I'm here with Talia Boshari, talking very much about the impact of behavior change interventions and behavior change in general on HIV and sexual health here in London. So Talia Boshari, tell me a bit about your role in HIV and sexual health services? So part of my role working in local government here is to cover sexual health and HIV, and that involves a lot of working with our local services, our local primary care providers, hospital trusts, and also thinking about health promotion, sexual health promotion on a population level. Now, how does international and national strategy and policy trickle-down to someone working where you are so close to a local population? I think that definitely are international policies will be setting decision I guess worldwide, but where different countries are coming from, the baselines will be very different and the routes that we take to get to that final destination will vary. So for example, our priorities and the points at which we're looking to intervene here in England and in London will be quite different than countries with they still have quite a high prevalence of HIV and lots of new diagnoses. Now we see HIV as being actually a huge success in terms of public health interventions. Just tell me what about all we here in London on the HIV story? So we've done phenomenally well, we know we'd exceeded the UNAIDS 90-90-90 targets which was that 90 percent of people with HIV are aware of their status, 90 percent of that cohort are on antiviral therapy, and 90 percent of those are virally suppressed and they can't pass on HIV, and London exceeded those targets. So that's amazing. But we still have about 100,000 people across the UK living with HIV most of which are in England. We still got about 4,000 new HIV diagnoses a year in England. So there's still more to do. Yeah. Behavior changes has been a huge part of that story while we've managed to prevent a huge number of HIV acquisitions and really change people's attitudes. Tell me a little bit about some of those behavior change type interventions that have been used. So I've only been in London for a couple of years, but I know that the history around this topic spans decades. So the NGOs and the Charity Lobby has been really successful at pushing this agenda around sexual health and HIV. So they've pushed for investment in research on the topic in mainstreaming testing really reducing stigma, so all of these are founded in behavioral changes making it acceptable and normalized for people to be testing to be engaging in safe sex and for the rest of the population to be accepting of that. I think we've also done quite a lot of work engaging colleagues in primary care and in hospital trusts so that, we're also screening for HIV in those locations. So it's really making sure that all avenues are being covered on HIV and that it's acceptable to be asked that and in different locations. What is the role of stigma, culture, and societal norms than in as tackling HIV transmission? I think the role is huge. It was a huge role and people engaging in care and people even been tested in the first place, and we think about stigma, there's a huge stigma still in the UK, in London even, around testing, and when going to a sexual health clinic, it's still seen as extremely stigmatizing by some people and we're doing quite a lot to reverse that. I think that itself is a huge barrier even to even get tested in the first place and know your status which is the first 90 of the UN AIDS target. There's also quite a lot of stigma around having HIV still even though we know is that with antiretroviral therapy and retention in care, you can live quite a long happy life and never pass on HIV to anybody. So we're trying to get that message across I guess to reduce the stigma associated with having an HIV diagnosis. I think culturally as well, there are some cultural norms that need to be addressed. So I know condom use is the other best way to prevent HIV acquisition and I guess the empowerment and ability to require your partner to use a condom or for you to use a condom does differ in different types of relationships from different backgrounds. So I think there's quite a lot of work we need to do there, and the MSN, the men who have sex with men community, have been their biggest champions. They've done phenomenal work with their population in changing their behaviors, getting them testing, using condoms, engaging in safe sex, but we haven't seen those same achievements in some of our other high-risk groups. On the back of the huge steps forward that we've made in using and applying behavioral theories to mitigate against the impact of HIV. We're now witnessing PrEP or pre-exposure prophylaxis come to market and be rolled out. What are some of the behavioral considerations that we need to be mindful of through that process as public health practitioners? Well, first I want to say that PrEP is phenomenon, I mean the fact that we have a drug that can prevent HIV acquisition is huge and it's life changing for so many people. Particularly, those who are in a serodiscordant couples where their partner might be HIV positive, it is a huge game changer. So it's amazing that we have this opportunity available, but I think that before, a condom use was the only way that we could prevent HIV and all of a sudden we've got another option. So I think we have to be wary of the fact that some people might change their condom use and then we might see associated increase of other STI rates. Now that hasn't been proven in the literature, we don't have conclusive evidence, and I think we need to just watch that space to see as more results come to light what the association might be but it's definitely something that we're thinking about. I think the other thing with PrEP is that it's amazing for getting people engaged in care and especially for high-risk groups who might not be testing. If we can get them on PrEP, them into it, they're going to be coming into the clinic which means we can address so many other of the health needs that they might have which is great, but at the same time we have limited resource and we have limited clinic space. So when we're opening up to so many other people, while that is an amazing thing, it's going to have to be at the disadvantage for other groups. So I think that balance is really interesting and it's also really challenging to get right. So substantial steps forward made in HIV, but still a lot of work left for us to do in public health. Talia Boshari, thank you very much. Thank you.
