because nurses refuse tosubordinate themselves to

(01:07:22):
physicians.
So physicians said, fine, we'lljust, we'll come up with our own
nurses.
We'll call them physicianassistants.
And we see even now withprescriptive authority that
physician assistants got outahead of nurses because they had
that, that, that relationshipwith physicians.
But I may have mischaracterizedthat a little bit.
And I think some of that had todo with people coming back from

(01:07:43):
the Vietnam war and needing toenter into healthcare positions.
But anyway, the, in Indonesia,for example, nurses, are nurses
are numerous they're distributedthroughout the country in a
decentralized healthcare system.
That includes lots of localmosques or community health

(01:08:04):
centers.
And community health centers aresort of the, the, the primary
care hubs for the healthcaresystem.
So that's where you go, if youhave the sniffles or if you need
reproductive health information.
It's also where a lot of HIVtreatment is being delivered
and, and methadone is also beingdone at the level.

(01:08:27):
So nurses are, and you and theuniversity of Indonesia was the
first program in the country tostart training nurses at the
clinical scientist level.
So at what we would think of asthe nurse practitioner level.
However, it wasn't until Ithink, 2014, okay, that they had
their first nurse practice act.

(01:08:48):
So nursing has not been codifiedin the same way that it has been
in the United States.
And the roles, the legalprotections, the
responsibilities, the licensingissues, all those are starting
to get sorted out in Indonesia,but it's in a framework where
physicians still want to controlthe decisions.
And so we've seen things likenursing has not had a seat at

(01:09:12):
the table.
When they build new hospitals,nursing gets put under
physicians instead of having itsown department.
And these control issues areimportant because if, if you see
a ceiling in your profession,then it discourages people from
aspiring to do the best thatthey can.

(01:09:32):
And that's everything fromclinical practice to research.
And so, as a result of this kindof the ceiling, that's put on
nurse practice and nurseresearch, nurses are not doing
everything that they're capableof.
Who does that really hurt?
Well, the patients.

Valerie (01:09:49):
Yeah.

Gabe (01:09:50):
Right.

Valerie (01:09:50):
Absolutely.

Gabe (01:09:51):
So like prescribing an antiretroviral therapy is, can
be done using an algorithm now,right.
More complicated decisionsalways need to be pushed over to
a specialist, but physiciansalready do this.
They don't make decisions thatare out of their training.
They refer it to a specialist.
And so why aren't we doing,especially only 17% of people

(01:10:14):
with HIV in Indonesia receivelifesaving therapy.
One of the lowest rates of artutilization in the world.
And again, if the is free, sowhy is it not getting it to the
bodies of the people that needit?
Part of that probably has to dowith a bottleneck effect of
limited numbers of physicians.
I was told once by an infectiousdisease specialist, that there's

(01:10:36):
eight infectious diseasespecialists for the country of
Indonesia.
This is the fourth most populouscountry in the world.

Valerie (01:10:44):
Wow.

Gabe (01:10:44):
And I know two of the eight p ersonally.
So in addition, in addition toincreasing the number of
physicians that t hey'regraduating and Indonesia has
always done a really good job ofmoving people out, into practice
settings, where they're likelyto have an impact they don't
have, they don't have probablythe same degree of brain drain a
nd people going into specialtieswhere t hat are very lucrative,

(01:11:07):
but are not going to have asignificant public health impact
of being in fact, up until a fewyears ago, all physicians who
graduated h ave had to have someservice or practice i n, in what
would be considered kind of a, alower resource or a community
setting.
So that's always been apriority, but the same needs to
happen with nursing, wherewe're, where we are.

(01:11:27):
We have the legal framework andthe regulatory framework that
supports them, practicing allthe knowledge and talent that
they have.
And that would include thingslike initiating antiretroviral
therapy and people monitoringthem.
A big part of what we do is whenpeople get out of prison, they
simply need somebody to bechecking in with them and

(01:11:48):
finding out how are you doing,how is this going?
Let's have an honestconversation about why it's
difficult for you to take themedicine, and what can we do to
help you overcome theseobstacles?
And so that seemsstraightforward enough.
If t here a re issues like,well, I have, I, you know, maybe
this person has g enotypicresistance.
Like the medicine just isn'tworking for them anymore.

(01:12:10):
That's a really importantproblem.
You want to catch it early.
And yes, it needs to be referredup to a specialist, but we can
think of nurses and probably alot of lay health workers who
could go and do the kinds ofthings that would make a huge
difference in the course of thisepidemic.
In t he l ast, in the study, inthe study that I'm referencing
from Vietnam, Indonesia, andUkraine, a quarter of the

(01:12:33):
Indonesian, HIV infectedIndonesian, people who inject
drugs h ad drug resistance.
This means the first linemedication, the free medication
no longer works.
So not only is this bad for thatindividual who will now have to
switch to a more aggressivetherapy or a different therapy,
think about the ripple effectsthrough the healthcare system.

(01:12:54):
This is a middle income countrythat through bold action and,
and resource allocation hasmanaged to provide ART for free.
Now, they're looking at a secondwave of drug resistant
infections.
I t's because in large partbecause there weren't health
workers out in the places wheret hey were needed to monitor
people who were receivingtherapy to make sure that they

(01:13:15):
were able to consistently takethose treatments.

Valerie (01:13:19):
Definitely seems like nurses can be a big part of the
solution.

Gabe (01:13:22):
Nurses can fill these gaps.

Valerie (01:13:24):
Yeah.
As the, as the daughter of anurse, I totally am with you on
that.
And Agung, if you could sort ofraise, if you could wave your
magic wand, what would you havenurses doing, um, in Indonesia
for HIV prevention andtreatment?

Agung (01:13:41):
Well, I actually, I still have faith that although it's
not really easy to implement,then the idea of empower
community nurse to do the job.

(01:14:03):
We are now, have for yourpresser from ministry of
misdemeanor, ministry of health,where beforehand we still have
the nurse, uh, for, uh, somecertain hospitals.

(01:14:28):
Now, for type a or type A, wehave, the head off nurse, in the
directorate, uh, the type B, C,D there is no nurse on

(01:14:48):
directorate.
So, I, I would like to offeringmy hands to those community,
nurse specialists or communitynurse who are working in public
health center to embrace thatbecome one of their job.

(01:15:17):
And if they can, if evidencethat their work can improve the
quality of life, people livingin, uh, HIV in the prison or
after they released thatprobably, they, help district

(01:15:38):
center.
A decision maker and make thatjob become of their, uh,
authority to, to do.
And when they have the authorityto become all the insurance

(01:16:02):
person for, uh, caring people,living with HIV in the prison or
in the community, then theyseems like to have another
option to be, receive attentionfrom the decision makers in the

(01:16:22):
ministry or a district officer,so, uh, yeah, it's...
Now we are not really easy to,to work, uh, in the environment
where, everyone tried to, uh,like Gabe said, under

(01:16:44):
supervision or under the medicalor medicine.
So it's, yeah, it's...
If we have to, uh, if we act toovocal, like we yell too much to
the ministry of health...
Then they, they built a thickerand higher wall where we cannot

(01:17:08):
climb and get through that wall.
But then with the help of thenursing associates, uh, with the
president of nursing associates,senior associates, as we have
now, uh, they asked us to, uh,act calmer.

(01:17:30):
So the ministry see us not as atrend or...
They feel threatened because ofthe nursing voices are made not
really feeling comfort in theircomfort zone.

(01:17:50):
So we try to play nicely withthem.
Uh, but, uh, at the same time,we try to use the opportunity
to, to be improve and show thegovernment that nursing can do
something for the nation.
And also, uh, in the future, we,we expect that the local

(01:18:17):
government or the districthealth officer may give
incentive for the nurses whowork in the prison and the
community better while we, theycaring for people.

Valerie (01:18:36):
Well Agung I feel like if anyone has the social skills
to navigate this and you to, tochange, it's probably you, so
that's great, that you know,you're on it.
And you've got thiscollaboration with Gabe to, to
keep it going too.
I've been so super grateful forthe opportunity to work with you
both and to learn from your boatfrom you both.

(01:18:58):
And we're really grateful foryour time today.
It's been really neat to bearwitness to what I think is a
really special and a reallyeffective collaboration.
So, yeah.
Thank you so much for all thework that you're doing, and
thank you so much for spendingsome time to come on the podcast
with us.
We really appreciate it.

Agung (01:19:22):
Thank you.

Gabe (01:19:23):
Thank you, Valerie.

Carly (01:19:37):
Wow.
So what a great conversation,and I just love that, you know,
right off the bat, these guys,you know, Agung starts in about
his experience, you know, withthe work and where he got a
little bit of feedback and that,you know, he thought maybe it
was uncomfortable because hegrew up a little bit, maybe
sheltered from, you know, thesethings that are happening, um,

(01:19:58):
and, uh, you know, at his home,and that Gabe just stops and
says like, no, no, like you'renot doing yourself justice.
The work that you're doing is,you know, or at the time,
especially really controversial.
And, you know, you really had tostick your neck out on the line
in, you know, sorta like fightfor, for what you believe in.
And that's why, you know, youfelt that way.

(01:20:20):
And I just thought it was like,honestly, like just the cutest
thing that here are these, youknow, they're not just two
scientists at this point.
And that's really, I think whatthat first part highlights is
that these are two humans thatare like, you know, in it for
the full human experience, youcan tell that they have such
like a genuine relationshipoutside of the science world.

(01:20:41):
And I just love that, that,that's how, you know, we got to
start off this conversation.

Valerie (01:20:45):
Yeah.
You can tell they're buds.
Yeah.
And yeah, no, I think it'sreally interesting.
Cause if we had only had Agungon the call, because often we're
only interviewing one scientist,then we wouldn't have had this
other perspective from Gabe tosay, no, no, no, hold on a sec,
like, right, this was a reallyintimidating and challenging

(01:21:06):
situation for you to be walkinginto.
And so that was superinteresting and neat to be able
to, to, to learn by talking toboth of them together.

Carly (01:21:17):
Right.
And I feel like that's mirroredthroughout the whole thing too.
It's just like that they bothhave, you know, bring to the
table such, you know, seeminglyradically different upbringings
and perspectives and likecultures that are just like
coming together in such awonderful way and obviously, you
know, really meaningful andimpactful way.
So yeah.

Valerie (01:21:37):
Do you know what I mean?
Yeah, it makes me think back tothe conversation we had in our
very first episode with CarmenLogie about how what's good ways
to do international researchand, and, you know, Agung and
Gabe just seem like the idealway to do international
research.
Like they are partners right intheir work.

(01:22:00):
And I know Gabe is always, youknow, thinking about Agung.
And, you know, it's, it justseems like that isn't, that's an
equitable research researchpartnership for just two people
who happen to live like halfwayaround the world.

Carly (01:22:16):
Right.
Exactly.
Yeah.
That was just so, so neat tosee.

Valerie (01:22:20):
Yeah.
It was really neat.
It's a, it's a great researchpartnership.
And I think, you know, when Gabetalked about going and living in
Indonesia for a w hile, with hisfamily during the interview that
was facilitated, I believe by aFogarty award.
Right.
And so F ogarty a wardssometimes a re designed to try

(01:22:44):
to really facilitate these l ikepartnerships and relationships.
So in some way I feel like thesetwo could be like a poster, you
know, the poster children forthe type of award.

Carly (01:22:53):
Yeah, absolutely.
Totally agree.

Valerie (01:22:56):
Yeah.
Well, the research assistantshad a few questions that they
thought might be useful aboutbackground information to kind
of contextualize some of thescience that ongoing and Gabe
were talking about.
So they wanted a little bit moreinformation on like on HIV in

(01:23:16):
Indonesia.

Carly (01:23:18):
Right.

Valerie (01:23:19):
So I thought it'd be useful to know that the HIV
prevalence, uh, which is thepercentage of the population
that's estimated to be livingwith HIV is 0.4% in 2018 is what
I found from UN AIDS.
And I wanted to compare that tothe US.
We're at 0.3%.

(01:23:39):
So it's actually super close.
And then if we keep kind ofgoing down the line, HIV testing
though is, at 51%, whichbasically means that they
estimate that about 51% ofpeople who are living with HIV
have been tested for that andknow that they are living with

(01:24:01):
HIV.
So that's actually kind ofstriking because it means that
almost half or 49% of people maynot know that they're even
living with HIV, which is really, hard to think about because,
or, you know, sad to thinkabout.
Because as soon as you know,that you're living with HIV, you

(01:24:22):
can access medications that aregoing to help you live a long
and healthy and lovely life.
But if you don't have access tothose medications, you're going
to get sick a lot sooner and diefaster.
By comparison in the UnitedStates, it's about 14% of people
with HIV are estimated to nothave been tested.

(01:24:45):
And so don't know that they'reliving with HIV.
So that's actually, so thatlooks quite different.
So number of people are aboutthe same, but the people who,
the number of people who knowthat they are living with HIV is
smaller in Indonesia.
And then if we look evenfurther, if we think about, if
you're living with HIV, are youaccessing treatment?

(01:25:07):
In Indonesia, it's about 17% ofadults with HIV who are
accessing medication.
So that becomes a quite smallnumber.
Um, interestingly UNH it's likeall those cells were blank for
the youth, for the US and, um,so I couldn't find that specific
number to be a good comparisonpoint, but in the US 64% of

(01:25:30):
people living with HIV receivedsome sort of care in 2016, 53%
of people living with HIV had asuppressed viral load, which
would suggest that they areprobably on a medication that is
suppressing the amount of HIVvirus that's circulating through
their blood.
So, you know, we might say that,you know, 17% of folks in

(01:25:54):
Indonesia are receivingmedications, whereas in the US
that's actually it's muchhigher.
So that's a big difference.
Yeah.
There are 30 countries that makeup 89% of the world's new HIV
infections.
They're called fast-trackcountries by the UN AIDS.
And they're usually prioritizedfor our HIV interventions and

(01:26:18):
both the US and Indonesia areon, are on that list.
So, um, so yeah, there's, Ithink important work to be done
in both of these places in boththe US and and Indonesia, um, to
try to do better on some ofthese statistics for sure.

Carly (01:26:35):
Right.
Absolutely.
And I think it's cool, you know,it's not great that we're both
on the fast track, but how greatthat we have these two people
from both of those places thatare working on the same issue,
you know, to get there.

Valerie (01:26:46):
Yeah, I think, yeah, absolutely.
That's right.
The other thing that the RAswanted to dig into a little bit
is, um, incarceration.
So why what's the situation hereabout HIV and substance use and,
and prisons essentially.
So what I thought I'd highlighthere is that Indonesia is one of

(01:27:11):
a handful of countries in whichthere's sort of this like
confluence, or I don't know ifit's like a tornado of substance
use disorders, um, and, andspecifically injection drug use
and heroin.
And then also HIV spreadingamong people with substance use

(01:27:33):
disorders.
And then third laws that aresending people with those
substance use disorders arepeople who are injecting drugs
to prison.
So essentially what you end upwith is a lot of people who have
injected drugs or who havesubstance use disorders.

(01:27:54):
And then who also have HIV whoare landing in prison.
And so Gabe actually talks aboutthis a lot.
Like he writes about this a lotin his work, and he draws
parallels between Indonesia andmaybe Russia and some other
countries where you have thesethings happening all together.
And I think it's reallyinteresting because the US is

(01:28:14):
also experiencing this opioidepidemic.
I mean, we also have, um, a lotof substance use disorders, and
then we also have a war ondrugs, which means that a lot of
people who use drugs or who havesubstance use disorders also end
up in prisons here.
But our HIV epidemic looks alittle bit different.

(01:28:36):
And I think, you know, one ofthe interesting things that
happens in the US but doesn'thappen everywhere is some of the
delivery of what people callharm reduction strategies.
And so, you know, in the earlieryears of the HIV epidemic, they
began things like needleexchange programs, where people

(01:28:58):
who are injecting drugs canbring in their used needles and
change those out for sterilizedneedles.
And they found that actuallyjust letting you know, just
letting people change out theirneedles has been a really
fantastic public health strategyto reduce HIV among people who

(01:29:19):
inject drugs.
And so that's, I think one ofthe, maybe, probably one of many
differences between, you know,the US and other places.
It was, it was interesting.
I don't know, Carly, if you wereat this meeting.
When I first got to Delaware, Iwent down, uh, to an HIV
consortium meeting, which isthis really cool umbrella group,

(01:29:43):
where our local stakeholderscome together and talk about
issues related to HIV in ourstate.
And there was as amazing a guythere from public health who is
just kind of like losing hismind about how we didn't have a
syringe exchange van going tosouthern Delaware.
And, you know, despite the factthat we know that we have like

(01:30:07):
an, an issue with injection druguse down there as a result of
the opioid epidemic.
So when I first got here, thatwas one of my first things that
I was learning about Delaware isthat A we need, we need some
more spread out harm reductionin the state, but then also we
had these really cool advocateswho were like.

Carly (01:30:28):
Right.
I was just going to say, yeah,in special shout out to the HIV
consortium for, you know, alltheir work with that.
Cause they, they now have one,right?

Valerie (01:30:37):
Yeah.
They had, there is a van thatnow goes down there and, um,
which is excellent becausethere's such good data showing
that when people can switch outtheir needles that they do and
that helps to prevent the spreadof HIV.
So that's really great.
All right.
A big, thank you to the Stigmaand Health Inequities Lab at the

(01:30:59):
University of Delaware,including Alyssa Leung and
McKenzie Sarnak.
And I would just like pause andsay a huge, thank you to
McKenzie.
She's been working with us forseveral weeks and we haven't
gotten a chance to thank heryet.
So huge thanks to her.
This episode was researched bySaray Lopez and the episode was
edited by Kristina Holsapple.

Carly (01:31:19):
And as always thanks to City Girl for the music.
And as an update this week, whydon't you guys follow us on Sex,
Drugs Science on Instagram,that's Sex Drugs Science without
the and.

Valerie (01:31:31):
And thanks to all of you for listening.

Speaker 4 (01:32:09):
[inaudible].