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1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
1045   3 1 final-beyond behaviours slides april 15 v5 Daniel Grace
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1045 3 1 final-beyond behaviours slides april 15 v5 Daniel Grace

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  • Thank you to the organizers of Beyond Behaviours for providing me with this opportunity. I am very glad to be presenting this preliminary analysis alongside the distinguished lineup of speakers today. It is a pleasure to have the chance to report on analysis being conducted by the CIHR Team in the Study of Acute HIV in Gay Men. Among other things, I hope that in my remarks I will be able to spark some thoughts regarding the need to consider the role of medical technologies inproducing new categories of infection and testing protocols in shaping men’s understandings of their health.Today I will present a taste of a our qualitative research with a cohort of HIV-positive gay men in Vancouver who received an acute or recent HIV diagnosis. I would like to acknowledge my coauthors on the forthcoming paper on which this presentation is based.
  • My presentation today focuses on the use of a new HIV diagnostic technology with gay men in Vancouver, BC. I will start by providing some context around the enhanced testing technology that was introduced as part of our study. I will then briefly review our study methods and then present our analysis of participants’ narratives about discovering their HIV status.In the discussion and conclusion section, I will offer our team’s early reflections on the implications of these findings, and delve into the questions raised by the theme of this conference. In short, I hope to open up discussion for the ways in which analysis of HIV testing must move ‘beyond behaviour’ to consider the contexts in which tests are taken, read and interpreted in the everyday world.
  • It is clear from estimates by the Public Health Agency of Canada, provincial surveillance statistics and local studies in the Vancouver region that gay, bisexual and other MSM are disproportionately represented in new HIV infections. While I will not review this relevant epidemiological data in my presentation I argue that the largely qualitative data which I present today, works to account for some of the diversity of men who are grouped in this orange line who have received an acute or recent diagnosis.
  • I first must say something about acute HIV infection. Acute HIV infection corresponds to the first two months of HIV infection, and is a period associated with very high viral loads.The graph illustrates the fluctuation in viral load over time. Notably, viral load peaks in the acute phase, and then naturally drops to significantly lower levels before beginning to increase again. Further, this graph points out the importance of detecting HIV during the early stages of infection due to increased risk of transmission during this stage, which accounts for somewhere between 11-49% of all HIV transmissions.Health Initiative for Men, one of our community partners, has worked to disseminate information on acute infection, including bus ads, posters and online advertisements which underscore that HIV is “hottest at the start”. The argument extends that by diagnosing individuals in active sexual networks earlier, there are both individual and population health benefits.
  • Our study introduced enhanced HIV testing technology in Vancouver with the purpose of diagnosing men during the acute HIV infection period, which is not detected by standard HIV tests. We worked closely with the labs and clinicians providing the testsprior to implementation. We also worked closely with one of our community partners, the Health Initiative for Men, to educate gay men about this new test. HIM led a campaign under the slogan, “What are you waiting for?” to promote awareness of the NAAT test, which was called “early HIV test”. To date, 25 men who would otherwise have been given an HIV-negative test result were identified in this early stage of infection. They were offered access to enhanced prevention programs, which have been designed in collaboration with gay community organizations and prevention experts, as well as entry into this research study.
  • Our study began in 2009 and completed enrollment of new study participants in June 2012.This slide provides a snapshot of our mixed-methods study activities. As you can see, we have six quantitative components (consisting of surveys and sexual networking grids) as well as four in-depth qualitative interviews that take place over the course of approximately 1 year.
  • 25 men were recruited after receiving an acute or recent HIV diagnoses at one of six clinical sites in VancouverAs you saw on the last slide, participants completed self-administered quantitative questionnaires and concurrent qualitative interviews at 4 time points over the yearIt is important to note that our earliest participants were among the first people to receive diagnoses via NAAT technology. There was an learning curve during these first diagnoses which led to modifications in testing & diagnosis protocols.
  • The majority of our participants lived in Vancouver at the time of study enrollment, identify as gay, are single, over 30, and Caucasian. 12% of our participants are South East Asian and 8% are Hispanic.Most participants are employed full-time, with considerable diversity among those who were not. This includes disability, employment insurance, student, unemployed.Most reported completing college or university and the mean income was between $30,001-$50,000
  • Participants were motivated to test based on a number of factors.For many participants, their motivations for testing informed their expected result. For example, one participant, who also reported having sex with a known HIV-positive partner expected he would test positive: “And when I got that flu, and then I was so sick, and I barely moved, and actually I went to St. Paul’s [Hospital] because I was burning fever. And I just knew that that was it.”In another case, a participant who routinely tested for HIV said, “I got used to the idea that it’s going to be negative every time.” This participant’s decision to seek testing was based on his usual pattern, and thus he was not expecting anything other than his typical experience.
  • Most participants received their test results in clinical settings. However, some participants received a phone call asking them to come in to receive their test results. For some participants, this call wasan indicator they tested positive. One participant describes his reaction to receiving a call from a clinician: At that moment I knew something was wrong […] I said, like, you know what? I think I’m positive. Most likely.However, in other cases, participants were not told their results over the phone. One participant received a phone call while on vacation, and was told to come into the clinic upon his return. While he thought this may be because he tested HIV-positive, he later rationalized with his partner that he would have been told immediately if he was HIV-positive. As a result, he continued to have condomless sex with his partner while on vacation. In some cases, clinicians relayed HIV-positive test results via phone. For one participant, this meant he received his HIV-diagnosis and then had to immediately return to work.
  • Men also highlighted the experience of officially learning of their HIV test results and interacting with health care providers in clinical settings at the time of diagnosis. It is important to note that participants felt very well supported by clinicians, who included ER doctors, primary care physicians, and nurses, at the time they received their diagnosis in clinical settings. Some participants reported being “relieved” once an official diagnosis was given. One man put it this way: “In a way, I felt relieved, because at least I knew and at least the uncertainty was over. So now there was, like, a game plan we could follow to get on with my life”(44 years old, acute HIV infection)This ‘game plan,’ as we will see in the next section of our results, included rapidly starting antiretroviral treatment for this man who received a diagnosis with acute HIV infection.
  • Participants who received an acute diagnosis (n=13) reflected on how they felt when they were told they were in the acute HIV phase and the extent to which this informed their diagnosis experience. We will highlight results from each of the five interconnected themes: Initial provider and patient uncertainty about HIV test resultsUncertainty about the meaning of acute infectionRelationship to starting treatmentRelationship to having sexRelationship to identity formation as an HIV positive man
  • In a few cases, participants noted the clinician they were with seemed uncertain about the HIV test results. For example, this participant recounted, “Everything was good until he got to the HIV test and he looked very puzzled because the results were confusing or conflicting and the results came back negative. However, there was uh, one other, blood screen test which is very new, was the early detection. When I met, showed the presence of antibodies, so, he didn’t seem too concerned about it, um, and I wasn’t either cause he was saying that there you know, could be false [positive].” Later that day, this participant received a phone call advising him he may have an early HIV infection.
  • Participants had varying levels of knowledge about AHI prior to their diagnosis. Some participants looked up information about AHI before or after they were diagnosed. Others recalled information about acute HIV infection from the “Hottest At the Start” campaign. However, some participants remained uncertain about acute HIV infection. A number of participants told us that they were not in the right head space to process information about AHI given to them by a clinician at the time of diagnosis. For example, this participant said, “So I was just worried about getting sick with a flu or something. […] I was just confused, you know. I didn't really know, understand what exactly my stage was, and you know, I was just kind of worried about it.”
  • Being acutely infected led some participants to seek HIV treatment immediately. In other cases, treatment was initiated by clinicians. For some participants, it was unclear why exactly they started treatment. However, their knowledge of treatment led them to associate the drop in viral load to being on treatment:I think it was because my counts went so high, and my CD4s dropped so low, whether they thought they were going to come back up or not, but they just decided to, say, “Go on it right away.” .
  • Participants were often told at diagnosis they were highly sexually infectious, or knew this information prior to diagnosis. For many participants, the increased risk of HIV transmission impacted their decisions about sex, with many reporting that they either abstained from sex or limited sex to low(er) risk activities, such as oral sex only. For example, this participant said, “I know how infectious one is in that early stage. So it just definitely just made me completely step back from sex for awhile.”
  • This participant was one of many to articulate that “being positive is positive.” Participants’ processes of identity formation related to their HIV status were largely not impacted by the acute diagnosis.
  • Our analysis examined the every day uses of new HIV technologies-in-practice and related testing and diagnosis protocols with gay men. We have shown that new testing protocols have shifted experiences of learning of one’s HIV-positive serostatus and created a new diagnostic category, with varying impact. Participants’ perceptions of uncertainty regarding HIV test results among practitioners emphasizes the important of clinician education about the ways the body responds virologically & immunologically to acute HIV infection. This may also include a discussion of how advances in technology relate to existing practices, such as treatment initiation.It is crucial to provide positive NAAT results to patients in a manner that is both sensitive and timely. Part of the reason we introduced NAAT technology was to diagnose people at an earlier stage in the infection. This is supported by evidence that people who know they are HIV-positive make concerted efforts to reduce the risks associated with onward transmission. Thus, to maximize the value-added of NAAT techonology for individuals & populations, it is important to notify people quickly of positive NAAT results.There are occasions when it makes sense to diagnose an individual over the phone; however, it is important to consider what is happening at the time for the patient. We must also recognize the ways people respond to an HIV diagnosis and take into account the fact that individuals may not absorb information about AHI at that time.We should also make efforts to contextualize an AHI diagnosis within patients’ existing knowledge of testing, treatment and HIV and support their ongoing psychosocial needs.
  • Theoverarching theoretical literature I am drawing upon today is based on the idea that technologies are relational and impacts the ways people understand their health in multiple ways. In our case, the NAAT test allows us to provide information to people closer to the time they seroconverted, and while they are in the acute HIV phase. It is a technological advance that allows us to identify a previously unrecognized stage of HIV infection.We must examine the impacts of this new technology, and the resulting ‘acute infection’ diagnostic category, on the people who use these services.The introduction of this new technology happens in the context of existing technologies for HIV diagnosis and treatment, and an existing understanding of HIV. By examining our participants’ experiences of these practices, we can learn about processes and structures in the BC context and move beyond individual behavioural analysis.
  • Theoverarching theoretical literature I am drawing upon today is based on the idea that technologies are relational and impacts the ways people understand their health in multiple ways. In our case, the NAAT test allows us to provide information to people closer to the time they seroconverted, and while they are in the acute HIV phase. It is a technological advance that allows us to identify a previously unrecognized stage of HIV infection.We must examine the impacts of this new technology, and the resulting ‘acute infection’ diagnostic category, on the people who use these services.The introduction of this new technology happens in the context of existing technologies for HIV diagnosis and treatment, and an existing understanding of HIV. By examining our participants’ experiences of these practices, we can learn about processes and structures in the BC context and move beyond individual behavioural analysis.
  • I would like to acknowledge: OurResearch ParticipantsThe Canadian Institutes of Health Research (CIHR)Health Initiative for Men The CIHR Team in the Study of Acute HIV Infection in Gay Men
  • As a study team we recognize the the importance of acknowledging the spaces in which research is both conducted and disseminated. This map illustrates the area now known as Greater Vancouver where 10 First Nations are known to have lived on and from the land and water systems before a colonial presence was established. This is both a historical legacy and a significant matter of justice.
  • Transcript

    • 1. DIAGNOSTIC TECHNOLOGIES-IN-PRACTICE:GAY MEN‟S NARRATIVES OF THEIR ACUTE ORRECENT HIV INFECTION DIAGNOSIS EXPERIENCESDaniel Grace, Malcolm Steinberg, Michael Kwag,Sarah A. Chown, Glenn Doupe, Terry Trussler,Michael Rekart and Mark GilbertCIHR Team in the Study of Acute HIV in Gay MenDANIEL GRACE, PHDUNIVERSITY OF BRITISH COLUMBIA, FACULTY OF MEDICINEDANIEL.GRACE@BCCDC.CA
    • 2. ContextEnhanced HIV testing technologyMethodsFindingsComing to know one‟s HIV-positivestatusReceiving an acute HIV diagnosisDiscussionConclusionOUTLINE2
    • 3. CONTEXT: HIV AMONG GAY, BISEXUALAND OTHER MSM IN BC3
    • 4.  Illustrates the importance ofadvancements in HIV testingtechnologies that can detect AHI For more information visit: www.acutehivstudy.com www.checkhimout.ca/hottest“HOTTEST AT THE START”:ACUTE HIV INFECTION“Hottest at the Start” AHI campaign(Health Initiative for Men, Vancouver, 2011)4
    • 5. Nucleic acidamplification testing(NAAT) introduced inVancouverPrevention counselling,sexual contact tracingand earlier treatmentdebut potential benefitsassociated with earlydiagnosis (Hogg et al., 2012)ENHANCED TESTING TECHNOLOGY5“What are you waiting for?” testing campaign(Health Initiative for Men)
    • 6. PARTICIPANT SELECTION PROCESSAND STUDY ACTIVITIES (HIV-POSITIVE COHORT)HIV-positive cohort1a(~day 7)1b(~day 14)2a(~day 30)2b(~day 45)3a(~day 90)4a &3b(~day 180)5a(~day 270)6a &4b(~day 360)Quant #1Network. #1Quant #2Network. #2Quant #3Network #3Quant #4Network. #4Quant. #5Network. #5Quant #6Network. #6Qual. #1 Qual. #2 Qual. #3 Qual. #4n= 25SignConsentFormParticipantsidentifiedandrecruited6
    • 7.  Recruited at six clinical sites in Vancouver 19% of eligible participants were recruited(n=25) Acute (n=13) and recent (n=12) diagnoses Year-long mixed-methods study Self-administered questionnaires Semi-structured face-to-face interviews Analysis of T1 interviews Independently coded by two researchers andcompared (Creswell, 2003; Mason, 2005)METHODS7
    • 8. DEMOGRAPHICS (N=25)The majority of participants:Lived in Vancouver (79.2%) at the time ofenrollmentIdentify as gay (96%)Are single (68%)Are over 30 (80%) and Caucasian (72%)Had employed full-time (64%)Reported completing college or university(64%)Mean income was between $30,001-$50,000 8
    • 9.  Coming to know one‟s HIV-positive status (n=25) Testing rationale & expectation of results Delivery of results over the telephone Delivery of results in clinical settings Receiving an acute HIV diagnosis (n=13) Initial provider and patient uncertainty about HIV testresults Uncertainty about the meaning of acute infection Relationship to starting treatment Relationship to having sex Relationship to identity formation as an HIV positive man* Other key domains beyond the scope of the data presentedtoday (e.g., likely infection event; issue of testing andtemporality; insights regarding syndemic production)FINDINGS*9
    • 10.  Seroconversion symptoms informed one participant‟sexpectation of the results: I think that’s why I knew before I got the results, that, youknow, this was not just a flu, and I had read about itbecause obviously I was very concerned about it, so I reada lot of information on the internet on how it happened.And when I got that flu, and then I was so sick, and Ibarely moved, and actually I went to St. Paul’s [Hospital]because I was burning fever. And I just knew that that wasit. (32 years old, acute HIV infection) Another participant soughta routine test: And after eighteen times two, thirty six results, I got usedto the idea that it’s going to be negative every time. (37years old, recent HIV infection)TESTING RATIONALE &EXPECTED RESULTS10
    • 11. Phone calls from clinicianswere an indicator of HIV-positivetest results:But at that moment I knewsomething was wrong […] I said, like, you knowwhat? I think I’m positive. Most likely. (31 years old,acute HIV infection)Receiving results via phone in unexpectedcircumstances was challenging:I was in the supply room, and I had to go back tothe front desk and do my job. (45 year old, recent HIVinfection)DELIVERY OF RESULTS VIA PHONE11
    • 12. Overwhelmingly, participants received strongsupport from clinicians:I was treated with a lot of respect, with a lot of loveand a lot of compassion. I think compassion is amain word. So, no, I would say I wouldn’t changeanything. (32 years old, acute HIV infection)Some participants reported being relieved oncean official diagnosis was given:In a way, I felt relieved, because at least I knew andat least the uncertainty was over. So now there was,like, a game plan we could follow to get on with mylife. (44 years old, acute HIV infection)DELIVERY OF RESULTS IN CLINICALSETTINGS12
    • 13. Participants diagnosed with AHI reflected onfive interconnected themes:Initial provider and patient uncertainty about HIVtest resultsUncertainty about the meaning of acute infectionRelationship to starting treatmentRelationship to having sexRelationship to identity formation as an HIVpositive manMAKING SENSE OF AN ACUTE DIAGNOSIS(N=13)13
    • 14.  Some participants perceived clinicians to be uncertainabout acute HIV test results: Everything was good until he got to the HIV test and helooked very puzzled because the results were confusing orconflicting and the results came back negative. However,there was uh, one other, blood screen test which is verynew, was the early detection. When I met, showed thepresence of antibodies, so, he didn’t seem too concernedabout it, um, and I wasn’t either cause he was saying thatthere you know, could be false [positive] […] But then I gota phone call from him […] And he said that there was thepossibility of an early infection. That he wanted me to domore blood work, uh, the next day. Uh, so I was veryconcerned and very upset at that point. Uh, confused anduh, didn’t know what to make of it. (55 years old, acute HIVinfection)UNCERTAINTY ABOUT HIV TEST RESULTS14
    • 15. Participants were confusedabout the meaning of acuteHIV infection:At that point I still wasnt exactlysure what acutely infected meant. .I know its a high viral load, which means thevirus was extremely, you know, high. My immunesystem was extremely low, obviously. So I wasjust worried about getting sick with a flu orsomething. […] I was just confused, you know. Ididnt really know, understand what exactly mystage was, and you know, I was just kind ofworried about it.(21 years old, acute HIV infection)UNCERTAINTY ABOUT ACUTE HIVINFECTION15
    • 16. High viral loads was a motivating factorfor some participants in startingtreatment immediately:I think it was because my counts went sohigh, and my CD4s dropped so low, whetherthey thought they were going to come backup or not, but they just decided to, say, “Go on itright away.” And, I mean, you know, the way thatI am right now, Im undetectable, and my CD4sare up, at this point, I expect to find themsomewhere between 350 and 450 at this point.You know, from a low of 250, when they took thefirst one. But they were already up at 350 by thetime I got my second test results, after a monthon the medication, three weeks on themedication, so. (64 years old, acute HIV infection)TasP logic informing decision-making?RELATIONSHIP TO STARTING TREATMENT16
    • 17. Participants reduced theirsexual activity during theacute phase of theirinfection:Well, it definitely made meterrified of having sex atall, because I know howinfectious one is in that earlystage. So it just definitely justmade me completely step backfrom sex for awhile.(30 years old, acute HIVinfection)Problem with “behaviourchange” logic (presupposeparticular actor?)RELATIONSHIP TO HAVING SEX17
    • 18. Acute diagnosis had very little impacton the ways most participants viewedthemselves as HIV-positive menI dont know, before, when I wasnegative, being positive is positive.Either acute or theyre not acute. Manypeople dont know about this phase, so itsjust the fact that you are positive. Like, Idont know, before if somebody said, like,okay, Im positive, but my viral load isundetectable, or someone is, like, oh, Impositive but my viral load is half a million,to me, youre positive, period.(31 years old, acute HIV infection)RELATIONSHIP TO IDENTITY FORMATION18
    • 19.  Importance of viewing NAAT technology-in-practice View as social process in everyday world Shifting technologically-mediated (broadly defined)experiences of learning of HIV-positive serostatus New diagnostic category of AHI has varying impacts atindividual level Ensure continued clinician education about virologicaland immunological responses to AHI Provide positive NAAT results to patients in a sensitiveand timely fashionDISCUSSION19
    • 20. Diagnosing HIV during early stages of infectionis a technologically-enabled processNeed to consider the relationships between newHIV „technology-in-practice‟ (Timmermans andBerg, 2003) and the users of these medicaltechnologies (e.g., patients and providers)Beyond technological determinismBeyond social essentialism“Beyond criticism” (Timmermans and Berg, 2003: 97) “technologies are embedded in relations of othertools, practices, groups, professionals, and patients and it is throughtheir location in these heterogeneous networks that treatment, orany other action, is possible in health care” (Timmermans andBerg, 2003: 104).VIEWING DIAGNOSTICTECHNOLOGIES-IN-PRACTICE20
    • 21.  Provide insight into social structure andinstitutional coordination of care (Pierret, 2003) Including albeit beyond only looking at process ofmeaning-making and coping methods and strategies inillness experience data Dialectic between individual (micro level) andstructural (macro level) experiences of illnessrepresents the challenging area for investigation “The challenge is to define a paradigm andmethodology for handling the problems related to thesocial structure. This entails working out theories aboutthe interrelations, reciprocal effects and feedbackbetween subjectivity, cultural factors and socialstructure” (Pierret, 2003: 17).GETTING TO STRUCTURE21
    • 22. CONCLUSIONIndividual experiences withtechnologies-in-practice revealinformation that can be used tostrengthen institutional processesRequires thinking beyond individualbehaviours and experiences related todiagnosis1. Further provider education2. Supporting communicationstrategies3. Addressing new psychosocialchallenges created**these findings are preliminary and subject to revision22
    • 23.  Research Participants The Canadian Institutes of HealthResearch (CIHR) Health Initiative for Men The CIHR Team in the Study ofAcute HIV Infection in Gay Men A special thank you to: Mark Gilbert Malcolm Steinberg Michael Kwag Sarah Chown Terry Trussler Adriana Nohpal Darlene Taylor Cory GenereauxACKNOWLEDGEMENTSFor more information please contact Dr. Daniel Grace,University of British Columbia, Faculty of Medicine: Daniel.Grace@bccdc.ca 23
    • 24. QUESTIONS &COMMENTS
    • 25. BIBLIOGRAPHYBrenner B. G., Roger M., Routy, J-P, Moisi, D., Ntemgwa, M., Matte C. … QuebecPrimary HIV Infection Study Group. (2007). High rates of forward transmission eventsafter acute/early HIV-1 infection. Journal of Infectious Diseases, 195 (7), 951-959.Creswell, J. W. 2003. Research design: qualitative, quantitative, and mixed methodapproaches. 2nd ed. Thousand Oaks, CA: Sage Publications.Fox, J., White, P. J., Macdonald, N., Weber, J., McClure, M., Fidler, S., … Ward, H.(2009). Reductions in HIV transmission risk behaviour following diagnosis of primaryHIV infection: a cohort of high-risk men who have sex with men. HIV Medicine, 10, (7),432–438. doi: 10.1111/j.1468-1293.2009.00708.xHogg, R. S., Heath, K., Lima, V.D., Nosyk, B., Kanters, S., Wood, E., … Montaner, J. S.G. (2012). Disparities in the Burden of HIV/AIDS in Canada. PLoS ONE, 7, (11),e47260. doi:10.1371/journal.pone.0047260.Marks, G., Crepaz, N., Senterfitt, J. W., & Janssen, R.S. (2005). Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in theUnited States: implications for HIV prevention programs. Journal of Acquired ImmuneDeficiency Syndrome, 39, (4), 446-453.Mason, J. 2005. Qualitative Researching. London: Sage Publications Ltd.Timmermans, S., & Berg, M. (2003). The practice of medical technology. Sociology ofHealth and Illness.25, 97-114.Pierret, J. (2003). The illness experience: state of knowledge and perspectives forresearch. Sociology of Health & Illness, 25, 4-22.Vallabhaneni, S., McConnell, J. J., Loeb, L., Hartogensis, W., Hecht, F.M., Grant, R.M.,& Pilcher, C. D. (2013). Changes in Seroadaptive Practices from before to afterDiagnosis of Recent HIV Infection among Men Who Have Sex with Men. PLoS One,8,(2): 1-7.25
    • 26. EXTRA SLIDES26
    • 27. INDIGENOUS LANDS27

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