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[Announcer] This podcast is presented by the Centers for Disease Control and Prevention. CDC - safer, healthier people.

[Dr. Antonia Novello] Our panelists have joined us now in the studio and in a few moments will take audience questions, so please, continue to fax and continue to e-mail your questions.

Dr. Nena Peragallo is the Dean of the School of Nursing and Health Studies at the University of Miami in Miami, Florida. A key area of her research has been health disparities among Latinos and HIV prevention activities at community-based organizations.

Mr. Heriberto Sanchez Soto, is the Executive Director of the Hispanic AIDS Forum in New York City. The Hispanic AIDS Forum concentrates on community mobilization and peer-driven community engagement by tailoring HIV prevention programs to promote leadership development.

Mr. Mario Pérez is Director of the Office of AIDS Program and Policy in the Department of Public Health for the County of Los Angeles in California. He manages a range of services including HIV prevention, care, and treatment and serves on several local and national boards.

Dr. Miriam Vega is the Director of Research and Evaluation at the Latino Commission on AIDS in New York City. Her research focus includes capacity-building issues, social networks strategies and stigma related to HIV prevention.

And last but not least, Dr. Raul Romaguera. As you know, he is the Associate Director for Prevention in Care in CDC's Division of HIV/AIDS Prevention and is also currently serving as the Acting Associate Director for Health Disparities at CDC's National Center for HIV, Viral Hepatitis, STDs, and TB Prevention. He also chairs a CDC Executive Committee to develop a national strategy for HIV prevention among Hispanics and Latinos. So, thank you all for being here today. Absolutely.

Now, our panel will respond to the viewer questions that you have submitted. And our first question is from the northeast and it is really directed to either Heriberto or Mario. And I will compound the question because I think it has ramifications. The first one is -- what are the benefits of HIV testing followed by what are the motivating factors for HIV testing among Latinos? So maybe we can start with Mario.

[Mr. Mario Pérez] Sure. So, the obvious benefit is we know that more than half the new infections among Latinos in the United States involve someone with undiagnosed HIV infection. So getting people diagnosed allows us to also avert many new infections across the country. And also, there's important treatment opportunities for people living with HIV, so getting them diagnosed, not just at all, but very early in the course of the infection, allows us a better opportunity to make sure that they thrive with their infection.

[Dr. Antonia Novello] So if it's so good to be able to get people tested, then, Heriberto, can you tell me what are some of the barriers of getting them tested?

[Mr. Heriberto Sanchez Soto] Well, for Latinos, the more significant barrier is the lack of insurance or underinsurance. Most folks believe or think that to get an HIV test they need to have an insurance. They're not aware, necessarily, that the services may be available in communities at no cost. The other barrier being accessibility. Immigrants, Latinos largely, tend to work long hours, and the services may not be available to them during the hours that they may have free. So, to provide a service to a Latino community, one needs to assure accessibility, meaning that the service is available where they're available and at the times that they're available.

[Dr. Antonia Novello] I think it's crucial that the motivating factor should be the more we find out, the more we will be able to diagnose and put them in treatment but also protect the rest of the family without getting infected, specifically the wife or the significant other. But the important thing in this one is, so the biggest barriers is the fear of having no insurance. And this is excellent when we tell them that if you will meet them, we will find a way for you to get them. And that fear has to be removed by telling them, when you want it, we will find a way by which we will be able to get it done.

So when we look into the barriers, absolutely is the fear of “I don't have insurance.,” “I don't speak the language.,” “You're giving it to me at the time that I cannot come, and then when I come, the first thing I know is that you only talk to me in English and you don't recognize my culture.”

[Mr. Heriberto Sanchez Soto] Right and the added fear or the other obstacle is the stigma which plays so heavily into HIV and immigrants in our country.

[Dr. Antonia Novello] We also have to tell them before, you know, sadly, 33% of Hispanics have no insurance. So, they feel, I want a test, that I can get the results today. I don't have a day extra to take off from work and to come over here and our point is: I want to give you the results myself, because I want to give you all the things that come with a positive and all the things that come with a negative test, so in case you were at risk in your mind, you’re [HIV] negative now; that means do not do what placed you at risk to begin with.

So, another question that has been sent to us is that people need to know, “Do I need prevention once I am positive for HIV?” Do we need to tell them that, yes, prevention is still important? Raul, what do you think about this?

[Dr. Raul Romaguera] This is critical. It is essential that people understand that there is a role for prevention services once you get a diagnosis of HIV. There is a role because we need to prevent other infections in persons that were diagnosed with HIV, for example, sexually transmitted diseases, and also that they need to understand also the responsibility they have as a patient to follow-up treatment and follow-up with their medications. There's also a role to deliver these prevention services, not only in a clinical setting, but also these community-based organizations that are working with Latinos need to understand the importance of emphasizing these prevention messages as they work with HIV positive patients. CDC has reported several interventions, for example healthy relationships and CRCS, that are excellent tools that could be used to work with persons infected with HIV.

[Dr. Antonia Novello] I think the point in here is, once you are positive, that does not give you the right to believe that you have no more problems because you already have the worst, which is in your mind, the diagnosis of HIV positive, so you're telling me, in spite of the positive, prevention still is needed. You can get reinfected with another variety of the virus and you can still have sexually transmitted diseases. So yes, prevention still is crucial, even though you are already positive. So, please, I think that's a point that we have to address in our communities in a very strong fashion.

[Dr. Raul Romaguera] Yeah, and if I may add, if you're working in a clinical setting, CDC has also developed a training program for providers. It's called “Ask, Screen, Intervene.” And actually, it packages very comprehensive services that clinicians – nurses and physicians - can offer to their patients. Basically assess what are the ongoing risk behaviors, screen for other sexually transmitted diseases and/or pregnancy, and then intervene. Provide short, brief messages that will help patients continue preventing engaging in high-risk sexual behaviors.

[Dr. Antonia Novello] Okay. And now that we have talked about prevention, let's not forget that great group of people who are getting infected which are women. And for that reason, I would like to ask Nena, what HIV prevention strategies work with women who basically take care of their families before they take care of themselves? What other prevention works for women?

[Dr. Nena Peragallo] I think one of the most important issues and things about prevention with women is that you need to go where the women are. I mean, community-based interventions are the best. Women do not have time out of their day to go to a special place. They need interventions that they can understand, that are given by people that they can relate with. And also you have to address what are the issues for women. And some of them have told us in our experience that we also need to tell them about communication and violence. That these areas should be addressed in an intervention for women as they are major parts of the barriers that we might find with prevention.

[Dr. Antonia Novello] I think it's important for us to tell the audience, for women, HIV is more than a virus. It has to do with power. It has to do with economic dependency. And it has to do with taking care of my children. It has to do with domestic violence and it has to do with “I'll take care of my family before I take care of myself.” But ladies, remember that when the woman in the family gets sick, as a consequence, everybody else in that family gets sick, because no one is out there to do the outreach; you are the caregiver. So ladies, take care of yourself because, when your health collapses, the health of all your family collapses as a consequence.

[Dr. Nena Peragallo] And that's why you enhance that role, that empowerment in the woman, that without you, you are the backbone of the community and of this family. Without you they cannot function.

[Dr. Antonia Novello] We cannot forget to enlist the husband and the significant other, but the women really is the center of the caregiver. And they are getting infected because they are getting infected because they are having sex with men that they trust and are afraid to ask “Are you [HIV] positive?”, afraid of having all the economic incentives removed or being taken away from their homes and their children. So, it's a very sensitive situation but that does not mean that we cannot ask them to be more empowered.

Now, another one is – and Miriam, maybe you can answer this one. What are some issues that are specific to HIV prevention in one population that we must discuss, and that is the transgender population?

[Dr. Miriam Vega] Yes, with the transgender population, a key part of working with them is building a sense of community within that group. They are often so marginalized in society and they’re so highly stigmatized that building a sense that they have a community, that they have other individuals to support them, is absolutely key to enhancing HIV prevention efforts with that population.

[Dr. Antonia Novello] And I think that's a great point, but when you talk about transgender, one of the questions that has come that I think is very important and interesting is, what do you do to prevent something in men, specifically Latino, that do not want to identify themselves as having sex with men? So how do you address men who you know need prevention but will not identify themselves as being heterosexual, transgender, or having sex with men?

[Dr. Miriam Vega] Well, to address men who won't identify as having sex with other men, this is something that many of us have been really concerned about in community-based organizations and in research organizations, that there aren't really that many interventions that target men in general. And I think we need to start building a sense of community amongst men themselves, amongst Latino men, instead of just putting men or addressing men who are substance users or related to incarceration rates. Let's address men for themselves and let's address some of their own concerns in their relationships. Let's not forget about men, because oftentimes we do and we need to stop doing that now.

[Dr. Antonia Novello] Yeah, one of the things that I have heard is that some of the messages of prevention made just for gay men, the ones who refuse to believe that they might be [gay], refuse to address that prevention [for gay men] because "that doesn't touch me." It's like, ”Not me, no problema.” And I think it's important for men to decide how do they want to incorporate that message as it pertains to what they want to be.

[Dr. Miriam Vega] That's absolutely crucial.

[Mr. Mario Perez] If I may add? I mean, the other reality is that a stigma-shamed homophobia have really marginalized this group even further. So, our attempts to try to engage them successfully have been really challenged by our cultural and social mores that really need to be, I think, addressed head-on. And if I just go back to the transgender issue very quickly, I think it's important to not lump the transgender community with the MSM community. We have to promote social connectiveness and I think we're having some success across the country with testing the Sista intervention with the transgender community in L.A.—it’s called Divas, it’s called something else, probably, in different places – but we need to continue to make sure that we are evolving our HIV prevention interventions for this community, who continues to be heavily, heavily impacted by HIV.

[Dr. Antonia Novello] I think that the point is an excellent one because in coupling everybody together because of the funds being minimal, we tend to put groups and I think they need the individualistic attention to their individualistic needs and that is also as crucial. Remember what we said: design it with the clientele that you are targeting in particular, not everyone, including Latinos, they are not all the same, as we said, Mexican, Central American, South [American], Puerto Rican, and Cuban, and so.

[Dr. Miriam Vega] And if I could just add to that? Everyone says, you know, we’re right now in an election season and everyone says not all politics are local. That's the same with interventions for our target populations. We need to think locally and be very culturally responsive to our specific target population.

[Mr. Heriberto Sanchez Soto] I want to add something to the transgender community because if HIV for the transgender community may not be the priority that most of us think it would be. For the transgender community, there are greater needs on health care, identity issues, gender issues. And so, to the extent that we're going to be successful with the transgender community, services need to be provided in that context. And until they are, we're not going to be effective at reducing the rates of HIV infection amongst that community.

[Dr. Antonia Novello] One thing that I find is crucial, and considering what one of the interventions is that we Latinos like to talk, is the issue of how do we protect the confidentiality of the clientele we are really to protect, in the context of how we like to discuss everybody else's businesses. And confidentiality is crucial if we're going to help everyone in the communities. So, one of the things that I think is also important is when we were talking about some of the interventions, the migrant population, when we are talking in the United States now about immigration, how do we target the migrants? How do we make them feel comfortable to come for testing and how are we sure that we have the facilities by which they can come if they work so much during the day and they are never in the same place at any particular time? How do we access the migrants to come for testing? And once they come, how do we cover them for care? I will ask that of any one of you, but Miriam and Raul, maybe you can address that one in particular, migrants.

[Dr. Raul Romaguera] Well, I will start. I think migrants, traditionally we have designed programs for migrant farm workers and there's a network of clinics throughout the country that really understand their needs and accommodate the hours of operation to reach the migrant farm workers. But, I think it's also critical to understand that migrants have so many other limitations in this country, and if they are not documented migrants, they may not have access to health care. And that's critical. I mean, there are many communities in the U.S. that are passing policies that restrict access to health care services for undocumented migrants. So where they are going to go? Most of them are actually going underground. They are afraid to show up to any government office because they are afraid that if they test positive, they may be deported from this country. So, I think we need to expand our outreach programs and make sure we can find migrants where they are, like we have said before, and that we have empathy to their needs and we support them, not only as migrants, but also as a network of people that are living in a community just struggling to survive.

[Dr. Antonia Novello] And I think we are so much versed into getting all the information in English, that we forget that when you have migrants, there might be another language in there that is totally something that none, even the one who is helping might be able to know that. So, substitute the language that you do not know with the language of care and I can tell you that they will come and visit your clinic, specifically, if you find them at the places they work, at the times they have gone, and give your message more than one time, but with a little bit of courage and always with a little bit of hope, and I assure you that they will come. And so, if helping the migrants and the rest of the population, maybe we can use one group that we need and that in the community of Latinos, it will be totally useful, and that's the faith community. How do we use the faith community to help us lure our own people to come for testing without this stigma that comes with it? And how do we plan to use them in the context of prevention? That's for all of you in general. Mario, maybe we can begin with you.

[Mr. Mario Pérez] Sure, well I think that many of us know that the Latino community often looks to our faith leaders to help shape our discussions – to give us permission. And I think that we need to continue to enlist faith leaders and make sure that they have the tools and skills and curricula to really reach out to their parishioners, to help shape discussions around sexuality, around homophobia, around stigma and shame that have been perpetuated, quite frankly, by some of the same institutions that we’re now trying to reach out to and say, “Look, you can be very effective partners to help us get ahead of this HIV epidemic.

[Dr. Miriam Vega] If I can add to that? At the Latino Commission on AIDS, for example, in 1995, they started a program called the Religious Latino Leadership Project, and what it’s main goal is to teach spiritual leaders, congregants about HIV/AIDS and to help disseminate, spread the message out there and help combat the stigma and prejudice and denial around HIV/AIDS. So, I think any collaboration that we can encourage with faith-based networks, that are so tightly woven into our communities, we should use any collaboration that we can with them, because through them, we can help mitigate the stigma that surrounds HIV/AIDS in our community.

[Dr. Antonia Novello] I think using the faith is excellent. However, don't forget to teach the teacher. Sometimes in their quest of helping, they might put their own values and their own negativism in trying to help. So, first, teach them what you want them to be taught and then use them completely, because studies have shown that when you have a minister doing their own [HIV] test in front of that pulpit, it really gets the people to motivate themselves, to say “If you can, so am I, becasue if you are protected, so would I.” And so, don't forget to teach the teacher, but absolutely, utilize them, a lot.

Another question that came is -- What kind of housing facilities are out there for Latinos living with HIV/AIDS? Maybe we can start with Heriberto.

[Mr. Heriberto Sanchez Soto] Well, I'm in New York City and New York City has a lot available, in terms of housing, for people with HIV and AIDS. Housing Works in New York City being one – a leading organization. But I also know that throughout the country, there are many transitional housing programs for Latinos living with HIV. We started one at PROCEED, when I was the Executive Director there, where folks that were in transition, homeless or did not have a place to stay or someone discovered that they were HIV positive and as a result there was a threat to become homeless, they would be provided with temporary housing, assisted with employment training or securing a job, securing a permanent apartment. And so we know that they're available out there.

[Dr. Antonia Novello] One of the things, too, that I think is important is, I think people want to come for [HIV] testing, and you know that statistics show that Hispanics is one of the groups that are really trying to be tested and really are coming for tests. However, one of the questions says, if a Hispanic who is a United States citizen is diagnosed with HIV, does this put his citizenship at risk?

[Every panelist]

>> The answer's no.

>> No.

>> No.

>> No.

[Dr. Antonia Novello] And the other question here is for Raul. Do federal and state prevention programs need to require that clients disclose their U.S. citizenship or their residency status?

[Dr. Raul Romaguera] CDC doesn't have any requirement that our prevention programs require evidence of citizenship to provide services. So, the question again is there's no evidence that needs to be submitted. If a person requests services, they should receive services.

[Dr. Antonia Novello] This is why I think part of the question and answer is to give assurance that the perception in the minds of our clientele is not really what is totally true.

One of the other questions that we have gotten is what can you do to help a client understand the difference between a preliminary positive result and a confirmatory result? Nena, do you know the answer to that one?

[Dr. Nena Peragallo] Well, I think that that's part of the testing preparation and the pre- and post-counseling. I mean, the person doing the test has to be totally clear what does it mean, you know, the preliminary positive test and that has to be confirmed so the person is not off. And the thing is to engage that person to have the counselors, be able to do this counseling in both languages, in English and Spanish -- so that. And assure the person that even if that result may happen to be positive, there is treatment. And, you know, too -- I mean, really explain to them the benefits of testing and how that can help them, even if they are [HIV] positive. You know, to take care of themselves and their families. I think that should be our message.

[Dr. Antonia Novello] One of the questions that comes in here, too, and forgive me for interrupting you, is crucial to our race and that’s machismo. And the question is: machismo -- does it apply to all races and do you think that Latino men should teach younger men and how to get rid of it?

[Dr. Nena Peragallo] You know, that's a very controversial question.

[Dr. Antonia Novello] I want a man to answer this.

[Dr. Nena Peragallo] That's good.

[Dr. Antonia Novello] Mario?

[Mr. Mario Pérez] Machismo. You know, I think that we need to challenge machismo, particularly given its sort of negative impact in our culture. There's certainly some benefit to machismo, protection of family is one obvious one. But there's also been, as has been clear, there have been some detrimental impacts to machismo: domestic violence, sexual coercion, not enabling women to openly disclose their HIV status. That does not have room in our cultures, particularly if it compromises public health. So…

[Dr. Antonia Novello] Heriberto?

[Mr. Heriberto Sanchez Soto] Well, I happen to be gay and I happen to travel extensively. So my contact with men all over the world has been substantial. And I don't see much of a difference between a Latino man, in the context of machismo, with any man anywhere else in the world. What I do remember as a young child, in the context of machismo, was that my father was a gallant and machismo -- being macho for him meant something completely different to what it means today or how it's been defined today. For him, it meant being a caretaker, being responsible to his wife, to the family, and to the household. And I think, in some ways, we need to be careful that we don't pathologize Latino men in this context, because it is damaging to Latino men, especially young men, to be perceived or to be socialized in a way that is so negative.

[Dr. Antonia Novello] I tend to agree with you, but talking about Latino men, we need to be able to enlist them, to be able to see that machismo, well-used, is perfect for our protection. But machismo for machismo's sake, is like they say, “Macho, just for macho, is not mucho.”

[Dr. Nena Peragallo] I just want to add something that in our experience with working with women, when they talk about machismo, they say, we blame ourselves. As the women perpetrate that thinking of giving men the best piece of steak, and even siblings, you know, over women, so I think it's more a matter of equality of genders and, you know, and that's changing. And I think we should enhance that thinking, both with men and Latino women.

[Dr. Antonia Novello] Yeah, I don't think that prevention for AIDS is going to work if we only put the importance on men or only the importance on women. We have to put it in all the members of the family. The other one is -- what about HIV prevention for homeless? How do you tap the homeless? Raul?

[Dr. Raul Romaguera] I think that's a very challenging population, just being homeless, alone, exposes you to so many vulnerabilities. I mean, there are many needs besides HIV if you're homeless - you don’t have a place to sleep, you may not have a meal that day, you may have children to take care of. And on top of that, if you have HIV, it’s very difficult. Now, how do your reach them and engage them in prevention activities, when also HIV may not be on their radar screen? I mean, some of them may be, at the least, seeking money, using sex for money, just to feed their children. So I think it will be very difficult, and we need to use the opportunity that we have already created with our outreach programs to find homeless, and also provide the services and sometimes the social and human support they may need to access these prevention services.

[Dr. Antonia Novello] Heriberto, I see you jumping out of the seat.

[Mr. Heriberto Sanchez Soto] Well, I'm jumping out of the seat because we have been, with our testing program in New York City, we have paired with -- you're talking about taking testing out into the community or going to where the communities are, the folks are? We have paired with soup kitchens, we've paired with churches, and we take our [HIV] testing services to them, often on Sundays after mass or before mass. And this intersect that we were talking about, about the faith community and HIV prevention and now the homeless community, this is one of the ways to go about it. Go to the church, after mass, have the preacher or the faith provider announce the [HIV testing] service, and then engage that population in the [HIV] services. And I also want to say that the trend in the country is to remove pretest counseling from HIV testing. And I make, this is where I make the strongest argument that there is a need, a dire need, to ensure that pretest counseling takes place -- good, thorough pre-test counseling takes place -- in the context of testing, because it may be the only opportunity that we may have to do HIV prevention counseling with populations like the homeless.

[Dr. Antonia Novello] This is where we say, that's what is so crucial. Because if your test happens to be negative, you might not see this person again. And when this person came for testing, it's because that's where in his or her mind that they might be positive. So, pretesting is crucial, if you use it accordingly as a means and ways of getting them in to follow-up.

[Mr. Heriberto Sanchez Soto] And if I may add? The issue of incentives -- we take a very strong position against incentives. But this is one population where we would address incentives, for example, incentives related to their condition. If they are homeless and they may not have anything to eat, we will come back to the soup kitchen or to the church where we did the [HIV] testing and offer some voucher, food voucher and whatnot, and that becomes a motivating factor for this homeless person who may not be eating on a regular basis to come back and receive the test results. And I will tell you that the folks that have been HIV positive, resulted positive with us, we have been successful getting them to care.

[Dr. Antonia Novello] The issue now of the questions that came, which I think is important, when you said 67% are Mexican-Americans and 10% Puerto Rican, 7% Central/South [America], and 5% Cubans, it says in here, how important for HIV prevention is the differences from cultural beliefs of Latinos who are from different regions of the world in trying to get prevention to them? What are the cultural problems that makes us unavailable to reach them at a particular site or what are their cultural beliefs that inhibits them to really get what we’re trying to teach them in prevention?

[Dr. Raul Romagera] Well, I think in many ways, if you’re coming from a rural area in Central America, you may have had access to a healthcare system, you may not have. And maybe you're using some traditional healers in your community and you're expecting to receive or find similar services when you come to this country. I think, even though we all, most of us, speak Spanish, there are also some subtle differences in how we communicate, especially health messages. And then I think it's also important to consider how long have we been in this country. I mean, some people, some first-generation Hispanics are different than second-, third-generation Hispanics. Actually, I would like to ask Miriam –

[Dr. Antonia Novello] Yes, we want to ask Miriam because one of the things too, in here is these myths. What are some of the myths that our people might have that makes them not come for testing and/or follow-up prevention, like this mosquito issue?

[Dr. Miriam Vega] Recent data from the Kaiser Family Foundation found that 53% of Latinos still think that you can get HIV/AIDS from mosquitoes. So, we definitely need to address the myths, the misconceptions that there are in the community, and I'd like to go back to what Raul said. You know, we may have all differing beliefs, cultural systems, but it's really, really important that we engage in informative assessment when we're designing our programs to make sure that we understand what our specific target population believes. We shouldn't make any assumptions as to where – you know, if someone comes from the Dominican Republic versus El Salvador -- we shouldn't make any assumptions as to what they believe. We should go into the community and ask them what it is that they believe so we can design the programs to address those cultural values and to address any misconceptions. But I would like to add that, unfortunately, many funders do not give enough resources to prevention programs to engage in these rigorous formative assessments, so I do encourage all community-based organizations out there that are working with Latinos and want to engage in this process to tap into various technical resources, technical assistance resources out there - capacity building - and look at the CDC website for further assistance with that.

[Dr. Antonia Novello] I think it's extremely important, too, to say, okay, we have to take the prevention messages. There are myths that we have to jump and the cultural beliefs. So, from what we have seen here today, what is the best way to get prevention? Is it through promotores? Is it the clinical way? Is it the medical way? Is it the lay person way? What do you think is the best approach that seems to be getting to the population so we can get them tested and then treated?

[Dr. Miriam Vega] There is no ‘one size fits all’ model. It depends on what you’re trying to use them [intervention approaches] for. And this can depend on acculturation, assimilation, and perceptions of what entails a credible source. We spoke earlier about migrant workers. Well, with migrant workers, promotores work very, very well because you’re using members from the community who can speak their language, who can speak to them, who may have gone through what they went through. And for migrant workers, promotores or navigantes or lay health workers, they’re often referred to, as well, are seen as a credible source of information. Meanwhile, other individuals who may have access to more urban areas, perhaps a medical model approach is more credible with them. But again, I hate to repeat myself, but it depends on what your target population views as culturally relevant and acceptable. Go back to your population and ask them, find out what they need, who is a credible source of information for them.

[Dr. Antonia Novello] This is why it's important to remember the Indian proverb, “Do not tell me what to do unless you have walked a mile in my moccasins.” And that's why it's important to know people that have suffered the same and can relate to what is expected for the next step. But I want to get to Nena now –

[Mr. Heriberto Sanchez Soto] Dr. Novello, if I may, on the issue, on the last question -- one of the things that we haven't done, and we should consider in Latino communities, is Latinos, for the most part, receive information via mass mediated services: photonovelas, the TV, print media, yet most of our efforts in the Latino community are not directed in those ways. So, there's a need to consider social marketing as an effective way of getting messages out. And then also considering national symbols that people relate to as we do those campaigns, because that's what people identify with.

[Dr. Antonia Novello] But on the same token, I’ve seen that some models are alive and well with treatment. And so, the young generation might assume: “If he has it and he's alive, why should I protect myself?” We have to be very sensitive about the model we use to get the right message. But, I have only two questions and a short time and one is for Nena. How do we protect the older generation that still can get infected with HIV?

[Dr. Nena Peragallo] That's an issue that we really need to address in interventions. Interventions have been focused on youth, on MSM, on reproductive-age women, and we need to go beyond that. Because people, number one get divorced, you know, get into new relationships, and all kinds of things happen in life. And we are seeing now that condoms are being, you know, given out in nursing homes and places like that, where people are still having sex. I mean, you know, you're not dead after 65. Hopefully continue to have, you know, a very healthful, sexual life and relationships so…

[Dr. Antonia Novello] And in some countries when you look into the global picture, people older than 65 are increasing in number of people infected [with HIV], so yes, one is not dead at 65, and specifically, when we talk about machismo and Hispanic men.

Now, the last question is something that I think is crucial. We’ve talked about promotores we spoke about mass media, we’ve spoken about the older generation, the migration issue, the homeless, the issues about how do you fit them when there’s no pattern -- am I MSM, am I transgender? We've talked about all that. But, how in the world do we remove the stigma? Twenty-five years into this epidemic, still dealing with the issue of HIV/AIDS, how do you deal with the stigma?

[Dr. Miriam Vega] Well, you need to get people to address the underlying moral attitudes that are associated with sigma. Get people to realize that we're all part of the problem. We're all part of the same community. We need people to understand that those that are stigmatized are being blamed for their condition and that we are all potentially stigmatizable. And for that, we need to engage, I think, in mass social marketing campaigns that address these moralizing attitudes. We've never had a national campaign to mitigate stigma in the U.S. and I think it’s time to do so.

[Dr. Antonia Novello] Heriberto?

[Mr. Heriberto Sanchez Soto] Specific to our testing program, what we have done is, because we’ve wanted to reach the larger community and we believe firmly that everyone should get tested, what we have done is we have used mass mediated interventions to reach the larger community with very simple language that doesn't necessarily point to the gay community as being the vectors, if you will, of HIV. And then the interventions that we do for gay men who are, happen to be at high risk, then they're more targeted. And they're targeted within the communities or the venues where they associate, so that the larger community may not have access to those targeted messages to gay men. And the success of our testing program speaks for itself. We test over 5,000 people a year 67% of them being non-gay, the balance being gay men. And then we're identifying the gay men who are HIV positive and getting them to care. And the heterosexuals, as well.

[Dr. Antonia Novello] Nena?

[Dr. Nena Peragallo] I think that stigma is a big issue. I mean, we talk about misconceptions in the community. And also there is this thing that only certain groups of people get this disease. I mean, you need to bring the disease home, if you will, and show -- what I do in our intervention, we show our women, you know, how is HIV spread in that community. And I say, you know, we are that community. We're not outside of this, you know, place or neighborhood, you know. That's us. So unless it's you or me, you know, who is it? So you need to bring it home, I think, in a way.

[Dr. Antonia Novello] Mario?

[Mr. Mario Pérez] Well, I think a few things. One is, stigma continues to really challenge our HIV testing patterns, our HIV prevention patterns, access to treatment is compromised, and people don't disclose their HIV status or their sexuality. So there's dire ramifications for stigma continuing to sort of shape our ethic around sex in this country. I think we need to really confront misunderstanding and we really need to sort of make sure people are aware around issues around sexual orientation and sexuality. And, you know, there's been some research that suggests that the more you sort of normalize or introduce this isolated group, you begin to sort of dissipate stigma around different issues. And, you know, as -- as has been pointed out in our discussions, we often stigmatize disease, and so we really need to get to a point in this country where disease, stigma related to disease, is really confronted and I think education through a national campaign is an excellent idea.

[Dr. Antonia Novello] Raul?

[Dr. Raul Romaguera] I think I agree with Miriam. I think we need to bring stigma home and understand that we are all part of this problem. And the only way we can eliminate stigma is recognizing that we are contributing to it. And, I think for Latinos with HIV or fear of having HIV, it's not just the stigma of HIV or being gay, it's just being Latino, not speaking English well, I mean there are many other factors that contribute to the stigma and isolates our communities. And so we need to address this from the point of view of let's look at recent immigrants, someone that just moved here, that most people look down at and on top of that may have HIV, may not speak English, and may not have access to health care. And now, local governments are denying services. So, I think it's just getting more complex. It's not just about the HIV or being gay.

[Dr. Antonia Novello] What can I tell you? It has been a wonderful discussion.

And that's all the time we have for our discussion segment today. So, thank you to our audience. Thank you for the wonderful questions. And thanks to all the panelists for all the great questions and answers that you also were able to participate at. So in just a few minutes, we'll announce the date and topic for our next broadcast and how to order a DVD of today's program. So please stay with us a few more minutes.

If you have feedback related to today's broadcast or questions that we didn't get to, don’t forget to send us an email at cdcinfo@cdc.gov. Please put "HIV Satellite Broadcast" in the subject line. And you can order a DVD of today's program by calling 800-458-5231.

We are very pleased to announce several new or enhanced sources of information. So, to receive automatic email updates on resources and information on HIV/AIDS, please visit cdc.gov/emailupdates And that's going to be important, because recently, major enhancements were added to the CDC's home page where you can now take a tour online and search by topic for resources or for publications. And the home page for HIV/AIDS now includes a rotating feature area, daily news section, various fact sheets, slide sets, and CDC reports and recommendations.

[Dr. Raul Romaguera] Please mark your calendar for important upcoming events that include World AIDS Day on December 1st and the National HIV Prevention Conference, December 2nd through the 5th, 2007, in Atlanta, Georgia. CDC joins other governmental and nongovernmental prevention partners to host the fifth conference highlighting HIV prevention in the United States. Please visit the conference website for more information.

Beginning May 15, 2008, CDC will present a webcast titled "Update on the Heightened National Response to the HIV/AIDS Crisis among African-Americans." This will be a 90-minute webcast that you may view any time, at your convenience, beginning May 15th and thereafter at the broadcast website. More information about this webcast will be provided after February 15 at the same website. To view this webcast, you will need an internet connection and Windows Media Player. If you do not have internet access, you may also obtain information by calling 1-800-458-5231.

[Dr. Antonia Novello] That brings us to the end of our broadcast. We sincerely hope that the information that we presented here today will aid your own efforts to prevent new HIV infection among Hispanics and Latinos in the United States because the HIV epidemic is far from over. We all must do our part to work together to improve access to HIV information, testing, and care for all persons. We must also address all the barriers for this HIV prevention, and then we must customize the programs for the local clientele. Not to mention to provide the best possible interventions to those persons who need them the most. Now is the time to re-evaluate and reinvigorate our HIV prevention efforts for Hispanics and Latinos and to further strengthen our individual and shared commitments to doing all that we can to stop the spread of HIV and AIDS.

[In Spanish says] And just a reminder: for a transcript in English and Spanish of today's program, visit the broadcast web site after December 1st.

So, on behalf of the Centers for Disease Control and Prevention and the Public Health Training Network, thank you for joining us. We wish you many successes in your HIV prevention work.

Good day and good luck from Atlanta.

[Announcer] To access the most accurate and relevant health information that affects you, your family and your community, please visit www.cdc.gov.