 Hey everyone, my name is Raju Fderazi and in this video I am excited to interview our special guest Fletcher Chu to discuss his work at PRAA in Taiwan and the current efforts to end the HIV epidemic. But first I'll introduce our esteemed guest. He is the Director of Communications at Persons with HIV Aids, Writes Advocacy Association of Taiwan, also known as PRAA. PRAA is a non-profit organization that was set up by and for people living with HIV along with advocates, friends and families in 1997. Fletcher's work focuses on HIV policy monitoring, community-led research and communications of the rights of people living with HIV. All right, Fletcher, thank you so much for joining me. I'm so glad to have you on. Thank you for having me and I'm so happy to be here to share with the audience here too. Yeah, so I'll start out with like a really broad question that I ask people as they when they come on. What is your general view of the current state of the global HIV AIDS epidemic? And you can answer that however you like. Okay, I think the current global HIV AIDS epidemic is still something that we need to address, especially with recently there's a launch of UN AIDS Global AIDS Update 2023. And the document was entitled The Path That End AIDS. I think it kind of like in the introductory of the documents it emphasized a lot about the political whales on the matter of how to end HIV and AIDS epidemic. And that's very important things because I think we know all the tools and all the methods that we can end this epidemic, but it's just a lack of the willingness to prioritize this work for the population to really end HIV and AIDS in different region and different places. Okay, very good. And then bringing it home to where you currently reside, what is the current state of HIV specifically in Taiwan? If we are talking about the current state of HIV in Taiwan, if we're using like UN AIDS 95-95-95 goal in that situation, like for Taiwan currently in 2022, we have 90% of people living with HIV already know their status. And among 95% of them are already on antiretroviral treatment. And among those who are on antiretroviral treatment, 95% of them already reach undetectable viral loss. So it's quite good at the moment for those indicators. It's 95-95, but it still gets us that a way that we need to move forward in terms of those testing targets or get people on treatment and maintain viral suppression. And you said for the moment, is the trend heading in a positive direction? Has it plateaued or what does that look like? The new infection actually has been decreasing for a couple of years. And especially for this year, we believe that it's going to be lower than a thousand for the new infections. And I think it's for the first time since 2017 that we got new infection lower than a thousand. And I think that's the efforts of all the prevention tools and the treatments available for the population to get access to. And I know there are countries that are aiming to have zero transmission to end transmission completely. Is that something that's also in your goal, in your near-term future? I think I believe for the governments and for public health aspect for zero new infection would be an ultimate goal of that. But I think from our side as an organization that advocating for rights of people living with HIV, we're mostly more focusing on at the time that we haven't had a cure for everybody. We focus more on how to maintain the quality of life for those who are living with HIV already and will be living with HIV for the rest of their life before the cure comes out. Yeah, and you mentioned fighting for the rights of people living with HIV. On that note, what is stigma like in Taiwan? I would say compared to the very beginning of the epidemic, the stigma is kind of like a hidden stigma for the current states. People wouldn't really say bad things about you in front of you, but if they're on the internet or other things that we observe in healthcare facilities or a nursing home, maybe they know about your status, they wouldn't decline you in front of you, but they will use other excuses, say maybe we don't have available services for you at the moment, maybe you can try to check out somewhere else. They do it politely, but you know they're refusing you based on your status. And do people have good access to care as well? For Taiwanese citizens, yes, because we have national health insurance, it's assistance that all of the Taiwanese citizens there will be included in that national health insurance and it's quite affordable and there are a couple options of first-line treatment that people can choose on, but for expats or foreigners it's quite different because the mechanism for that treatment is different. So for the expats and foreigners, if they already have the national health insurance, but they haven't have like a register in Taiwan for their HIV status, they might still have to wait two years for the first two-year periods. And for those periods, they kind of need to come up with their own means to try to find treatments or if they found the brand medicine is affordable for them in Taiwan, they can buy it in Taiwan, but mostly it's quite expensive for them. So what part of our work, we are also assisting people who are foreigners or experts in Taiwan and they try to get access to the treatment, whether from their home country or they will buy from online pharmacy and import it into Taiwan. And on that note, they will need to apply for food and drug administration, drug importation approval, and it's quite, although it's free, but it's quite complicated for that process. So and it's all only in Mandarin in that survey, so we will help them with the language and all the process. And do you find that there's adequate funding support from the government as well? From our perspective, because we're doing advocacy and advocacy is always not a very like the piece that the government would tend to fund. So to our knowledge, most of the government or domestic funding for AIDS or HIV would mostly focus in on prevention and also like some of the care cascade and healthcare facility for the healthcare staff to maintain the relationship with the patient to get them on the treatment and maintain virus oppression. Yeah, I'm curious because here in the US, you know, we're dealing with a phenomenon, especially recently, where certain political leaders are trying to actually roll back some protections and then especially preventative care like PREP, based on the right on the belief that it infringes on religious beliefs and what have you. But essentially at the end of the day, it targets marginalized groups. And I wonder if you have any kind of similar issues where you are. I think as you talk about PREP, I think PREP is kind of also a little bit scaling up in Taiwan at the moment, but not very big scaling. But our government have some pilot project where they provide partial of the funding to supplements people who need PREP if they meet certain criteria for that. But at the very beginning of the stage to launch those pilot projects, it also got some kind of backlash from the anti group. And it's also kind of based on the religious problem that you just mentioned about. So, but I think the government stand on their point at some kind of the status they have seen, especially with that mention that the new infection rate are decreasing and coming in the last couple years. I think it's a combination of the prevention tool available and also the treatment available for people who in need of those tools. Can you tell us, because I initially I saw you because I forget I think it was on LinkedIn, but you were talking about the U equals U campaign. And then I saw on YouTube as well, you mentioning about that too. So can you tell us about your U equals U efforts? Yeah, so it's actually so, so we had our U equals U day campaign this year on second of July in Taiwan. And it's awareness campaign for the general population. And we are lucky that this was supported by Gilead where we can like kind of bigger scale of this campaign to really reach the bigger population. Because at the very first that why we want to do this U equals U day campaign is that we want to take out this a message of U equals U very specifically to send out to general population. Instead of I think a lot of time that when we are doing communication, our mode focusing on our community, I'm not saying it's not important, but I think our community have already have a lot of different resource and different organization working on delivering this kind of message to them to understand what's the science for nowadays. But for the general population, it's always very difficult for non-profit organization to deliver a message to them. So we came up this second of July a U equals U day in Taiwan is try to raise the awareness among general population. And it's a very local context. Maybe you'll wonder why second of July, what is not another day? It's because like back in 2021 on second of July, two years ago, we our government amended U equals U into one of the executive order of our regulations where they define what is unsafe sexual sex. So in the past, they define the unsafe sex solely based on the content use or not. They didn't really care about your HIV status or not, and your viral status or available condition. But that has come to a place that in 2018, the expert consensus statements addressing HIV in criminal law context and those kind of information coming out. So we kind of like want to do an advocacy about removing that barrier in the regulation where people will think about even you are undetectable legally, you're still defined as you are able to transmit the virus. So we want to do more things on that context. So because the amendment happened on second of July to include U equals U into that criteria of unsafe sexual behavior, which means that after second of July 2021 in Taiwan, if you're undetectable and you have condoned sex with others, it's not considered unsafe sex in terms of in the context of HIV. So it's kind of the remarkable day for us in Taiwan. So we make it on second of July and we also think that it would be easier for our people to really try to find information online. And we are very happy that our government CDC also stand in solidarity with us. They come to the press conference on the second of July of the launch day of the UE course U day. And how did it go? How was it? Was it well received? I think for media coverage, because we try to reach as much as media we can. But we haven't done evaluation, we already done an evaluation on the media coverage. But in terms of people who really get the message, I think maybe there will be a post evaluation to see how many people really know about UE course U after this big campaign. But it haven't been really ended for the campaign because for the second of July, it's one off, it's on that day. But along with this second of July campaign, we also create a social experiment video on YouTube where we invite a celebrity in Taiwan who is a very straight man, he's a straight and middle-aged man and he's quite famous and very hilarious host in Taiwan. And his target audience is like those people we are never going to reach. So that's the reason why we invited, we invited him. So he come and he's very good at doing entertaining shows and programs on TV. And what he famous for is a scary box. I don't know if you have ever had those kind of like you have scary thing inside box and you put a handsome. He's very famous for that. So we invited him to, we put UE course U inside the box, but we make it with different materials, maybe like brushes or something. So when you put inside your hands into the box, you couldn't see what inside. So you kind of like scare and not know what it do when you touch it. But once you reveal what is inside, it's actually nothing to you. And it's the same idea for HIV and AIDS. Like when you don't see, when you see the box HIV and AIDS and you don't see U equals U or PrEP or PAP inside, you'll be scary. But once you know this kind of information that you will clear out the scary you might have around this issue. So that's the social experiment video that we do with the celebrity on the streets of Taiwan. And following down that videos that we still gonna have several posts with some of the key influencers in Taiwan on 21 of July this year, because we found out it's zero stigma day, zero HIV stigma day on 21 July this year, maybe every year. But it's also for us another day to try to raise more awareness around stigma and how to use U equals U equals U to destigmatize the the misconceptions around HIV. Well, what what an innovative and creative and entertaining way to you know, get the attention of the masses of people like you said who normally wouldn't you wouldn't be able to reach or maybe wouldn't feel like it's relevant to them and be able to get such an important message across I think that's so genius. And I think we we in the US can definitely take notes from that and execute in that way. That's that's really brilliant. So now that the government has acknowledged that viral load is important, being undetectable is important. And that that leads to safer sex, not just condoms. Does that mean that criminalization HIV laws have also been laxed? Or what does that look like? Yeah, so currently, the criminalization though is still there. So we have an HIV special law in Taiwan since 1990. I couldn't remember exact 1919, I guess. So the criminalization though is still there. But it just like for the component that if you are undetectable at the moment, if someone take the charge on you or sue you or prosecute you and you have the evidence to prove that you're undetectable, then it's like high possibility that you are not going to the trial or going to the court. But it's still it's still possible to sue you or threaten you on that matter. So kind of like in the long term goal for us is still try to abolish or remove that ball. And is that are you talking about disclosure specifically? Yeah, so the elements of the criminalization around HIV, there are three components around that. First one is knowing yourself are HIV positive. And second one is by not telling the person that you're having sex with about your HIV status. And the last one is having on safe sex with them. So the part that we kind of already address is about the unsafe sex. If you are undetectable, then you are not having on safe sex with them. Because we know about you equals you. But we are still kind of very aware about what if people who are not undetectable, it shouldn't really just based on their HIV status. And another big component of that law is also about for people who are not for the case where the new infection didn't really occurred. It's still punishable. So it's quite a goal against the principle that your needs are holding that your needs are actually very rooting for if there there's no infection, there's no new infections happen in this kind of context, and there shouldn't be any prosecution or sue among those cases. Well, okay. And speaking of the government and overall healthcare organizations here in the U.S., especially, I think it was aggravated by the COVID pandemic, but there is intense distrust between community and healthcare, community and government, institutions, scientists. What's it like in Taiwan? I would say that healthcare provider, especially physicians are usually and they are still kind of like very well-respected in Asian region, in Asia regions. And for Taiwan, I think during COVID pandemic, there's not that much mistrust happening in between the healthcare provider scientists and with the society, because I think our government tried to control it pretty well. And I think one thing that COVID have contributed to HIV during this period of time is the health literacy for the people, because like during COVID, a lot of people are talking about PCR. It's one of the tests, how you test the viral law within somebody. And in the past, there are a lot of people who are not, who don't care about how to really understand what is PCR, what this viral law means to them. But during COVID pandemic, it's actually kind of become a norm for people to talk about, oh, do you know PCR? Do you know what viral law and if you're infected with COVID, how's your viral right now? So it's kind of give us an options also in the U.E. course, U.D. campaign I mentioned earlier this year. We can use this idea in terms of the viral load. We can use that to explain to the general population. Like back in the COVID, you know about if you have less virus in your body and it's not able to transmit, it's the same idea for HIV. So as HIV positive, you can take medication to lower the viral law in your body, and it wouldn't be able to transmit just like COVID. Okay, brilliant. So there's some, you found some intersectionality there between COVID and HIV, and you were able to piggyback on what people were already learning about the science and the medicine, and then use that to explain HIV. That's great. Speaking of COVID, did the pandemic have an impact? I mean, I guess we talked about it a little bit, but did it have a negative impact on HIV transmission rates, or was it well maintained? I think for, for during the COVID pandemic, there's not that much effects in terms of the HIV epidemic in Taiwan, because I think for different places or regions, maybe there are some of the disrupt of treatments in terms of people maybe being locked down or not able to go back to a healthcare facility to get access to treatment. But I think mostly in Taiwan during that time, people are still able to access to treatment. So the infection rate didn't really go off. And also because of social distancing, so people are not able to interact with other people sexually. So I guess that's one of the reasons why there's not a climb up in terms of the new infections rates during that time. And what would you say are the most at-risk groups, populations in Taiwan for HIV transmission? For the moment, it's still the men who have sex with men population. But generally, if we're talking about the transmitting methods as mostly about on safe sex transmissions, and within that, MSNR is still a big population of that. And okay, so what are your short-term long-term goals to achieve through PRAA in Taiwan? I think short-term is still like for this year and next year, we'll try to like really get the message out about UE course U because we found it could be a very helpful and powerful tool for a general population to really understand the science of HIV has progress that much. And the reason why we want to pick it up like very individually is that we think this is very easy message for a general population to understand. And the long-term goal I would say is still like very broadly the quality of life of people living with HIV and to remove the punitive law, especially the part that we just talked about about the decriminalizations. And I think stigma is also a very big component. It's kind of like related to what you just mentioned about, you asked about how's the population affected by HIV right now at the moment in Taiwan. It's still mostly the MSN population and it will kind of give the general society an idea that this is just an issue that relevant to a certain population and it kind of recreate the stigma. And although the statistic really shows that, but I think for us we know it's because of the lack of information, lack of access to treatment or prevention tools, those kind of inequities that lead to that result that we are seeing now. But for them they only see as an issue that relevant to a certain group. I think that certainly would be a part that we need to address whether it's in short or long term. I realized I meant to ask you this earlier, but how did you get involved with PRAA and HIV advocacy in general? Yeah, I started out with a research called stigma index. It's a research that was initiated by GMP plus global network of people living with HIV and ICW and urnates. So it's a research tool to evaluate the people living with HIV, how they feel about the stigma, the stigma they are experiencing in their country. So back in 2017, I was part of that research team doing the stigma index in Taiwan. And after that, because on that research, I was working in a hospital with a doctor on that project and we collaborated with PRAA at that time. And after I done that project, I found I want to do more about the community size. So I come back and go to PRAA and stay here until now. Amazing. Well, everyone is fortunate to have you on board. Because during that stigma index, although it's a questionnaire, but it's a semi construct questionnaire. So we get to interview a lot of people living with HIV in Taiwan. I think we interview 843 people living with HIV all over Taiwan. And half of them were done by me. And it's actually an experience that you get to hear a lot of different life stories and how they struggle or not struggle anymore and already live in their life in their ways. But throughout that time, you can really feel that there's a lot more to do to really make the community feel that they can leave the life as people who live in without the virus. Is there something that you learned from those interviews that was surprising or unexpected? I think it's the interactions that give me a lot of impressions. Like I remember one interview that I did is that a middle-aged man, when I was doing an interview with him and after the interview, because he shared a story about, he's not the only one who is HIV positive in his family. His brother also is HIV positive because of the share of needles in the back where they were not aware of their serious range program where they can get access to clean needles. So they share a needle and they get infected. And his brother killed himself because of that back in that time where he kind of like didn't have enough information knowing that he can survive and he can get access to treatment. But it was kind of like 20 years ago. So the situation was quite different. But when he kind of like shared all those stories that he experienced and after the interview, I wanted to give him a hug, then I asked him about that. And the questions, the response from him is that, are you really willing to touch me? Like when I say to him that, can I give you a hug? Then his reaction is like, oh, are you not afraid? I think that that kind of internal stigma that still withholds on some of the populations that maybe, I think, but it's mostly for people who may be elder or lack of information. Because I'm also seeing that those young people living with HIV or people living with HIV who are newly diagnosed, but with more information and knowledge like you equals you, they are more confident with their status and maybe more confident about coming out on their HIV status. Wow. Yeah. Thank you for sharing that story. It reminds me too, when shortly after I was diagnosed, I remember my doctor made an effort to take off their glove and touch my hand. And I just remember kind of get shocked a little bit because you don't realize when you learn certain things about, for example, people living with HIV that you internalize this perception on yourself and then almost see yourself as less than human and less valuable. And so for someone to make that gesture, it means a lot and communicates a lot more than just words. And especially, I think when you talk about that, how we internalize the concept of people living with HIV might be not good in a certain way. For people who don't know a message about you equals you or don't know a message about HIV prevention tools, it will be very easily for that kind of things to happen. And what we're trying to do in terms of the communication to the journal society is that whether you are living with HIV or not, it's all the same. Right. And it should be treated like any other chronic manageable condition. If someone has diabetes, okay, you manage it. And it's also your personal and private medical information as well and should be treated that way. Yeah, totally agree. Well, you know, I've noticed over the years on YouTube, especially a lot of my viewership is from Asian region. And I like to think that it's because my content is just so amazingly good. But I think the reality is probably that there isn't that many people like me speaking out openly on social media, that a lot of people from different parts of the world have to turn to my content to get that information. So my question is how do you feel about the visibility in the public media? I mean, you talked a little bit about you equals you day and doing campaigns. But overall, do you think in media there is enough visibility in role models and things of that nature? Yeah, that's very good questions. And when we were talking about the social experiment videos that we have in Taiwan, and you said that's something that you can learn from the States. But at the same time, in my mind, from my perspective, I see a lot of different figures on the Internet or TVs or stars that on whether it's from the States or from Europe or typically Western countries are willing to stand out and share their life journey about being HIV positive. I think that's very big components for people to really see a person, not just a story behind the scenes or a picture behind it and to get the real human human context of how people living with HIV would look like. And I think to my knowledge, they're actually some of the public people living with HIV in HIV positive region, but that the problem may lies in the language and the cultural differences. So huge difference in different countries in our region, whether it's in Southeast Asia or in East Asia, we speak totally different language. And I think to my knowledge, there are South Korea and Japan and Taiwan and Thailand and Indonesia. I kind of all know there are certain people with HIV would go public about their status. But it's just that how the social media is helping to get those message out to the general population. Or on the other side, is the general population being interested in getting this kind of information? And if not, what kind of strategy that we need to use to really generate their interest on this topic? Well, I mean, I think that your country has served in many ways as a very good model of how to handle the epidemic. I mean, you've shown that by getting very close to 95, 95, 95. And you continue to have government support, funding, you have trust. I think that's another important element that we sometimes overlook is how important you can have all the best resources, you can have all the best doctors, you can have all the best programs. But if you don't have that trust there, then what does it matter? Because no one's going to listen to you and no one's going to take what you're giving, what you're offering. So that's important, having the visibility to the extent that you do. And yeah, I just think it can serve as a model and Western countries should and can take note of that. But I think that when you talk about trust, it also reminds me about the partnerships. I think in the last couple of years in Taiwan, it's kind of like a close partnership within the community and also the professional, especially the physician, where they are willing to help to promote the science of you equals you and the message of you equals you. And I think I also see that trend states as well that especially, I remember on 4th of July National Day on Twitter, HIV, CDC HIV, they tweet about a picture about you equals you. I think like for us, it's context of 2nd of July. But for you, National Day, 4th of July, for governments, institutions, they're willing to get the message out on that. I think that's also a very important component for the citizen to see the political willingness to acknowledge that kind of information. Absolutely. And especially having a more progressive government at the moment also helps. But again, at the end of the day, there is so much more distrust here that you can see those things. But I think I find often it's met with cynicism. So it's hard to get past that. So that's our challenge here, for sure. I'm sure you're kind of like push it through with advocates like you. Yeah, we'll do our best. And part of that is really understanding community and understanding what the community needs and what the community wants instead of just saying, okay, we're going to develop a drug. And here you go. Take it. It's like, well, what are the needs of the person? Are they unhoused? Do they have drug use problems? Do they have mental health struggles? Are they financially okay? Because if they're worrying about all these other things, then going to a clinic to get prepped on a regular basis, and maybe pay for it if they have to, is going to be at the bottom of that list. So it's like this holistic way of approaching it with wrap, we'll call it wrap around care. That I think is how you begin to foster trust again. All right. Well, we are coming up on our time here. So before we go, is there anything else that you would like to talk about or share or say to our viewers that we haven't discussed already? I think we pretty much cover all of it. But because I mentioned about U equals U day in Taiwan, it's on 2nd of July. But the idea of that is not try to only talk about U equals U on that day. I think the concept that we are coming out for that day is kind of like the pride. You will have a prideful for a day or for a month. But it's not only for that day or for that month to talk about LGBTI rights. But it's a month or a special time for you to unapologically allow to make the message out for the people around you. And it's also an opportunity for people who want to support this kind of message. But I think some people maybe found awkward to share on day to day basis because they will find the people around them asking them why do you share this kind of information? Is this relevant to you? Are you gay? Are you HIV positive? So I think a special day or a special period of time, it creates a savior song for the people who would like to stand in solidarity with us to get the message out as possible as you can. Okay, wonderful. Well, thank you so much for taking the time. I love all the work that you're doing and let's keep in touch. If you have updates or want to fill me in on anything, I'd love to bring you back on or just share some information that you have. Everyone at home, please comment below your thoughts, your questions if you have any, I'm happy to follow up on those with Fletcher as well. And do let me know if you'd also be interested in having him back on the channel. Thanks so much, everyone. Please like this video, subscribe, hit that bell so you get a notification every time there's a new video. And please share this with anyone who you might feel might find this valuable. I will continue to do content that talks about HIV, not just here in the US or in the Western world, but all around the world because it's a global epidemic and we need to have these discussions all around the world. Cheers, everyone. Thank you.