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Chelsea & Westminster Postgraduate Medical Education, Hot Topics in Global Health Presents...

  • HIV and sexual health implementation research in Indonesia—international collaborative work by Dr Keerti Gedela, Consultant Physician in HIV/Chief Investigator, UTAMA Project, UK-Indonesia Joint Partnership (Infectious Diseases)

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Thank you for the day. Welcome to Day two. Thank you to those of you who are joining us again today. I know it's known to start both days, but hopefully you're looking forward to all the talks and welcome to everyone joining today just for day to only um just a few things before I introduce our first speaker. Um We will be putting some extra Bs in here again today. Uh So bear with us for the temperature again. Um Just a note on Q and A s if you put your hands straight up high again, when we have our Q and A sessions introduce yourself um as well as where you're from. Um And for all of the catering breaks, we know it's quite a tight time for them. So please um keep moving along the line and use the other spaces around you uh to help with the networking and mentor, mentorship just to make sure that everyone is getting through the queue. Um So today we're going to start with Doctor Ella. Uh Doctor Ella is a consultant physician and researcher specializing in HIV and sexual health medicine at 56 street. She has a master's in tropical medicine and International Health and is a fellow of the Royal College of Physicians and an honorary senior lecturer at Imperial College London. She is EDI lead for the NIH R Clinical Research Network in Northwest London. She has worked in infectious diseases and is a HIV physician researcher and lecturer within Southern Africa, India, Brazil and Indonesia and is the chief investigator for the collaborative, the UK Indonesia Partnership and infectious Diseases. So people will come to me. I need to. Oh OK. Can you hear me? Ok, good morning, good morning. Thanks so much for that um introduction and congratulations on this conference. So I've been here about since 2008. I've been at Chelsea Registrar and a consultant and I've never had this, never been to this before. So this is awesome. So, thank you for this and congratulations. So, yeah, I'm a consultant man at 56 De Street and I've um done some research through um MRC Grants that I've led that. We, we now have a collaborative for a few welcome trust grants as well. And I've done that predominantly just to say through Charton and Westminster NHS Trust. I know broadly where people are from. But um you can usually, we usually do that through an academic university. But for this talk that I speak about, we've done it through the trust and that's something maybe we can talk about later. It's not necessarily something the trust likes to tick off. They, they love to have that money but they're about local, um, innovation, UK innovation, global housing innovation, space it somewhere else. But perhaps that's something I think that's, that has leverage in a certain way. It takes it away from a different way. It might be something we can talk about at the end. Um, but when I read, they asked me to speak about this. I wasn't, uh, I asked her kind of, how do you know what legs should I give? So I'm gonna give her kind of whistle stop tour on, on HIV is a global health challenge. And then some of the work we're doing and then perhaps we can have a discussion and yeah, and I think this conference is a lot about what are the biggest global health issues. How can you track them through research and then at the end, maybe what are some of those challenges and food before around equity and how we move forward? Um Just for hand, how many people would say that HIV is still a global health challenge? Gosh. Ok, great. Does anyone feel actually that maybe it's either not or maybe we lean too much towards it comparatively? Does anyone? Eola? Oh, ok. Um Right. No. Ok. Thank you for that. So, in terms of just snapshot with HIV, um it's claimed 40.4 million lives to date, estimated 39 million people living with HIV, at the end of 22 two thirds of whom are in the wh O region, 54% are women and girls. 1.5 million Children. These are all big estimates. Um, in 22 there were 630,000 people who died from HIV related causes. 1.3 million acquired HIV, 100 and 30 among Children. Um, and in terms of just again, a snapshot, I'm gonna assume actually in many ways that you're all at a certain education level, but you may not know about certain HIV targets. So UN A S wh O targets, they have this 90 90 90 that's now moved to 95 95 95 and their goals or benchmarks that, that they want each country or each setting to get to towards eliminating HIV. So it, when you w whenever you see that 90 90 90 reported, the 1st 90 is about the proportion of people living with HIV, who know their status. So people must have been tested, they have to be tested. They can't be living without it without knowing that proportion, the proportion of those individuals that are on antiretroviral treatment, who know their status and the proportion of those people who are on treatment and are virally suppressed. I'm not gonna talk about you equals you. But can you come to that at the end? But that's again, moving towards you equals you, which is excellent for someone's health. It also prevents onward transmission. Um and just a, a quick thing about that is that we, we like global, we like targets in research, we want targets, but it's maybe just to give an understanding that for the UK to fit to a target and then compare that to a very different setting to have that target, it may be less meaningful. And I think that's just important when you think about benchmarks uh and, and globally. Um I'm not gonna go through all these in detail, but it's just a snapshot thinking about the, the, the world in general. So this is some bit of data from Europe and then I'll show you a bit for um different regions and England are doing phenomenally really phenomenally. And if anyone, if you don't know about 56 De Street, it's worth having and look at some of the stuff we do. We're one of a number of different services in London and the UK that have done some really nice, some really great innovation work. NHS innovation work. And um actually some of the work I do in, in Indonesia is about translating NHS innovation, adapting its thinking about that technology for different settings and context analysis in those settings and applying that. Um But like, actually, well, we've busted 95 95 95. Um We've eliminated mother to child transmission of HIV prevalence of all is, is low anyway. So in, in the UK, it's a concentrated epidemic. I haven't put that a difference. But in many settings, particularly in the global North, you talk about concentrated epidemics. HIV is more, is prevalent and people are at greater risk than certain key affected populations. And in other settings, it's a generalized epidemic. It's the entire population that, that are at risk. Um But let's just look at the Russian Federation, so a prevalence of 1.2% and that's 1 million people. So it's huge comparatively. And what's interesting if you look at the 9090 nineties, so they've got 81% reporters. So 81% of people living with HIV know their status. But look at that gap. So sometimes I think it's really important to look at the gaps between those goals. The gap between 81 and 85 is huge. That is people that know about their status, not in care, not on antiretroviral treatment. That's what that essentially in clots. Um OK, let's move then to Africa or um sub Saharan Africa predominantly is where um the greatest burden of HIV exists. And the thing that always frustrates me about, um when we talk about Africa, we often talk about Africa, you know, we talk about Italy and England, very distinct places in Europe. And then in Africa, it's Africa, I mean, you know, they, they couldn't be more different between countries and settings. And that also is important when you think about um the HIV epidemic. Um So if you look at uh South Africa, for example, prevalence of 13.3%. That's a concept that's a generalized academic 7.9 million. 9919, not bad. 85 71 86. They're doing well. Also with mother to child transmission, that's a setting that has a lot of investment, healthcare systems that are diverse. But actually there's, there's quite a lot of research investment in that setting. But some of the sh the really shining examples of Rwanda and Namibia. So Rwanda um have got an excellent 1990 90 for their country. 93 92 89 they're nearly at elimination of mother to child transmission of HIV. And if you look at this, the narrative for Rwanda, there really was this kind of um in incredible investment from the government after the genocide and this, this uh political will to do something about the HIV epidemic, which is clearly for me, actually, the kind of take home messages about this is about political will and health system leadership. You have those two things and you can work certain magic. It's not actually about funding from the UK and let's go there and do this that and the other. It's pretty much about political will and health system leadership, Namibia. If you've seen recently, it's been in the news a bit. It's on linkedin and sorry, a few think it's on linkedin. But Namibia the first um high burden sub Saharan African nation to reach elimination of mother to child transmission of HEP of HIV. And also Hepatitis B. Just to say the other thing in the UN AIDS news about that is that Belize Jamaica Grenadine and Saint Vincent's have also reached elimination of, um HIV, mother to child transmission of HIV and syphilis. And that's in a context where congenital syphilis in the United States has gone up 200% in the last 10 years in the UK. We're seeing more cases of congenital syphilis than we have in the last 10 years. So that's what they've done now. And that's what's happening in a different setting. So sometimes again, it's, it's just thinking about what we're doing and what we're learning where we're going wrong. Um And then uh uh Asia Pacific Region. So this is, I work mainly in Indonesia Asia Pacific region region would also include Australia. You say Southeast Asia, you won't include Australia, but in there. But again, um when you compare, for example, Australia, and it's interesting, you look at Australia, they've got a concentrating epidemic, about 25,000 people living with HIV excellent 90 90 90. Um When you look generally at kind of health, economic data, maternal mortality, life expectancy 8 to 2 years, it just gives you an example, a snapshot of the health system to that population. And then you look at Pakistan. So Pakistan also is a concentrating epidemic roughly around the same number of people. 5000 more, incredibly poor 9090 data. In fact, we don't really have the data. It's grossly, um estimated, but, you know, life expectancy, 65 maternal mortality per year, 100 and 40 compared the rate of five. So, it's just looking at health systems, if we're looking at snapshot data, it's important to look a little bit of the background. All right. Well, I'll show I'll tell you a little bit more about Indonesia. So the reason I asked the question about whether you think it's a global health challenge or not is, you know, in the United Kingdom and in, in, in the global north, in some places, maybe there are other, I mean, I'm a HIV physician but maybe there are other challenges need health actually. And maybe we need to think through how we innovate for other services and health challenges. We're doing very well with HIV. Um we have the tools and I haven't gone into that too much but antiretroviral treatment, pre exposure, prophylaxis, um innovations and drugs that are amazing. I mean, if there's medical students who do pharmacology, I always say to them have a look at what's happened in their HIV space because you can learn about pharmacogenomics, you can learn about pharmacokinetics. You can learn about different drug delivery systems that are just trying to revolutionize the space. So it's been amazing investment. So we have the tools and this is just an example of the fact I'm going from 99 1992 2020 that there was a sharp decline in deaths due to HIV and AIDS. Um globally you can see around 2005. Um And if you look at this, I know our later. But if you, if you look at this for Western Europe, you can see that that really sharp decline happened in about 90 between 95 to 2000, around 1997 it massively dropped. So as soon as we knew that combination antiretroviral treatment worked, the United Kingdom, United States took that on. It got um you know, uh put into public health and and and AIDS desk dropped. If you look at that for South Africa, they do have a decline but you can see it happened about a decade later and that's not only I would say about um issues, you know, related to p and all of those issues, it's also political will. There is also there are other challenges. It's not like it's obvious as you might. And then another way of um putting that again, this comes from our world in data. So the blue are death averted due to antiretroviral treatment and the red is HIV AIDS death. So death not divert by antiretroviral treatment. This is for western central Europe and North America. So there's a lot of blue which is fantastic and this is from, this is the, this is effectively from the millennium from 2010 to about now. Oh, some slides I missed out. So, yeah. So, but if you compare that to Indonesia for this setting, I work much more red than you have blue. And another way of putting that is looking at this graph. So AIDS deaths in Indonesia have not declined. And I sometimes think that's to me, the most powerful thing to look at. Yes, we're not talking a, we're talking about a low prevalent epidemic in the majority of Indonesia. Certainly not in some parts of Indonesia like Pap, but aids deaths in adults and Children have not determined that's a horrific situation. And then again, when you look at that related to antiretroviral treatment, there's, there's, there, there's challenges across the cascade that people are not accessing life saving innovations, that's kind of a given in so many other places. So Indonesia um is the fourth largest, fourth most populous country in the world. Um It's uh geographically diverse. It's fascinating, it's about 17,000 different islands. Um It's history of colonialism, culturally, incredible, very many different languages across Indonesia, but they do speak one national language which is Bahasa, Indonesia. Um They have a, a concentrated epidemic in Papua. Um The, the estimate is about 3% of the general population living with HIV and Papua. If you know anything about Papua, there is some civil unrest and there are political challenges within Papua. There's some fascinating history of, of. Um but colony was a, within that region and there have been dramatic increases in new HIV infections among particular groups and the group that I work with predominantly are men who have sex with men. Some of our work he's leaning towards um understanding what's happening within um diagnoses in Children and mother to child transmission because that is, yeah, I mean, ii think sometimes when you look at that that gets neglected and when you actually look at mother to child transmission in, in Indonesia and infections in Children and Children dying of AIDS. It's a huge problem that's not being tackled. And I often think this is actually in some ways, although it's been massively challenging the easier one to tackle than that one. However, if you had great health system, you know, um will and political will kind of elevate that. But you know, it makes you think about what, what, what you're doing and what your role is. Um but particularly in, in um urban men who have sex with men, women, um transgender women and in female sex workers. And that unfortunately, and, and actually, so just to show you this, this is just the I VBS, this comes from Indonesia, how they collect data has challenges but even in the way that they collect data and do their surveillance from 2007, 2015, particularly in some high prevalent in some particular urban areas, you saw how great within MSM um went dramatically up and that effectively I mean, there's, it's, there's a lot to talk about related to the context analysis for Indonesia. This is just really giving you some messages which I do realize can be a bit maybe leading. But it is a reality. It's not, it's not. Um you know, this is the reality. So in the last decade, 10 to 15 years, you've seen um a political environment change within Indonesia and within other settings in the world and the impact on that has been what's happened to public health. So public health outreach has therefore changed align with that. So in terms of uh funding for HIV programs, there's a huge amount of money given by the Global Fund. And so um the Global Fund Fund effectively all of the HIV um services accessed within Indonesia and that's about 100 million over um 1 to 2 years. If you compare that to Thailand and I haven't given you what's happening in Thailand. But Thailand, there is a lot of research and health system investment. And what's interesting about that? Just thinking about political will is they've decided strategically to take less and less money from the Global Fund and more on the money from their own government prioritization of that. So as soon as you prioritize it with your funding, then there's a little bit more governance than what you need to do with it. Whereas unfortunately, we have challenges where you look at the Global fund investment and the Global Fund at one stage did say to Indonesia if we don't see improvements, we'll take the money away. But then you're like, well, you can't do that because then you've got cat, you know, catastrophe. But so, so there, although there, there is now leaning into that, it's about how that's done. We often have a conversation with, with um different organizations, particularly across the Ministry of Health about what the reality is for their epidemic and where they should lean in what the issue is related to health care stigma, different draft laws, et cetera. But so some specific laws you may have seen in the news. So Indonesia has passed a criminal code of BB sex outside marriage. So when I was based in Jakarta and Bali in 2019, at that time, they had the bill, um what, what they call the rehabilitation law. So that was a bill that was coming through that effectively um was going through parliament and is still sitting there. But it's not been passed through to say that if, if um you're aware of a child or a partner or a friend, et cetera who is interested in same sex relationships, you need to um report them to the Domestic Health Office for conversion therapy. So that was, that was kind of the narrative at that time. And all the so um being in a relationship, same sex relationship isn't put in, it's not illegal. Oh, it is in Aceh the Aceh province. But it, it's not illegal but it's not legal, I guess. And so there's been a push to around whether they make it illegal, whether they do something else to e, effectively, um, legitimize the challenge that they, they, they feel they need to. But I, what, what's come from that is because same sex relation, you can't, you can't have a skilled partnership or a marriage between same sex, um, individuals. If you pass this, then effectively, if you have sex, then you're a criminal. So that's been passed. It hasn't come into fruition as yet. It'll take about 1 to 2 years. One of the reasons we worked in Bali and one of the strategic things about Bali is because Bali has such high levels of tourism, that district health offices often push back on this. Not so much necessarily because they don't ethically believe in it, but because it might affect tourism. And then recently, actually the tourists, um what they, what um the government has said is look, we're not going to apply this to tourists. I'm not gonna check. So that will pass that through because it's been the other um big change was about a decade ago. They criminalized uh brothels. So, um female sex work. So they closed down brothels, brothels for prior to about a decade ago were places that people could visit. And, and it means that there's a safer way that female sex workers could, could have sex and with, with clients, for example, but that, that's also illegal. So that's pushed public health um outreach also away from those routes. Um However, there's a lot more to think about even this and just a snapshot. But um I've become much more into social science and I, I'd, I'd love to do some more training within social science. Actually, we, we've done, we published a few, so social science pieces of work. But what's very interesting is when you see a setting, for example, like Indonesia or anywhere in the world that has such challenges that for us, we might feel as, you know, backward and, and what's going on and um you know, uh fight that issue alongside the situation that's happening to all of us in terms of digitalization, how we access sex, what we look at how we get information. Um And we certainly know that in Indonesia within the MSM population, they access sex similarly to what happens in London. That's through apps. So it's often anonymized, digitalized us. And so in that sense as well and, and it might have information on, um um certainly in the UK, there are information on things like grinder, whether you're living with HIV, whether you're on pre so you can look at that. But um that might, wouldn't necessarily be the case in some settings or even if it is, it's less um trustworthy. There's been digital advancements and secretive access to sex, advancing sexual networks and acute infections. We've seen there's been data from Southeast Asia regions, particularly Bangkok that aligns a little bit with what we're seeing in, in Europe where new infections and acute infections drive new infections in um MSM populations that might be different for the generalized population or, or, or other people. So we know that maybe intervening at acute infection would be a strategy, global trends or recreational drug use if you know about chems or chem sex, that's again a global issue. It's not just a European issue. There might be different drugs that people might use, but drugs that are used to facilitate sex that are often used in sex parties and can facilitate networks on this background of, of effectively a rhetoric to, to victimize and increase show um along that. So the individual also have a um anti pornography law and they don't know it certainly from our, they don't necessarily tend to, to use it um in the public health space. But theoretically, if there was public health information that looked to engage men who have sex with men, that what we've always come across is theoretically that could be put within and then we have to take it down because, and so we do a lot of social media but it, it's where it's how that might be viewed depending on. Uh um this has been updated and it's a similar number. So this is just again, what wh o occasionally do after cycles, discriminatory attitudes towards people living with HIV. And what they ask is, would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had, had HIV? And II understand now from 2020 23 that's at about 72%. So about 72% of people surveyed in that region in Indonesia say, no, I didn't. Um So how am I doing the time? Oh, ok. Um So in terms of our partnerships just moving on to research, um we started with the project. So um I was a chief investigator of this project that was from 2019 to 2021 and that was an MRC grant that came into Elston Westminster NHS. Um This is a growing collaboration but that, that work was uh predominantly implemented within Bali and that was strategic, it was strategic because we had two NGO services there. We had brilliant leadership related to the relationship that was already there between the UK and, and who was there. Um And also we were able to implement interventions digitally and implement a behavioral intervention that would have been seen much more uh acceptable than anywhere else. So we wanted to start there and then build. Um Unfortunately, that got massively hit by COVID like it effectively. We didn't implement anything within a service during that time because of COVID because we all shut down, you know, and we pivoted and we did a little bit more, we did much more COVID work. But actually the, you know, you have to say, I think you have to take positive in a journey and the positive was that it enabled us to um network with fantastic people and build our collaboration. Um And also it enabled us to do um a really strong context analysis. So health system context analysis, engage with ministries of health, have conversations with them. Think about what COVID was perhaps was doing to um HIV services and to people living with HIV and anti res treatment communicate that. So actually, there was a real beauty in that. And to be honest, from my perspective, II think, how could you even do this work if we didn't have that time to do it because it took a lot of time and to build that trust, if you can't build trust in two days by meeting, it's got to, it's got to be believed. Um So these are a whole load of our partners now and we've moved this on to a larger MRC grant of which I lead with a guy called Ro Ra Hammers, who's an Oxford unit in Jakarta. He, he's um he's a lead for that and uh for the kind of biomedical side and I'm the lead on the um behavioral engagement side and is called a combination intervention approach for acute HIV infections to curb the explosive epidemic among high risk populations in Indonesia. Um And it in it involves this kind of combination intervention that we know that we know has worked SARS and there's some pictures of us and for people. So, um again, very quickly I II wasn't gonna get too much into this work. But what, where um what we're effectively doing through two clinics through, through a main clinic in Jakarta and two in Bali and the clinic in Jakarta is really the most incredible place. So it's a very high through but highly active um uh clinic which is an NGO clinic. So it sits, it's, it's not profit making, but it sits within the private space. Um It, it aligns with the Ministry of Health because in order to provide, you have to align with the Ministry of Health. And um um and we've applied in that clinic through research, a combination intervention, but primarily one of the key things and the researchy bit of it is that we're, we're trying to diagnose acute infection within the resources that we have. So just as an example at, at any sexual health clinic, I can't say for the UK actually, but certainly in London, you have 1/4 generation, an um HIV antibody test that goes to the lab as goes to Imperial um goes on to a number of platforms. But what it can tell you is whether your HIV antibodies, so whether your S converted or whether you're P 24 antigen positive. So it gives, so that antigen I'm I'm sorry for the antigen that comes within two weeks of, of infection can be picked up before you see her convert. If we have people that we believe might be s converting and there's either disc results, I mean, it's an excellent test and there discrepant results, we can do HIV viral loads and do have that ability and capacity. Although there are pros and cons of that, what I haven't de described within Indonesia is viral load testing for people living with HIV is not a, is not implemented. Um Well that over so certainly within the government service, you can test well, you can get on to treatment reasonably well, but then you're not monitored. So actually that's that, that last 90 that you saw for Indonesia was absent up until last year where there was a really strong pressure for Indonesia to report on it. So they did a pot of surveillance work in one area, one small region where they did viral loads in a population and they reported that. So it's not actually representative. So viral load testing is absent for monitoring, let alone for kind of um testing. So what we're applying is a HIV RNA test strategically, either to an individual who is very high risk or in a pooled fashion if you're low risk. And then we're applying an AL algorithm when you come into the clinic um through an ipad to ask people to look through that. And then along with the standard HIV test. They either get RNA or they get a pulled RNA. Now, unfortunately, it's not on everyone that comes through the clinic and you have to join and that's a challenge, but we've got very good numbers, but that is a challenge that might change. The other thing we're doing through a digital tool which, which I'll show you a little bit of is we're engaging a population at the at risk population at large to ask them to do it online through some uh community design engagement tools. Um So this is just a, a quick thing of, of, of, of what happens. So they'll do the risk checker. We'll get the HIV uh PCR, they'll be identified, get onto a RT quicker and then we'll get to them through um a behavioral strategy. So I like to describe it as there's two arms to it. There's a biomedical side, there's a behavioral side and there's a digital engagement tool that we've just applied. And this um it seems very simple when you see it actually, but it's really not simple to, to get out because it's got to be community curated fundamentally. And we found that really, really hard to find those people on that network to do this without it being led by, by me or by, you know, someone that's not in based in Indonesia or part of the community. Um So, alongside this work, we've got regular um stakeholder community events and meetings where we're sharing our learning, we're getting feedback from them. We're getting feedback from the behavioral tool that just was launched in March. And we're looking at how we build our capacity for clinical research infrastructure, how we lean into people getting um the grants come through Indonesian uh researchers rather than the other way round. Um But the, the, the issues of how we want this behavioral tool to be in terms of, we want it to be really tailored. So when you look at London, Dean Street, if you look at our website, you may or may not like it, some people don't like it. It's incredibly tailored at Dean Street to what we would say is the highest as the community with the highest risk and highest burden of HIV within our local community. So how we acknowledge that we don't do that well for other communities and if my colleague don't certainly do, we, we don't do that, but we do to AAA burden that is particularly a community that is particularly at risk. Um But to do that in Indonesia is obviously much more difficult. Um if we're thinking about MSN how it's digitally savvy and there's such, I mean, in some ways a we it's a community across the social um deprivation sphere that incredibly digital digitally savvy, not obviously a crop but not completely but certainly more than maybe I am. Um in terms of how you might deal with, with with, with digital stuff. Um How is it culturally appropriate? Does it involve the same, the right stakeholders and you know, who do we have to strategically not involve, for example, and the iterative thing I think is so key with anything that it's constantly changing, it can't stay static, it's got to move forward. Um So I skipped out. Yeah, this is just a little bit about acute HIV infection and, and uh uh pathophysiology related to that. So obviously you get a, it's a time when people are affection, massively infectious. The times that you're most infectious are either acute infection or very or at the advanced stage of age when you have the same situation, but much less likely to transmit each other than. Um But in general, it's 12 times higher during acute infection. It, it accounts for 10 to 50% big range in all HIV transmissions. That's specifically a thing within MSM network, urban communities within cities. Um And so that's where we've looked to intervene. Um And in terms of, again, thinking about what that strategy can do for our communities and it aligns with unequal you so undetectable, undetectable, being untransmitted. So it's one of the most beautiful things I think that as clinicians, we can say that we used to kind of think about before, but now we can say it so fundamentally as a professional that if you're persistently undetectable. So if you're on, if you're living with HIV, on antiretroviral treatment and persistently undetectable. You are not going to infect your partner through sex. Any type of sex unprotected is not gonna happen. And so it's just such a wonderful thing to be able to. It's what you, so it's in some ways, I think it's the because we find it, we ju ju traditionally find it difficult to do things like that in science. It's a, it's a great thing. So you're breaking the chain of transmission by dramatically reducing someone's viral load when they're in acute infection. So we already dramatically reducing the likelihood of them transmitting. Even if they're not taking the advice of you're in acute infection, you've started using antiretroviral treatment. But until you're undetectable, you need to use condoms or the partner needs to be on prep or you don't have sex. People related to all kinds of challenges related to their mental health and other aspects of their lives mean that that might not happen. But as soon as you get them into treatment, you drop that you drop the community viral load. There's a chance for enhanced department notification. There's an ability to enroll partners into programs or people that test negative that are high risk. Um But it, and we also know that it improves clinical outcomes. If um there's very fascinating data related to, if you do it really quickly, you're gonna be much more eligible for certain cure strategies. Um And it can have um an a um an impact on increasing retention in care and reducing stigma. Um And it's been demonstrated in London, it's been demonstrated in different mostly uh global and world settings in, in Bali. And these are examples of the clinics that we're working out. Yeah. And so current time we screened um about 3.5 within the study. And that's actually ii wasn't sure what I say. That's about um 60% of the COVID coming through. So we're missing 40% which is a challenge. My, my, I, I've been looking at really how we should have avoided that from the first place and everyone coming through was opt out. But from a, from a ethics perspective for Indonesia, that, that was a bit of a challenge, we've had about 2600 enroll in the study I tested because um the people enrolled, you'd have, may have more tests. So there's more tests of, of people. There's about 3.5 1000 people who were tested. And in that 100 and 69 are um newly diagnosed for HIV with a 5% positivity rate. And we've got nine acute HIV infections that were detected from the RNA strategy. And we're hoping to see that evolve as we now implement the um engagement tool, the digital engagement tool, which they have an algorithm and a way to book directly into the clinic. Um So, in terms of developing that tool, um we had a whole number of workshops with, with the community, there were a big, big challenge of developing this community tool because in initially for interest, really, initially we linked with a really good digital media group that were based in Jakarta. They have two Canadian founders that they're based in Jakarta. And they've done some really beautiful animation and engaging work. They've worked for UN A S and also for other commercial organizations and they were looking wonderful and we worked with them for a long time actually, and built up relationship and we were very transparent about the funding we had. And then when we came to the crunch, what they wanted financially was crazy. We couldn't afford it. It was a learning lesson for me. But um in the end, we actually are now implementing this through a group called and, and it's, it's the best thing ever. That's all that's always how it should have been. Um And I'm very excited about the idea of working directly with them to apply for funding. So they are, if they're not the recipient of the fund that we work together with ra and to do that and with, with our Indonesian partners because they are a group of people who are skilled and talented. They are also part of the community. Many are living with HIV, many are either part of um the MSM community, either openly or not or people who have narratives that are, you know, in incredibly compelling and do this work with Dution. But what, what is most compelling with them is they're just so talented. Um, we designed this, which I can, which haven't come out actually on the slide. But it's, um, it's, yeah, it looks a bit better than this actually, but you can see it online but it's all in the HSA. It's all in English. There's no reason to have it in English. It's actually not in any other language. You decided it doesn't need to be in any other dialect, but only in the H um and we have tools doing. So we, we, we through this work, we created different tools to engage people into research for social science research, but predominantly to engage them within the intervention at the clinics. Um And we have um uh animations that we've also converted the Dean Street animations that we've converted into the report just to give you an idea of the I know they already have a presence, for example, on social media, which is why we could never compete with a group like this and why it was so wonderful to, to work with a group like this because already, you know, they have this is one, this is their, their Tanya Malos, they created Tanya Ma and they did that with un ac arm means um I am brave and Tanya Malo is just Malo. Um but they have, you know, high numbers of followers. What's fascinating on tiktok is the number of views they get on tiktok translated to what actually happens. It's a huge gap. I don't really understand tiktok, but it's amazing how there's so many views, but that doesn't necessarily translate to what they're saying or what they are, what the, what the call to action is. Um Yeah, amazingly you've got some um nice publications related to the social science work. Um Yeah, that's all I wanted to say really. And I thought it might be worth maybe just having a discussion related to uh maybe other people's work or questions related to challenges. Um There's been AAA number of challenges. Um I like this and I like this because it reminds me I'm quite spiritual and I might think of other things, but it reminds me about concepts within social science and, and where we need to keep thinking about this. And this is, this is just something II took from my son's kid social science book. And it was a concept that came, you know, from 1914 Western capitalist orders taking root stratifying nations are only along economic and political lines, but also by forms of knowledge. This resulted in a cultural cultural b in which the global, no, it's culture rooted in science regards the global South as culturally inferior, global equality. Mainly the achievement venture into a dialogue based on mutual respect of knowledge of different forms of knowledge. There can't be social justice without um cognitive knowledge. And I don't the third, we just don't do very well. We still don't do it really. We just, um, we, we know better and it's, it's, it's hard when you look at data that looks at mortality that is clearly skewed to say that you're doing something wrong and then arguing that with people that really don't see it like that. But I think there is a, a big space now to think about how we have dialogues on, on how we uh look at our outcomes and our goals and how we might move forward in ways that we may feel uncomfortable to do. Um Yeah, thank you and thank you so much, Doctor Ella for that amazing call. It was really great to hear about all your work and we're gonna do some Q and A s now. So um as yesterday, if you have a question, please just put your hand, really hand hair um or bring your microphone and you can just introduce us and say where you're from before you question. Um For those online, please do post your questions in the chat. Um We have had one question about um you mentioned about the law, new laws in Indonesia. How has that affected people's health seeking behaviors? Are people still getting involved for treatment or has that just massively dropped? Yeah, that's so to be honest, I think the, the answer I'd give from my experience to that is that communities uh and health organizations saw this coming. So in many ways, the people seeking um access are still the same people. I mean, that's another thing also to acknowledge the work that we're doing still better enables a certain group of people to seek access. So those people who despite what's happening have either an amount of self um belief or, or, or less stigma for whatever reason to come through. So there's always gonna be that challenge of not um navigating access to certain groups. But it, yeah, it absolutely has. But more, more powerfully we've seen in the clinic actually than this because uh to a degree I think it has been uh coming is occasionally you get um raids. So very occasionally the police in Jakarta will go to clubs that they um understand are where um MSM community are gathering, et cetera and they'll raid it, they'll um take all those guys out, they'll put them in, into a, a van, they'll take photos of it and that'll be everywhere. And when that's there, that's when you see that that's had a big impact. Um One of the things is anyone from Indonesia? Just one of the things I don't know much about this. But um there's a political change at the moment going through and, and we understand that like the, you know, the son of a leader may himself be, you know, AAA gay man. And so there's been some change in how a lot of this is now reported. So things like that often can have a positive, they know they can have a negative thing as well. But I hope that answers the question. So it absolutely has seen, um, a decline in access, but we've been seeing that clearly over the last decade and we've got another question online. Uh Thank you doctor. Good for the excellent presentation. How did it affect you and your team members morale when things didn't go as planned? Given, it was cha given, it was challenging on so many levels. And what kept you going? That's a very nice question. Um Is that money? Is that? Thank you. So, so um we've got a great team. I love the team. Um So I'll tell you another example when I was in, I had, when I was in Bay, I thought it a nice place to live, but it was also the pandemic. But it um when I was in Bali, my son, how old was he? He was nine, my daughter was three. Um There was this, the rehabilitation law came out then and we were just working with this young woman called Kaita, a wonderful singer to get some stuff onto social media and there was a real backlash on it. Um And, but I haven't, I haven't explained this, but the, the research regulation in Indonesia is crazy. So one of the reasons I may not go and live there again, you know, it is changing is the bureaucracy involved in me getting a visa and getting a research permit was crazy and fine for me. Not so fine to do that to my husband and two Children who were all thinking could, you know, maybe not have to go through that type of thing. And so I got really worried about that backlash personally and I thought this is not who I am. I thought this is not what I would do to my family. The other thing, just the third thing and this is the most traumatic is unfortunately, my daughter became septic. So she actually nearly, she we all had flu. She then got just deteriorated and clearly got pneumonia. And when horribly deteriorated, the health system in Bali for when you're sick, they don't even have pediatric masks. Um He is appalling. So we had to airlift her to itu in Singapore. Make, she didn't really done that again. Also made me think this is and to come back to London and like not do this stuff. And then, you know, actually these are all journeys, aren't they? They're all journeys. You end up reflecting, you end up figuring out that this can happen in any space. Um People do incredible work in the United Kingdom. People do different bits of work in other places selfishly, this interests me actually, there is there, there is a selfish bit to it. It's, it's this type of stuff interests me. Um Yeah, so I think always, you know, keeping a, keeping an eye on that and we have a wonderful collaboration. They're just fun people. Gummy HIV is great like that. You know, you just get lovely people with smiles on their face. Pepsi. Oh, no, we got, we've got time maybe two in the room. So, hello. Uh hi, my name is Carmel. I'm an addiction and pregnancy medicine doctor. And um I just had a couple, a couple of questions. First of all, how uh how this service is integrated or, or what uh opportunities to integrate it into other services that may exist in countries such as sexual health services that may help tackle stigma. Obviously, maybe that's another issue. And then also I was wondering uh like working in with these brain marginalized communities in these conservative societies, what, what arguments do you find uh particularly helpful when making the case to make the policymakers uh to tackle that statement? Yeah, that's a great question. So to your first question and just related to the role you have. So the issue of aligning this work with work um to support people who use recreational drugs is a big space. It's, it's to add to the law there. Narcotics laws um were also introduced about a decade ago along uh aside the the the laws related to sex work. So it makes it very tricky. We also need to understand that space because it's very different. It's not, I'm sure you know as well, you know, the the chems, for example, intravenous drug use with a different dynamic to use to track the et cetera. You know, it's very so understanding that for our region is a challenge. Um but there is work on that. And for example, we have International Aids fellows coming from Thailand and one from Indonesia. And we're gonna share learning in that space in terms of sexual health. Sexual health doesn't exist in Indonesia. It, it doesn't. So, no. So sexual health is not a specialty in Indonesia. It doesn't exist um where it utilizes service, where it utilizes funds to implement sexual health services is through the HIV Global Fund funding. So we are, this is a sexual health service, but that's not how it's packaged because if you criminalize sex before marriage, there isn't really sexual health. So it's not the space that, that, what was your last question? So, so cost effectiveness. So when you look at that graph about AIDS death going up, that's pretty much in a young male, economically strong population. Um And the recording of AIDS desks, particularly in young men isn't very good. It's all we need to rely on hospital data and how that's reported is often strategic related to the insurance that they have. It's not universal healthcare, it's just, it's insurance based. So all of reporting is just chaotic, right? So a lot of the things that Raith does, you know a lot of the data work they do with COVID and TB et cetera is really trying to get accurate data. But uh often depending on what the narrative and who you are speaking to me is related often to cost effectiveness, to um saving lives, to enabling a very uh you know, a young economical community to thrive and offer better health care. Um and also the digital space, they're really digitally s so we're kind of speaking a language of actually maybe we can take this or we can make this cheaper for you and we can make it more cost effective by doing it through apps because actually a lot of the adverse population are an educated population who can use these clearly. Again, I'm, we're marginalizing another group by doing that. But, but, but that's one, that's another piece of lever. We've noted how so the the Minister for Innovation in Indonesia is the guy that developed Gojek. So Gojek is Uber he's doing for Indonesia. It's amazing. I mean, it's, it's even better than, but but that guy, young guy is now the Minister of Education and Innovation. So, you know, you can see where. So we might just keep that. Thank you so much. Um We're out of time for this session. But those of you who have your hands up, please keep hold of your questions because we've got AQ and a slot after the next session. And thank you.