Appendix B (Current HIV/AIDS research): Population-Specific HIV/AIDS Status Report: Gay, Bisexual, Two-Spirit and Other Men Who Have Sex With Men

Appendix B – Current HIV/AIDS Research on Gay, Bisexual, Two-spirit and Other Men who have Sex with Men (MSM) in Canada

Project R1

A small-group intervention to reduce HIV sexual transmission risk behaviour among HIV-positive men who have sex with men

Principal investigator: Trevor A. Hart, Ryerson University

Co-principal: Barry D. Adam

Co-investigators: Herbert Co; David E. Hoe; Robert C. Leahy; Mona R. Loutfy; Robert A. Mackay; Eleanor Maticka-Tyndale; John D. Maxwell; James R. Murray

Abstract: The primary objective of this project is to develop, implement, and provide an evaluation of an HIV prevention program for HIV-positive gay and bisexual men in a sexual health and community-based research framework. This collaboration between the Positive Prevention Working Group and researchers comes at a time when HIV rates have begun to rise among men who have sex with men, and when rates of unprotected sex have been rising among HIV-positive men. The project will build on evidence-based HIV prevention programs reported in the research literature, consult with leading developers and practitioners of prevention programs directed toward HIV-positive men across North America, and engage local men to find the kind of program they would find attractive and effective. A small-scale series of workshops will be mounted for four groups of a dozen men who have a recent history of unprotected sex. Workshop participants will subsequently be followed to discover the degree to which the intervention has a sustained effect on risk behaviour. Findings from this study will provide the foundation for a subsequent effective, evidence-based, large-scale intervention.

Dates: April 2009 – March 2011

Funder: Canadian Institutes of Health Research (CIHR) HIV/AIDS Community-Based Research Program - General - Operating Grant

Reference: CIHR database

Topic: PHA; prevention; sexual behaviour; knowledge translation

Project R2

Anal cancer screening in HIV: progression and transmission

Principal investigator: Jill M. Tinmouth, University Health Network (Toronto)

Abstract: Cancer of the anus occurs at much higher rates in HIV-infected men who have sex with men (MSM). Both anal and cervical cancers are caused by a sexually transmitted virus called human papillomavirus (HPV), so these conditions may be passed on to sexual partners. Anal Pap smears can be used to screen for precancerous anal growths. If the pap is positive, then a high-powered examination can be done to identify the precancerous growth which can then be removed using laser treatment. Our team has used HPV tests, anal Pap smears and high-power examinations of the anal canal to look for pre-cancerous changes in a large group of HIV-infected MSM. We found that the Pap smear was moderately accurate and that 1/4 of our group had advanced pre-cancerous growths. These findings are important but more knowledge is needed before formal screening programs can be instituted. In the current project, we intend to evaluate how precancerous anal growths have changed over a 4-year period in the original group of HIV-infected men that we studied. The sexual partners will also be examined to see if they have the same kinds of HPV as the original subjects. These studies will help us determine: a) how often HIV-infected men [have] to be re-checked in order to find advanced pre-cancer, b) how effective their previous treatments have been, and c) whether their partners are at risk for similar conditions. These results will help design screening programs for anal cancer.

Dates: July 2010 – June 2015

Funder: CIHR-New Investigator Award in the Area of HIV/AIDS Biomedical/Clinical Research

Reference: CIHR database

Topic: biomedical/clinical research; treatment; prevention; co-infections; knowledge translation

Project R3

Analysis of the implementation of a rapid HIV testing community intervention for men who have sex with men in the Montreal area

Principal investigator: Joanne Otis, Université du Québec à Montréal

Co-principal: Robert Rousseau

Co-investigators: Martin Blais; John Cox; Gilbert Emond; Ghayas Fadel; Gaston Godin; Thomas A. Haig; Gilles Lambert; Mark A. Wainberg

Abstract: Recent data show that many men who have sex with men (MSM) and who are HIV positive are unaware of that fact. This shows that MSM are reached only somewhat or not at all by available testing services. In response to these concerns, academic and community researchers have developed the SPOT project, an innovative rapid HIV test provided by community workers who provide pre- and post-test counselling using a motivational interviewing approach, according to the participant's profile. The purpose of the study is to trace the taking of ownership of SPOT by the community by describing the implementation of the intervention, and documenting, from the standpoint of the players involved (community workers, nurses and users), the contextual factors of all kinds affecting implementation. This analysis will bring out the difficulties they encounter, the opportunities they take advantage of, and the strategies they develop to reduce obstacles and adjust the intervention. A three-year participatory study, evaluative and formative in nature, is planned. It corresponds to a case study with nested analysis levels. Several data collection methods will be used: logbooks (coordinator and workers), semi-structured interviews with workers and users (n=4000), and shared evaluation groups. In conjunction with the federal HIV/AIDS strategy, this participatory project builds the capacities of community groups and will generate useful evidence for other front-line organizations (community and others) that are interested in implementing rapid HIV testing.

Dates: April 2009 – March 2012

Funder: Canadian Institutes of Health Research (CIHR) HIV/AIDS Community-Based Research Program - General - Operating Grant

Reference: CIHR database

Topic: access to services

Project R4

Asking the right questions: a capacity building workshop to increase methodological understanding of community-based prevention research with MSM

Principal investigator: Glen Moulton

Co-investigators: Phillip G. Banks and Rick Marchand

Abstract: A consensus among community educators and prevention researchers has grown that a broader approach other than condoms and safe sex messages needs to be applied to gay men's HIV prevention. Current trends in BC research show sexual risk behaviours on the rise [across] all ages, especially young gay men. Testing frequency has declined with an increase in those who have never tested. Meeting men online has increased significantly with a subsequent decline in community involvement. Health promotion has the potential to accomplish HIV prevention by addressing the vulnerabilities underlying risk behaviour. This capacity-building workshop is needed to support a process to develop the right questions for an evidence-based strategy with the aim of reducing HIV transmission and improving health outcomes. The initiative would enhance CBR capacity within a newly created gay men's health community organization in BC mandated to do HIV prevention, and produce the direction to better understand the determinants that influence the health of gay men. It will enable the development of new partnerships, survey tools, recruitment strategies and dissemination activities. The workshop will bring together academic and non-academic prevention researchers and community and public health representatives to consider the changing environment of HIV prevention with MSM in BC, reaffirm CBR practices and conceptualize new directions in sexual health survey research for the purpose of evidence-based HIV health promotion planning.

Dates: November 2008 – October 2009

Funder: Canadian Institutes of Health Research (CIHR) – HIV/AIDS Community-Based Research Program - General - Workshop

Reference: CIHR database

Topic: prevention; social determinants of health; capacity building

Project R5

Attitudes and stigma: A community-based approach to understanding the social determinants of health with respect to HIV in MSM of London, Ontario

Principal investigator: Todd A. Coleman, University of Western Ontario

Abstract: Middlesex County, Ontario, with the largest city in Southwestern Ontario and fourth largest in the province, has the third highest incidence rate of HIV in Ontario, behind Toronto and Ottawa. Among gay, bisexual, and other men who have sex with men (GB-MSM) in Ontario, reasons for higher HIV incidence rates are not clear. In 2006, the AIDS Committee of London (ACOL) held the LGBT2SQ Health Forum, identifying three main themes: homophobia (internal/external), isolation/social exclusion, and communication. In communities affected by HIV, these factors may interact significantly to impact HIV within the group.

Goals: 1) Identify, explore, and describe themes of homophobia and social support relating to HIV and health care access. 2) Measure the prevalence of self-reported HIV seroposivity, HIV-related risk and HIV testing behaviours. 3) Describe health seeking behaviours of GB-MSM, including people living with HIV/AIDS (PHAs). 4) Determine if social exclusion, homophobia (internal/external), communication (within the community, with healthcare providers) significantly affect healthcare utilization (HIV-related care, HIV testing, mental health services, and family medicine). 5) Explore bias in a sample collected through respondent-driven sampling (RDS) methods versus traditional venue-based and time-space samples.

Methods: Interviews with fifteen (n=15) GB-MSM and five (n=5) service providers will identify new[,] and expand on themes of the LGBT2SQ Health Forum. Interview results will drive an online survey, delivered via RDS, of 400 GB-MSM.

Relevance: Local GB-MSM communities will work to achieve better health and access to services and understand how social exclusion, homophobia, and communication interact to impact HIV risk behaviour and HIV diagnostic testing; and healthcare utilization and HIV treatment for PHAs. Groups involved in health promotion and treatment for GB-MSM and other communities facing similar challenges will also benefit.

Dates: May 2008 – August 2009

Funder: CIHR HIV/AIDS Community-Based Research Program - General - Master's Award

Reference: CIHR database

Topic: access to services; homophobia, stigma and discrimination; mental health

Project R6

Beyond behaviour: a national deliberative dialogue on research and programming in gay men's health

Principal investigator: Ed Jackson, CATIE

Abstract: We would like to be considered for HIV/AIDS Research Initiative Funding. There is an urgent need to develop [and] exchange knowledge of HIV prevention in the context of gay men's health. This can be met via dialogue on HIV research, prevention and programming for gay men between community, researchers and policy makers. The Deliberative Dialogue is an opportunity for stakeholders to identify gaps in HIV prevention programs and research, highlight areas for collaboration between researchers and research-users, build consensus on research priorities and identify high needs in KTE [knowledge translation and exchange]. In preparation for this event, a discussion document based on the PHAC Status Report for MSM and other research will be developed to highlight current research and programming directions [and] gaps, and to propose strategic directions for the future. A satellite of the 2010 CAS Skills Building Conference, this meeting will be co-chaired by Barry Adam and Ed Jackson. Participants include stakeholders from program planning, policy development and research focused on gay men. The program includes a catalyst panel of experts providing an overview of gay men's HIV prevention and sexual health programming; research initiatives in Canada involving diverse populations of gay men; and research related to stigma, discrimination and access to health services. The focus of the day will be a facilitated discussion of strategic issues in gay men's health programming and research. KTE activities used to disseminate the outcomes of the event include the creation of a consensus document which, along with background papers and presentations, will be available on the CATIE website and distributed widely. This document will be used as a catalyst in future meetings and as a guide to research priority setting and program and policy development. Opportunities for ongoing collaboration between program planners and researchers will be encouraged and facilitated to spark promising new program models.

Dates: September 2009 – August 2010

Funder: Canadian Institutes of Health Research (CIHR) – Planning Grant – Priority Announcement: Institute of Infection and Immunity

Reference: CIHR database

Topic: prevention; access to services; homophobia, stigma and discrimination; capacity building

Project R7

Bringing risk prevention models into the bedroom: Sex appraisals, coping and their roles in condom use consistency

Principal investigator: Eli Puterman, University of British Colombia

Abstract: HIV transmission remains a threat in Canada and around the world. Men who have sex with men account for 41 percent of all new cases of HIV in Canada, and continue to be the largest proportion of new cases. However, recent trends suggest nearly 30 percent of new HIV cases occur among heterosexuals following sexual contact. Although new HIV drugs have brought hope to patients, they have also lessened the perception of HIV risk. In fact, new cases of HIV infection increased 17 percent in 2002, compared to 2000. Eli Puterman is developing a new model to predict and understand safe sex practices in two at-risk groups: heterosexuals with multiple partners, and men who have sex with men. While present HIV prevention models can predict the intention to use condoms, they are less successful at predicting whether condom use will actually occur, because they do not consider the uniqueness of each sexual encounter. Instead, Eli is investigating how individuals appraise and respond to HIV risk in different sexual situations over time. This research could provide a new model for HIV prevention strategies both within Canada and other developed countries.

Dates: 2005 – May 2008

Funder: Michael Smith Foundation for Health Research - 2005 Research Trainee Award, Senior Graduate Studentship

Reference: http://www.msfhr.org/who_we_fund/archive/2005/EliPuterman

Topic: prevention; sexual behaviour

Project R8

Building capacity to improve sampling and data collection methods for HIV prevention research with gay men

Principal investigator: Glen Moulton, Community-Based Research Centre (Vancouver)

Abstract: Gay men continue to be one of the priority populations for HIV research and interventions in British Columbia and Canada. 40% of 2004 HIV infections in BC were identified in men who have sex with men. In BC a network of community and public health groups conducted a provincial survey for gay men at Pride events in 2002 and 2004. Findings from Sex Now have informed social marketing campaigns and prevention programs. Our proposal is to organize a research capacity-building workshop to improve and expand our sampling and data collection methods on the Sex Now survey. Both convenience and purposive sampling methods will be examined. Our emphasis will be on how to reach gay men with research in venues, on the Internet and through social networks.

Dates: April 2006 – March 2007

Funder: CIHR HIV/AIDS Community-Based Research Program - General - Workshop

Reference: CIHR database

Topic: prevention; social and physical environments; sexual networks; capacity building

Project R9

Building partnerships and increasing community capacity for conducting HIV/AIDS, health and housing instability research in African and Caribbean communities in Canada

Principal investigators: Clemon George and Saara Greene, Fife House (Toronto)

Co-investigators: Steve Byers; David C. Este; Josephine B. Etowa; Jacqueline C. Gahagan; Winston C. Husbands; Stephen W. Hwang; Randy Jackson; Jay Koornstra; Erica S. Lawson; Jessica F. Leech; Laverne E. Monette; Sean B. Rourke; Ruthann Tucker; and Catherine A. Worthington

Abstract: The proposed partnership is aimed at building strong and sustainable relationships among academics, community-based researchers, health and social services, and community members who have a shared interest in the health and well-being of people living with HIV/AIDS from African and Caribbean communities in Canada. This partnership will succeed in building the research capacity of our community partners, advisory committee and peer researchers from African and Caribbean communities. We also aim to build partnerships that reflect a shared commitment to applied research and to increase the research capacity of the African and Caribbean HIV-positive community in Canada. To this end, this project will lead to the development of a research plan and proposal in the area of HIV/AIDS, health and housing instability in Canada's African and Caribbean communities. The partnership will enable us to highlight the housing experiences and needs of African and Caribbean communities and to address specific concerns including: high rates of housing instability; stigma and racial discrimination; and barriers to health and social services for PHAs who lack supportive and/or stable housing. Moreover, the research partnership will also support a process of identifying those communities within the larger African and Caribbean communities (e.g. women, families, MSM) who are [at] the greatest risk of homelessness and housing instability.

Dates: April 2008 – March 2009

Funder: CIHR - HIV/AIDS Community-Based Research Program - General - Catalyst Grant

Reference: CIHR database

Topic: People from countries where HIV is endemic; PHA; access to services; social determinants of health; stigma and discrimination; capacity building

Project R10

CIHR team in the study of acute HIV infection in gay men

Principal investigator: Rekart Michael, University of British Columbia

Co-principals: Babak Pourbohloul and Eric Roth

Co-investigators: Daniel Coombs, Benedikt Fischer, Mel Krajden, Gilbert Mark, Gina Ogilvie, Valencia Remple, and Terrence Trussler

Abstract: People newly infected with HIV are at their most infectious phase but mostly unaware of their infection status at this time. This is because routine tests for HIV infection are unable to identify persons in this phase as being infected. Fortunately, new laboratory testing methods can now identify HIV infection at a much earlier stage. This makes it possible to offer programs to these early infected individuals, including support to prevent transmission of HIV to others. An exciting new team of researchers has been formed to work with the gay community in British Columbia to strengthen prevention programs for persons with new infections from this community. The team members are from the biomedical sciences, public health, the social sciences, and researchers based in the community itself. The program will investigate gay men's understanding of HIV testing, their motivations and challenges in taking an HIV test, and the impacts of new testing technologies that are able to identify very infectious persons, on their testing practices. This information will be used to design messages to encourage gay men in BC to be tested for HIV. People diagnosed with early HIV infection will be offered enhanced prevention programs, which will be designed with gay community organizations and prevention experts. Gay men identified with early infections will also be interviewed to better understand their needs to fine tune the prevention programs. An important aspect of this program will be to investigate how to follow up with the sexual partners of those infected in the most efficient manner so that these partners can be offered access to prevention and follow-up programs as soon as possible. A key aspect of the research will involve the evaluation of these new programs so that they can be continually improved. The results of this research program will also be used to promote similar programs for people with new HIV infections from other communities in BC and Canada.

Dates: October 2007 – September 2012

Funder: Canadian Institutes of Health Research (CIHR) – Emerging Team Grant Program - HIV/AIDS

Reference: CIHR database

Topic: biomedical/clinical; prevention; testing; access to services

Project R11

CIHR team in HIV and co-infections

Principal investigator: Rupert Kaul, University of Toronto

Co-principals: Scott D. Gray-Owen; Charu Kaushic; Kelly S. Macdonald; Mario A. Ostrowski; and Robert S. Remis

Co-investigators: Mona R Loutfy and Wangari E Tharao

Abstract: There is tremendous variability in the rates of HIV acquisition, disease progression and secondary transmission. We hypothesize that common co-infections are critical mediators of this variability, and may partly explain differences in HIV rates in different communities. Interventions targeted at these co-infections will provide novel strategies to prevent HIV disease progression and transmission. We will show the role of selected co-infections in three critical events: (1) enhancing HIV acquisition, through alterations in genital susceptibility; (2) accelerating disease progression, by increasing viral load and impairing host immunity; and (3) increasing secondary sexual transmission to partners. This work will focus on several co- infections, particularly genital herpes, human papilloma virus, and gonorrhea. The work will be done in close collaboration with two highly HIV-affected communities in Toronto: men who have sex with men, and the African-Caribbean community. Three types of projects are proposed. First, we will measure rates of these co-infections in HIV-affected communities; then we will do experiments, both in participating people and in the lab, to understand how these co-infections may influence HIV; finally, we will design ways to intervene, hopefully providing new strategies to prevent HIV transmission and disease. The dissemination of results back to participating communities and caregivers, in a meaningful way, is a key objective throughout this process.

Dates: October 2007 – September 2012

Funder: Canadian Institutes of Health Research (CIHR) – Emerging Team Grant Program - HIV/AIDS

Reference: CIHR database

Topic: co-infections; prevention; people from countries where HIV is endemic

Project R12

Community-based prevention strategy to reduce vulnerability to HIV in LGTB communities

Principal investigator: Beatriz E. Alvarado, Queen's University

Co-investigators: Barry D. Adam; Gerardo Betancourt; Stevenson Ferbus; Jaime Galindo; and Jorge L. Martinez

Abstract: We are requesting funding to conduct two workshops whose main objectives are to plan a community-based prevention project to reduce HIV vulnerability in LGTB (Lesbian, Gay, Trans, Bisexual) Latino populations in Canada (Toronto) and Colombia (Cali and Pereira). The specific objectives of the activity are: 1) To identify main successful community-based research and education projects for LGTB populations implemented in Latino and other related communities in Canada, and based on those experiences, 2) To plan a community-based project that serves to implement new prevention strategies in Canada (Toronto) and Colombia (Cali, Pereira) with the aim of reducing HIV vulnerability among LGTB populations in both contexts. The workshops will be conducted with community organizations working with LGTB Latino populations in Ontario, two NGOs in Colombia working in prevention and care of people with HIV/AIDS, LGTB communities from two Colombian cities (Cali and Pereira) and from Ontario, and Canadian and Colombian academics. One workshop will be conducted in Toronto, where we will define: 1) needs that should be addressed by prevention projects; 2) major educational and promotional theories/strategies that have been proven to work in LGTB communities; 3) better ways to approach LGTB communities; and 4) important steps to build a community-based prevention project. The other workshop will be conducted in Cali, Colombia. In this workshop, we will present the conclusions of the Toronto workshop and then we will search to identify the main ways to approach the project in the Colombian LGTB communities, including the different mechanisms that could be developed to increase networking between health providers, NGOs, researchers and LGTB communities. Our main expected outcome is to have the first outline for the community-based prevention project completed.

Dates: February 2011 – January 2012

Funder: Canadian Institutes of Health Research (CIHR) – Planning Grants – Priority Announcement: HIV/AIDS (biomedical/clinical research and health services/population health research)

Reference: CIHR database

Topic: prevention

Project R13

Correlates and control of HIV shedding and transmission in semen

Principal investigator: Rupert Kaul, University of Toronto

Co-principal: Dr. Charu Kaushic

Co-investigators: Colin Kovacs, Mona Loutfy, and Janet Raboud

Abstract: The HIV-1 pandemic has claimed over 20 million lives, and 43 million people are currently infected. Sexual contact with HIV-infected semen is the major driving force behind the global pandemic, but many aspects of HIV transmission through semen are incompletely understood, and much work is needed to lay the groundwork for the development of rational public health policy and novel therapeutic strategies. Our research group has a long-standing interest in the virology, immunology and clinical correlates of HIV shedding and transmission in the genital tract, and we propose to expand our studies of HIV semen shedding to define the correlates of virus transmission within an established cohort of HIV-infected men from Toronto, as follows: 1) To understand the clinical and biological correlates of disproportionately high and low semen HIV shedding in HIV-infected men, both on and off antiretroviral therapy. 2) To study the transmission of HIV in semen across the epithelium of the female genital tract, and to study the impact of specific host and viral factors. 3) To prospectively examine differences in the characteristics of HIV in the semen and blood of HIV-infected men. These studies will help us to understand why HIV levels in semen are so variable, how levels are affected by host and viral factors, and to develop better public health and therapeutic tools to prevent HIV semen transmission.

Dates: October 2006 – September 2011

Funder: Canadian Institutes of Health Research (CIHR)-Operating grant

Reference: http://www.hivresearch.ca/index.asp?navid=17&csid1=1816

Topic: biomedical/clinical research

Project R14

Correlates of HIV testing among men who have sex with men from a Montreal cohort

Principal investigator: Serge Gallant, McGill University

Abstract: Background: ARGUS is a cyclical survey of Montréal MSM that monitors the occurrence of HIV and other sexually transmitted and blood-borne infections (STBBI). It is part of M-Track, the Public Health Agency of Canada's national second-generation surveillance system. Data were collected in 2005 and 2008. Objectives: To examine trends and correlates of recent HIV testing since 2005. Methods: Participants completed a self-administered questionnaire. Analysis was limited to MSM currently living in Montréal, 18 years or older and self-reported HIV-negative or of unknown status. Logistic regression analyses were stratified by year of study and adjusted for age. The outcome of interest was having had at least one HIV test within the previous 6 months. Demographics, sexual behaviours, and knowledge/beliefs on HIV were examined. Results: In total, 1,741 and 1,051 questionnaires were completed in 2005 and 2008, respectively. In the previous 6 months, 26% of men had been tested for HIV in 2005 and 41% in 2008. Multivariate analyses indicated that in 2005, engaging in risky anal intercourse (e.g., unprotected intercourse with a one-night stand) (OR=1.5 [1.2-2.0]), injecting with used needles (OR=4.1[1.4-12.1]), looking for/meeting a partner online (OR=1.7 [1.4-2.2]), and number of sexual partners (categorized in groups of 10) (test for trend of odds =11.01, p<0.001) were independently and positively associated with the outcome. In 2008, the only significant variables that carried over from 2005 were meeting a partner online (OR=1.5 [1.2-2.1]) and total number of sexual partners (2 test for trend of odds = 10.2, p< 0.01). Conclusion: While recent HIV testing by Montreal MSM increased between 2005 and 2008, the profiles of men testing between years differed. The prevalence of most risk factors remained stable across both cycles, yet some high risk-taking behaviours were no longer associated, or not as strongly associated with testing in 2008. This may be due to promotional campaigns emerging after 2005 targeting all MSM to get tested.

Dates: September 2009 – August 2010

Funder: Canadian Institutes of Health Research (CIHR) – Frederick Banting and Charles Best Canada Graduate Scholarships - Master's Award

Reference: CIHR database

Topic: testing

Project R15

Desire, place, stigma, and unsafe sex: understanding the subculture of men who use gay Internet cruise sites

Principal investigator: Patrick O'Byrne, University of Ottawa

Co-principal: Dave Holmes

Abstract: In Canada, men who have sex with men (MSM) represent the largest proportion of new HIV infections and sexual partnerships that are arranged via the Internet are described as contributing to this elevated infection rate. However, a review of the research that correlates the Internet and HIV-transmission revealed that it often excluded the perspective of MSM who live with HIV/AIDS (MSMHA). Consequently, many HIV advocacy groups have criticized researchers of further marginalizing an already stigmatized illness/group. In response to this, the first step of this project was to seek the guidance of Ontario's "Poz Prevention Group" in order to diminish these ethical/scientific issues. With such input, and the results of two previous CIHR-funded studies in bathhouses and circuit parties, the objective of this project is to qualitatively explore the role and sequence of 'desire, place, stigma, and unsafe sex' as it relates to MSMHA who meet sexual partners via the Internet. The importance of this is that it incorporates the psychosocial nature of human sexuality by acknowledging that unsafe sexual practices are not always the outcome of simple decision-making processes that follow the rules of doing what is best for one's health. This research aims at exploring this sequence in an effort to gain a better understanding of the motivations of MSMHA so as to develop more culturally sensitive HIV prevention initiatives. In other words, the goal of this project is to better understand how desire helps guide the selection of specific sexual practices and places, and how this process is also guided by public and personal perceptions of stigma. Qualitative methods will be used to explore these four dimensions as they relate to MSMHA who arrange sexual contacts via the Internet. More specifically, this will involve analysis of the websites which are used to arrange sexual contacts, in addition to 45 in-depth qualitative interviews with men in Montreal, Ottawa, and Toronto.

Dates: March 2010 – February 2011

Funder: Canadian Institutes of Health Research (CIHR) – HIV/AIDS Bridge Funding - Biomedical/Clinical Stream

Reference: CIHR database

Topic: stigma; sexual behaviour; prevention

Project R16

Development of an HIV prevention and sexual health intervention for positive men

Principal investigator: Trevor A. Hart, Ryerson University

Abstract: not available

Date: 2008

Funder: Ontario HIV/AIDS Treatment Network (OHTN)

Reference: http://www.ohtn.on.ca/Pages/Funding/Results-All.aspx

Topic: prevention; PHA

Project R17

Development of strategies to curb the HIV epidemic based on molecular epidemiological surveillance

Principal investigator: Bluma G. Brenner, Lady Davis Institute for Medical Research (Montréal)

Co-investigators: Erica E.M. Moodie; Michel Roger; and Mark A. Wainberg

Abstract: While antiretroviral therapy has prolonged and improved the lives of persons infected with HIV/AIDS, the onward spread of regional epidemics in most-at-risk populations shows no evidence of decline. Phylogenetic approaches, using large viral sequence datasets from genotyping programs, provide an important tool to identify HIV transmission networks. Our findings show half of the male-sex-male (MSM) epidemic in Quebec is driven by newly infected persons, often unaware of their status. Transmission networks arise wherein one infection is associated with 10 onward transmissions. Our study will combine phylogenetic, epidemiologic and cohort approaches to ascertain the driving forces of the provincial MSM and heterosexual epidemics with a view to improving testing, treating, and prevention paradigms so as to avert and ideally eradicate onward spread of HIV.

Dates: April 2011 – March 2014

Funder: Canadian Institutes of Health Research (CIHR) – Operating Grant

Reference: CIHR database

Topic: prevention; sexual networks; biomedical/clinical

Project R18

Development of an evaluative study comparing the relative efficacy of means of intervention based on different theoretical perspectives on HIV prevention in men who have sex with men and who are HIV negative at risk of HIV infection

Principal investigator: Joanne Otis, Université du Québec à Montréal

Co-principal: Gaston Godin

Co-investigators: Michel Alary; Martin Blais; Karine J. Igartua; Gilles Lambert; René Lavoie; and Richard Montoro

Abstract: Of all persons vulnerable to HIV in Canada and Quebec, MSM account for the largest number of new and existing HIV cases (ASP, 2005; MSSS, 2004). As well, recent cohort studies report an increase in risk practices both in Montreal and Vancouver. These data demonstrate the difficulties some MSM experience in sustainably incorporating the use of condoms into their sexual scenarios, and underscore certain limitations in current approaches to health promotion. According to several authors, preventive intervention should, in addition to the sociocognitive factors associated with risk factors, target sexological factors such as the significance associated with anal sex for some MSM who take risks, and the characteristics of their preferred sexual scenarios. Through this pilot project (R&D), two innovative interventions will be developed with HIV-negative MSM, the first aimed exclusively at sociocognitive factors and the second at sexological factors. These two interventions will be developed according to two separate intervention methods, one individual and the other group-based. As well, the feasibility of future implementation of internet access will be evaluated. Validation of these two interventions will involve the participation of 32 MSM who will be asked to evaluate the resources invested, the activities produced and the objectives achieved by each one of these interventions. This pilot project should contribute to the success of HIV efforts under the Canadian federal HIV/AIDS strategy because it will develop interventions based on scientific outcomes and adapted to the needs of Montreal MSM.

Dates: March 2006 – February 2007

Funder: CIHR- Pilot project in HIV/AIDS

Reference: CIHR database

Topic: sexual behaviour; prevention

Project R19

Effect of HAART expansion on community levels of HIV viral load and HIV risk behaviours among MSM in British Columbia

Principal investigators: Robert Hogg and David Moore, Simon Fraser University

Co-investigators: Roland Barrios, Trevor A. Corneil, Vivane D. Lima, Willi McFarland, Warren D. Michelow, Julio S. Montaner, Thomas L. Patterson, and Eric Roth

Abstract: Recently the BC Ministry of Health endorsed expanding access to antiretroviral therapy (ART) as a strategy that could reduce the number of new HIV infections by reducing community infectivity levels. Guidelines have also been revised so that many more HIV-infected people may now access ART. The success of ART expansion in reducing new HIV infections might be affected if "ART optimism" causes higher levels of risk behaviour for HIV transmission. Men who have sex with men (MSM) remain the risk group most affected by HIV in Canada and BC. We wish to examine the impact of expansion of access to ART on risk behaviour among the MSM population in Greater Vancouver and on community HIV viral load as a marker of community infectivity. We will conduct two cross-sectional surveys of MSM, spaced over a 5-year period. The surveys will be designed to be representative of the ethnic and sub-cultural diversity of MSM in Greater Vancouver. We will sample 1000 MSM aged 15 years and over at each survey, using members of different sub-populations of MSM (seeds) to recruit a diverse group of MSM. All study participants will be asked to sign a consent form, complete a questionnaire, take a rapid HIV blood test, syphilis test, and hepatitis C serology, and provide consent to allow researchers access to health services databases. HIV+ participants in the surveys will be invited to enrol in a longitudinal sub-study with follow-up at 6-month intervals that will examine the effectiveness of a peer-based treatment literacy intervention for increasing ART uptake among HIV+ men currently not on treatment, and on risk behaviour for HIV transmission. The study results will assist service providers and program planners to respond to potential increases in HIV risk behaviours. The results will also directly inform policy makers in Canada and other countries with regards to the added preventive value of ART and influence decisions regarding the further expansion of ART in industrialized countries.

Dates: 2010 – 2013

Funder: CIHR HIV/AIDS Research Initiative – Health Services/Population Health Stream

Reference: Simon Fraser University website

Topic: prevention; access to services; treatment; PHA; sexual behaviour

Project R20

Evaluation of “Action to Mobilize Change” (ATOMC), a social network intervention for increasing HIV testing among MSM at high-risk for infection in Montreal

Principal investigator: John Cox and Mark Hapanowicz, AIDS Community Care Montreal

Co-investigators: Elysabeth Lacombe; Gilles Lambert; and Kenneth M. Monteith

Abstract: A social network HIV testing pilot project for MSM (Action TO Mobilize Change, ATOMC) was recently funded by the Public Health Department of the Health and Social Services Agency of Montreal. The pilot project is based on work done by the US Centers for Disease Control and Prevention using social network strategies to increase HIV testing among HIV vulnerable populations. The project has the funds to adequately coordinate and implement the intervention but insufficient resources (expertise and financial) to permit the development of a data base, data entry and detailed analyses to be able to document the effectiveness of the project. Ultimately, this research will answer the question: Are social network strategies useful for affecting HIV testing behaviours among MSM? Specifically, will more at-risk men and men not aware of their diagnosis be identified and received voluntary HIV counselling and testing in Montreal. Knowledge generated from this thorough evaluation will enable the development of a larger grant wherein social network strategies could be used for other at-risk populations including people who use injection drug[s], street-involved youth and people representing ethnocultural minorities.

Dates: October 2010 – September 2011

Funder: Canadian Institutes of Health Research (CIHR) – Catalyst Grant: HIV/AIDS Community-Based Research Program – General Stream

Reference: CIHR database

Topic: testing; sexual networks

Project R21

Getting to know the community: Who are the black men who have sex with other men in Toronto?

Principal investigator: George Clemon, University of Ottawa

Abstract: Canadian studies of sexual behaviour and determinants of HIV infection among homosexual men have included Black men who have sex with men (BMSM), but the results and service implications are indeterminate for 2 main reasons: 1. researchers have found it difficult to recruit large enough numbers of BMSM for studies that are designed for (mainstream) gay populations; and 2. recruitment is normally done from places that may not be frequented by non gay-identified BMSM. This leaves us with an incomplete understanding of the risk behaviours and sexual relationships of BMSM. Further, HIV prevention activities that are designed for gay (white) men and target BMSM may not be well informed. The study seeks to: describe the risk behaviour of BMSM and variables associated with these behaviours; understand how experiences and everyday decision-making are associated with (un)protected sex; understand how BMSM interpret and assess the role of AIDS Service Organisations (ASO) in their communities. The study will use both survey and in-depth interviews. Surveys are appropriate to describe behaviours while in-depth interviews are suitable to understand behaviours. African and Caribbean identifying BMSM aged 18 years or older and living in or socializing in Toronto will be eligible to complete the survey and some individuals will be interviewed. Individuals from ASOs who are knowledgeable of BMSM will be interviewed. The study will present a clearer picture of BMSM thereby allowing health promotion agencies to design targeted prevention/intervention activities for BMSM. The study will also promote knowledge of agencies/stakeholders and ensure value for limited resources. The study addresses a knowledge gap articulated by the African and Caribbean Council on HIV/AIDS in Ontario, a coalition of agencies working with African and Caribbean communities. The research will enhance prevention and support services for BMSM through improved understanding of BMSM communities and risk behaviours.

Dates: September 2007 – August 2012

Funder: Canadian Institutes of Health Research (CIHR) – New Investigator Award in Area of HIV/AIDS Services/Population Health Research

Reference: CIHR database

Topic: prevention; people from countries where HIV is endemic; culture; sexual behaviour

Project R22

HAART optimism, drug use and risky sexual behaviour among MSM in British Columbia

Principal investigator: Robert Hogg, Simon Fraser University

Co-investigators: D. Moore, J. Montaner, W. McFarland, V. Lima, R. Barrios, E.R. Roth, and T. Patterson

Abstract: This proposed study examines the effect of a recently initiated population-level biomedical intervention–expanded universal and free of cost highly active antiretroviral therapy (HAART)–on HIV risk behaviours among a high-risk population, men who have sex with men (MSM), in British Columbia (BC), Canada. Of particular interest is whether the efficacy of expanded HAART access as an HIV prevention measure might be negated by socio-cultural/bio-behavioural factors, including risk compensation or "HAART optimism" within the MSM communities. The majority of new HIV infections in BC occur among MSM and this has remained largely unchanged since the year 2003 with approximately 200 new infections each year. The preventive value of HAART has been highlighted and the BC Ministry of Health has massively increased funding to expand access to HAART as a strategy to reduce the number of new HIV infections in the province. BC HIV treatment guidelines have also been relaxed so that HAART is available to almost all HIV-infected individuals in the province. Approximately 40% of persons who die from HIV-related causes in BC do not receive ART prior to death and approximately 27% of HIV-infected individuals may be unaware of their HIV status. This major expansion of access to HAART constitutes a population-level biomedical intervention—a rare, natural experiment—thereby creating an opportunity to examine the impact of expanded HAART access on complex determinants of HIV risk behaviors at the individual level. Over the 5-year study period, we propose to use respondent-driven sampling (RDS) to recruit a cohort of 270 HIV-positive and 410 HIV-negative MSM (680 in total) aged 16 years and older, and follow them up every 6 months for a median of four years. We propose to use RDS for its strength in recruiting deeply from hidden and diverse populations. Our main aims are to 1) examine trends in sexual risk behaviour and attitudes regarding the preventive value of HAART over a 4.5-year period as the numbers of MSM on HAART dramatically increase and the concept of HAART as prevention becomes widely diffused; 2) examine how self-reported drug-use before and during sex explains HIV sexual risk behaviour; and 3) examine the interactions between soft and hard drug use, HAART optimism and treatment adherence and continuation among HIV-positive MSM receiving HAART. All study participants will be asked to sign a consent form, complete a questionnaire using Computer Assisted Self-Interview technology, and undergo a rapid HIV test, syphilis test, hepatitis C serology, urine and anal swab screens for N. gonnorhea and Chlamydia trachomatis and to provide consent to allow researchers access to health services databases in the province. All HIV-positive individuals not already accessing regular HIV care will be linked to local healthcare providers for regular medical care and for assessment of need for HAART.

Dates: 2011 – 2016

Funder: National Institutes of Mental Health (United States)

Reference: Simon Fraser University website

Topic: prevention; treatment; PHA; sexual behaviour

Project R23

Health in Middlesex Men Matters (The HIMMM Project)

Principal investigator: Greta Bauer, University of Western Ontario

Abstract: In 2006, the AIDS Committee of London held the first LGBT2SQ (Lesbian, Gay, Bisexual, Transgender, Two-Spirit, Questioning) Health Forum in London, Ontario to initiate dialogue and identify health concerns in our local communities. The discussions identified three notable areas of concern: homophobia (internal and external), isolation and social exclusion, and communication. There was consensus that when LGBT2SQ persons interface with the healthcare system in the region, an area known to be socially conservative, they experience overt and covert homophobia, systemically and individually. These experiences reflect the breadth of financial, structural, personal, and cultural barriers that the Gay and Lesbian Medical Association has identified as impacting access, and have all been shown to have a spectrum of detrimental effects on personal health and well-being. For communities affected by both homophobia and HIV, these factors may interact to impact risk of new infection, late diagnosis, or less-than-optimal care for those living with HIV. With this understanding, a team of stakeholders from, and allies of, the gay, bisexual, and other men who have sex with men community was formed to examine the individual and collective impacts of these themes on HIV and health care more broadly within this community in Middlesex County. These will be accomplished through a series of stakeholder interviews and in the preparation of a survey to be delivered via respondent-driven sampling (RDS), a network-based sampling method, to gather information from the community.

Dates: 2009

Funder: Ontario HIV/AIDS Treatment Network (OHTN)

Reference: http://www.ohtn.on.ca/Pages/Funding/Results-All.aspx

Topic: access to services; homophobia, stigma and discrimination

Project R24

'HIV is no picnic': social constructions of the queer HIV-positive body in HIV prevention pedagogies of fear

Principal investigator: Domenico Calla, University of Toronto

Abstract: This thesis examines the HIV-positive queer male body as a surface for the production of meaning and discursive inscription of AIDS-related ideologies. The bodies I examine appear in a fear-based HIV prevention campaign entitled 'HIV is no picnic.' Campaign images depict four suffering bodies to highlight the consequences of unprotected sex. My analysis is situated at the juncture of queerness, disability, HIV/AIDS, and prevention pedagogy which collaborate to construct the HIV-positive body as a cultural artifact. These corporeal representations are analyzed for how HIV-related suffering (re)produces the social world by structuring the cultural intelligibility of a pandemic and the subjectivities configured within its discourse. By using a Foucauldian and phenomenological lens, I explore how 'HIV is no picnic' enlists spectators into a mediated interpretive labour of embodiment through the deployment of historically based ruling relations of power/knowledge which organize the visual scene of recognition to make bodies appear in circumscribed ways.

Date: 2007

Funder: Social Sciences and Humanities Research Council (SSHRC) - Canada Graduate Scholarships Program - Masters Scholarships

Reference: http://www.outil.ost.uqam.ca/CRSH/Detail.aspx?Cle=54736&Langue=2

Topic: prevention; PHA; homophobia, stigma and discrimination

Project R25

HIV prevention needs of Asian Canadian men who have sex with men

Principal investigator: Suji Moon and Nadine M.S. Nakamura, Simon Fraser University

Co-investigators: Benedikt Fischer, Mark P.J. Gilbert, and Robert S. Hogg

Abstract: Asian Canadian men represented 9.7 percent of new HIV cases among men in B.C. in 2008. Only a handful of studies have explored issues related to HIV and Asian men who have sex with men (MSM) in Canada. The limited data suggest that Asian MSM, particularly less acculturated immigrant men, appear to be at greater risk for contracting HIV as they are more likely to engage in unprotected anal and oral sex. U.S. studies have also found that Asian MSM have high rates of unprotected anal intercourse and sex under the influence of drugs or alcohol. Asian MSM in Canada are also at risk because they do not seek early HIV testing. Compared to other racial groups in the U.S., Asians were more likely to be at an advanced stage of AIDS and have opportunistic infections at the time of diagnosis. A significantly lower percentage of HIV-positive Asians were aware of their current CD4 count and they were less aware of care-related services compared to Whites, which puts HIV-positive Asians at a disadvantage in terms of survival. This study will explore risk factors of Asian Canadian MSM for contracting HIV and examine attitudes toward and barriers to HIV testing among Asian MSM through focus groups. Community-based participatory research will be utilized through collaboration with the Asian Society for the Intervention of AIDS (ASIA) and other community-based HIV organizations in Vancouver, BC to determine what service providers and staff view as the greatest needs for HIV prevention in their community. Community members will also be recruited to participate in focus groups about what Asian Canadian MSM perceive as strengths and limitations to current HIV prevention and what needs they have as a community. The data from the focus groups will guide the development of research questions for future quantitative data collection. These data will inform the development of culturally appropriate HIV-prevention interventions for Asian Canadian MSM.

Dates: October 2010 – September 2011

Funder: Canadian Institutes of Health Research (CIHR) – Catalyst Grant : HIV/AIDS Community-Based Research Program – General Stream

Reference: CIHR database

Topic: prevention; access to services

Project R26

Identifying social determinants of HIV-related and broader health-issues facing Kingston's gay and bisexual men's community

Principal investigator: Fergus Stevenson, Queen's University

Abstract: Together with a group of five local gay men (a community advisory board, or CAB), we conducted a study of Kingston's gay and bisexual men's community. The research was to help understand men's experiences coming or being out, involvement in and views of the gay community, HIV/AIDS, being gay in Kingston, experiences of heterosexism and homophobia, and knowledge of and experiences with HARS, the local AIDS service organization. In the spring of 2007, KAMP CAB members facilitated 11 focus groups with 53 members of the community and conducted in-depth interviews with five community leaders. After collecting the data, we analyzed it as a team. Participants were generally fairly out, and despite fear and anxiety prior to coming out, reported having had positive coming out experiences. Participants explained that hearing other people's positive coming out stories can be beneficial, and described a continuum of being out. Men mentioned a lack of a central meeting place for the community as a drawback to being gay in Kingston. Some wish for a space that wasn't a bar such as a community centre, while others wish for a gay-identified pub where community members could gather at different times during the day. Gay and bisexual men in Kingston believe that the lesbian and bisexual women's community in Kingston is more organized than the men's community. Participants were mostly not sure why that is. Despite the large effect that the HIV/AIDS epidemic has had on gay and bisexual men in Canada, HIV is not discussed in a community context. Men see HIV as an individual issue, not something that affects the community as a whole. Focus group discussions of homophobia were contradictory. Most participants initially reported that Kingston and the area is not a very homophobic place. Participants also reported feeling, however, that a certain amount of homophobia is inevitable, and told stories of verbal and physical harassment. To date, we have conducted a number of activities and produced a number of documents to disseminate our experiences and findings to the community, practitioners, and academics. These have included a community presentation and discussion, postcard-type brochures, a presentation to HARS staff, four conference presentations, and six invited lecturers. The results of our study have already been integrated into HARS's gay and bisexual men's outreach strategy, resulting in expanded counselling services and new promotional flyers dedicated to raising the visibility of the agency's services for men regardless of their HIV status. We have submitted two papers for publication in academic journals, and plan to submit more. We contracted with two professional filmmakers to create a 10-minute animated short film in order to distribute our results more widely. The film can be viewed at http://www.youtube.com/KampKingston. Finally, we conducted a process evaluation of the project, focused on the extent to which the project followed principles of community-based research.

Dates: September 2006 – August 2007

Funder: Ontario HIV Treatment Network (OHTN)

Reference: http://www.hivresearch.ca/index.asp?navid=17&csid1=2278

Topic: homophobia, stigma and discrimination; social and physical environments; capacity building

Project R27

Improving the capacity of the HIV sector to respond to ethno-racial MSM: tapping front-line expertise and wisdom

Principal investigator: Alan Li, Asian Community AIDS Services

Abstract: N/A

Dates: 2007

Funder: Ontario HIV/AIDS Treatment Network (OHTN)

Reference: http://www.ohtn.on.ca/Pages/Funding/Recipient-Profiles-Alan-Li.aspx

Topic: people from countries where HIV is endemic; capacity building

Project R28 (a)

Keeping gay and bisexual men safe: a history of HIV prevention work in Toronto

Principal investigator: Adam Green, University of Toronto

Abstract: HIV prevention work for men who have sex with men (MSM) represents a front-line institutional response to the HIV/AIDS epidemic, but one that is highly contested and complex in its organization, substance and execution. This study provides a social history of MSM HIV prevention work in Toronto--a city with the highest concentration of HIV-infected MSM and one of the most well-developed outreach and prevention programs in Canada. The study will focus on the institutional processes that underpin front-line HIV prevention outreach and service organizations, including: 1) How have MSM HIV prevention programs executed prevention services over time and what has been their relationship to each other and to the state? 2) What expert epidemiological, social scientific and local folk knowledges regarding HIV have emerged over the past 25 years and how have they been translated to prevention work? 3) What impact have external stakeholders, including federal and provincial funders and non-state actors such as the media and ethnic-based community leaders, had on the form and substance of prevention work? 4) How has the target MSM subject been constructed in discourse and how has it changed over time? Through interviews with past and present service providers, organizational leaders and policy makers, along with archival research and analysis of prevention materials and organizational documents and minutes, the study will examine the history in which key AIDS Service Organizations (ASO) and ethnocultural community-based organizations contested, coordinated and transformed HIV prevention for the MSM population of Toronto.

Dates: April 2009 – March 2014

Funder: Canadian Institutes of Health Research (CIHR) – Operating Grant

Reference: CIHR database

Topic: prevention; capacity building

Project R28 (b)

Keeping gay and bisexual men safe: a history of HIV prevention work in Toronto

Principal investigator: Adam Green, University of Toronto

Abstract: HIV prevention work for men who have sex with men (MSM) represents a front-line institutional response to the HIV/AIDS epidemic, but one that is highly contested and complex in its organization, substance and execution. This study provides a social history of MSM HIV prevention work in Toronto--a city with the highest concentration of HIV-infected MSM and one of the most well-developed outreach and prevention programs in Canada. The study will focus on the institutional processes that underpin front-line HIV prevention outreach and service organizations, including: 1) How have MSM HIV prevention programs executed prevention services over time and what has been their relationship to each other and to the state? 2) What expert epidemiological, social scientific and local folk knowledges regarding HIV have emerged over the past 25 years and how have they been translated to prevention work? 3) What impact have external stakeholders, including federal and provincial funders and non-state actors such as the media and ethnic-based community leaders, had on the form and substance of prevention work? 4) How has the target MSM subject been constructed in discourse and how has it changed over time? Through interviews with past and present service providers, organizational leaders and policy makers, along with archival research and analysis of prevention materials and organizational documents and minutes, the study will examine the history in which key AIDS Service Organizations (ASO) and ethnocultural community-based organizations contested, coordinated and transformed HIV prevention for the MSM population of Toronto.

Dates: September 2009 – August 2014

Funder: Canadian Institutes of Health Research (CIHR) – New Investigator Award

Reference: CIHR database

Topic: prevention; capacity building

Project R29

Male-call Canada: An in-depth study of current and emerging issues, and the changing social and behavioural determinants related to HIV transmission among men who have sex with men

Principal investigator: Ted Myers, University of Toronto

Abstract:This proposal results from a national research needs assessment, entitled. The 2005 Sexual Health Promotion Research Needs Assessment for Men Who have Sex with Men in Canada, which was undertaken by the research team with funding from NHRDP/CIHR. This study will utilize a 1-800 toll-free telephone number method, which has been successfully utilized in Australia, New Zealand, the United Kingdom and Canada, to survey a broad national sample of men who have sex with men. The study is undertaken by a team of investigators from across Canada, and includes both academic and community researchers, along with a National Advisory Committee. In order to ensure a high level of response a multidimensional promotional campaign that seeks to blanket Canada, as a whole, will be undertaken. The major goal of Male Call Canada is to conduct a cross-sectional nationwide toll-free telephone survey to gather self-reported information on a broad spectrum of HIV behaviours and related social and behavioural determinants and issues for men who have sex with men (MSM) in Canada. The telephone survey will permit the acquisition of data from closed ended fixed-choice questions, as well as exploratory open-ended questions, with a subgroup of the participants. Quantitative and qualitative data analysis will be undertaken.

Dates: October 2006 – Ongoing

Funder: Canadian Institutes of Health Research (CIHR) – Operating Grant

Reference: CIHR database

Topic: sexual behaviour

Project R30

MSM and WSW in sexual networks in Winnipeg, Manitoba: Exploring changes in network dynamics and HIV risk

Principal investigator: Stephanie S. Harvard, University of Manitoba

Abstract: Statement of the problem: Men who have sex with men (MSM) are a high-risk group for HIV infection. Women who have sex with women (WSW) may be at elevated risk for HIV from male sex partners.

Methods: The 'M-Track' HIV surveillance study of MSM was conducted in Winnipeg, Manitoba. A pilot study was undertaken concurrently to assess HIV risk among WSW. Convenience samples of MSM and WSW were surveyed concerning HIV risk behaviours and tested for HIV, hepatitis C, and syphilis.

Results: MSM and WSW surveyed reported inconsistent condom use and high rates of injection drug use and sex trade involvement. Prevalence of blood-borne pathogens was high among both groups. High rates of response error suggested difficulty in survey participation among both groups.

Conclusions: The samples of MSM and WSW reached may represent a high-risk subset of MSM and WSW. Study methods may be improved to better invite and be appropriate for diverse participants.

Dates: September 2006 – August 2008

Funder: CIHR- HIV/AIDS Community-Based Research Program - General - Master's Award

Reference: CIHR database

Topic: injection drug use; sexual behaviour

Project R31

Socio-structural parameters of the individualization of sexual risk-taking and typical trajectories of HIV infection in MSM

Principal investigator: Martin Blais, Université du Québec à Montréal

Abstract: Despite numerous prevention campaigns that have had a positive effect on the sexual behaviours of MSM, these individuals still account for a large percentage of persons newly infected with HIV. However, it is not true that all the men who have contracted the virus have taken the same sexual risks, or that they have taken them for the same reasons. Martin Blais, a sexology researcher at the Université du Québec à Montréal, has studied the personal accounts of 24 men who have sex with men, aged 23 to 60, and who contracted the virus through sexual relations. The objective was to understand the reasons, circumstances, and trajectory that led to HIV infection. Martin Blais has identified five typical trajectories. These include three in which infection is the conclusion of a series of events that disrupt life and sexual scenarios. Sexual risk taking can be a way of escaping an onerous day-day-existence, or an expression of love towards the partner, or a sign of renewed exhilaration. In other trajectories, HIV infection is the expected outcome of a risk-focused lifestyle. Some men said the infection was totally unexpected, and that they had taken every precaution to prevent it. This research clearly shows that there are many routes to the infection. The heterogeneity of these profiles underscores the importance of formulating educational prevention messages that do not assume a single profile, but that reflect the life experiences and concerns of the men they target.

Dates: 2006 – 2007

Funder: FQRSC

Reference: FQRSC database

Topic: prevention; sexual behaviour; capacity building

Project R32

Phénix: an opportunity to mobilize organizations involved with HIV and STDs

Principal investigator: Joanne Otis, Université du Québec à Montréal

Co-investigators: Stephen T. Alexander; Martin Blais; Ghayas Fadel; Gilles Lambert; Jean-Marie Le Gall; and Richard Montoro

Abstract: In the wake of the disturbing results from the Omega Cohort and the Argus survey, conducted in the Montréal gay community and showing a resurgence of at-risk anal relations, a number of researchers involved in these two studies joined with the community to develop an innovative intervention (Phénix) aimed at reducing at-risk behaviours for HIV infection in the Montréal gay community. From 2006 to 2007, the Phénix program was developed and validated by a multidisciplinary team of researchers and their community partners through a CIHR funding initiative (pilot project). Following the validation of Phénix in 2007, a number of Quebec and Canadian community organizations took the preparatory training for Phénix implementation in their communities. However, owing to a lack of funding, this further implementation is not currently supported by a research process. We therefore propose to organize a workshop which would be attended by researchers, community workers or leaders and decision makers involved in HIV and STD efforts with men who have sex with men, in order to mobilize them around the Phénix program. The specific goals of the workshop are: 1. to share knowledge and experiences around Phénix implementation; 2. to support community actors in implementing Phénix in their communities; 3. to issue recommendations for improving and adapting the program on the basis of implementation experiences; 4. to develop, in partnership, the bases of a community research program to evaluate the implementation and efficacy of Phénix in the communities.

Dates: September 2009 – August 2010

Funder: Canadian Institutes of Health Research (CIHR) – Meetings, Planning and Dissemination Grant - Planning Grant - Priority Announcement: Institute of Infection and Immunity

Reference: CIHR database

Topic: prevention; sexual behaviour; capacity building

Project R33

Pro-active intervention to limit HIV transmission among MSM populations

Principal investigator: Mark A. Wainberg

Co-investigators: Martin Blais; Bluma G. Brenner; John Cox; Gilbert Emond; Gaston Godin; Gilles Lambert; Joanne Otis; and Michel Roger

Abstract: This project brings together a team from the Réseau SIDA of the FRSQ to work together HIV prevention regarding men who have sex with men (MSM). Our project is based on the competence of virologists, public health officials, social scientists, clinicians, and community workers and will utilize a pro-active approach to try to identify individuals who are at risk of both contracting and transmitting HIV. We believe that an earlier diagnosis, accompanied by efficient counselling, will lead to far lower rates of HIV transmission. The project will utilize a rapid test procedure to diagnose HIV infection on the basis of serology, but will also involve testing of blood samples, in order that recently infected individuals who test negatively on the basis of an antibody test, may potentially be diagnosed using more sensitive nucleic acid-based diagnostic procedures (Polymerase Chain Reaction). The success of this project will be measured by whether or not lower HIV infection rates prevail among members of the Montreal MSM community during the final stages of the work, as well as by whether we are able to demonstrate a smaller number of new HIV transmission clusters within the MSM population in addition to fewer numbers of infected individuals on average within a cluster.

Dates: November 2007 – October 2010

Funder: Canadian Institutes of Health Research (CIHR) – Operating Grant: HIV Prevention

Reference: CIHR database

Topic: testing; biomedical/clinical

Project R34

Project PRIDE (Promoting Resilience in Discriminatory Environments): a primary HIV prevention intervention for gay/bisexual men

Principal investigator: Trevor A. Hart and Nathan G. Smith, McGill University

Co-investigators: Barry D. Adam and Martin Blais

Abstract: Prevalence rates of HIV infection in young gay and bisexual (GB) men have increased in recent years. Young GB men face personal and societal challenges related to their sexual orientation; moreover, these challenges have implications for HIV prevention. Minority stress, such as anti-gay discrimination (instances of verbal or physical threats or attacks) and internalized homophobia (the internalization of negative societal views about bi/homosexuality), is a constant stressor facing young GB men. Minority stress has been shown to be related to negative psychological health outcomes, substance use/abuse, and HIV-risk behaviours. However, HIV prevention interventions aimed at young GB men have not addressed minority stress and its correlates. The purpose of the current study is to develop and test a group psychotherapy intervention for young GB men to develop adaptive coping strategies for dealing with minority stress. The efficacy of this type of intervention in the reduction of HIV risk behaviours will be explored. The intervention will be developed based on existing models and theory, along with the results of focus groups with service providers and young GB men. The intervention is expected to consist of 10 sessions that will address minority stress, social support, and HIV risk behaviours. Post-test and follow-up assessments will determine the efficacy of the intervention's ability to reduce negative mental health outcomes, substance use/abuse, and HIV-risk behaviours.

Dates: October 2010 – September 2012

Funder: Canadian Institutes of Health Research (CIHR) – Operating Grant – Priority Announcement: HIV/AIDS Research Initiative – Health Services – Population Health Stream

Reference: CIHR database

Topic: prevention; homophobia, stigma and discrimination; sexual behaviour

Project R35

Research on transpeople's lack of access to healthcare services and its effects on their health and well-being

Principal investigator: Anna Travers, Sherbourne Health Centre

Abstract: N/A

Date: 2006

Funder: Ontario HIV/AIDS Treatment Network (OHTN)

Reference: http://www.ohtn.on.ca/Pages/Funding/Results-All.aspx

Topic: access to services; Trans populations; mental health

Project R36

Risking it: examining the experiences of gay/bi/queer transmen and HIV/AIDS

Principal investigator: Broden Giambrone, University of Toronto

Abstract: N/A

Date: 2009

Funder: Social Sciences and Humanities Research Council (SSHRC) – Canada Graduate Scholarships Program – Masters Scholarships

Reference: http://www.outil.ost.uqam.ca/CRSH/Detail.aspx?Cle=76935&Langue=2

Topic: Trans populations

Project R37

Social anxiety as a risk factor for HIV transmission risk behaviour among HIV-seropositive and HIV-seronegative men who have sex with men: mechanisms of action

Principal investigator: Trevor Hart, Ryerson University

Co-investigator: Ted Myers

Abstract: As persons with HIV and AIDS live longer and fuller lives as a result of advances in medical treatment, there is increasing need for systemic research on risk behaviours in HIV-seropositive and HIV-seronegative persons. Guided by previous research documenting associations between social anxiety and unprotected intercourse among samples of adolescent men who have sex with men (MSM) and HIV-positive adult MSM in the United States, this study examines how social anxiety may lead to risky sexual behaviour among adult HIV-positive and HIV-negative MSM in Ontario. Participants will complete brief semi-structured interviews and self-report measures assessing social anxiety, mood problems, alcohol and drug use, attitudes regarding HIV/AIDS, and sexual behaviour. This study will provide information to help […] healthcare providers improve health care and to prevent HIV and AIDS among men who have sex with men and other populations at higher risk for HIV- and AIDS-related problems.

Dates: October 2005 – September 2009

Funder: Canadian Institutes of Health Research (CIHR) – Operating Grant

Reference: CIHR database

Topic: prevention; PHA; mental health; sexual behaviour

Project R38

Sociobehavioural factors related to the HIV and AIDS epidemic within the men who have sex with men population

Principal investigator: Nathan J. Lachowsky, University of Otago (New Zealand)

Abstract: N/A

Date: March 2011

Funder: Canadian Institutes of Health Research (CIHR) – Canadian Graduate Scholarships – Michael Smith Foreign Study Supplement

Reference: CIHR database

Project R39

Stigma, place, and unsafe sex: continued explorations with men who use gay Internet cruise sites

Principal investigator: Dave Holmes and Patrick O'Byrne, University of Ottawa

Abstract: In Canada, men who have sex with men (MSM) represent the largest proportion of new HIV infections, and sexual partnerships that are arranged via the Internet are described as contributing to this elevated infection rate. However, a review of the research that correlates the Internet and HIV-transmission revealed that it often excludes the perspective of HIV+MSM. Consequently, many HIV advocacy groups have criticized researchers of further marginalizing an already stigmatized group. In response to this, the first step of this project was to seek the guidance of Ontario's "Poz Prevention Group" in order to diminish these ethical/scientific issues. With such input, and the results of three previous CIHR funded studies in (1) bathhouses, (2) circuit parties and (3) amongst men who meet their sex partners via the Internet, the objective of this project is to qualitatively explore the sequence of desire, place, stigma, and unsafe sex as it relates to HIV+MSM who meet their sex partners via the Internet. This research thus aims to explore this sequence in an effort to gain a better understanding about Internet-based (place), sexual risk-taking (unsafe sex) behaviour of men who are, at times, stigmatized as 'un-masculine' due to their homosexual desires. The importance of this is that it incorporates the psychosocial nature of human sexuality by acknowledging that unsafe sex is not always the outcome of simple decision-making processes that follow the rules of doing what is best for one's health. Qualitative methods will be used to undertake this exploration involving HIV+ MSM who arrange their sexual contacts via the Internet because previous research has correlated HIV transmission and the Internet, but has done so without subsequent in-depth exploration of this link.

Dates: October 2010 – September 2011

Funder: Canadian Institutes of Health Research (CIHR) – Operating Grant – Priority Announcement: HIV/AIDS Bridge Funding – Health Services/Population Health Stream

Reference: CIHR database

Topic: PHA; sexual behaviour; sexual networks

Project R40

Teens Resisting Urban Trans/Homophobia (TRUTH)

Principal investigator: Robb Travers, Wilfrid Laurier University

Co-investigators: Susan Flynn and Heidi H. Newton

Abstract: Toronto, Canada's largest and most diverse city, is home to many newcomers from all corners of the globe. This includes lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals seeking safety and freedom from gender- and sexuality-based forms of oppression. LGBTQ youth are part of Toronto's newcomers, yet their experiences and needs, and the factors that make them vulnerable for HIV infection remain largely unknown.

Methods: Teens Resisting Urban Trans/Homophobia (TRUTH) is a CBR collaborative led by Planned Parenthood Toronto and Wilfrid Laurier University. TRUTH is designed to explore the impact of various forms of social exclusion on LGBTQ youth. Between July 2009 and July 2010 more than 70 LGBTQ youth and 16 service providers took part in focus groups and key informant interviews designed to 1) capture youth's diverse experiences with homo/transphobia, 2) explore the impact of those experiences on their health and emotional well-being, 3) provide a theoretical framework that would contextualize the 'risk factors' identified in a broad body of empirical literature, including HIV vulnerability, and 4) identify strategies/interventions to enhance health and well-being. In this presentation, we draw upon a subset of the data (N= 30) focused specifically on the needs of newcomer LGBTQ youth.

Results: LGBTQ newcomer youth report experiencing homophobia and transphobia in their countries of origin, as well as in Toronto (even though it is often heralded as a "multicultural" haven). Youth also report racism and systemic barriers to accessing much-needed services in Toronto. "Being LGBTQ" in Canada, meant taking on or adopting a western 'gay' identity, which presented inherent risks for HIV, including relative sexual freedom (bathhouses, access to alcohol and drugs, etc.), and language barriers that complicate negotiating sexual encounters. Youth described feeling lonely, with an accompanying need for closeness. For our participants, both of these had the potential to lead to sexual activity with unsafe exchange of bodily fluids.

Conclusions: When viewed within a lens of "intersectionality," our data illuminate the specific and unique forms of HIV vulnerability among newcomer LGBTQ youth in Toronto. Newcomers' preconceptions of a Canadian multicultural haven are superseded by unanticipated new forms of social exclusion. With relevant risk contexts revealed, opportunities for innovative HIV interventions are provided.

Date: 2009

Funder: Ontario HIV/AIDS Treatment Network (2009); CIHR- HIV/AIDS Community-Based Research Program - General - Master's Award (September 2009 – August 2011)

Reference: CIHR database

Topic: Trans populations; youth; homophobia, stigma and discrimination; mental health; culture

Project R41

The changing HIV/AIDS epidemic: contextual and social structural challenges to sustaining health, safety and well-being

Principal investigator: Ted Myers, HIV Social, Behavioural and Epidemiological Studies Unit, University of Toronto

Abstract: N/A

Date: 2008

Funder: Ontario HIV/AIDS Treatment Network (OHTN)

Reference: CIHR database

Topic: mental health; social and physical environments

Project R42

The intersection of desire, drugs, and unsafe sexual practices: An ethnographic study of the gay circuit party subculture

Principal investigator: Patrick O'Byrne, University of Ottawa

Abstract: In recent years, gay circuit parties (GCP) have grown in popularity and anecdotal and scientific reports indicate that these parties may have led to an upsurge in crystal meth consumption and a rise in risky sexual practices. As such, it has also been speculated that the GCP could be linked with a large proportion of new HIV infections within the gay community. Yet, when this anecdotal and scientific evidence is used to design public health initiatives for use within these parties, most interventions are disregarded. Furthermore, since current crystal meth rehabilitation programs have a 93% failure rate, it is essential that scientific evidence be collected to create a better understanding of the motivations of users. As illustrated in the preliminary results of a CIHR study by Holmes & Gastaldo (2005/6), a large number of HIV+ and HIV- gay men are aware of the risks of their sexual practices, yet engage nonetheless. This project will try to understand the GCP from the insider perspective by using a qualitative design (ethnography) to identify the motivations of gay men who use drugs and engage in risky sexual practices within the GCP, and to understand the effects of the GCP environment upon drug use and sexual practices.

Dates: January 2007 – September 2008

Funder: Canadian Institutes of Health Research (CIHR) – CIHR III HIV/AIDS & IGH Doctoral Research Award

Reference: CIHR database

Topic: injection drug use; sexual behaviour; social and physical environments

Project R43

The molecular epidemiology of primary HIV infections in MSM of Montreal: is there a role for it in public health?

Principal investigator: John Cox, Research Institute of the McGill University Health Centre

Co-investigators: Michel Alary; Robert Allard; Chris P. Archibald; Gilles Lambert; Pascale Leclerc; Robert S. Remis; and Paul A. Sandstrom

Abstract: Individuals who are newly infected with HIV are more infectious because of high levels of HIV in the blood and semen. These patients are often unaware of their infectious status and may continue the same at-risk sexual behaviours that resulted in infection. In the men who have sex with men (MSM) population, it has been suggested that almost half of new HIV infections may be acquired during this primary HIV infection (PHI) phase and that HIV transmission during PHI helps sustain the HIV epidemic in this population. In this pilot study, we will apply molecular epidemiological methods to link HIV sequences of PHI cases identified during two epidemiological studies of MSM in Montreal from 1996 to 2005 (Argus and Omega Cohort studies). We will determine the degree of PHI clustering/transmission and examine socio-demographic and behavioural determinants of clustered cases. Demonstrating the utility of this approach and possibly describing PHI clustering in this small sample of cases could justify a larger study on the role of PHI clustering in HIV-positive MSM and other HIV at-risk populations such as injection drug users, street youth and people from endemic countries. If PHI clustering proves to be an important element in sustaining the HIV epidemic, public health prevention programs could focus on improving the rates of diagnosis of individuals during PHI, timely risk reduction counselling and contact tracing, and possibly early treatment with antiretroviral medications.

Dates: April 2006 – March 2007

Funder: Canadian Institutes of Health Research (CIHR) – Pilot Project in HIV/AIDS

Reference: CIHR database

Topic: prevention; access to services; PHA; sexual behaviour; biomedical/clinical

Project R44

Process of taking ownership by community workers of a rapid HIV testing intervention for men who have sex with men in the Montreal area

Principal investigator: Ludivine Veillette-Bourbeau, Université de Montréal

Abstract: N/A

Dates: September 2009 – October 2010

Funder: Canadian Institutes of Health Research (CIHR) – HIV/AIDS Community-Based Research Program - General - Master's Award

Reference: CIHR database

Topic: testing; capacity building

Project R45

Trans PULSE project: exploring HIV vulnerability in Ontario's trans communities

Principal investigator: Greta Bauer, University of Western Ontario

Co-principal investigator: Robb Travers

Co-investigators: Rebecca Hammond; Michelle J. Hancock-Boyce; Matthias Kaay; Rupert Raj; Kyle A. Scanlon; and Anna Travers

Abstract: HIV does not affect all groups equally. Studies from across North America strongly suggest that trans communities have higher than expected rates of HIV. This is perhaps not surprising considering evidence that many trans people experience violence and discrimination, and are having difficulty accessing the most basic of services. These include employment, health care, and housing. It is critical to consider these broader factors when trying to understand HIV in marginalized groups such as Ontario's trans communities. To address this, members of these communities - with partners from the Ontario HIV Treatment Network, Sherbourne Health Centre, The 519 Community Centre, The University of Western Ontario, and TGStation.com - have formed a community-based research project - The Trans PULSE Project. Trans PULSE will use a mix of qualitative and quantitative methods to provide the richest possible understanding of the ways that social marginalization may produce HIV vulnerability within trans communities and how social factors, such as healthcare access as well as the source and stability of one's income, can affect quality of life for those trans people who live with HIV. This project addresses a significant lack of relevant information, and reflects a desire by community members to see HIV within a broader context of trans lives and experiences. The project is made up of a[n] 8 person Investigators Committee, 5 of whom are trans, who have worked together in identifying research goals, designing the study, and increasing community involvement to ensure that this research is relevant to the needs of trans communities. Community soundings, wherein trans community members in three different Ontario communities discussed their experiences around health, health care, and HIV risk, have been important in shaping the research.

Dates: April 2007 – March 2010

Funder: Canadian Institutes of Health Research (CIHR) – HIV/AIDS Community-Based Research Program - General - Operating Grant

Reference: CIHR database

Topic: access to services; Trans populations; homophobia, stigma and discrimination

Project R46

Understanding HIV testing, status, condom use and other risky behaviours of First Nations two-spirited men and women from a sociobehavioural perspective using sexual attitudes and sexual scripts

Principal investigator: Nathan J. Lachowsky, University of Guelph

Abstract: HIV/AIDS is a major global health issue that has disproportionately affected the Canadian population (58,000 people living with HIV/AIDS in 2005, a 16% increase from 2002). Social, economic and behavioural factors have been attributed to the higher rates in certain populations. Although First Nations people represent 3.3% of the Canadian people, they have disproportionate rates of HIV infections (6%-12% of new infections annually). Although the majority of First Nations people recognize that HIV/AIDS is a serious problem in Canada, the infection rates continue to rise. The majority of HIV/AIDS cases (58%) and new infections (40%) are seen in Canada's men who have sex with men category. It is estimated that approximately 30% of individuals who are HIV positive are unaware of their status. First Nations people use the term "two-spirited" as the label for mixed gender individuals who would otherwise be included in the umbrella term "queer." Research on two-spirited individuals is limited and underrepresented, particularly in the health field. It is important to understand differences in perception, attitudes and roles between First Nations and non-First Nations groups particularly with respect to sexual practice and sexual risk. The proposed exploratory study will investigate issues of HIV/AIDS in two-spirited First Nations populations compared with attitudes and practices in non-First Nations groups. It will comprise both quantitative and qualitative analysis of the sociobehavioural attitudes and activities. Rates of HIV testing, status, condom use and other risky behaviour will be collected and compared in parallel with qualitative thematic analysis pertaining to sexual attitudes and scripts.

Dates: September 2010 – August 2011

Funder: Canadian Institutes of Health Research (CIHR) Master's Award – Frederick Banting and Charles Best Canada Graduate Scholarship

Reference: CIHR database

Topic: testing; Aboriginal populations; sexual behaviour

Project R47

Unsafe sexual practices in public spaces: An ethnographic study of bareback sex in gay bath houses

Principal investigator: Dave Holmes, School of Nursing, University of Ottawa

Co-investigator: Denise Gastaldo

Abstract: While unsafe sex has been reported since the beginning of the HIV epidemic, the underlying assumption has been that most gay and bisexual men do not seek to intentionally have unprotected anal sex. Results of a recent qualitative investigation (Holmes, 2003) proves that voluntary unprotected anal intercourse (VUAI) among HIV + and HIV negative gay and bisexual men occurs frequently in public spaces such as bath houses. According to some non-scientific journal articles, gay and bisexual men practice VUAI for various reasons: increase in sexual pleasure, a feeling of true connection and intimacy with one's partner, sexual arousal at the thought of transgressing recommendations from public health organizations and HIV prevention campaigns, symbolic bonding through the exchange of semen between partners and finally, new treatments in the battle against AIDS (Scarce, 1998). The actual (epidemiological) understanding of unsafe sexual practices does not take into account several socio-cultural and psychological dimensions that we would like to explore from an ethnographic perspective. It is our contention that this scholarship, though helpful and somewhat illuminative, obfuscates the most essential component powering the practice of bareback sex. A better understanding of motivations as they pertain to VUAI and of representation of risk behind the practice of VUAI by gay and bisexual men frequenting bath houses is necessary in order to lead to the implementation of healthcare providers interventions further adapted to the needs of this population.

Dates: April 2004 – March 2006

Funder: Canadian Institutes of Health Research (CIHR)

Reference: CIHR database Operating Grant - Priority Announcement: HIV/AIDS Research Initiative - Health Services/Population Health Stream

Topic: prevention; sexual behaviour; social and physical environments;

Project R48

Willingness of men who have sex with men (MSM) and injection drug users (IDUs), both HIV-ve and HIV+ve, to take part in a vaccine preparedness study (VPS) and a hypothetical vaccine study

Principal investigator: Shayesta Dhalla, University of British Columbia

Co-investigator: Denise Gastaldo

Abstract: The HIV acquisition rate in MSM and IDUs in B.C. is low by international standards, but generally higher than other rates in North America. It is high enough to allow for a vaccine study. A VPS is necessary prior to a vaccine study. In our VPS, we will look at MSM and IDUs in B.C., both HIV-ve and HIV+ve. After obtaining informed consent, differences between refusers and non-refusers of a VPS will be examined. Sociodemographic variables analyzed will be age; gender; race/ethnicity, use of needle-exchange programs and safe injection sites, sharing needles, compensation for IDUs, prostitution, receptive anal sex with HIV+ve/unknown status partner, >5 partners (all in last 6 mos). Clinical variables will include CD4 count, viral load, number of injections, and HIV antibody status. We will also assess willingness to participate in a hypothetical vaccine study. Follow-up will take place at 6 and 12 months. This will identify people who want to be in a VPS and vaccine study who follow up, people who don't want a vaccine but follow up, people who refuse to follow up, and people who change their minds. Also, we will determine whether enough people would enrol in a vaccine study, so that the potential indirect HIV risk would be less to the rest of the population.

Dates: September 2005 – August 2008

Funder: Canadian Institutes of Health Research (CIHR) – Doctoral Research Award Area of Health Services/Pop. Heath HIV/AIDS Research

Reference: CIHR database

Topic: prevention; injection drug use; PHA; sexual behaviour

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