Right. Hello, my name is Mitchell Warden. I'm a nurse practitioner and president elect for the Association of nurses in AIDS Care. I'm also the Associate dean for equity and inclusion at the University of Rochester School of Nursing. I'd like to welcome you to this learning activity entitled creating an inclusive space. This activity is part of an ex HIV and aging learning series in these modules will highlight considerations for organizations and healthcare providers on how to develop and implement best practices for creating an inclusive environment for persons living and aging with HIV. As you learned in our other HIV and aging videos retaining and engaging patients in care is an integral part of the HIV care continuum. One key strategy for engaging individuals is making sure that people feel welcome, safe and included. You also learned how stigma and discrimination can impact individuals and can be a barrier to access and care. In these modules, you hear from three different experts who will share information on ways that primary care practices. Long term care facilities and acute care hospitals can create an environment that is inclusive and recognizes the diversity of those living and aging with HIV. We'll also hear from Vincent crista como, a person living and aging with HIV who will discuss his personal experiences and the importance of inclusivity in health care will focus not only on how to create an environment that addresses the needs of persons living with HIV but will also discuss ways to create an age friendly health care system. Thank you for taking the time to view these modules for additional information and resources. Please refer to the links provided on the main page of this learning activity. Hello, I'm Anjali Sharma in infectious diseases, physician and professor of medicine in the division of General internal Medicine and infectious diseases at Albert Einstein College of Medicine. Welcome to this module on creating an inclusive space in the primary care setting for older persons with HIV. This is one of several modules which are part of the association of nurses in AIDS cares, HIV and aging Educational series. We'll begin by identifying strategies for adapting health services and systems in primary care to meet the needs of adults aging with HIV. We will discuss the significance of creating an inclusive space for L G B T. Q. Persons with HIV as well as strategies to address stigma and barriers to care. And next we'll discuss ways community based providers and inter professional teams can deliver care that is concordant with what matters most as a result of the success of effective antiretroviral therapy. There are growing numbers of people living with HIV surviving into older age. Along with this increased survival, we are seeing the emergence of age related medical conditions and the emergence of geriatric syndromes such as falls poly pharmacy and disturbances of cognition among others. In addition, older persons with HIV have high rates of substance use depression and anxiety and there's an interplay between stigma disclosure of HIV status and social support. Older people with HIV report high rates of loneliness and social isolation and often have fragile social networks. For more details on this topic. Please see the other modules in this series, let's talk about the caregiving needs of L G B t. Q. Adults. Aging with HIV HIV has had a disproportionate impact in the LGBT community, particularly among older gay and bisexual men. Older L G B T. Q adults with HIV report greater co morbidity and worse mental health compared to their peers who don't have HIV. HIV itself can worsen health disparities in L. G B. T. Q adults and this can result in greater caregiving needs. Many older L G B T. Q adults with and without HIV lack family support and older L G B T. Q adults are both recipients and providers of caregiving to both their families of origin and families of choice. Social networks of older LGBTQ adults rely on family of choice. This is comprised of close friends and neighbors. Many of them have suffered rejection and discrimination from family members or may have relocated to large urban areas that have viable gay communities, informal social networks of older L. G. B. T. Q adults may lack resources that characterize those of older heterosexuals, non related significant others may have limited ability to provide long term care, especially if decision making is required. They may be also unable to provide the material or instrumental and emotional support for older L. G B. T. Q. Adults living with HIV that are necessary to live independently in their communities as they survive into older age. There are also provider based barriers to care for older L. G. B. T. Q. Adults with HIV providers may assume heterosexual identity. They may not recognize same sex partners and they may provide unequal treatment due to negative biases towards LGBT adults. Providers may also lack cultural awareness or they may be discriminatory or stigmatizing of their L. G. B. T. Q patients including those with HIV lack of training about LGBT Q. Issues for providers of mental health, substance use, aging and health services is a key barrier to serving members of this population in a culturally competent manner. So how can we create an inclusive environment for L. G. B. T. Q patients? First, it is important to examine our own policies and procedures in the outpatient setting. We need to define families broadly to include partners, Children and friends who might not have legal status in accordance with patient's wishes. It is important to provide attention to the inclusiveness of care plans and decision making processes including inpatient visitation and rooming policies. Post your policies in high visibility areas to signal openness to same sex partners and non traditional families. Non discrimination and employment policies should include terms such as sexual orientation, gender identity and gender expression. This signals your health centers values regarding a commitment to L. G. B. T. Q. Inclusive care and can also be important to help recruit a more diverse workforce. There are a number of ways we can let L. G. B. T. Q. Patients know that they are recognized and welcomed in their health care setting. First start with the registration process, routinely collect data on sexual orientation and gender identity document the patients preferred name and pronouns and ensure that all staff used them consistently ask about gender identity in two parts current gender identity and sex assigned at birth. And make sure to include options for people who have a non binary gender identity. When a patient's name or gender identity does not match their insurance or medical records respectfully clarify. You could ask something like could your chart be under a different name. Sexual history is an essential part of a comprehensive health history. Questions about sexual history should not assume heterosexual relationships or that every sexually active person requires contraception. Sexual health should not focus narrowly on behavior and associated sexually transmission infection risks. Keep the discussion brought include questions about sexual health and sexual function and ask about past or present abuse and reproductive options remove questions with female only or male only, add a non applicable option. Remember that transgender people often retain some of their natal organs. Questions should be answered by all relevant patients to receive regular preventive care. Make sure to include L. G. B. T. Q. Inclusive language, avoid gender specific terms like husband or wife and instead ask about relationships, partners and parents. Family history forms can use the term blood relative, for example, instead of simply mother or father when taking a biological family history, allow the patient to specify who they're talking about. Use gender neutral images or diagrams without a human outline to document pain or areas of concern such as the example shown in the image below. So what is an age friendly health system? Our US health systems are not prepared for the complexity of care that results as persons age, older adults suffer disproportionate amount of harm while in the care of the health system. An age friendly health system aims to follow an essential set of evidence based practices that causes no harm and that aligns with what matters to the older adults and their family caregivers. The four M. Model, an age friendly health system is an initiative of the john A. Hartford Foundation and the Institute for Healthcare Improvement in partnership with the American Hospital Association and the catholic Health Association of the United States. The 4M's framework to guide care of older adults, attempt to make the complex care of older adults more manageable. It identifies core issues that should drive all care and decision making and it organizes care and focuses on the older adults wellness and strengths rather than solely focusing on disease. The 4M's framework is applicable regardless of the number of functional problems in an individual faces or that person's cultural, ethnic or religious background. So how might a geriatric approach help people aging with HIV? So we actually often concentrate on five M. S, which includes multi morbidity, mobility, mente shin medication and what matters. The five MG of geriatrics has a number of key focus areas with examples shown below. I'm going to go through each of them in a little more detail first. What matters. In addition to asking what is the matter? Think about asking what matters to you? What matters is the foundation of the Age friendly Health Systems initiative. It includes knowing and aligning care with care preferences and health outcome goals. And this expands beyond simply end of life care to all care across the lifespan and across settings. When we talk about care preferences, what we're referring to are activities that patients either are or are not willing and able to do or receive. And when we talk about health outcome goals that relates to values and activities that matter most to an individual health outcome goals, motivate individuals to sustain and improve their health and may be impacted by decline in health health outcome goals. Can guide decision making, ongoing communication and relationship building with older adults and their caregivers is important. These conversations should take place across multiple care points. Touch points including routine and recurrent care and any member of the care team can initiate and document a conversation with an older adult about their care goals and preferences. This slide shows a checklist for culturally appropriate what matters conversations. These are examples of the types of questions or conversations that are part of the what matters discussion. So for example, it is important to learn an older adults preferred term for his or her cultural identity, determine the appropriate degree of formality, understand the adults preferred language and to address issues linked to culture such as lack of trust, fear of medical experimentation, fear of side effects and unfamiliarity with Western biomedical belief systems. Yeah, next medications actively managed pol if arm asI to avoid drug fatigue, serious interactions, hospitalizations and early mortality management of medications also includes regular medication, reconciliation, beers, criteria, identification of potentially inappropriate medications and attention to opioid prescription management, including assessment of risks and benefits of opioid prescriptions. In an older adult, this slide lists high risk medications and older adults. These are medication classes that are commonly implicated in falls. Older adults are at increased risk for experiencing medication adverse effects which includes falls and other adverse events related to medication use. Thinking about older persons with HIV, it is important to realize that poly pharmacy is often premature in people living with HIV when they are diagnosed with HIV, they are often prescribed combination antiretroviral therapy. Now on the day of diagnosis and as they survive longer and longer they're experiencing a greater lifetime exposure to multiple medications compared to similarly aged people without HIV poly pharmacy is often defined as use of five or more medications and is the strongest predictor of serious adverse drug events and drug drug interactions. The more medications a person takes, the more likely they are to have associated harm with that medication. People with HIV may indeed be at higher risk for many age associated conditions driven both by HIV infection, as well as antiretroviral therapy. Poly pharmacy has been associated with poor adherence to antiretroviral therapy and in studies of people aging with HIV has been associated with increased risk of cognitive impairment, falls, mortality and hospitalization. This slide shows a suggested scheme to optimize medication prescribing as people age. So the first thing that you want to do is to complete a full medication reconciliation, specifically evaluate for tobacco, alcohol and substance use treatments for these conditions. Should be among the highest priority medications. Next assess and rank each medication based on weighing the risks and benefits of this treatment. Next prioritize a plan with the patient based on their goals of care and the value and risks and adverse effects associated with each of their treatments and tailor their interventions based on the goals of care for that individual patient. Next we'll move on to meditation. This really discusses the prevention identification treatment and management of depression, delirium and dementia. For more details on this topic, please see the other modules in this series when thinking about mobility, it is important that we ensure that each older adult moves safely each day to maintain function and does what matters most to them. This slide gives an example of evaluation for falls risk. The first step is asking three key questions. Does the patient feel unsteady when they're standing or walking? Are they worried or afraid of falling? And have they fallen in the past year? Based on the responses to these three questions, you'll identify whether the patient is at risk or not at risk for falls if not at risk. This still represents an opportunity to prevent future falls risk. You can recommend effective preventive strategies for falls, including patient education, assessment of vitamin D intake, referral to a community exercise of fall prevention program and then continue on a regular basis to re assess risk of falls or to reevaluate anytime a patient presents with an acute fall. If on the other hand, you've identified that that patient either has fallen or is at risk for falling. You then follow a different process where you assess modifiable risk factors for falls. As shown in the slide here, moving on to multi morbidity, there's a growing burden of multi morbidity that has anticipated in people with HIV as they age and as the population of older adults with HIV increases, It is projected that by the year 2030 In the United States, one out of four antiretroviral therapy, users will be age 65 and older and a third or more of people with HIV will have multi morbidity. Mhm. The projected increases in, depression, anxiety, diabetes, chronic kidney disease and myocardial infraction or cardiovascular disease are expected to be particularly great. It is expected that among older people with HIV by the year 2031/3 of those aged 50-60 will have multi morbidity. One half of those aged 60 to 70 will have multi morbidity. And over two thirds of people with HIV age 60 and older are anticipated to have multi morbidity by 2030. The greatest increase in multi morbidity is projected to occur among M. S. M. Or men who have sex with men as they age. Additionally, large increases in the prevalence of multi morbidity are expected in heterosexual women and men who inject drugs. So what can we do as HIV primary care providers to adapt our practices to meet the growing needs of this population of aging. People with HIV. The first thing we can do is update our provider skills in the principles of aging. That includes education for all staff and providers about aging. Age related resources in the communities, aging related syndromes and ageism and aging related stereotypes. We can work to blend access to both HIV based and age based community services and supports and build and create linkages with community agencies that serve older adults. Alternatively, we can incorporate geriatric expertise within our practice that may include utilizing the five M. S. Framework to guide age friendly care. Yeah, This can be done through assessing and incorporating the five M. S into the plan of care accordingly. Using a comprehensive geriatric assessment, referring to a geriatrician as needed or embedding geriatric expertise within an HIV program. It is important to also consider accessibility in the structure of primary care settings. This can include adapting physical spaces by making sure that there's adequate room for wheelchairs and walking devices such as walkers, elimination of trip hazards and exam rooms such as chords stretching across spaces, adjustable height, exam table so that patients don't have to climb up onto an exam table and to have handrails and other devices in settings as needed, such as in the restrooms for patients. Educational materials may require larger font for those with visual impairment. An adjustment of appointment times may be necessary as people age. HIV providers often have limited time and limited geriatric knowledge and may focus primarily on comorbidities, antiretroviral therapy management and preventive care. Comprehensive geriatric assessment may also help us provide prognostic information necessary in guiding decisions and part of the conversations that occur when thinking about what matters most. What you can see in the table. On the left are the elements that are included in a comprehensive geriatric assessment, including evaluation for disability such as basic activities of daily living, instrumental activities of daily living and assessments of cognition, medication appropriateness, co morbidity, ease discussions on living situation and accessibility, social networks and financial status and advanced care planning, among others. The Medicare, annual wellness visit is an important tool that can be utilized in primary care settings for people aging with HIV. The goals of the Medicare. Annual wellness visit include health promotion, disease detection and coordination of screening and preventive services. What you can see in the wheel on the right are the components that are required as part of Medicare's annual wellness visit. So what we're seeing as people age with HIV is this silver tsunami, the growing wave of older adults who are surviving into older age. There are a number of ways that we can think about how to approach and how to adapt the care of these individuals as they survive into their senior years. It is important to consider the age friendly approach such as the five M. S. Utilization of a comprehensive geriatric assessment or a screen of your choice. That is quick and easy and that works for your own care settings such as the annual wellness visit and to prioritize function and quality of life over simply just living longer as providers, we need to address stigma and create a welcoming environment for our older L. G. B. T. Q patients with attention to the changing psychosocial needs for our patients as they age. HIV care providers and HIV ambulatory clinics need to create connections to communities that serve seniors to address isolation and loneliness and fragile social networks that our patients deal with in their older age and to make sure that care is concordant with what matters. Ultimately, our goal is to ensure that each older adults, health outcome goals and care preferences are understood, captured and integrated into their care. Thank you for viewing this learning module. Please be sure to view our other learning activities as part of the Association of nurses and AIDS care HIV and aging educational series. Thank you. The focus of this module will be on strategies and considerations for long term care facilities. In creating a more inclusive space. Nearly 70% of persons over the age of 65 will require some form of long term care or assisted living in their lifetime. Unfortunately, many providers and long term care facilities may be unfamiliar with or have misconceptions about HIV. This leads to decreased quality of care stigma and poor health outcomes. In an effort to help address this critical issue of stigma and discrimination US Older americans act now includes language that protects the rights of L G B T Q I plus older adults in long term care. This is a positive step forward in helping ensure that long term care and assisted care facilities work towards decreasing barriers and improving the care provided in these settings. Let's hear firsthand from a clinician who has expertise in this area. Welcome to this module on considerations for long term care and assisted living facilities. This episode is part of the annex HIV and aging learning series and creating an inclusive space. My name is Mitchell Warton, president elect of an ac and associate dean for equity and inclusion at the University of Rochester School of Nursing in Rochester new york. Joining me today is Gwen Denham, R N A C R N, who is a residential care facility administrator at our house in Portland Oregon. Gwen is certified by the HIV AIDS nursing, the certification board and has been working in residential care for over 18 years. She's here to share her expertise on creating an inclusive space in long term care facilities. Hello Gwen and thank you for joining me today. Thank you so much Mitchell for having me. Very excited. Wonderful. When can you tell us a little bit about your role as a residential care facility administrator? Yeah, I have been um, at a house for a long time and it's relatively new to be the administrator to be an administrator at a facility. You know, it takes a lot of thought doing assessments going out into the community when we have referrals and seeing if it's a good fit for our community. And this has been just a really big honor. Um, having been put in this role, It really opens up having good communications with discharge planners about like what we do and I get to hear a lot from discharge planners about their struggles in placing people in the community that have HIV and other difficulties around substance use. And we've been kind of a beacon here in Portland Oregon of specializing in that. So it's really been nice but we try to open up a little bit towards like how can we help people be placed in other places because there's more people that are needing services and that's part of my role also is to do some community engagement and education. Wonderful. It sounds like a very comprehensive holistic role as more persons with HIV are entering long term care and home care settings. What are some important points that organizations need to be aware of in terms of making their environments more inclusive for our patients? Yeah. I think that one of the biggest things for me is never making assumptions. I think that sometimes people look at a list of diagnoses and have like a preconceived notion of what that patient might be like in their setting. But the best thing is face to face interviews and asking people truly from a patient centered way like how they want to be addressed anywhere from pronouns to what's most important for diversity inclusion. Like from their perspective, instead of us making guesses at what, how they want to be respected. Um, one of the biggest things I think at least in our organization as we always have when the residents coming to move in, making sure they're making some agreements about that. We hold having safe spaces of inclusion in our facility. So if people are having difficulties as sometimes happens with aging is filters or come down and people who might have had problems with like racist beliefs in their past and now are having reminiscing about being in war or we've had this problem before. We try to talk about these things, not making assumptions, but just trying to explore and making kind of a safe agreements before somebody moves in that we we don't talk like that here, but if they want to speak about their experience that we do that in private, that we're not trying to also limit somebody's expression of who they are in their lived experiences. But in a safe manner. Can you talk a little bit about staff training and things that administrators as well as frontline staff need to be aware of in terms of creating an inclusive environment. Yeah, our perspective is evolved over time as as new evidence based information comes out, I will say that we have used nonviolent communication as a training tool for frontline staff um that really helped educate I think a lot of staff who might be triggered by behaviors as talking about like looking at how behaviors communicate information and getting down to like feelings and needs of the residents. So that's one of our foundation trainings that we do here as well as we go into the community and do trauma informed trainings. We give stuff when it comes down to HIV because I think that a lot of administrators and people in the community do reach out to us. Um definitely HIV 101 is something that we do in house and we go out and do into the community and I think that that helps as things have evolved. One of the things that still surprises me is when an administrator maybe doesn't know what U equals U is and just being able to talk about what that means for safe sex and then how does that translate I think is still trying to be understood about safety with staff caring for residents. So that's a really big red flag for a lot of organizations. I still do get questions about like should we have disposable silverware and plates and so it just shows that there's still lots of education that can be improved uh and I think that it just happens with like, like I said like a beacon and we just keep moving it out and keep sharing this information as much as we can help other other places learn and um make their staff feel safe, taking care of people, we can make it better for everybody. Excellent. One of the things that you were just talking about speaks to kind of the reminiscence of stigma. Can you tell us a little bit about the impact that stigma continues to have? Yes. Um Well without, I guess this one's a hard question for me because I get a little verklempt um is that stigma is really interesting as we have sometimes in our care facility when we try to do an age in place and so that if somebody is in need of care that they get to stay here for as long as they need care at times their care has exceeded our abilities and we have to look to other placement for them with a different equipment or more more staff and we have sometimes come up empty handed. Um In fact that is like one of the biggest things of people not understanding how HIV is transmitted. Um sometimes it's people that are new to the United States and so it might be trying to do teaching from being culturally competent to where they come from and how government information might have been not the best. And so being able to Almost like Build Trust 1st to help them feel like they really are going to be cared for. I think sometimes staff just there's just no trust when it's like oh the CDC says you know U. Equals U. And they were like, I don't, I'll believe it when I see it. And so um trying to figure out how to break down some of the information. So it's really digestible, but again like making sure that staff know we're here to make sure that you're safe. Also, not just the residents. So it's everybody, it's all inclusive and I think that that's the way we can break down stigma is making sure that people know that we care about them too. I know you do a lot of work with persons who have substance abuse history are the best practices that organizations can can do to help make these patients feel safe and to make them feel at home. Yeah I think that our number one thing is doing again a really good patient centered evaluation and figuring out where they're at but ultimately it's the unconditional positive regard that we give our residents that ends up turning the corner for a lot of things in their life. I think that when you build trust and you build relationships, somebody can actually lean into and we see a decrease in substance use. I think when people are going into other facilities administrators sometimes always are looking at the risk and there are substantial amount of risk with the behaviors related to substance abuse disorder and it can look like damage to property, it can be needles and and soft safety and I believe that all of these things can be mitigated and they lessen over time when there is a good relationship with that individual. And um definitely that part of stigma also has a problem with people getting into facilities that have needs for their I. D. L. S. And there I A. D. L. S. And so I would say that it speaks to a large part of the homeless population. In fact um what I have been hearing to from city leaders is that they know that some people on the street actually have diagnosed dementia and that they're not being a housed in facilities due to administrators not wanting to take on the risk. So at least in Oregon there's for facilities administrators should know is that they can apply for special needs contracts and these special needs contracts can be geared towards helping certain populations target populations that might have increased behaviors or increased risk and they can apply to get potentially more money so that they can support people. So I think that that's one of the biggest needs out there is for more facilities to be under special needs contracts, um, and understand how to, how to keep the staff safe, how to train the staff so that you have good retention. They know the good work that they are doing. Um, these are all ways that we can break down barriers and make an inclusive space for people with substance abuse disorder. So if I can summarize very briefly, it sounds like a person centered evaluations unconditional positive regard, making sure that the staff has adequate training and retraining if necessary. Um, and then the last piece that you mentioned was the special needs contracts. So getting some additional financial assistance or resources to help with with facilities, is that correct? Excellent. Um, what advice do you have to give to long term care organizations that are challenged with creating a more inclusive environments for their patients. The number one thing is community, I think, going to networking meetings um and making time to make connections with other people who are doing the same work. I think one of the biggest things is this is stressful work, um It's very taxing, especially to keep staff retention um and balance all the different needs to ultimately give the highest quality care to the residents. So reach out, make good connections yourself as administrators with others that and moving for towards really high quality trainings. Okay, excellent. Do you have any other thoughts or any of the girls you'd like to share with us? I think that's about it. I really appreciate the opportunity to speak to this and I'm so happy that Enac has um taken a lens to this to help other people, you know, be able to move and grow in this direction. Excellent. And we greatly appreciate your insight and your expertise. So, thank you Gwen for sharing your thoughts and your perspectives on this important issue on behalf of an IQ. I'd like to thank everyone for viewing this learning module. Please be sure that your other modules as part of the HIV and aging educational series. This module will be on strategies and considerations for hospitals and acute care facilities. In creating an inclusive space, as you've heard in previous modules, stigma and discrimination are significant barriers to care. In a recent survey of L G. B. T. Q. I plus individuals and persons living with HIV. More than 50% of L G B T Q I plus patients reported experiencing some form of discrimination in health care or hospital settings. Nearly 20% of persons with HIV reported being denied care because of their HIV status and transgender and gender. Nonconforming individuals reported the highest rates of discrimination and barriers to care. We'll hear from one expert on our hospitals and healthcare organizations can help address this issue. Welcome to this module on considerations for hospitals. This episode is part of an ex HIV and aging learning series on creating an inclusive space. My name is Mitchell Warton and I'm the president elect of annex, as well as the Associate Dean for Equity and Inclusion at the University of Rochester School of Nursing in Rochester new york. Joining me today is Jackie Baris are in. Jackie is the director of L G B T Q I A Plus programs at robert Wood johnson Hospital in New Jersey. She's here to share her expertise on creating an inclusive space and acute care settings. Hello, Jackie, thank you for joining me today. Hi Michelle, thank you for having me today. Wonderful, Jackie, can you tell us a little bit about your current role as the director for L G B T. Q I A Plus programs at robert Wood johnson Hospital as the director of the LGBT program at robert Wood johnson University Hospital. My role is to oversee the different programs or initiatives that we have for the hospital, primarily for our patients, including our employees as well? Um creating programs is one thing that is important to the organization so that we can provide a more welcoming and affirming environment for all patients, including our employees excellence. So as you're working in a hospital setting, the Joint commission has developed guidelines for inclusivity. Can you tell us um why this is important as well as how organizations have incorporated these recommendations? Um I believe that the Joint Commission has set some standards in terms of patient safety. One of the mission is to address equipped herbal health care services throughout the United States and when we are looking at addressing health disparities, Joint Commission has been a far front in addressing this, in which every hospital should make some form of assessment and addressing issues that will impact patient care. Um this particular standards of Joint Commission is to ensure that everyone receiving a welcoming and affirming healthcare, particularly the L G. B T. Q. I. A. Population, as we all know, this population has historically been um experience a lot of health care disparities that lead to poor health outcomes and I think it's important that Joint Commission now is taking a stand that every hospital should really provide programs in addressing issues, particularly to this population. Excellent. And so, Jackie, you were just talking about the Joint Commission which oversees accreditation, but there's also the more community minded aspect of things. And so I wonder the human rights campaign has developed a health equity index. Can you explain a little about what this is and why this is important? Yes. Um the health Equality Index to the Human rights campaign provide benchmarking tools to ensure that there is some equitable service provided, not only to the L G B T Q I A Plus patients but as well as their family. Um there are almost 1000 hospitals that have been designated to become the LGBT Healthcare Leaders and it is not easy to be an LGBT Healthcare Leaders primarily because You need to reach certain points. I think it's 100 points at least to be able to achieve that designation. There are many criteria that they are looking for. Um I remember one of that is the nondiscrimination and staff training, also patient services and support. They are going to ask also to provide you a documentation on if you provide employee benefits and policies that identify as a member of the L G B T Q I A Plus community. Do you provide patient community engagement? And I think new criteria is about responsible citizenship. So this particular benchmarking tools is not only to ensure that organization have some sort of policy in place, but also it's a way to improve services, particularly for our patients. You know, the only way we can improve services is when we have certain standards and do we meet them or we don't. So basically it's important to to talk about human rights, campaign health equality index to become an LGBT health leaders because it gives you the affirmation that you're a hospital that truly welcomes this community. Absolutely. And it's wonderful that we have such a, such a tool to help guide uh individuals to know where they can get quality health care. So we've talked a little about from an accreditation standpoint, we've talked about from a organizational standpoint, I want to talk a little bit about staffing and staff training. Um can you talk a little bit about what staff training and things that administrators as well as frontline staff need to be aware of in terms of creating an inclusive environment. I think there are multiple staff training available nowadays. Um you can get some staff training from the Fenway or the National LGBT Health Education. There are some staff training available provided by private organization. But overall that stuff training is really the key to ensure that everybody are in the same page, that they are trained to be culturally competent in addressing the health care means of the L G B T Q I A patient's. Um it's important that training is also being confirmed by its competency. It's not like just purely providing education, but more so on following it up that what we do is basically what we practice every single day of our life when we work in organization that provides healthcare services. Excellent. Are there particular things in training that either staff as well as administrators should be aware of or should be learning? I think basic understanding of the history of the L G B T Q i A plus, you know, for us to understand the health care needs of this community, is to look back historically. Where is it coming from? As we all know if you remember prior to 1973, the American psychiatric association um includes homosexuality as a mental disorder. And I think that is the beginning of a conversation that we need to talk about as to why this community somehow um had been isolated or had been silenced by the society in terms of being part of um addressing the issues in health care. So, I think um understanding the different disparities that the experience is one thing what causes this disparity and especially some strategies in order to address the healthcare needs of this population should also be included in the train. Can you talk to us a little bit about the impact that stigma has had on L G B T. Q I A plus individuals who are seeking health care. Like I said a while ago in my conversation with you pertaining to part of the staff training. Um the unconscious biases is one second is stigma and how this impacts their health care. I think it's because stigma somehow give them the discrimination, um issues that most of this community experience because of stigma hinders them to access care. Um For example, when we think about HIV it always correlated to L. G. B. T. Q I A plus population and the question is fine. And when you think about transgender men or women, we always think about sexuality. I think there's so many issues that needs to digest, needs to uncover and we need to unlearn some of those biases, particularly in terms of stigma. Great and I know that you do a lot of work with the transgender community. Are there best practices that organizations can do to make transgender patients feel more welcomed? I think there is a lot of initiatives that are now being pushed to address the issues of transgender health disparities. Um one of which is the sexual orientation, gender identity data collection or the Sochi. This is the only way for us to really identify what are the different health disparities that they experience. If we do not have data then we are kind of like not able to address their main issues because if we don't have data then we don't know the problem is um in terms of how can we address all this issue. One is we need to start collecting data as I said, second is we look at the electronic health records or even your medical forms or intake forms. It has to have um certain questions that needs to affirm their gender identity, such as what is your legal name and what is your affirming name questions like what is your sex assigned at birth? Your gender identity and your pronouns. And these are some of the basic questions that we can incorporate to our intake forms or electronic records. Um There are many ways by which you can provide more affirming environment such as probably you can put a flag um or even in your marketing materials such as your brochures that you are affirming organization to the LGBT community um identification. Like in our organization, we now incorporate um the affirming name in the I. D. Band. And we remove the gender marker because if you look at joint commission standards in terms of patients identification, you only need name and date of birth. You don't need the gender, although we keep the gender for the babies. But for the adult patients, if you look at our, I demand you don't see um the gender anymore. But we incorporate the affirming name or the preferred name. I'd like to use the word affirming name and prefer because that is the chosen name that most transgender patients would like to be called. Um And one of which also is to create a employee resource group or a business resource group where your employees who may identify as a member of the community um can do different programs or events so that it shows diversity and inclusions and create more programs that will address the disparities that your employees and even the patients experience. Um creating a support group is also important. Um I run a tweet support group. Support group for transgender and non binary. A support group for parents, ally spouses, brothers, sisters of a transgender individuals and transgender who speaks spanish. Um, you know, patients from all over the world has started joining us. Um, there are members of the community. I think there is a dire mean in terms of providing a safe space that they can be authentic and true to themselves and by having this kind of programs. It's really important since I work in the O. R. It is also kind of like give us an opportunity to look at our protocols, our policy and procedures such as the pregnancy tests. How is that impact in terms of the gender dysphoria that our patients, transgender patients experience when we asked them to provide us urine sample for pregnancy tests. Um, we also change some of the terminology that is more affirming instead of mastectomy. We used the word chess, masculine. Ization surgery or chess feminization surgery. We also look at things such as the use of bathrooms or restrooms and room assignments. I think there are so many best practices that are now um part of the organizations that we would like to foster and really encourage other facilities, other organizations to embrace this kind of best practices that will truly provide a more affirming and welcoming environment for our L. G. B T K I A plus community. You know, it's important that we also ensure to in corporate provides some practices that provide employment to the members of the LGBT. You know, recently we have hired members of the trans community because I believe that disability is very important and by doing so, the other members of the organization are more aware that this is truly um an example where we can say we truly walk the talk by by saying we have some employees who identify as a member of the community. You know, it's important that we really provide some sort of opportunity for them to work in an organization. And also like I said, you know, um highlight and elevate some of the members of the community, including community leaders who have done so much for the community. Um for example, it can be either um, on HIV can be either for um adv advocacy on human rights, you know, elevating some of these LGBT community leaders is very important. Um flag racing, you know, upcoming june, we know that june is a pride month and we celebrate by doing a flag racing where we see the community um part of the ceremony and the members of the leadership of the organization and some members of the employee and patients are gathering together just to to celebrate um the pride month. I think this is very important and a key with a strong message that we are one into that, you know, we're working together to to have a best practice. I think that's very key. Excellent. Thank you for those tips. What advice do you have to give to an acute care organization that is challenging, creating these more inclusive spaces and environments for patients? I know you gave us some, but are there other tips that you would offer? I think it's important to do needs assessment first. Um look at your surroundings, make a scan your environment, the population that you serve As to. Why is this important? That's one. Um is there a need to address this? Absolutely. But each organization has its own priorities and we need to make sure that one of the priorities is to address the needs of the L G B T Q I A plus community. Um, but I think that's one you need to do a needs assessment. Um that's a very valuable tool on how you can start on your program. So what are the steps did you like to think because now you're addressing their meat specifically. I would like for organization also to have a conversation with multiple organization that advocates for the LGBT human rights or the needs of the community. Um, invite them to organized sanction have that conversation. I think you can start from there and say, you know, you are new to this um space and you would like to pursue a program that somehow will address the needs of the community, but more so to send a message that you are affirming and welcoming to for them. So I think that's very important. Um I think those are some of the key tips before you even do big programs. Um it's important that you look at yourself first look at your readiness before you even create more programs. So I think that's the key, do needs assessment and have a conversation with the community. Those are excellent points. Are there any additional takeaways that you think we should be aware of? Absolutely. You know, the even the terminology for the L G. B. T. Q. I A plus, it's constantly evolving. You know, there are more and more terminology would probably be coming up. I think we just need to be more open and embrace the community with open arms so that we can move forward with whatever it is, whatever challenges or opportunities that they may have. I think it's important that we need to have the ability to listen and um understand the healthcare needs of this community as we all know, that they have been marginalized. They've been discriminated, they've been silenced for a very long time and by having this opportunity to have the conversation is very important, very key. And I know I've been a very strong advocate for um the L. G. B. T. Q. I. A plus, but more so for the trans community because I myself as a transgender woman and I know how difficult it was for me to to take those steps. You know, my own story and my own journey has been um somehow inspirational for for a lot of people has been served as an inspiration to particularly young kids that you know, may experience of challenges and personal challenges. Um a lot of them have been asking, you know, fighting for equality. And again, you know, like I said, um in my case, I will not fight for equality because I don't believe in fighting for equality. It is something that we will never achieve in this lifetime. I believe that equality is a principle that our goal to achieve, but I don't think it's achievable. I will continue to fight for humanity because I believe that regardless of our sex or gender identity, we all deserve to be treated with respect. And David, I could not agree with you more. That is such a powerful note to end on. And so, Jackie, I do want to thank you for sharing time with us today and sharing your thoughts and your insights. Um as we as we think about different perspectives on this important issue. Thank you for having Mitchell and I and I hope that I'll see you soon on behalf of an IQ I'd like to thank everyone for watching and doing this learning module. Please be sure to visit our other modules as part of an ex HIV and aging educational series. This module will provide a patient's perspective on creating an inclusive space. Thank you Vince for being a part of our inclusive space module. Can you tell us a little bit about yourself and your journey as a person living and aging with HIV? Sure. So my name is Vince Crisostomo, I've been openly gay tomorrow mail. I've been living with HIV since 1987 And I got an AIDS diagnosis in 1995. Um I am I still have actually an AIDS diagnosis due to a low cd four count, um but you know Where my story is a little bit different, like I've worked straight through. Um so I found out I was positive in 1989 and they told me I could probably expect to not see, 30. But I just turned 61 in February. So, you know, it's been it's been almost 35 years, so I'm older now, you know, I lived more of my life with HIV than without. I'm very grateful to be here. So, thank you for having me and we are extremely grateful to have you with us. So, throughout this learning activity, we've heard from various experts on ways to make organizations more inclusive and more welcoming. Can you share with us from your perspective, as someone living in aging with HIV what inclusivity and having a safe space means to you um in my current work as a long term survivor. Remember the age generation, I realize there's so many things like before I was willing to settle. I worked with people, some people for 20 years and they can't still can't say my last name and I kind of do what I always do, make a joke about it or kind of um, and there was a young person that I do some work with this. You know, you don't have to do that. They should know how to say your last name. I'm like, really, I've lived with this all my life. And so for me, a safe spaces, you can go, you can say you can speak your opinion. Um, you shouldn't have to start with an apology. Okay? Which so many people, you know, who look like me when they're, I'm gonna say something, what they think is going to upset or rock the boat a bit, they'll apologize. And so I try to like with my staff. Um, right now, all my staff are by park and different ages. Um, I said, you don't ever have to apologize before you state something. Um, that's your truth. And um, it's been interesting because the younger people embrace that really quickly, but my couple of older staff, it's taken them a while. Like really you mean I have permission. So I guess a safe space means you don't need to have permission. You can come, you can tell your story. Um, you shouldn't have to apologize. And as you, as we think about what safe spaces mean in the moments are there other lingering aspects of what a safe space can do? So, you mentioned being long term Survivor and living with HIV for over 30 years, um what does that safe space mean to you outside of the physical location, but in terms of creating that space for you, as you just mentioned, not needing to apologize for who you are or how you show up, um you know, for my um you know, I've always believed that, you know, the services that we do should be client centered and therefore nonjudgmental, that you won't be judged um that we will take everything that is shared with us somewhat seriously until proven otherwise, um that you can introduce something like, you know, pronouns right now are, It's something that my generation did not um did not grow up with and it creates and people are off people of my age, you know, 55 and older, I guess they don't always welcome that practice, but you know, um you should be able to do that and be okay and it should be okay and um you know, I tried to explain to my peers that, you know, this is what we fought for so that people could be who they are, and so if someone is asking us, you know, and it's taken a little bit of education and awareness raising with some of the members in my 50 plus group that you know what we grew up with, What we were taught was acceptable to is not is no longer that so we always try to look at everything as an opportunity to teach and raise awareness and we've had some success. Um The other thing I think first taste races if we disagree, you know, they have those rules, those group agreements, you agree to disagree, but if we do disagree that you won't leave that you at least well at least complete the process um and get through this excellent, thank you for sharing that. I want to go back to something that you said just a moment ago and that is care should be patient centered. Um And so have you ever had any experience where provider was not welcoming to you go I have a five page complaint. So you know I'm um which I just actually filed last week but I recently had to contact the provider for myself, not from one of my clients. And I went to the intake line and then I got a call back and they were doing the and at one point the person told me um I do not need to sit here and be antagonized by your life experiences by your life experience. I have real clients that I can talk to that I that I serve and I ended up apologizing and um and then I tried to explain myself and she said something else to me. And I finally just said you know what I think we need to end this call. And um so then I was totally traumatized by this took me about two weeks before I could um And I talked to one of my friends, 78 year old black woman. I told her what had happened to me and she said you know first they blame you, then they insult you. Then they belittle you and you don't even want their services. And I said is that what happened to you? And she said yeah and she says so she told me you can imagine if that happened to you, what it happens to other people. And so you know I call my filed a grievance and I they did the process wrong. And so the person who took this set um well I can bring it up but what more you know what more do you want me to do? And I was kind of taken back by that. So um and it just so happens that I'm on one of the advisory committees for this particular city department. And so I called my friend that worked there and I said this is what happened. And she said I got a letter back from her boss an email saying it's like now you have two grievances. I'm like wow. Um that was not client centered. So just yesterday actually the supervisor but that supervisor called me and I said you know what she said, I heard you had a challenging situation. I said no it wasn't a challenging, it was a traumatizing situation. I said I came to you, I asked for help and this is what your organization, this is what your employee did. And you know they were like and this time I was ready with what they could do. I said first I think your person doing this intake who followed up with me needs to be trained. They need to learn how to deescalate and um you know maybe they shouldn't be the one answering the phones. You know I said I'm not sure what happened there. So you know I've had that happen. You know I've had um I've seen some of my clients, you know who are all older people and most of them living with HIV but they have, you know they have like a lot of complex trauma and post traumatic stress and they'll go to an office and sometimes it doesn't go, you know like they may have taken them hours to get there and then they close their not going somewhere and then they get upset and there are rules that say you know if you're being disagreeable today we will just not see you and like there is a reason why people get upset. You know they don't they're coming to you for a service. And so I tell my staff it's like you know they can go the people that we serve can go anywhere else in the city and be misunderstood, that's not gonna happen here. Um even when I got my HIV diagnosis, which would know was in the It may have 1989, it's like the person um that gave me the diagnosis um seems more comfortable about it than me and that made me feel uncomfortable and I actually had to and I had no background in service at that time, you know, or medical, whatever. I had to kind of take control of it and sort of to get the information that I needed. And I realized back then that, you know, for a lot of people, you know, HIV was a death sentence and they never knew how the person in front of them was going to respond. And so I sort of understood that. Um so we came back to, you know, cause Covid is my second pandemic. It's like um I realized that we've not been here before and so to try to, you know, take a step back when I need to and then understand, you know? Um but yeah, I'll let you cut it because I could keep going on and then I could go off on a tangent, I'm not sure that's going to be useful. Well, there's two things that you said that I think are really important for our viewers to recognize and one is the idea of trauma and then post traumatic experiences as well. So even in the first experience that you were talked about, the most recent one with the intake person, um that was a traumatic experience and it colored the way that you were able to receive care to show up. And even in the interactions that you spoke about with your friends or your colleagues who had another similar traumatic experience. Right? The second thing is the idea of post traumatic stress. And so you talked about the person who had to, I shared, not shared but delivered your diagnosis with you was more uncomfortable than you were. And that was a traumatic experience. But it's the interaction that happened within the health care setting from someone who should be trained to deliver this type of news or share this. That creates this post traumatic experience that continually can kind of come up for a person or individual or individuals or even sometimes for specific health centers or groups of people who are going to specific centers for help. And that is uh indicative of one of the major problems that we're experiencing right now in terms of, you know, going back to that experience. Um as I was leaving, it was all I could do to get out of the clinic that morning. And as I was leaving after getting my diagnosis, um I was like, are you okay? They kept asking me if I was okay, are you okay? Finally got towards the end of the thing that they give you all the brochures and they go, um, the Briscoe's did, you know you were infected? I'm like, no, I had no idea because there was a, there was a rumor going around in the late eighties that asians didn't get HIV and um, and then they said, well, you know, you're handling this quite well. You know, you are really quite the exception. I'm like, you know what? I'm the exception. I don't think that it's that I handle it well. I think you handled it poorly. And um, I used to tell this story in the early 90s when I was training our volunteers and our staff about, you know, about this using this experience. It's like we need to handle this well where we're talking about a life or death situation at that time. In most cases someone's life being changed your vote, you know, damaged beyond repair or something. And so you know, we need to handle it well. And just that realization that there are still situations and encounters that aren't being dealt with well or exchanges that happen within health care situations or health care settings that really can just move people away from health care when exactly, I mean, I wasn't gonna go back to this organization, I'm like, I've had enough trauma in my life around this specific incident. I do not need to go back and be re traumatized, but you know, people pushed me, um, to say you know what vince but has an advocate you need because how is the system going to change and so you know and I realized that true, I mean there's you know you can get angry and hurt and sometimes it doesn't go beyond that but you can get angry and piste and then you get motivated to kind of change the system and um so in regards to that, I felt that you know I had to talk about it with three or four different people before I was able to when this other person called me yesterday to follow up, I was ready and was able to speak clearly and it was not re traumatizing, that's great some of our other presenters have discussed the importance of respectful communication. I know you just gave us an example of some communication that didn't sound as though it was very respectful but what does respectful communication mean for you? Well you know this is another thing going back to the pronoun issue. If you ask somebody, you know what their pronouns are then they should they should be able to be referred to in the way that they feel that they that you've asked them how and um and so respectful is when someone talks you not only listen you hear you know it's like um if someone makes a complaint and then you just turn around like or like I'll use my last name which is something not so you know like someone says my last name and they say it wrong and I correct them and they continue to say it wrong like how many times am I supposed to correct them with that? Um but you know, I think that I do a lot of, I've done a lot of work with english as a second language and you know, some of the things that are terms around HIV are not um are not culturally like they're not easily to translate. And so I was in Asia and we were doing a session with with the U. N. And the translators were interpreting the L G B T Q. Um folks as normal and not normal and I thought whoa and so I actually stopped, you know, and I went to them, I said hey you know what's up with this? And like well no one told us, we don't know what else to say, like what, you can't say normal and not normal because that's telling the whole, you know, everybody in this, the L G B T Q folks are not normal. And then it was interesting because when I went to Korea and I organized a conference there that actually the translators actually came to me before and they said, hey, you know, no one has explained to us how we're supposed to use this, how we're supposed to translate this, can you give us some guidance and actually I was able to give them some guidance that you can say this, you can say this and I would ask them does that translate into your language? And they're like yeah we could we could or they would tell me what they could do which would and so now whenever I'm doing something there's gonna be translation. I always ask if they were going to be talking about um technically hard terms like how how do we translate this and how would you like to be referred to it? Can someone share you know I mean there's another example around that this invasion is that I was in I don't know I should say the state but you know there were a group of Vietnamese women who had breast cancer and they needed radiation And there had been a lot of work that had gone into doing you know getting the radiation set up for them because I guess they also couldn't pay or whatever. They were about four or five of them. And so the person who translated told them that they were going to be set on fire and that would cure their cancer. But what they should have told them is that you're going to get this radiation treatment that will cure your cancer. But so none of them showed up and you know that pistol lot of people because a lot of work had gone into getting them there and so it turned out it was a translation issue because whoever, you know, this is one of the things like sometimes they use kids like young kids to translate and it's like you can't you can't do that, you know? And so if you tell someone, if you told someone, if someone told you you were gonna be set on fire, would you show up? And they're like no. So I said so that's the issue, you know, and people think I make this stuff up, but you know, it happens every single day in the health care field. It absolutely doesn't. So there are a couple of things I just want to reiterate. So I thought I heard you saying it's not just about respectful communication isn't just about listening, it's about hearing. Um it's also about having a cultural context around words and what they mean. Um being able to do that translation if it's a different language or if it's just a different cultural context. I wonder if there are any um if you have any ideas or any any wisdom to share around respectful communication when it comes to Egypt with aging. Well, you know, I've done some work around this as well and we did, there's a, there's a couple of really good books on this, but we found out that a lot of people don't like the word senior that they find in disagreement. I'm like the whole culture senior discount, you know, everything is about seniors, you know, so it's like they prefer elder. Um but when in depth, just ask people, like some people have no problem being called whatever, but you know, I think you should just ask them um and not make assumptions, you know, like um I told some, but I recommended somebody for something once And you need to be 60 and older, turned out this person was A lot younger than that, like in the early 50s, but life, their life experience had changed in there, you know, and their their HIV I guess had aged their bodies too. And you do see this now, I mean this was earlier on when I was started doing this work. Um I do see that for some people, how HIV has either called their experiences have caused them to age faster. So I always ask first, I don't make those assumptions. Um you know, people always think I was younger than my age now, that doesn't, that doesn't doesn't happen, but you know, I always say check your assumptions is a way of, you know, respectful communication. Um and when in doubt just ask so two great pieces of advice that anyone can take up check your assumptions and just ask that's perfect. I'd like to transition to another question and that is what matters most to you when you're seeking services or care as a person living and aging with HIV um things like that customer service question they asked you, were you able to resolve the issue that you came here for today and so you know, it's like I have better things to do with my time than showing up, you know. Um and so if I make the effort to show up somewhere, try to get it done. Um you know, I had to tell some of my clients because they have a lot of challenges transportation getting, you know, especially during Covid. Um Yeah, but to try to find out, you know, what is the issue as opposed to like no, we're not going to see, I mean, you know, everybody's patients right now coming out of Covid is just really thin and you know, sometimes you can't even get people to answer yes or no question. So to get to complete what I, you know what I am, what I set out to do. I mean like when I filed this, when I, when I called to ask for help but this, you know at this navigation line and you know I got referred and all that. So one phone call has led now to a few dozen conversations, a bunch of emails and three grievances, profits and I still don't have that. Like I still don't have the help that I set out to request. And then people are always telling, you should ask for help. You know, you do so much, it's okay to ask for help but you ask for help and then you just need more help. Um So um Yeah, I mean so you know, so so I'd like to think that I would get done. You know whatever, you know, whatever I set out to do that day. And if you can't do that, then say, well what are your priorities? You know, if we only have this and I also tell this to my staff. Like if you only have a limited amount of time, tell the client before that and ask them what they would like to constant time that you have available to them. That's perfect. Is there anything else that you would want providers to know? Um keep your biases to yourself? You know, it's like um well I'm gonna go back to this situation just was just such a bad situation. Like I was talking about something that has happened with this organization and they said I don't believe they do that. I'm like why would I give you my time if this didn't happen? I mean, I know that there's all kinds of things but it's just yeah, it's just a challenge. You know, it's like um you only have limited time and if you're gonna go through the story at least you know, see what the merits are. I mean I related to the five page complaint about this other you can think all I do is file complaints for all these things. But you know, the person told me that okay we're gonna go visit the facility on this date But that person has called me three times to tell me that it's been changed. And I don't know if this is part of the system where that you know they just keep telling you you're gonna give up and then you'll stop calling back. I'm not going to forget this and so I'm gonna call her and say so where are you at now and I appreciate that she's called me to keep me informed but I also want to see some action or some resolution so um if I can just summarize it sounds like a couple of things are really important for providers to know. Um You said for providers to check their assumptions, I might modify that or add on to that and saying make sure that providers have some insight into what their assumptions and their biases are would be a nice first way of attacking that. The second was when you're going for care. Um I want to make sure they don't get this right stick with the plan whatever that plan happens to be and if there are modifications, if there are changes or alterations then provide timely updates for what that's going to be. As you mentioned you're coming in for a particular service um And you want to make sure that you get that service as you're going through and so um uh having an updated schedule or updated awareness of what's going to happen. And then the last thing that I think I heard you say was make sure that the priorities are well identified at the beginning of the visit rather than, you know, going into extemporaneous conversation about something that may or may not be what you're there for. Um as someone who is seeking care, um or the provider may have some other priorities that they want to address, but coming to that common understanding of what are the, what are the important things that we want to make sure that happened during this visit. Does that sound accurate? Is there anything else that you'd like to add for that that providers that you like, Like this job is not working for you and your serving clients and it's not working for your clients either. So someone has to be the big enough person to tell to make that call and it might as well be you? Um But yeah, I mean, I have seen so many, you know, like, I'm really sure that the people that I've had these complaints about this, like, I'm perfectly sure that the woman that did is a perfectly nice person, but clearly she either is not suited for this job or she's working too hard or there's just something not because for me to have the experience that I had, um it's not acceptable. Were there, were there any exceptionally positive experiences that you've had? Oh, I had a lot. So when I first got my diagnosis, um I had to come back the second person, the person that I met was just incredible. In fact, I really feel that she's the reason why I didn't get lost to care because she treated me humanely. Um I got gay bashed shortly after being diagnosed with a friend and there was a wonderful counselor that who's based in new york, I think he's still based in new york, it's been like 30 years who was just incredible. He just, he took me under his wing and really another, so I, you know, even though it had all these, like, I've talked about negative experience, I've had so many great experience, like my caseworkers, my case managers have all been phenomenal. Um I've been very lucky when I lived in Thailand I had to go to the um I forget what kind of hospital is a hospital where, you know, for the, where your, it's not one of the big fancy hospitals and I just happened to look out to find the only person that spoke english there and she was about to leave, but because she was the only person who spoke english took me and walked me through this incredibly complex thai hospital um had me moved up ahead of all these other people who are more sick than I was because it was an access thing, I couldn't speak, I don't speak thai but you know, for whatever reason I had to go there for this treatment so so I've had a lot I've had great doctors I don't think I've ever had a bad doctor um characteristics or actions that these providers have done that has really made this a great experience for you particularly as we think there is some empathy some preparedness explaining something that might be uncomfortable. Um But really it's just it's really just a connection. Taking time to connect with me so I would be able to trust you. Oh I had one and I was able to thank him a couple of years ago but my doctor you know I was so adamant to not take meds because you know I went to the A. C. T. Thing I didn't take it but I saw some one of my friends and so I refused to take any medications. And so when the when the antiretrovirals came out in 96 he was in his office he said I really think it's time you know you're down to four C. T. Fours and you really need to um you really need to consider medication. And I was like no and he blew up told me like you are the most he said these things to me and he said you know how many people's lives I I tried to save and I couldn't because I couldn't hear you are and you know you're here and you're done you have to like I thought wow he really cares. So I said okay I will take this medication. And so he wrote the prescription and I said I it's this is a big change for me. So I but I said I'm gonna go on a trip and when I come back I will know what decision I'm like. So I did that, I came back, I took the pills and I'm still alive today. And so I actually ran into him in a like a retreat. It's called Learning Our Experience where we talk about our experiences and try to heal from that. And so he turned out to be there and I was she able I said do you remember this? And he didn't remember, I'm sure he saw but I said it totally changed my purse. You know, it's like I really got the sense that you care about the outcome there. And um anyway he said he thought this must be fair because he had come to this thing trying to find something and he said he found it with me by me telling him thank you. So yeah, so even though you know and the other thing is I talked about the negatives today but I also try to focus on the positive. Like I really do not think that people come to work every day with this idea that they're gonna make decisions that are gonna make your life miserable. But there are times I know your role. I think that would be another thing is that um it doesn't matter what I do outside of um of your office today. I'm here as a client or a patient, and I need you to treat me as such. Excellent. Well, thank you so much for your time vince. We're grateful for your insight and your perspectives. You're welcome. Thank you for taking the time to interview.
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