Screening: A Further Purpose and Reach?

Can simply asking someone how often they smoke marijuana, or how much alcohol they drink, or what impact doing cocaine is having on them, cause them to rethink their use pattern? Questions like these are part of common screening tools. Can they play a broader, more dynamic role?

Typically, the questionnaires help a professional identify those at risk for – or already experiencing – associated harms. As such, screening serves a clinical function to distinguish appropriate candidates for further assessment, diagnosis and intervention. Screening can facilitate the timely delivery of service to those who require it. However – somewhat to the surprise of researchers and clinicians – another positive result is not uncommon. Giving people opportunity to report signs of risk or difficulty in their substance use has at times, by itself, prompted a positive change on their part, without need for any further treatment.

This reality, that screening can prove effective on its own without referral to specialists for continued assistance, suggests a broader beneficial role for it than just functioning as a prelude in the clinical process. People often engage in habitual behaviours without considering various influences on those patterns or adverse impacts arising from them. Screening can be used as a conversation starter, to open an exchange that prompts critical self-reflection, raises awareness, and increases intentionality around such behaviours. Using screening in this way can enhance someone’s literacy around wellness – including not just their capacity to understand health-related messaging or access support services but also their ability and skill to better manage their own health. Rather than leading to an intervention, this approach to screening is brief intervention – an occasion in which attentive care is actively exercised toward another’s well-being.

What are the important implications for screening with this educational purpose? For one, it aims to reinforce agency and self-efficacy, without ignoring interdependence and the benefit of support from fellow human beings. The client or patient in the clinical setting is not a passive recipient of authoritative care, but the primary actor. Miller and Rollnick’s Motivational Interviewing approach to counselling is perhaps the most acclaimed way of evoking the other person’s internal resources for making change.

But this empowering orientation is far from being the domain of professionals only; screening as an educational exercise can be carried out by non-specialists in unofficial or casual settings, reaching a much larger circle of people. In these contexts, laypersons without clinical credentials act as helpers to those who are essentially their peers. The “screen” may consist of a few relevant questions around another person’s substance use. The aim again will be engagement, to initiate a respectful and receptive dialogue that explores why the person might want to make changes to their behaviour, in the process eliciting and encouraging their ownership and pursuit of such change.

At CARBC, we have developed a variety of screening tools for educational purposes, for both adults and youth. Since people can also self-screen using web-based aids, Alcohol Reality Check is available in online and paper versions that provide personalized feedback or short guides with suggestions on offering such feedback face-to-face. The Art of Motivation and AME are more extensive educational resources that also use screening as a gateway to conversation rather than a precursor to assessment and diagnosis. But learning can happen in any relationship. Respectfully asking a friend about their pattern of use and how it may be affecting them and others now or in the future can open the door to some enlightening and transformative discussion.

Author: Tim Dyck is a Research Associate in CARBC’s Vancouver-based knowledge mobilization unit.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

Trading Places: Young People Educating Adults

Young people frequently listen to adults talk, question, give advice, direct, correct, educate, praise, cajole, and more.  But what if youth had an opportunity to educate adults, such as parents, teachers and others? Would a youth voice sway adult attitudes and understandings regarding communication, youth culture,  parenting approaches, adolescent substance use?

Based on experience from conversations over the last seven years the answer to the above questions is a resounding “yes.”

What is a Capacity Café?

A Capacity Café is a youth-friendly environment where youth openly talk about what matters to them while adults sit and listen!  It is a unique, structured opportunity where grownups can come to understand and appreciate life from a youth’s perspective, thus becoming better equipped to support and be an ally for youth.

How is a Capacity Café conducted?

Capacity Cafés are held several times a year in local Vancouver high schools and are organized by SACY, the School Age Children and Youth Substance Use Education and Health Promotion Initiative. Secondary school students with and without substance use experience are recruited, primarily from those whose voices are least attended to by adults. Prior to the café, these young people participate in activities with SACY facilitators to help them develop trust and comfort within a group setting, build confidence and a sense of safety for speaking their truth, and prepare for a larger group discussion with adults. The adults (from a different school than the youth speakers) meet separately to identify topics they would like to know more about from the youth perspective, hear about the safety guidelines for the evening and learn how to participate in an effective listening activity.

During the Capacity Café, adults sit in a facilitated circle listening to youth share their perspectives and experiences on the issues anonymously identified by the adults. They do not speak.  Their role while with the youth is simply to listen. The one-way talk sees youth addressing questions such as:

• What stresses young people out?
• What gives you confidence?
• Why do some youth use substances? Why do some youth not use substances?
• What do parents/caregivers do that doesn’t work for you? What works well?

What are the benefits of the Capacity Café?

According to an evaluation by Arbor Educational & Clinical Consulting Inc., as a result of attending the Café, adults report spending more time listening to youth, more patience, more perspective-taking, and providing more space for the youth to approach them for conversation. Both youth and adults report feeling empowered by the event.

As a result of the Capacity Café,

• 84% of adults strongly agreed that they felt that they had a better understanding of life from a teen’s perspective. “It was helpful to hear about other kids talk about “stress” – I thought my son was just sensitive.”
• 70% of adults strongly agreed that they felt more confident that they could talk to their youth about difficult subjects. “I’ve learned to work with my son and not against my son.”
• 57% of adults strongly agreed that they intended to spend more time talking with their youth about substance use issues. “Listening to the kids (at the Capacity Café) reminded me to slow down, and stop nagging and really hear my kids.”

Youth who have participated in several events have also experienced positive development in their role as community leaders. Youth say:

“That is the longest an adult has ever listened to me in my whole life!”

“I can’t believe they (group of parents) wanted to hear what I had to say!”

Making space for the youth voice has the potential to shift adults’ understanding of youth experience, while strengthening adolescents’ sense of value and self-respect.

Author: Art Steinmann, Manager, Substance Use Health Promotion and SACY

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

The Politics of Drug Education

A lot of drug education is based on what Carl Rogers calls the “jug and mug” theory of education.[1] That is, the instructor (the jug) is seen as possessing knowledge that needs to be poured into the students (the mugs). The requisite knowledge is defined by the powers-that-be as information about drugs, particularly about the potential harms that might result from drug use. Generally, the “jug” exercises power over the “mug” through a combination of rewards (grades and career opportunities) and punishments (failure and fear). In the context of drug education, many of the incentives have little influence, so there has been an over-dependence on fear as a primary mechanism of power and control. As a result drug education focuses predominantly on negative consequences – often over-stating these.  And punishments for drug offences are often more severe than for other potentially harmful behaviours.

The iMinds Health Literacy Resource draws on Carl Rogers’ humanistic person-centred approach to education in combination with Bandura’s social cognitive theory.

Traditional drug education has not been very effective. There is an alternative. In developing iMinds, we have drawn on Rogers’ humanistic person-centred approach to education in combination with Bandura’s social cognitive theory. Essential to this approach is the presence of learning facilitators who trust that people can think for themselves. The other major element of this alternative approach involves striking a balance between a person’s autonomy and their social interdependence – what we sometimes call “the frog and the pond.” We need to be interested in the individual in terms of capacity and resilience (“the frog”). But we also need to give attention to the social, cultural and political dynamics of the classroom, school and community (“the pond”).

Both of these critical elements are “political” in nature in that they have to do with power, control and the making of choices. Humanistic education gives the power to the student. It is about preparing young people to be citizens – participants in our democratic institutions. As one writer puts it: “If democracy is to work, its citizens must be educated. They must know how to gather information, distinguish fact from opinion, analyze propaganda, understand many different viewpoints, understand justice, think for themselves, communicate their opinions clearly, and work with others for the common good.”[2] This seems like a good road map for drug education.

There are several rational reasons why a person might choose to use a drug. But the impact of that use almost always is affected by many factors related to the drug, the person using the drug and the social and physical context in which the drug is used. Drug education is not about saving young people from the evils of drugs or protecting them from the dangers of drugs. The stakes are far greater. Drug education involves giving young people the power to make decisions and helping them to develop the skills to make good decisions that will enhance their own lives, the lives of their peers, and the lives of those who come after them.

If we know that simply pouring out our knowledge about the risks involved is not effective, maybe it is time to give up the illusion of power and try a different approach.

[1] Rogers, C. (1983). Freedom to Learn for the 80’s. Toronto: Collier Macmillan Canada, p. 187.
[2] Herron, J. (1999). The Complete Facilitator’s Handbook. London: Kogan Page, p. 4.

 

Author: Dan Reist, Assistant Director (Knowledge Exchange), Centre for Addictions Research of BC

 

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

Plant the Seeds and See What Grows: Education and Culture Change

When I try to explain the kind of work that I do for CARBC, I often use the analogy of being a farmer. I am the Coordinator of the Changing the Culture of Substance Use Project, a multi-year project to build a vibrant community of practice on BC’s post-secondary campuses. But my work is similar to the farmer; I research, prepare and plan what we should grow, examine the growing conditions, help plant the seeds, and then I, along with my team, continuously encourage their growth so that we will have a fruitful harvest. Of course, our seeds are very different from the farmer’s. Ours are the seeds of thought as to how we might change a culture of substance use in a growing campus community of practice. And what we hope to eventually see is the changing norms, attitudes, programs, policies, and practices that reflect this kind of thinking on campus.

Education with respect to culture change is a unique challenge. When the goal is culture change, education becomes about engagement. We need to think about whom we engage in this learning, how we engage them and what we engage them about. We are not necessarily concerned with equipping these folks with the tools to manage their own patterns of use (although that may be a by-product of the process). Rather, we hope that they will become part of a larger concerted effort to co-develop efforts on campus that have the power to significantly impact generations of students.

• So who should we engage in this kind of learning? We engage those who are intrinsically interested and motivated to be part of a culture change effort on campus. These could include counselling staff, health practitioners, faculty members, students, access and support services, deans, as well as many others.  Our basic premise is that all members of a campus community can potentially be or become leaders in culture change.

• And how do we engage them? Our engagement is constructivist and collaborative. We harness the expertise in the room and in this field around what might change a culture on a particular campus. Campuses will learn from each other and pick up tools and techniques that have been successful for others for adaptation. For instance, Selkirk College recently developed an innovative Dinner Basket program that encourages students to share a meal and discuss substance use in a nonjudgmental manner. Several other campuses are now adapting this approach for their own contexts.

• And what do we engage about? Often it is a combination of a wide variety of topics. These topics generally focus on how we go about shifting a culture. For instance, we might begin with some discussions on the role of culture in influencing behavior around substance use. As we become more familiar with the topic, we look at mechanisms for changing a culture, such as community of practice building, motivational approaches or situational assessment. The goal is to build the toolbox campuses have at their disposal with the best in current thinking and see what takes hold. This may sound haphazard, but it allows us to avoid being prescriptive in what we endorse and encourages campuses to identify their own goals, resources, areas of strength and required efforts in this process.

This type of work is not easy or simple. Much like the farmer’s work, it requires patience, flexibility, responsiveness and the ability to see the forest for the trees. It also requires the ability to release control and allow the community to grow and develop, guided by a caring hand. With dedicated, strategic and consistent efforts, we are hopeful for a plentiful harvest.

To learn more about the Changing the Culture of Substance Use Project and/or how to join our community of practice, please check out this article in CMHA-BC’s Visions Journal or visit our website at www.healthycampuses.ca.

Author: Catriona Remocker, Research Associate, Centre for Addictions Research of BC; Coordinator of the Changing the Culture of Substance Use Project

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

 

Drug Education Takes Many Forms

Drug education does not solely require educating people about drugs; it can also mean educating them about how to use drugs safely. This increases their capacity to mitigate the risks related to drugs, empowering them to manage their substance use. In turn, this helps them make better decisions about use in the context of their own unique situation.

The Safer Use series, developed by the Centre for Addictions Research of BC, offers practical ways for people who use substances to be active players in their own well-being, including helping them develop skills in managing their patterns of use, as well as adopt safer modes of use and ways to mitigate risk.

One of the challenges in developing the series was how to address effectively the needs of people who are experienced in substance use yet may be using in risky ways.  As the development process unfolded, it was helpful to constantly ask is the content …

• Easy to understand. “Clear but not simplistic” is a useful principle to keep in mind. The aim is to help the reader grasp and use the content as easily as possible. Some ways to do this include using audience-appropriate everyday words (e.g., “drunk” rather than “intoxicated”) as well as clarifying with illustrations and using informative headings such as “before you start” and “things to avoid.”
• Relevant. Knowing the audience is so important. Material that is tailored to address specific concerns helps engage people and draw them in. For instance, techniques of safer injecting may matter to street-entrenched youth, but would be less relevant for club- or party-going youth who may be more concerned about “safer tripping” strategies.
• Useful. Ensuring suggested practices are doable and practical improves the chances they will be adopted. This involves going beyond the ideal (e.g., recommending the use of sterile water) and providing more accessible alternative measures (e.g., boiling tap water). While it’s critical to ground content in sound theory and evidence, lengthy explanations of the research behind a suggested practice can obscure key messages.
• Credible. Making sure the content is objective and balanced helps build trust. Drug education efforts risk being discredited when messages conflict with the experience of the audience. Therefore it is important to offer an honest and even-handed discussion that acknowledges the positive effects of drugs as well as potential harms.

No substance use is completely without risk, but educating people who use drugs to manage use more safely affirms their self-efficacy – the capacity to increase control over their own health.

Author: Bette Reimer, Research Associate, Centre for Addictions Research of BC

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

How Peer Education can make Festivals Safer

With the recent deaths at Toronto’s VELD festival or the Boonstock Festival in Penticton, BC, many people are now scrambling to come up with explanations for the tragedies. Toronto Police are blaming bad drugs. Many media outlets are taking the opportunity to blame youth culture. Whatever story we tell, the fact is that people are doing drugs at parties.

How can we encourage people to party more safely? (image courtesy of the Trip! Project)

That’s where The Trip! Project comes in. We go where the party is. We hit up bars, festivals, frosh events, concerts, bathhouses, raves, after hours clubs – wherever folks are getting down. Here at Trip! we neither condemn nor condone drug use. Trip! is a harm reduction outreach group based in Toronto. We offer peer support, tripsitting (supporting someone through a psychedelic crisis) and give out tons of information about how to party safer.

The Trip! Project is run by peers, youth who party themselves and are active in the scene. Peer education is an invaluable tool in harm reduction. When we set up a Trip! booth, we are able to engage with people who party on a different level than other drug educators. As peers, we are able to meet people where they are at, have honest and frank discussions about substances and create a sense of trust. When we do rounds at a party, we’re checking in on people who are suspicious of security and medics but tend to be in situations outside of their experiences. We are able to offer on the spot support, answer basic questions, suggest ways to reduce harm, and spot signs of medical distress. Peers are trusted because they operate outside of formal institutions associated with one-sided information linked to an abstinence-based, prohibition model.

At parties, we set up Trip! booths, which have all kinds of non-judgemental and helpful information on different substances, safer use and safer sex. We give out condoms and lube as well as different coloured straws, so that if folks are snorting with friends they can keep track of their straw and reduce the risk of spreading Hepatitis C.

Our outreach workers also liaise with venues and promoters to help them make their parties safer. We advocate for free water. We encourage clubs and venues to allow ins and outs so that people can cool down and suggest other simple measures to help create a safer nightlife. At festivals, we encourage organizers to keep police away from medic tents unless absolutely necessary. This stops people in need of medical attention from avoiding medics because of fear of criminalization. Most importantly, we try to help organizers acknowledge drug use at their events and allow us to help make it safer.

Festivals can be safer. Nobody has to die at a party. But we need a harm reduction approach that gives people the information and resources they need to stay safe.

Contact us at: info@tripproject.ca and like us on Facebook!

Author: Steff Pinch, harm reduction outreach worker at the Trip! Project

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

Must we punish in order to teach?

The great appeal of “just say no” is that it is simple – straightforward. But that simplicity replaces a broad commitment to “education” with a narrow application of “social marketing” (the art of selling someone on an idea or behaviour that promotes the social good). Nothing wrong with social marketing, but it should never be all there is to drug education.

A similar narrowing process seems to have happened with our concept of discipline which has largely come to be seen as punishment. But discipline is from the root “disciple,” and a disciple is a student or apprentice – one who is learning. So how did discipline come to mean punishment? Well, because some ancient one discovered that humans do not like pain. And, if you induce pain and associate it with a particular behaviour, a person may learn to avoid the pain by avoiding the behaviour – a sort of hands-on social marketing. All of this is true – but it is not the whole truth.

It is too simple.

Life is more complex. Not everyone has had the same past experiences or holds the same beliefs or has the same personality. As a result, not everyone reacts the same way to any specific situation, including punishment or a social marketing message. In practice a social marketing campaign that works with some people may, in fact, have a negative impact on those most vulnerable to harm. The same is true for punishment.

So, for example, a zero-tolerance policy related to drug use may help students who are highly connected to the school and motivated to achieve high marks to make sure they do not get caught smoking weed at school. But the same policy might have a very different effect on a student who feels little connection to the school. The resulting suspension may actually be a “badge of achievement” rather than something to be avoided. That means, the punishment has little deterrent effect, but it is, nonetheless, harmful in that it lowers the student’s connection to school and the chance of successful completion. The evidence is mounting that punitive responses are doing more harm than good.

So what can schools do about drugs? The available evidence seems to suggest that multiple strategies are needed and that these various elements of a comprehensive approach need to work together. For example, clear policies that articulate acceptable behaviour can define a positive school culture. But, it is also important that the policies and practices engage all members of the community (including students and their families) in nurturing this positive physical and social environment. Well-trained and supported teachers will facilitate learning environments that engage students as active learners. Restorative approaches to discipline will contribute to, rather than interrupt, learning for students who get into trouble. And a continuum of school- and community-based services will support and promote student and staff health and well-being.

None of this, of course is simple, but then …

“For every complex problem there is an answer that is clear, simple, and wrong” (H. L. Mencken).

Author: Dan Reist, Assistant Director (Knowledge Exchange), Centre for Addictions Research of BC

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

What IS Drug Education?

When we hear the words “drug education”, we often conjure up an image of a police officer in front of a classroom talking about the dangers of trying drugs. But these outdated (and often ineffective) school-based drug education programs are not the be-all, end-all of drug ed. As the prevalence of alcohol and drug use, experiences of substance-related harms, and societal costs of substance use have increased, so too has the demand for alcohol and drug education and awareness programs.

Today, we regularly see awareness campaigns trying to educate us about the dangers of substance use and offering tips for how to reduce these risks. There are federal policies in place requiring tobacco companies to include health education messages on cigarette cartons. Health service providers deliver alcohol and drug education to patients. Parents often provide informal drug education to their children and the development of new drug education apps and online discussion forums help to facilitate self-education. Broadly, the goal of this type of education is to minimize the health and social costs of substance use on individuals and society. But what should alcohol and drug education actually look like? Who should it target? Who should teach it? And more importantly — does drug education actually work?

These are some of the questions that will be explored in our “Drug Education” blog series over the next few months. We will hear from researchers, non-profit organizations, teachers, students, and peers as they reflect on different drug education philosophies, review the research evidence about best practices for drug education, review a variety of exciting educational tools, and highlight new innovative ways to disseminate drug education. We hope you will share your thoughts on drug education with us over the next few months!

Author: Dr. Kara Thompson, Centre for Addictions Research of BC

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

 

Reducing harm? There’s an app for that.

Imagine you’re out enjoying a sunny patio at a pub with a few friends. You’re just about to finish your pint of beer and are really craving another one, but are trying to cut back on your drinking. You pull out your phone and open up an app that reminds you your goal for the week is to not have more than two standard drinks per day, and that pint you punched into the tracker was actually 1.7. You pause for a moment, then take a look at coping strategies you’ve tracked over the past few weeks to help deal with the desire to drink. One you’ve found particularly effective is treating yourself to a fancy booze-free cocktail while out with friends, so you order one of those instead of another beer.

Given our society’s increasing tech obsession, it’s no surprise that harm-reduction tools have made their way into the digital realm. Here are three helpful Canadian web- or app-based harm-reduction tools we’ve come across in our travels (or, in one case, created ourselves). Are there others you’d like to add? Share them with us!

Saying When: How to quit drinking or cut down: This app was designed by the Centre for Addiction and Mental Health. It’s the app I basically described above: it starts by asking you some questions about your drinking habits, the impacts of your drinking and goals you would like to set for yourself, then reminds you of Canada’s low-risk drinking guidelines. You can then track both your drinks and urges to drink, document effective coping strategies and access other information on tips for meeting your goals or accessing more help if you feel you need it. It actually reminds me of some popular fitness tracker apps that are available these days.

 

Good to Go? This app was developed as part of our Drugs and Driving website, which is aimed at helping young people to make informed decisions about getting behind the wheel after using a substance. The app includes a brief quiz that asks you questions about things like your mood, what substances you’ve used and how long ago you used them and then lets you know if you are “good to go” or not. But it is really designed more as a fun educational resource with embedded videos and factual content than as a real-time screening tool. It builds awareness about how different substances and other factors can impair your driving in different ways.

 

Gam_iQ: This quiz website is one of BC Responsible Gaming‘s prevention efforts. Answer the questions to find out how much you know about gambling, how to gamble responsibly and the resources available if you are a problem gambler. It’s also aimed at younger folks and initially launched with a chance to win a post-secondary scholarship. While the prize has already been awarded, it’s a brief and interactive way to get people thinking about gambling responsibly. The website also contains lots of other online tools aimed at different age groups or demographics.

If you have found any other harm-reduction apps, websites or digital tools, we would love to hear about them!

Author: Amanda Farrell-Low, Research Assistant: Social Media, Centre for Addictions Research of BC

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

 

Sex & Substance Use Among Transgender Gay, Bisexual & Other Men Who Have Sex with Men

Gay, bisexual and other men who have sex with men (GBMSM) make up over 50% of new HIV infections in British Columbia, as well as almost half of those living with HIV in the province. Despite up to two-thirds of transgender men identifying as gay, bisexual or queer, the presence of transgender GBMSM within the largely cisgender (people whose gender identity is consistent with their sex assigned at birth) gay men’s communities is often invisible. While the link between substance use and HIV sexual risk is well-documented among gay men, little is known about trans GBMSM’s relationship to this culture of substance use with sex.

Trans people are generally left out of epidemiological surveillance and the collection of other public health data, sometimes explicitly excluded from research studies. What we do know about the size of the population and their health profile is largely based on small convenience samples, with the recent exception of theTransPULSEstudy conducted in Ontario which used respondent driven sampling (RDS) to recruit 433 trans people across the province. Further to the lack of data, research with transgender people has generally focused on gender identity, leaving the experiences of trans GBMSM not well documented.

The Momentum Health Study is a new opportunity to learn more about the health of GBMSM. A five-year bio-behavioural longitudinal study, Momentum is open to HIV-positive and HIV-negative cisgender and transgender men who are sexually active with other men in the Greater Vancouver Region. Following participants in the cohort over the study period Momentum will produce quantitative clinical, behavioural and psychometric data and provide a deeper understanding of some of the complexities around sexual health, gender identity and sexual orientation, sexual risk and decision making through qualitative interviewing.

In preliminary quantitative analysis, almost half the trans GBMSM in Momentum used at least one substance (primarily alcohol and cannabis) as did their partners, during one of their most recent sexual encounters while one-quarter did not know the HIV status of their sexual partner prior to sex. Overall, transgender GBMSM in the study appear to be engaging in lower HIV sexual risk behaviours than their cisgender peers as well as employing more HIV risk reduction strategies, despite not testing for HIV as frequently.

As a longitudinal bio-behavioural study, Momentum will provide an opportunity to gain a picture of the clinical and behavioural sexual health of trans GBMSM over time, adding to the limited knowledge on these men’s health. The initial take away is that public health prevention and harm reduction interventions targeting gay, bisexual and other men who have sex with men need to acknowledge the inclusion of trans men within these communities and ensure they are inclusive of trans gay men.

Author: Ashleigh Rich, Research Coordinator, Momentum Health Study, BC Centre for Excellence in HIV/AIDS in Vancouver

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC