HIV and AIDS in the United States


Overview


Human immunodeficiency virus, or HIV, is the virus which causes Acquired Immune Deficiency Syndrome, or AIDS. Once in the body, HIV destroys the immune system by binding to CD4 or T-helper cells, which are white blood cells that recognize and fight infections. HIV causes these cells to replicate to fight the present HIV infection, while also recreating the cells as the actual HIV virus, until eventually CD4 cells are outnumbered by HIV infected cells.

People with HIV have their CD4 cell count monitored often to measure of the progression of their infection. Once one’s CD4 count drops below 200, they are said to have AIDS. Those uninfected with HIV are considered to have a normal CD4 count if it is between 500 and 1500 cells/mm3. Alongside CD4 counts, one’s viral load is measured to determine how quickly the virus is replicating in the body, as well as a guideline for beginning an HIV treatment regimen, known as Antiretroviral Therapy (ART). ART works by slowing the replication of the virus in the body. The use of ART can reduce one’s viral load to "undetectable", or less than 50 copies/mL in the blood.

The first case of HIV was discovered in 1981, when young gay men in New York and California were diagnosed with two rare infections: Kaposi’s Sarcoma and Pneumocystis carinii pneumonia. Originally named GRID, or Gay Related Immune Deficiency, because it commonly occurred among gay men, HIV/AIDS quickly became associated with certain subgroups called the 4-H’s: Homosexuals, heroin-users, hemophiliacs and Haitians [1] As time progressed, HIV spread and it was realized anyone can become infected, yet high rates HIV infection do exist today, especially in African Americans and throughout Sub Saharan Africa.

Many experience no symptoms when they are first infected with HIV and may not begin to notice any symptoms for up to ten years. Those who do have early signs of infection, or Acute HIV infection, may misinterpret this illness as the flu. Occurring 2 to 4 weeks after initial infection, symptoms include: “decreased appetite, fatigue, fever, headache, malaise, muscle stiffness or aching, rash, sore throat swollen lymph glands, and ulcers of the mouth or esophagus.” [2] HIV can still be transmitted even if one exhibits no symptoms, making HIV testing and knowledge of one’s serostatus (seropositive meaning HIV is present, seronegative meaning no HIV is present in the blood) essential in prevention efforts.

Tests for HIV are looking for HIV antibodies, which the body will create when HIV is present. Antibodies can be detected in saliva or blood with an initial screening test (called an ELISA) which takes about 20 minutes to complete; if antibodies are detected, an additional test (called a Western Blot) is completed to confirm ELISA results. When someone receives a negative test result it is often suggested they return for another test in three months if they believe there is any chance they have been exposed to the virus because of a “window period,” or the three to six months it can take for the body to develop antibodies after initial infection.

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HIV Rapid ELISA Test


HIV is transmitted through contact with semen, vaginal fluid, breast milk or blood of an infected individual. The most common modes of transmission are anal and vaginal sex, sharing of used needles/syringes and from mother to child via breast milk; less frequently HIV is transmitted via oral sex or blood transfusions. Even 31 years after the discovery of the virus, misconceptions about HIV are common, especially about how HIV is transmitted. HIV cannot be shared through insects, saliva, kissing, hugging or other casual contact.

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Modes of HIV transmission


Health Impact in the U.S.


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Rate of HIV infections by state per 100,00 in 2008


Within the United States, the most common modes of transmission are male-to-male sexual contact (61%), heterosexual contact (28%), injection drug use (IDU) (8%) and male-to-male sexual contact and IDU (3%). [3] When separated by sex, most women (86%) are infected via heterosexual sexual contact, and 77% of men are infected through male-to-male contact. [4] HIV does not distribute itself among ethnicities evenly though, with black Americans disproportionately affected by the HIV/AIDS epidemic. In 2009, they made up 14% of the population, yet represented 44% of new HIV infections [5]

From the beginning of the epidemic, HIV prevention efforts have focused quantifying risk behaviors and reducing them among individuals deemed high risk. [6] While important to understand what places people at risk for infection, anthropology has built upon epidemiological data in order to understand how culture and political economic structures have shaped HIV/AIDS transmission and why it remains concentrated in some populations but not others. [7]

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HIV prevention advertisement
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HIV prevention advertisement


Medical Anthropology Research in the U.S.


According to the 2010 Census data, black Americans live in poverty at a higher rate than any other ethnic minority group. [8] Nearly 26% of African Americans live below the poverty line, as compared to 14.3% of Americans of all ethnicities. [9] Anthropologist and medical doctor Paul Farmer argues that HIV/AIDS is concentrated among poor, black Americans because of structural violence, preventing them from “reaching their full potential” and making them more likely to become infected because they are socially limited. [10] These limitations may come in the form of poor access to resources such as health care and transportation, concurrent coexisting illnesses and/or malnutrition, inadequate housing and/or job opportunities, all of which are created and compounded by poverty. [11]

Because HIV is transmitted via morally charged behaviors such as sex and injection drug use, HIV/AIDS is a highly stigmatized disease. Those living with HIV are assumed to have engaged in risky activities such as unprotected sex with multiple partners, sharing needles during injection drug use, prostitution, or exchanging sex for drugs or money. While these behaviors are well-known to transmit the virus, an anthropological perspective can shed light onto the macro level factors which place people in situations where these activities are not atypical, or are even done out of necessity.

When explaining why African Americans are overburdened by the virus, it is important to realize that evidence shows that blacks are not engaging in more high risk sexual behavior than other groups. [12] Anthropologists will often consider sociocultural and political economic reasons to discover why black Americans have such high prevalence of HIV/AIDS. HIV transmission and risk is multifactorial and often extends beyond individual risk factors.

Disproportionate Rates of Incarcertation

Within their lifetime, a black men has a 1 in 4 chance of going to prison while his white counterpart has a 1 in 23 chance. [13] This discrepancy is said to be due to the “War on Drugs” which began in the 1980s, which increased consequences for drug use and sales, lengthened the time of minimum sentences and worsened the penalties for crack cocaine. [14] Some argue that areas concentrated with African Americans were targeted, suggesting a war was “declared against the black poor.” [15]

While in prison men, men may engage in unprotected sex with other men, or needle sharing, as clean syringes and condoms forbidden (with a few exceptions). [16] Additionally, prisons have a higher prevalence of HIV infection than the general population, increasing the likelihood of exposure of the virus. [17] If one becomes infected while incarcerated, it is then brought back into the community upon release.

Unequal Sex Ratios

With so many black men in prison, the shortage of viable men are available in society creates unequal sex ratios. For every five African American women, there is one black man between the ages of 20 and 59, in contrast to white men and women who are of “nearly equal” proportion. [18] Because most people tend to choose partners from the same racial group, it naturally makes disease transmission more likely based upon its higher concentration among blacks. [19] In addition, it is suggested that based upon this lack of available partners, women may make “sacrifices” in order to keep their partner around (including, but not limited to, condom negotiation). [20]

Men on the Down Low

Homosexuality and bisexuality are stigmatized in the black community, leading many men to engage in sexual behaviors in secrecy, or “on the down low." [21] Many of these men maintain heterosexual relationships with wives or girlfriends, and infect them due to the presumed monogamy; to suddenly bring up condom use may signal infidelity. [22]

Concurrent Sexual Relationships

Anthropologist Tony Whitehead suggests that lower socioeconomic achievement among blacks (due to poverty, unemployment, imprisonment, unstable housing opportunities, etc.) leads men to overcompensate by increasing sexual prowess and their number of sexual partners. [23] Additionally, these relationships may create denser social networks, leading to pockets of heightened HIV infection [24]

Black Women and HIV/AIDS

Because of the differences in modes of transmission between men and women, additional factors must be considered when explaining HIV in African American women. In 2007, HIV represented between the eighth and third most common causes of death among black women ages 10-64, yet was not represented in the top ten for white women in the same age range. [25] In a white woman’s lifetime, she has a 1 in 526 chance of contracting the virus, while a black woman faces a 1 in 32 chance [26]

Monogamy Narratives and Wisdom Narratives

Anthropologist Elisa Sobo’s work with poor black women in urban Cleveland states that women of color put themselves at risk based upon their desire to uphold the social belief that they are in an “idealized, monogamous, heterosexual union” known as the “monogamy narrative” [27] Women deny their risk for HIV or other STIs by failing to use condoms based upon a “wisdom narrative,” which is used to justify that a woman was able to find a “clean” and “conscious” man who is disease free and would not cheat. [28] Additionally, black women who request condoms may be seen by men as too forward, as having an STI [29] or being “’too schooled’ sexually” [30]

The following is a CBS news report about disproportionate rates of HIV among black Americans.


Applied Work


Medical anthropologist Merrill Singer and colleagues provide an excellent example of applied anthropology working to lessen HIV transmission rates among injection drug users (IDUs) in the Northeastern United States. A three year Syringe Access, Use, and Discard project was conducted in Hartford and New Haven, Connecticut and Springfield, Massachusetts, all of which have comparable rates of HIV infection and use of injection drugs. The purpose of this study was to compare neighborhood and city level differences that may influence risk behaviors among IDUs and engage with city and state organizations and policy makers to advocate for empirically based changes. [31]

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Merrill Singer


Methods

  • Recruitment of 40 IDUs to serve as outreach workers. All outreach workers were trained in the following methods to recruit study participants:
    • Identification of target group or target areas and strategies to approach and begin discussion with them, build rapport, and inform them about in the project
    • Forming relationships with the local community by visiting “community agencies, service providers, shelters, churches, neighborhood stores, and community police.”
    • Approaching IDUs and discussing AIDS risk reduction strategies
    • Assessing interest in project participation, gaining consent and setting up appointments for future interviews
  • 988 one hour structured interviews with qualifying IDUs
  • Focus groups with IDUs by neighborhood
  • participants were asked to keep diaries of their drug use, equipment used and how they came to obtain that equipment
  • participant observation and unstructured interviews with IDUs
  • observation of syringe acquistion
  • interviews with street syringe sellers
  • collection and testing of discarded syringes for previous human use and HIV antibodies, and Hepatitis B and C presence[32]

Who participated?

  • Of the 988 interviewees
    • 70.2% men and 29.8% women
    • 46.2% Hispanic, 33.5% African American, 20.2% white
    • mean age of participant was 35.9 years, range of ages was 18-67
    • 67.6% single and never married, 25% separated or divorced, 7.6% married
**43.7% had not completed high school
    • 83.4% unemployed[33]

Results and Findings


1. Importance of tailoring interventions to local contexts
Singer and colleagues discovered subtle differences between the three cities, even between neighborhoods within the same cities. Unlike New Haven and Hartford, Springfield does not have a legal Syringe Exchange Program (SEP) where IDUs can obtain clean needles. Instead, Springfield IDUs often relied on diabetics who were able to purchase syringes with a prescription from their local pharmacy to obtain clean needles. Street syringe sellers were available, though these were not always new needles.[34]

While the location and services of SEPs were fairly well known by participants, many feared utilizing them for fear of being recognized as an IDU. Additionally, IDUs were reluctant to carry their own syringes as they may be arrested for possession if they were to be stopped by a police officer. This can increase the likelihood of needle sharing or syringe storage for later use, which can increase the risk of needle-sticks in public areas. The availability of SEPs also allows for safe disposal of syringes which are no longer usable.[35]

2. The need to create ethnically and culturally sensitive prevention
Of the Latino participants recruited, 98% of them were Puerto Rican, leading Singer and colleagues to consider the cultural differences which may shape their drug use and risk behaviors. Despite what many might assume to be a homogenous cultural group, Puerto Rican IDUs varied between cities. In Hartford, they tended to be younger, more likely to be homeless and unemployed, and less likely to be using government assistance compared to Puerto Ricans in New Haven or Springfield, among numerous other differences in reported physical and mental health statuses and HIV serostatus. [36] This shows the necessity of taking local subpopulations into consideration.

3. Take into account the local barriers to prevention
As previously mentioned, police enforcement of syringe possession laws could be contributing to HIV rates and inhibit the success of risk reduction interventions. The availability of SEPs, the hours they are open for exchange and the willingness of pharmacies to sell syringes without a prescription are also factors to consider when working with IDUs. Even the best planning and implementation of risk reduction programs will fail without consideration of potential barriers on a state and local level.[37]

4. Use research as a new approach to interventions
During this study, it was discovered that ethnographers served dual purposes—not only were they collecting information, but their open demeanors as unbiased data collectors allowed for participants to share their experiences and troubles with them. This relationship was found to encourage safer drug and sexual activities. The diaries, as well, were said to have a self-appraisal function, causing some participants to enter treatment earlier after reflecting on their writings in the drug use diary. [38]

5. Create local databases of research findings.
In order to increase the use and applicability of the data collected from this study, Singer and colleagues encourage the creation of a database for local use. This would include epidemiological data such as HIV and Hepatitis rates, availability, location and frequency of use of SEPs, rates of incarceration, how locals understand and perceive their risk behaviors and level of risk, and areas where drug use frequently occurs. [39] This database would serve as a location to store information retrieved from ongoing studies, provide background data for grant writing and aid in prevention techniques for local service providers.

6. Anthropologists as activists and advocates
Members of the research team were engaged in advocacy work with legislators and city council members, as well as appearing on local television stations to advance their HIV/AIDS prevention goals. Letters to the editor were written to the New York Times and other local newspapers to raise awareness. This use of knowledge served as a way to demonstrate their concern to the community where they conducted research. [40]

Conclusion

The work of Singer and his colleagues allow for not only rigorous research of the individual and interpersonal behaviors, attitudes, and beliefs about injection drug use and HIV risk, but brought to light the potential barriers to risk reduction efforts. The application of this study through community activism, informing the public via local and national media outlets, and recommendations for future endeavors (e.g. a database) allows anthropological knowledge to be put to use to make practical changes in the lives of many. [41]

Online Resources



Further Reading



  • Parker, Richard 2001 Sexuality, Culture, and Power in HIV/AIDS Research. Annual Reviews of Anthropology 30:163-179.
  • Friedman, S. R., H. L. Cooper, and A. H. Osborne 2009 Structural and social contexts of HIV risk Among African Americans. Am J Public Health 99(6):1002-8.
  • Aral, Sevgi O., Adaora A. Adimora, and Kevin A. Fenton 2008 Understanding and Responding to Disparities in HIV and Other Sexually Transmitted Infections in African Americans. Lancet 372:337-340.
  • Dodge, Brian, William L. Jeffries IV, and Theo G. Sandort 2008 Beyond the Down Low: Sexual Risk, Protection, and Disclosure Among At-Risk Black Men Who Have Sex With Both Men and Women (MSMW). Arch Sex Behav 37(5):683-696.
  • Millett, Gregorio A., John L. Peterson, Richard J. Wolitski, and Ron Stal 2006 Greater Risk for HIV Infection of Black Men Who Have Sex With Men: A Critical Literature Review. American Journal of Public Health 96:1007-1019.
  • Singer, Merrill 1994 AIDS and the Health Crisis of the U.S. Urban Poor; The Perspective of Critical Medical Anthropology. Soc. Sci. Med. 39(7): 931-948.
  • Abraham, and Anna Marie Nicolaysen 2006 Syndemics, Sex and the City: Understanding Sexually Transmitted Dieases in Social and Cultural Context. Social Science and Medicine 63:2010-2021.
  • Williams, Kim M. and Cynthia M. Prather 2003 Racism, Poverty and HIV/AIDS Among African Americans. In African Americans and HIV/AIDS. D.H. McCree et al. (eds.) Atlanta: Centers for Disease Control and Prevention.







References



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  2. ^ The New York Times Health Guide n.d. Acute HIV Infection. http://health.nytimes.com/health/guides/disease/acute-hiv-infection/overview.html, accessed March 20, 2012
  3. ^ Centers for Disease Control and Prevention 2012 HIV Surveillance - Epidemiology of HIV Infection (through 2010). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm
  4. ^ Centers for Disease Control and Prevention 2012 HIV Surveillance - Epidemiology of HIV Infection (through 2010). http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm
  5. ^ Centers for Disease Control and Prevention 2012 HIV among African Americans. http://www.cdc.gov/hiv/topics/aa/. Accessed March 25, 2012.
  6. ^ Parker, Richard 2001 Sexuality, Culture, and Power in HIV/AIDS Research. Annual Reviews of Anthropology 30:163-179.
  7. ^ Parker, Richard 2001 Sexuality, Culture, and Power in HIV/AIDS Research. Annual Reviews of Anthropology 30:163-179.
  8. ^ DeNavas-Walt, Carmen, Bernadette D. Proctor, and Jessica C. Smith 2010 Income, Poverty, and Health Insurance Coverage in the United States: 2009. U. S. Census Bureau.
  9. ^ DeNavas-Walt, Carmen, Bernadette D. Proctor, and Jessica C. Smith 2010 Income, Poverty, and Health Insurance Coverage in the United States: 2009. U. S. Census Bureau.
  10. ^ Farmer, Paul E., Bruce Nizeye, Sara Stulac and Salmaan Keshavjee 2006 Structural Violence and Clinical Medicine. PLoS Medicine 3(10):1686-1691.
  11. ^ Farmer, Paul E., Bruce Nizeye, Sara Stulac and Salmaan Keshavjee 2006 Structural Violence and Clinical Medicine. PLoS Medicine 3(10):1686-1691.
  12. ^ Adimora, Adaora A., and Victor J. Schoenbach 2002 Contextual Factors and the Black-White Disparity in Heterosexual HIV Transmission. Epidemiology 13(6):707-712.
  13. ^ Blankenship, Kim M., Amy B. Smoyer, Sarah J. Bray, and Kristin Mattocks 2005 Black-White Disparities in HIV/AIDS: The Role of Drug Policy and the Corrections System. Journal of Health Care for the Poor and Underserved 16(4 Supplemental B):140-156.
  14. ^ Blankenship, Kim M., Amy B. Smoyer, Sarah J. Bray, and Kristin Mattocks 2005 Black-White Disparities in HIV/AIDS: The Role of Drug Policy and the Corrections System. Journal of Health Care for the Poor and Underserved 16(4 Supplemental B):140-156.
  15. ^ Kelley, Robin D.G. 1997 Looking Backward: The Limits of Self-Help Ideology. In Yo' Mama's DisFUNKtional!: Fighting the Culture Wars in Urban America. Pp. 78-102. Boston: Beacon Press.
  16. ^ Blankenship, Kim M., Amy B. Smoyer, Sarah J. Bray, and Kristin Mattocks 2005 Black-White Disparities in HIV/AIDS: The Role of Drug Policy and the Corrections System. Journal of Health Care for the Poor and Underserved 16(4 Supplemental B):140-156.
  17. ^ Braithewaithe, Ronald L., and Kimberly Arriola 2003 Male Prisoners and HIV Prevention: A Call for Action Ignored. American Jouranl of Public Health 93:759-763.
  18. ^ Lane, Sandra D., Robert H. Keefe, Robert A. Rubinstein, Brooke A. Levandowski, Michael Freedman, Alan Rosenthal, Donald A. Cibula, and Maria Czerwinski 2004 Marriage Promotion and Missing Men: African American Women in a Demographic Double Bind. Medical Anthropology Quarterly 18(4):405-428.
  19. ^ Lane, Sandra D., Robert H. Keefe, Robert A. Rubinstein, Brooke A. Levandowski, Michael Freedman, Alan Rosenthal, Donald A. Cibula, and Maria Czerwinski 2004 Marriage Promotion and Missing Men: African American Women in a Demographic Double Bind. Medical Anthropology Quarterly 18(4):405-428.
  20. ^ Lane, Sandra D., Robert H. Keefe, Robert A. Rubinstein, Brooke A. Levandowski, Michael Freedman, Alan Rosenthal, Donald A. Cibula, and Maria Czerwinski 2004 Marriage Promotion and Missing Men: African American Women in a Demographic Double Bind. Medical Anthropology Quarterly 18(4):405-428.
  21. ^ Martinez, Jaime and Sybil G. Hosek 2005 An Exploration of the Down-Low Identity: Nongay-Identified Young African-American Men Who Have Sex with Men. Journal of the National Medical Association 97(8):1103-1112.
  22. ^ Small, Eusebius, Maxine L. Weinman, Ruth S. Buzi, and Peggy B. Smith 2009 Risk Factors, Knowledge, and Attitutdes as Predictors of Intent to Use Condoms among Minority Female Adolescents Attending Family Planning Clinics. Journal of HIV/AIDS & Social Services 8(3):251-268.
  23. ^ Whitehead, Tony L. 1997 Urban Low-Income African American Men, HIV/AIDS, and Gender Identity. Medical Anthropology Quarterly 11(4):411-447.
  24. ^ Adimora, Adaora A., and Victor J. Schoenbach 2002 Contextual Factors and the Black-White Disparity in Heterosexual HIV Transmission. Epidemiology 13(6):707-712.
  25. ^ Heron, Melonie 2011 Deaths: Leading Causes for 2007. National Vital Statistics Report 59(8):1-96.
  26. ^ Centers for Disease Control and Prevention 2011 HIV among Women. Atlanta: Centers for Disease Control and Prevention. http://www.cdc.gov/hiv/topics/women/pdf/women.pdf, accessed March 23, 2012.
  27. ^ Sobo, Elisa J. 1995 Choosing Unsafe Sex: AIDS-Risk Denial Among Disadvantaged Women. Philadelphia: University of Pennsylvania Press.
  28. ^ Sobo, Elisa J.1995 Choosing Unsafe Sex: AIDS-Risk Denial Among Disadvantaged Women. Philadelphia: University of Pennsylvania Press.
  29. ^ Bowleg, Lisa, Michelle Teti, Jenne S. Massie, Aditi Patel, David J. Malebranche and Jeanne M. Tschann 2011 'What does it take to be a man?' What is a real man?': ideologies of masculinity and HIV sexual risk among Black heterosexual men. Culture, Health & Sexuality 13(5):545-559.
  30. ^ Whitehead, Tony L. 1997 Urban Low-Income African American Men, HIV/AIDS, and Gender Identity. Medical Anthropology Quarterly 11(4):411-447.
  31. ^ Singer, Merrill, Tom Stopka, Susan Shaw, Claudia Santelices, David Buchanan, Wei Teng, Kaveh Khooshnood, and Robert Heimer 2005 Lessons from the Field: From Research to Application in the Fight Against AIDS among Injection Drug Users in Three New England Cities. Human Organization 64(2):179-191
  32. ^ Singer, Merrill, Tom Stopka, Susan Shaw, Claudia Santelices, David Buchanan, Wei Teng, Kaveh Khooshnood, and Robert Heimer 2005 Lessons from the Field: From Research to Application in the Fight Against AIDS among Injection Drug Users in Three New England Cities. Human Organization 64(2):179-191
  33. ^ Singer, Merrill, Tom Stopka, Susan Shaw, Claudia Santelices, David Buchanan, Wei Teng, Kaveh Khooshnood, and Robert Heimer 2005 Lessons from the Field: From Research to Application in the Fight Against AIDS among Injection Drug Users in Three New England Cities. Human Organization 64(2):179-191
  34. ^ Singer, Merrill, Tom Stopka, Susan Shaw, Claudia Santelices, David Buchanan, Wei Teng, Kaveh Khooshnood, and Robert Heimer 2005 Lessons from the Field: From Research to Application in the Fight Against AIDS among Injection Drug Users in Three New England Cities. Human Organization 64(2):179-191
  35. ^ Singer, Merrill, Tom Stopka, Susan Shaw, Claudia Santelices, David Buchanan, Wei Teng, Kaveh Khooshnood, and Robert Heimer 2005 Lessons from the Field: From Research to Application in the Fight Against AIDS among Injection Drug Users in Three New England Cities. Human Organization 64(2):179-191
  36. ^ Singer, Merrill, Tom Stopka, Susan Shaw, Claudia Santelices, David Buchanan, Wei Teng, Kaveh Khooshnood, and Robert Heimer 2005 Lessons from the Field: From Research to Application in the Fight Against AIDS among Injection Drug Users in Three New England Cities. Human Organization 64(2):179-191
  37. ^ Singer, Merrill, Tom Stopka, Susan Shaw, Claudia Santelices, David Buchanan, Wei Teng, Kaveh Khooshnood, and Robert Heimer 2005 Lessons from the Field: From Research to Application in the Fight Against AIDS among Injection Drug Users in Three New England Cities. Human Organization 64(2):179-191
  38. ^ Singer, Merrill, Tom Stopka, Susan Shaw, Claudia Santelices, David Buchanan, Wei Teng, Kaveh Khooshnood, and Robert Heimer 2005 Lessons from the Field: From Research to Application in the Fight Against AIDS among Injection Drug Users in Three New England Cities. Human Organization 64(2):179-191
  39. ^ Singer, Merrill, Tom Stopka, Susan Shaw, Claudia Santelices, David Buchanan, Wei Teng, Kaveh Khooshnood, and Robert Heimer 2005 Lessons from the Field: From Research to Application in the Fight Against AIDS among Injection Drug Users in Three New England Cities. Human Organization 64(2):179-191
  40. ^ Singer, Merrill, Tom Stopka, Susan Shaw, Claudia Santelices, David Buchanan, Wei Teng, Kaveh Khooshnood, and Robert Heimer 2005 Lessons from the Field: From Research to Application in the Fight Against AIDS among Injection Drug Users in Three New England Cities. Human Organization 64(2):179-191
  41. ^ Singer, Merrill, Tom Stopka, Susan Shaw, Claudia Santelices, David Buchanan, Wei Teng, Kaveh Khooshnood, and Robert Heimer 2005 Lessons from the Field: From Research to Application in the Fight Against AIDS among Injection Drug Users in Three New England Cities. Human Organization 64(2):179-191