Gregg Masters  00:07  This episode of PopHealth Week is sponsored by Health Innovation Media. Health Innovation Media brings your brand narrative alive both on the ground and in the virtual space for major trade show, conference and innovation summits via our signature pop up studio connect with us at www.popupstudio.productions. I’m Gregg Masters, Managing Director ofHealth Innovation Media publisher of ACOwatch.com, and your PopHealth Week co-host with my partner co founder Fred Goldstein, President of Accountable Health, LLC, a Jacksonville, Florida based consulting firm. Our guest today is Dr. Dennis Flores, Assistant Professor at the University of Pennsylvania School of Nursing and affiliated faculty member at the gender, sexuality and women’s program and visiting professor at the Center for Research on AIDS at Yale University’s School of Public Health. Dr. Flores has led several studies that investigate the role of parents in sexual health education of their adolescent sons who identify as LGBTQ. Dr. Flores earned his PhD from Duke University, a Master’s in Public Health Nursing leadership at Emory University, and a bachelor’s degree in nursing from Kennesaw State University in Georgia.

Fred Goldstein  01:29  Thank you so much, Greg and Dr. Flores. Welcome to PopHealth Week.

Dennis Flores  01:33  Thank you so much for having me.

Fred Goldstein  01:35  really a pleasure, very excited about this conversation. It gets into an area that I worked in a while ago. And there’s been a lot of change in it. So first, perhaps could we start with you given a little bit of your background and what you do at U Penn and some of your research?

Dennis Flores  01:47  Yeah, definitely. I am an assistant professor in the School of Nursing at the University of Pennsylvania. This is my second year. But prior to that I was actually an HIV/AIDS nurse at the bedside in Atlanta at Grady Hospital. So my first job out of nursing school in the mid 2000s, early 2000s really was in a 42 bed unit, which turned out to be the very last AIDS dedicated hospital waiting for people with HIV and AIDS. So I did that doing bedside care for a couple of years. And then I moved around in the city doing ICU at some point and then research nursing, but eventually coming back to Grady coming back to that unit, because it really is where my passion lies. And on my off days, I also did work in the community, doing HIV prevention. So I feel like I just found my niche right out of nursing school. And then one of those things that happens is you don’t plan for it, but you get you signed up for grad school, and my master’s turned into a PhD, all the while still concentrating on HIV/AIDS, particularly HIV prevention involving youth and their family. So I had to move to Durham in North Carolina for my PhD at Duke University, again, very engaged with that local community and the LGBTQ community, and then finishing my degree and then moving up to Philadelphia for a postdoc, and eventually just staying within the University where I currently still am. I do teach, I do have a class that on a regular basis, it’s social determinants of health. And it’s an undergraduate course where we do talk about all of these other myriad factors that affect people taking into account these social determinants that really are intractable, the relationships are intractable with one’s health. So yeah, in a nutshell, that’s me.

Fred Goldstein  03:44  Yeah. Fantastic. And you, you brought up right away this whole issue of social determinants of health. And could you talk about, you know, we’ve been discussing on the show the issues of health disparities in social terms, etc. Over the last couple of weeks, can you talk about how they impact specifically those living with HIV and AIDS?

Dennis Flores  04:02  Oh, most definitely. From the very early years of the local epidemic, the US epidemic, there had been specific subpopulations that were more disproportionately affected by HIV and AIDS. And it really is not a surprise, you know, historically, we know that this issue was closely linked with men who have sex with men, and back in the day, and then in the 80s. This was actually a gay white man’s disease. But even during those years, there was not much focus being given on other subpopulations that did bear disproportionate burden. I’m thinking about men who have sex with men from minority communities from immigrant communities. And so there are specific subpopulations that by virtue of say their socio-economic status, or the race and ethnicity compounds, once risk for eventual infection or for transmission. And so while people would like to believe that It’s primarily behavior driven issue. There are still some tangible factors that, as I said that if you have two or three risk factors, and I’m using air quotes, as I say that it does dramatically increase your risk for infection or transmission.

Fred Goldstein  05:16  And you also I know, in one of the articles, you talked about this issue of de-medicalizing HIV and looking at it more from a community perspective, etc. Could you touch on that and how that’s impacting it?

Dennis Flores  05:29  Oh, definitely. So, you know, we’re looking now at 30 plus years of HIV/AIDS here in the United States. And one may look at it from just a purely medical point of view of the science of transmission, and who is most likely to transmit and who is most likely to be at risk for it. But beyond that surface, if we look at the individuals who are most at risk, then we can start considering their lived experiences and the trends that go with that, for example, my current work, I work with young adolescents and young adults who identify as gay, bisexual, or queer males. What we know is that a lot of teenagers are those folks in their early 20s. They grew up in a world where we knew the science of HIV, we knew the medicine of HIV and AIDS. Yet, despite that, we have decades upon decades of them being the most at risk. And why is that? Why is our public health programming seemingly ineffective when we already know what the virus is and how its transmitted? Right? And what that shows is, it’s actually an indictment on some of these other factors that we’re just not doing so well with, for example, I’m thinking of sex education in the public school setting. I’m thinking about, you know, are there programming that assist this specific sub population as they come of age? Are there mentoring programs that might be inclusive of somebody who is questioning their sexual orientation? So this is not technically falling under the rubric of medical programming or you know, things that happen in the medical setting? But really, what are the social opportunities out there beyond the walls of a hospital that we need to be focusing on as well. So that’s what I meant by less on the medicalization, but more of really considering the entire package the entire socio-ecological factors that surround those who are vulnerable for HIV infection.

Fred Goldstein  07:35  And you talked about those who are vulnerable. And obviously, now we have Prep, and perhaps you can explain that for our audience first, but then how is that being impacted maybe the distribution of Prep or the ability to get prep, depending upon the community you live in, etc.

Dennis Flores  07:50  Yeah, so pre exposure prophylaxis really is is a medication that people with HIV in use, we we’ve come a long way from the 80s, where it used to be a cocktail medication, where folks would have 10, 15 different pills that they had to take every day or several hours, several times each day. And now we’ve got medications that it’s it’s a one pill that folks can take and keep the HIV at a very managed level where they don’t progress to AIDS, or you know, they have a good immune system with this one medication. And in the last few years since 2012, it has been shown that people without HIV, if they take this medication once a day, it would actually diminish their risk for contracting HIV from a partner that might transmit the virus. So you know, this is groundbreaking, take an HIV un-infected person taking a prophylaxis, a pill, every day, essentially can be about 97% effective and keeping keeping them from becoming infected. And while that’s wonderful, there still are though some barriers for folks in in getting this medication, for example, it’s not cheap, you need to it’s several $1,000 worth a month to be on this medication. And for some folks, their health insurance, their coverage might not allow for them to you know, have minimal co-pay to to be able to access this on a regular basis. And so unfortunately, there still, I mean, there are some programs that do allow for for folks who need subsidies or sliding scale programs so that folks who are most at risk are able to access it. But on the whole, there still are some just structural barriers that keep folks from say, just going to the pharmacy and you know, like an over the counter medication.

Fred Goldstein  09:43  And also how much of that might be community awareness. And how much of that might be lack of access to physician to my prescribe it Are we seeing those issues as well, when you look at Prep?

Dennis Flores  09:55  Oh, yes. You totally hit it in the head. First, there are specific subpopulations not just those folks who are LGBTQ who don’t have the most up to date information that this is actually part of their arsenal for HIV prevention. And I’m thinking most of the initial work for Prep has been focused on it being used by men who have sex with men. And we know that, for example, women of childbearing age, they certainly can have great use for Prep. But it’s only been in the last few years, that marketing for that specific population has been catching up or has started. And so there’s that lack of education there. And it’s slowly trickling down. But certainly, there’s room for opportunities to really emphasize this or normalize this as an option within those communities. Additionally, while HIV care is not folks who take additional certifications, or additional classes, providers are able to jump on board and know how to manage HIV and AIDS and even prescribe Prep. It’s not there still are some areas in the medical industry where there’s stigma surrounding, say, sexuality, discussions around safe sex, there’s still a lot of work, in terms of having medical providers be comfortable in broaching this topic, especially with different members of the population. And that’s one of the things that I’m mindful about as a nurse, as retrain the future cadre of nurses and nurse practitioners really normalizing ways to, to bring up sexuality as just a routine part of one’s life, such as their appetite or such as wellness issues, and having free flowing conversation so that prep, or other technologies become just a routine part of a medical visit.

Fred Goldstein  11:51  Yeah, that makes a lot of sense. And what about in terms of, you know, other things going on in the community I know, and some of your articles and research, you looked at things like even diet, and its impact of the access to food and other things, obviously, I guess if we help with those as well, we could potentially see better outcomes in those who are living with HIV.

Dennis Flores  12:10  It’s not been my work as of the most recent times, but definitely, there was a point and I still feel like there are some subpopulations of especially men who have sex with men where they need to be considering if they’re on older regiments of the medication, diet and, you know, medication that they have to take in with food is a consideration. And there’s a lot of folks who are, you know, still belong to lower socio-economic status within this community. And so if we’re thinking about, especially if you’re if you’re on fixed income, how rich is your diet, that would be ideal for all the other meds that you’re taking not just for HIV? Or would you rather have to pay for rent? Or would you rather pay for another item that is part of your budget, that is a very valid consideration. And I know a lot of your work has focused on teens. And just as people are beginning to grow up again, in the teen years or a little bit older than that. And, you know, whether it’s talking with their parents about their sexuality or coming out, what sort of things you finding in that population? And are there differences when we look at socioeconomic status or communities that may be handling that differently.

Gregg Masters  13:20  And if you’re just tuning in, you’re listening to PopHealth Week, our guest is Dr. Dennis Flores, Assistant Professor at the University of Pennsylvania School of Nursing and affiliate faculty at the gender, sexuality and women’s program and a visiting professor at the Center for Research on AIDS at Yale University’s School of Public Health.

Dennis Flores  13:40  Younger generations of LGBTQ adolescents are coming of age, particularly boys who identify as having same sex attractions, behaviors of identity or identities. So for example, as I’ve been looking into sex communication, you know, this whole notion of the talk or the conversation about the birds and the bees, it’s been an area that’s been studied for about 40 years now. And majority of the studies we know. Yeah, definitely. It’s very nuanced, the way I’m believe to have upfront conversations about sex and condom use and contraception. They pretty much involve heterosexual parents with their heterosexual adolescence, which is understandable majority of the population are heterosexual folks. And the thing though, is that we’ve missed an opportunity to incorporate parents as wellness ambassadors or even HIV prevention agents for their kids who happen to be LGBTQ or those who identify as gay teenagers. And so my work has started to look at, well, what are the experiences of these teens with same sex attractions? And can we expect parents who are getting on board and more accepting of folks who are LGBTQ can we expect straight parents to actually hold up a condom to us to a teenage boy and say, This is not just for pregnancy prevention, but it can also be used for anal sex. And leave it at that, you know, it’s almost a paradigm shift when when folks hear the kind of work that I do, but I feel that the trend is there is more social acceptance of LGBTQ individuals in the last few years. And then another trend that we can’t disregard is that LGBTQ adolescents are coming out at earlier and earlier ages, compared to generations like myself. And so those two things, parents being more accepting of LGBTQ adolescence, and these adolescents coming out at earlier ages, means that the number of they live at home with their parents are actually you know, it extends opportunities for parents to partner with kids, before they go out of the house and start acting out on their burgeoning sexuality or their curiosities or experimentation. And I think it’s a perfect time to start looking at, how can we start arming parents with the right kind of information for the right adolescent population that then will minimize their risk for HIV and STI s? So that’s what I’m trying to do, instead of just the talk about the birds and the bees. What about the unicorn? Can we include the unicorn child? perspectives or questions?

Fred Goldstein  16:26  Right, and let me ask you, so as a parent, where could parents or other individuals go to find that information to help them work through that to be able to have that conversation?

Dennis Flores  16:37  Well, so there are a lot of resources online, there are a lot of resources in their local communities, especially urban and semi-urban areas where you know, you have LGBT centers, or even healthcare related facilities that are now becoming a lot more LGBTQ competent. The task at hand for parents, though, is sifting through all of that information, all of that online resource to figure out what’s legitimate, or what’s credible versus those that are not, because unfortunately, to this day, there still are some interventions, and I’m using air quotes on that, or some programming that we know is not correct, such as reparative therapy, curing away the gay, you know, that comes out in snazzy looking websites with all of these testimonials, that if you’re not really a very discriminating parent, you might think, Oh, this looks legit, when really, it can be very harmful. And so part of the work that I’m doing at the School of Nursing is coming up with additional resources, or partnering with parents to come up with ways that we can package the information that’s been vetted the information that’s most useful for them, and to make that accessible for them.

Fred Goldstein  17:52  I think, at the end of the day, this is about allowing people to live their lives and be healthy. And so by getting this information out early, and appropriately, the individuals and they can make the appropriate decisions as they go forward. When you think about that, have you It looks like you’ve done some studies and research on differences in when parents have good relationships and are able to talk about this issue with their children, their young LGBTQ children versus parents that may be struggle with that, are there differences we now see in the health and the results of those individuals as they have those conversations?

Dennis Flores  18:25  So I wish that I did have a definitive answer that shows differential outcomes between parents who do talk versus parents who don’t, it’s a little early in the research for, for me to, to say that with with the full amount of confidence. But with with a lot of the work that we’ve done so far, what we know though, is for the teens who received inclusive information that has normalized or affirm for them, that being queer, being gay is a non issue, it seems like they know more than those teens who do not have parents who normalize information for them. And their mental health is actually better or on a more positive level than those teens who didn’t have the opportunity to come out and be forthright with those parents. We also know from other studies, that if parents are more open in their communication with their teens, those teens are able to access sexual and reproductive health services a little bit better than those teens who didn’t have that benefit as they were growing up. It’s also been associated with sex communication, being affirming with accessing Prep, and those studies are in the early stages and further investigation needs to be done to really say, oh, x leads to y. But it’s very promising is what I what I can say, which is why I’m staying on this track and really trying to establish the science around that.

Fred Goldstein  19:56  Right But But in essence, you’re seeing some of the precursors that you would expect to see  in the differences in those groups, and ultimately, over time, hopefully, as you study it more, you will see that, and and you mentioned something around the mental health of the individuals being more improved, you know it. In the end, while we go through our teen years, and it’s a struggle and separation from your parents, etc. There’s still people that have a fair amount of respect from us as individuals. So if they’re able to, say these messages and talk in an appropriate way and discuss it with their kids, it’s typically would be listened to, wouldn’t that be true?

Dennis Flores  20:31  That is definitely true. I started this line of questioning in North Carolina, really just focused on sexual health, because as a nurse that, you know, if I was really gung ho and focused on the medical outcomes, and I’m thinking anything that just leads to the reduction of STI, and HIV in particular, is a win for me. And incidentally, and I wasn’t looking for this, but it just steadily came out in the data, it was being volunteered by our initial set of participants in North Carolina. And now here in Philadelphia, that hearing about inclusive information, while it leads to them being more comfortable with notions of taking care of oneself, condom use, for avoiding HIV and STI. It also, apparently, is proxy for parental acceptance. And so what that means is, if a kid hears about gay sexuality as a normalized concept at home, while they’re getting the benefit of, as I said, a condom use and accessing reproductive health services, it’s also signaling to them that you know what, nothing is wrong with this sexuality. And so depression, suicidality, we think it also has an impact there. I haven’t fully established it yet. But anecdotally, there are some positive repercussions positive impact on the mental health, I think, and this is where I actually two of  my current study right now this summer is looking into,

Fred Goldstein  22:02  that’s great. And so as we’re thinking about this in the future, what areas do you think we should focus on? Or where do you think we could get the most impact early within this community to help individuals, one, you know, practice safer sex, understand Prep, have those opportunities to, to do that? Are there certain things you think are going to have the most impact going forward?

Dennis Flores  22:27  Well, definitely I would, my work is staying focused on on the family within the home. So partnering with schools is definitely an option, because that is where majority of kids spend their time during the day. Well, this and this is prior to COVID. And hopefully, this is the reality that we’ll go back to. So for example, having school nurses normalize this and actually start having conversations with adolescents for whom this might be relevant, or even having our science teachers or those folks who provide sex ed, throughout elementary, middle school or high school, if they can start incorporating LGBT health, or at least acknowledging these identities and these orientations, that would go a long way in supporting what parents might be saying at home. And so we have these two ecological factors, really, that has a direct interaction with the youth population, saying providing consistent messaging, then I think we are hopefully, and I’m very optimistic, we can make a dent in addressing the needs of this population.

Fred Goldstein  23:39  Obviously, there is we’re living now in this world of COVID. How is that impacting this population and LGBTQ people in general?

Dennis Flores  23:48  Oh, most definitely. There’s a lot of pertinent issues regarding COVID and LGBTQ individuals, for my population of adolescents and young adults. The reality is, while I said earlier, that majority of these kids are coming out at earlier ages, many of them still are not out. And that’s just the nature of things. And so if you’re a high school student who was at who is out at school, but wasn’t at home, now that you’re at home full time, there’s really consideration for you know, you’re not living your most true, honest self. Same thing with college kids who are who used to live in another state because they were in school and now had to be back home and suddenly having to go back into the closet. And that’s one of those mental health issues that we talked about and are concerned about. Now in terms of the and I’m using air quotes. classic case of COVID patients are those most at risk older folks. A lot of elder LGBTQ folks who may live in nursing homes, or who may live by themselves prior to the pandemic social isolation is a major concern for them. Because unlike their straight peers, you know, they don’t have families, they don’t have kids that they raise who are now looking out after them. The A lot of them are probably just living with a partner or with a few friends. And so social isolation needed to be addressed even prior to the pandemic. And now that we have social restrictions in place, folks needing to be quarantined, it’s even more grave, we need to check up on these LGBTQ elders to make sure that they have sufficient support as they’re stuck at home, just as the younger folks are. And I really wish we had programming that was geared towards addressing that.

Fred Goldstein  25:42  That’s a fascinating problem. Have you seen anything out there that is like that, that would reach out to these individuals and at least provide them with some sort of a connection?

Dennis Flores  25:51  Yeah, I all I know are anecdotal stories from friends, or from a random email that says, hey, we’re doing this effort for this high rise, nursing home, but really, in terms of an actual solid program in a specific city, I have not come across that. Now, granted, it might be out there. It’s just not something that I’m particularly focused on. But I would love to, I would love to, you know, hope that there are coordinated efforts that address this subpopulation of LGBTQ older adults,

Fred Goldstein  26:23  hopefully what we can do is create that impetus, see the change, begin to start to happen and flow throughout to all of those individuals in whatever the community is in that they’re being struggling with. So thank you so much for joining us. It’s been a pleasure.

Dennis Flores  26:37  Of course. Thank you so much for having me.

Fred Goldstein  26:39  Great. Back to you, Greg.

Gregg Masters  26:41  And thank you for that is the last word on today’s broadcast. I want to thank Dr. Dennis Flores, Assistant Professor at the University of Pennsylvania School of Nursing for his time and generous insights today for more information on Dr. Flores’ work in this space do follow him on twitter via @DFloresRn. That’s D Flores RN and the schools work @PennNursing respectively. And for more information on the school go to www.nursing.upenn.edu. For PopHealth Week, my colleague Fred Goldstein and Health Innovation Media This is Gregg Masters saying please stay safe everyone we are in this together and we will get through this if we toe the line on social distancing proper hygiene and by all means, please wear those masks in public there is power in masking. Bye now.