Monthly Archives: September 2015

Where Passion Meets Persuasion

By: Marcus J. Hopkins, Blogger

This past week marked the ADAP Advocacy Association’s 8th Annual Conference, and I was privileged enough to attend and participate in the event entitled, “A National Conversation about the Ryan White CARE Act and the AIDS Drug Assistance Programs.” In years past, this conference has followed the traditional conference format, with group plenary sessions separated by breakout sessions featuring various topics and speakers, between which one had to choose which topic was of most interest to them. It has always been my belief that this format, while certain informative, leaves those who serve as the lone representative of their organization with the difficult choice of prioritizing one topic at the expense of another, thereby limiting their learning opportunities. In 2015, however, saw a much welcome and much needed change to the format.

In keeping with the theme, this year’s conference was set up much like a talk show – five chairs lined across a stage with a moderator in place to guide the conversation back on topic, should the guests veer too far afield. Each panel had a topic about which they served as experts, and each session allowed both them and the audience to passionately debate and discuss the various aspects of each facet of Ryan White. If every conference were held in this format, I might dread going to D.C. far less than I previously have.

The benefits of this format are myriad – personally, I’ve always felt that a more Socratic approach to educating and informing keeps audiences and students better engaged in the discussion. When experts, advocates, and “field operatives” – those who do work within the existing structure of any given field – are allowed to interject at any given point and respond, expand upon, or provide insight into a discussion, the conversations become more robust, and people hopefully leave with a better understanding of the topics at hand, rather than wondering what the hell it was they just spent an hour-and-a-half attending.

This has, for me, consistently been a problem. As much as I am a data-driven person, better at understanding the numbers that shape and inform healthcare and medical research, whenever it comes to enduring “stories,” I find myself more often than not wishing I had stayed out in the lobby to speak to someone about their research. Where other advocates find inspiration in hearing about the journeys of others, I tend to sit in the audience bored out of my mind, wondering why I gave up smoking.

While I am very adept at identifying, understanding, and working to dissolve barriers to healthcare services, it would be disingenuous of me to suggest that I am a “people person.” I have a very low tolerance for individuals whom, for whatever reason, seem entirely disinclined to take control of their situations and help themselves so that others can help them. Whenever I hear stories about HIV-positive individuals who aren’t adherent to their regimens out of negligence, rather than because they lack access, I find myself wanting to shake someone. Because healthcare is often a matter of life and death, I tend to be more black and white when it comes to discussions about adherence – you either take your meds, or you don’t; it’s a simple as that, for me. It’s this very lack of empathy on my part that makes me a very good researcher and consultant, but likely the last person you’d want to serve in any position advising patients.

My reasons behind this are deceptively simple, but stating this reason in public leaves many people wanting to strangle me in my sleep:

Advocates are very good about being very passionate, very driven, and very loud, but we are not always very good at coming to the table with actual evidence to back up our claims.

This, as it turns out, is a very unpopular opinion, because when it comes to HIV/AIDS, the first decade of the fight to gain attention and action for the disease was fueled almost entirely by passion, an endless supply of drive, and making a lot of noise. This is how HIV advocates cut their teeth, in the 80s, and those who are still around find it both troublesome and infuriating that younger audiences don’t share their enthusiasm. What they often don’t remember is that the fight for recognition and action had to rely upon these elements, because good, research-driven data was either entirely unavailable, or not sufficient for the purposes of bolstering another approach. People were (and still are) dying, and what we needed more than anything was for someone to stand up and pay attention to that fact.

It is safe to say that those attentions were received. Without the tireless and very vocal efforts of early AIDS activists, we might not be where we are, today. It should go without saying that the actions led by ACT UP in Times Square, the New York Stock Exchange, and at the FDA Headquarters in Rockville, Maryland, were instrumental in the fight to gain access to potentially life-saving treatments that were hampered by long trial and approval processes. Without these very passionate, very driven, and very loud activists, we may not have been able to capture the nation’s and the world’s attention, and we very likely might have continued to die in silence. At that point in time, having faces to attach to the disease was vitally important in the attempt to humanize us. But, we did get that attention; we didn’t stay silent; we gained access to treatment.

There are few people under the age of thirty-five who vividly remember how AIDS was portrayed in the 1980s; most of us are too young to remember watching news reports or reading articles accompanied by pictures of living skeletons essentially trapped behind isolation tents surrounded by doctors and nurses whom, out of fear, refused to treat us. We also don’t remember this because, as research efforts and science advanced, AIDS was finally able to undergo a facelift.

Newer technologies and scientific breakthroughs in medicine were finally able to begin addressing the virus in a way that no longer left patients to fester in soiled hospital beds, unable to hold down their meals, and looking like they were auditioning for a role in a George A. Romero zombie film. The HIV Patient of the 1990s was portrayed not as someone dying of AIDS, but as someone “living with HIV.” We could go to the gym, participate in outdoor activities, and yes, even go to work! HIV was effectively rebranded, repackaged, and resold to the public, effectively changing the way the advocacy game was played.

By the time the Aughts rolled around, HIV had largely lost some of its “sexiness.” Now that HIV was no longer a death sentence, it sort of fell off the national radar. When fiscal austerity became the popular spending priority, vocal and passionate activism began to serve less as a useful awareness tool, and more of an annoyance.

What we, as advocates, need to understand is that there is little appetite to increase spending, and just shouting loud enough isn’t enough to make it happen. While names and faces are still important components of an effective advocacy strategy, if we what to effect meaningful and long-lasting legislative change, we must approach these situations differently than we have, historically; simply “rising up” isn’t enough.

This reality is something that tends to “make waves” in the activism community, because this is the way we’ve always done things; the HIV community long struggled to gain not just recognition, but acceptance, and now that the treatment and stigma landscapes have changed (and are continuing to do so), many advocates struggle to keep up with the pace. As with every movement, evolution is a necessity if it wants to remain relevant and survive the changing climate.

Lest the reader think I’m lumping all advocates under the same tent, it must be acknowledged that many activists and advocates are very effective at defining, researching, collaborating, explaining, and achieving their goals as it relates to HIV and HCV policy. What rankles me, however, is the failure of others to recognize that, in order to accomplish great things, a multi-front plan of attack is needed.

The most prescient example of this arose during the panel on HIV criminalization and the impact it has on already marginalized communities. The arguments against the practice of HIV criminalization – that it is inherently discriminatory, that defendants often have few persuasive arguments to make in court to prove their innocence, and that the very nature of these bills criminalizes a virus by trumping up the charges to include bioterrorism – are all very compelling arguments, and they are ones that make sense. But, we cannot rely on arguments of Pathos, alone.

While I heard a lot of passion against criminalization, as well as a seemingly endless amount of handwringing, what I did not hear was a strategy to overturn these laws on the State and Federal levels. And so, I asked the following:

“While I think that we all can agree that HIV criminalization is a travesty, what are some steps that we can take, at the local and Federal level, to go about overturning these statutes and laws?”

What I heard in response was, sadly, nothing comprehensive; in fact, outside of “talk to your local legislators,” there was little functional advice from our panel of experts. Honestly, I think the question caught them largely off guard, as they had been fielding, rather than questions, longwinded stories and inspirational affirmations (Pathos). The gentleman from the American Civil Liberties Union (ACLU) did suggest that we should research our state’s laws on HIV criminalization, but beyond that, the well of suggestions seemed alarmingly dry.

I felt the same sense of incredulity during the post-election Proposition 8 arguments. For some reason, older activists seem to loathe getting litigious, believing that, after thirty-plus years of advancements for LGBT Americans, we still have an inherently unfair court system that is unsympathetic to these aims. In reality, what we had were arguments based on Pathos, and well-meaning, but not necessarily talented lawyers with little social science to back up their claims in court. I can’t even begin to count the number of argument I entered where a senescent survivor of the 80s told me that taking our fight to the courts was the worst thing we could do. Funny how those very same advocates who railed against Equality California’s (EQCA) decision to pursue the matter in the courts conveniently became “ardent supporters, from Day One!” …right after that first legal victory.

When it comes to HIV criminalization, if we continue to find our statehouses filled with social and religious conservative legislators who are unwilling to even entertain evidence-based arguments in favor of repealing these laws, we are going to have to take a page out of EQCA’s book, and pursue the matter in court. We cannot continue to rely upon the ACLU to fight our battles for us; we need to involve the big guns who will insist that we make reasoned, evidence-based, and passionate arguments in court.

This is how we need to begin reshaping our advocacy landscape – by including all types of advocacy into a united front that attacks from every front. We cannot continue to hope that identity politics and passion will be enough to convince our legislative foes that we are in the right; we must begin to strategize, and include people who are good with gathering research and evidence to back up our claims, alongside people who are willing to take our arguments out of the Legislative Branch, and into the judicial branch, and to do so successfully.

The sad truth, from this cynic’s perspective, is that the political system, as it stands, best serves the interests of the rich, the powerful, and the manipulative, and as such, when we go to these elected officials from the perspective of “this is who WE are; WE are the face of HIV,” they simply couldn’t care less. Our legislators, frankly, don’t care who we are, because we don’t fund their campaigns; we don’t line their pockets; we can’t do anything for them.

During the panel on which I sat related to Hepatitis C (HCV) in Appalachia and the effectiveness of harm reduction strategies (namely syringe exchange programs), one very passionate activist made the argument that “…drug users vote, too.” And this, sadly, is where I take issue.

Statistically speaking, drug users, particularly those who use or abuse opioid drugs, tend to fall into the lower end of the income brackets – the least likely bracket of people to vote in elections. The reality is that the poor, the disenfranchised, the minority population, and the young are less likely to vote, in no small part because they simply don’t see the point in participating in a system that seems to have nothing but enmity towards their kind of people.

So, rather than assuming that “…drug users vote, too,” we need to be realistic and assume that they are neither registered, nor interested in voting, and go about using our time and energy to mobilize these populations to go to the polls, even if they’re disinclined to vote in our favor. The first step is to get people registered and to the polls; if, along the way, you can discuss with them the issues that most impact their lives, and provide an impassioned, evidence-based argument to sway them over to your position, you will have won the day.

All things considered, I felt that the 8th Annual aaa+ Conference was a rousing success, even though I left feeling personally frustrated with the types of advocates who were in the audience. Regardless of my issues with the currently feckless state of HIV and HCV advocacy, I also left feeling, to some degree, inspired to take my argument back with me, and work at engaging and inspiring others to become not only advocates for others, but for themselves, as well.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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You’re Not Fully Clean, Unless You’re STD-Clean

By: Marcus J. Hopkins, Blogger

I tested HIV-Positive on April 12th, 2005, while living in Atlanta, GA, and after a six-month self-destructive phase of methamphetamine and alcohol abuse, I entered into a year of self-enforced sexual sobriety. I escaped Atlanta, and fled north, to the cooler climes of Kingsport, TN and Morgantown, WV – two places where I felt certain I would never run the risk of having sex with anyone, both because of the dearth of attractive men (by my own standards) and my innate ability to be “refreshingly” candid about my HIV status. I put that word in quotation marks because, what I consider to be brutal honesty, many people perceive as inappropriate oversharing.

I grew up with the threat of HIV throughout my entire life, so for me, testing Positive never really existed in the context of “Clean vs. Dirty;” you either had it, or you didn’t, and being a gay teen living in the 90s, one grew up learning that it was always best to assume that everyone had HIV, and if they didn’t have that, they probably had something else. While many in the gay male community now view that type of thinking as “sex negative” or “slut shaming” – it isn’t – for many of us, it erased the line between “Clean” and “Dirty.”

This officially licensed Elf Shirt features a silhouette of Buddy the Elf (Will Ferrell) stating that he knows Santa.

This officially licensed Elf Shirt features a silhouette of Buddy the Elf (Will Ferrell) stating that he knows Santa.

From the day I tested Positive, I have never been ashamed of that fact. Shame is for the weak-minded, to my way of the thinking, and allowing oneself to feel ashamed about something that’s not going to change is an act of self-loathing that shouldn’t be tolerated. I also recognize that, thanks to my outright refusal to be indoctrinated into any sort of religious mythology, my concepts of “shame” and “guilt” don’t necessarily align with others’. As such, I have never had a problem with telling someone that I have AIDS, whether or not I’m interested in a sexual encounter with them, because I feel that it’s an opportunity to educate others.

For many others, though, shame, guilt, and self-loathing are behaviors that have been beaten into them (both literally and figuratively) over the course of their lives. Much of this relates to the role that religion has played not only in their own lives, but in the lives of the parents, grandparents, and ancestors in shaping the way we think about sex, our bodies, our sexual predilections – the most basic blocks that help to shape who we are, as human beings. We are taught that our bodies are temples; that sex is shameful and should be hidden; that the types of sex we enjoy are outside the norm if they aren’t engaged in solely for procreative purposes.

Disease has always been associated with cleanliness – that of mind, body, and soul – and despite the light years of advancement made from the days when leprosy’s necrotic physical manifestations defined the “unwashed masses,” we still hold on to the belief that, if someone has contracted a disease, they must be “unclean;” that they are in some way inferior to the “clean” people around them who manage to keep their actions, thought, and spirits “pure.”

Since the sexual revolutions of the 1960s and ‘70s, increased attention has been paid to venereal disease (VD) than ever before in human history. “The diseases of Venus,” – the diseases of love – blood borne sexually transmitted diseases (STDs) and sexually transmitted infections (STIs) have taken the health and medicine communities by storm, since the early ‘80s, when medical science had finally advanced enough to the point where we could properly attribute their spread to certain behaviors and methods of transmission. The AIDS crisis played a particularly important role in helping us to better understand how VDs worked, and how best to treat them.

But, as with anything related to sex, the tyranny of Puritanism still plays an outsized role in how we view human sexuality. Now that leprosy is largely contained to certain parts of the world, largely thanks to penicillin and better sanitation, the new “filth” is that of STDs. Because most transmission of STDs/STIs is related to specific behaviors – sex, sex with multiple partners, injection drug use, et cetera – it is easy to draw a line between those who are “clean” and those who are “dirty.” If someone has managed to contract an STD, regardless of how they’ve done so, it is immediately assumed by some that the person must be behaving in a “dirty” manner.

The truth of the matter is this – the relationship between “cleanliness” and “diseased” is always going to exist; people who believe otherwise are deluding themselves. Truth be told, there is some merit to the argument made by the “sex negative” crowd: if you don’t engage in behaviors that are consistently shown to result in negative health consequences, you generally don’t have to worry about getting an STD.

That said, there are those who argue that, if proper precautions are taken, you can still engage in those types of activities with a far lesser likelihood of contracting an STD:

If you’re HIV-Negative and PrEP is properly utilized, you can avoid contracting HIV; the caveat to that is the fact that Truvada (Gilead) does not prevent the transmission of any other STD (save, pending further research, Hepatitis B), and if used without additional prophylaxis (i.e. – barrier devices such as condoms), there is still the risk on contracting another STD/STI, such as Syphilis, Gonorrhea, or Chlamydia.

If you’re HIV-Positive, recent studies have shown that consistent use of Anti-Retroviral Treatment (ART) to suppress the HIV viral load (the number of actively replicating HIV cells in one’s system) greatly reduces the risk of transmission to a sero-discordant partner.

If you’re an injection drug user (IDU), don’t share needles with other people…ever. Use “clean” needles to inject your drugs. Sterilize the needles and the injection sites to reduce the risk of infection.

There is a “cleanliness” component to reduction of disease transmission, and to pretend that that component will not be applied to people is simply ridiculous. The purging of toxins and infective agents from the body has always been referred to as “cleansing.” If you’re drug and alcohol free, you’re “clean;” when you’re eating all the “right” foods, you’re leading a “clean” lifestyle. These are standards of living by which we all live our lives, to one degree or another, and so long as “cleanliness” is measured, this will literally always be the case. When the scientific reality is that better standards of cleanliness, sanitation, and application are used, the risk of disease transmission is greatly reduced in virtually every case, to expect that standard not to be applied to an individual’s behaviors and habits is unrealistic.

More importantly, there is a contingent within the gay male community who gladly adopt the “clean” and “dirty” labels for themselves, and apply them, also, to others. If you don’t believe me, take a trip to the dark side and read some of the “Bug Chasing” fiction – stories whose topics include the purposeful infecting of someone with HIV – to learn how many people fetishize the taboo of “dirtiness.” While those examples are not reflective of everyone within the gay male community, so long as the fetishizing and glorification of the “taboo” of being “dirty” exists and is popularized, the stigma of HIV infection as “dirty” will remain.

So, how do we address these stigmata? Honestly, I don’t know. Personally, I don’t ever feel “dirty” because I have AIDS; but, again, I didn’t really have the same indoctrination that others had as a child. Perhaps the best way for people to address the “Clean vs. Dirty” stigma is to be open and honest about their status, regardless of the social norm. The saying that “sunlight is the best disinfectant” (notice, again, the reference to cleanliness) doesn’t just apply to dirty political structures; when people have greater exposure to people living with HIV who attempt to live “clean” lifestyles, they are less likely to conflate “HIV-Positive” with “dirty.”
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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The Scarlet Letters

By: Marcus J. Hopkins, Blogger

One of the downsides of working in the field of Health Communication is that, whenever people find out that you have a lot of information about specific diseases, you will inevitably find yourself being peppered with questions at the least opportune moments. This is particularly true of co-workers whom, for whatever reason, seem to believe that I am some sort of medical authority on the subjects of HIV and Hepatitis C (HCV).

This was the case, several months ago, when a former co-worker of mine at GameStop informed me that her grandmother had been diagnosed with HCV, and how she didn’t know what to do to help her. She was, at the time, managing the store, which makes for an inopportune situation for discussing the finer points of treatment and access, but I still managed to give her the pertinent information, while hopefully allaying her belief that her grandmother had become infected at the elder care facility in which she had been residing.

I honestly don’t mind when people come to me for advice; I always make certain to let them know that I am not, in fact, a medical doctor, and as such, my advice should not be taken as prescriptive. That’s really what the field of Health Communication ends up entailing in the Appalachian Mountains – non-professional healthcare education and advice.

What makes Appalachia unique is the almost wholesale avoidance of healthcare providers its residents seem to employ. A region beset by geographic limitations when it comes to access, getting people to go to clinics and doctor’s offices is a Herculean effort, particularly when factoring in generations of distrust in authority of any type. Big Government, Big Business, Big Agra, Big Pharma – if it’s Big, it’s bad, and in the hearts and minds of many Appalachians, “Big” never has anything good in mind for them. Even within my own household, I find myself having to all but force my family members to go to see a doctor for even the most serious of ailments (most recently, continued chest pains over the course of a week, that resulted in a sixth heart attack the day after I left for meetings in D.C.).

This seemingly innate aversion to professional healthcare providers usually results in people asking for anecdotal and non-professional medical advice, a practice that rarely results to desirable outcomes, unless that advice is, “You should consult with a professional.” The problem with this is that it helps to reinforce preconceived notions about diseases like HIV and Hepatitis C that are simply false.

What’s sadder, still, is when people come to me terrified that they’ve contracted HIV or HCV, but are too afraid to go get tested, because they don’t want the stigma of being branded with AIDS or HCV. In a place where Big Authority is distrusted, the reality is that long-discarded stigmata continue to run rampant. In Appalachia, AIDS can still be spread through sharing silverware, and everyone with Hepatitis is hooked on Hillbilly Heroin (OxyContin).

The latter stigma of opioid abuse is further reinforced by the unfortunate reality of the method of transmission, particularly in the case of Scott County, Indiana. Though not, itself, an Appalachian state, Scott County abuts Kentucky and Ohio, both of which fall under that proviso (although the specific areas within those states may not). West Virginia, as I covered in my previous article, Cassandra in the Coal Mines, has a long, troubled history with opioid abuse, and with that abuse came a wave of Hepatitis infections (both B and C) that have left many people in the state afraid of having that stigma attached to them.

The stigma of being perceived to be “dirty” is a very real barrier to testing, treatment, and recovery. Now that HIV and HCV are popular in the news cycle, old stigmata are being resurrected, which may have the negative effect of making Appalachians, already suspicious of Big Healthcare, even less likely to get tested, regardless of how serious the treat to their lives and livelihoods.

What we need, now, in Appalachia, more so than men and women in suits at press conferences, are on-the-ground advocates, providers, and survivors. In rural areas, these types of approaches to healthcare often have the best net results. In my own experience, when people find out that I am living with AIDS, I frequently hear, “I would’ve never thought that you have AIDS! You look so healthy! What’s it like?”

These are the conversations that break down barriers; these are the stories that help convince people to go get tested. With HIV, we have those success stories, made especially poignant after a decade of well-publicized devastation; with HCV, although we have many passionate survivors as advocates, the advocacy and treatment communities are not quite as successful at lionizing these people, and helping to give HCV a national face.

One would assume that, in the post-HIV marketing world, pharmaceutical companies, government agencies, and advocacy groups, alike, would be clamoring to create an effective marketing campaign to raise awareness of HCV. This has yet to be the case. Instead, we are inundated by negative press about HCV – it’s too costly to treat; people are likely to be denied treatment; everyone with HCV is an injection drug user – this is the narrative to which we’ve been subjected.

As someone living only with HIV/AIDS, I am not the survivor that people need for the HCV message. I do, however, believe that we, as activists, advocates, providers, and payers, need to come up with a better information strategy for areas where stigmata still play a big role in preventing treatment.

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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HCV Workshops

By: Marcus J. Hopkins, Blogger

September 2015 will mark the ADAP Advocacy Association’s (aaa+) 8th Annual ADAP Conference — A National Conversation about the Ryan White CARE Act and the AIDS Drug Assistance Programs — an event that brings together patients, advocates, activists, program coordinators, and government administrators to discuss issues relevant to the AIDS Drugs Assistance Program (ADAP). The conference is filled with educational and networking opportunities designed to unite all parties in the conversation about what is most important to people living with HIV/AIDS for whom access to ADAP is a vital part of their survival.

Prior to the start of this year’s conference, two free pre-conference workshops are available on September 24th, 2015, focusing specifically on the burgeoning healthcare crisis that is HCV. These two workshops – Nightmare in Appalachia: How Co-Infection is Disproportionately Impacting Rural Communities and Tactical Changes: Why Comprehensive Harm Reduction Policies Work – will feature a group of panelists (myself, included) who will help to lend some level of insight and expertise to what can often be a confusing situation of which to keep track.

I am very honored to be included on this panel, and look forward to bringing my own experiences dealing with access issues in the Appalachian region. With the recent reveal of the White House strategy to further investigate the root causes and potential solutions to the HCV epidemic sweeping across several states, it seems the perfect time to hear the perspective of someone who not only advocates for Appalachians living with HIV and HCV, but who also lives and works in the area

Having lived for most of my life in and around the Appalachian Region, I can personally attest to the unique challenges people living in this geographically unique region of the United States face when attempting to access low-cost, quality healthcare services. There are many issues working in tandem to create seemingly insurmountable barriers to healthcare:

  • Higher incidence and concentration of poverty
  • Fewer local and regional healthcare options
  • Lower healthcare-related education levels (AKA – Healthcare IQ)
  • Generational and traditional distrust of authority/government institutions
  • Physical geography (distance and ease of travel to healthcare locations)
  • Rampant and resurging stigmata related to health conditions

When people speak of Appalachia, many write the area off as a lost cause. Generations of poverty, drug and alcohol abuse, and social immobility have largely prevented many short-term healthcare initiatives from taking hold. Furthermore, most of the Appalachian states have governments leery of accepting or establishing long-term healthcare initiatives and programs designed to work over time, rather than produce immediate results.

It’s often difficult for people to understand how issues of access really do hamper the ability of Appalachians living with HIV and HCV to receive testing, treatment, and rehabilitative services. This is something I hope to bring to these workshops, and I look forward to helping shed some light on the difficult road ahead.

CLICK HERE to register for the pre-con workshops, or to learn more about them.

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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