Nature & Nurture: A whole health approach to PrEP

Nature & Nurture: A whole health approach to PrEP
By Morgan Jade, PrEP Navigator

People are often surprised to find they can get PrEP (HIV Pre-Exposure Prophylaxis) from a Naturopathic Doctor (ND). NDs focus on prevention, treatment, and optimal wellness by combining modern science and medicine with a natural, whole-person approach to health care. J. Brooke Huffman is an ND at Portland’s 2BWell Clinic who provides primary care services including PrEP.

PrEP is a prevention option that can help individuals stay HIV-negative. Patients take a daily HIV medication called Truvada to help block the virus if it gets in the body. Being on PrEP requires a patient to visit their health care provider every couple of months for repeat HIV testing, STD testing, and medication refills. When taken every day, the medication provides over 90% protection against HIV1.

So why aren’t more people taking PrEP? Some medical providers are unaware of PrEP while others are unwilling to prescribe it, preferring to advocate for traditional prevention methods like condom use or abstinence. However, Dr. Huffman argues “it’s not realistic to ask people to stop doing behaviors they enjoy”. “With PrEP, people are informed; think consciously and intentionally about health….and are more apt to allow themselves to have fun”.

  J. Brooke Huffman, ND

Dr. Huffman’s interest in PrEP stems from her background in harm reduction and education through work with a street outreach program. She’s also a co-founder of People’s Health Clinic of Portland, which provides free health care one night per month at Sisters of the Road. Some of Dr. Huffman’s PrEP patients come to 2BWell Clinic asking about PrEP, while for others it may come up during the office visit. Routine testing and a conversation about sexual health sometimes result in getting PrEP. “I normalize testing with my clients by letting them know I recommend at least yearly testing for everyone,” Dr. Huffman says.

A patient’s first visit for PrEP is 60 minutes. Dr. Huffman takes a whole health history including current medications; current and past concerns; family history; lifestyle behaviors such as diet, sleep, and exercise; and completes a quick physical exam. Doctor and patient talk about the patient’s concerns which often include side effects, how the medication works in the body, and how much of a commitment is required to be on PrEP. An additional concern for some of her trans patients is whether Truvada interacts with hormones. The last step is getting the required labs drawn (HIV and STD tests, and kidney function), which patients can get at 2BWell Clinic or offsite.

So how does a patient know if PrEP is right for them? “Each patient needs to be informed well enough to make the decision,” Dr. Huffman says. “PrEP is not for everyone. The patient is the only one who knows [their risks]”, she says, adding the importance of trusting the patient when they think it’s a good option.

While PrEP is gaining momentum in Portland, and across the state, this work is far from complete. “Trans women and sex workers are still left out of the PrEP conversation. In addition, we need more public knowledge of Truvada, more public awareness of PrEP clinical services, and more providers bringing up PrEP with their patients” she says.

For more information about 2BWell Clinic or to schedule an appointment, call 503.841.6828, visit or stop by 2 NW 3rd Ave. in Portland.

For more information about PrEP:
• Cascade AIDS Project’s PrEP Provider List:


1. Centers for Disease Control and Prevention (2014). Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2014. Retrieved from

There has now been one case in which PrEP didn’t work: what that means

If you follow HIV news or your Facebook feed, you may have already seen the report that a 43-year-old man who was taking Truvada as PrEP has been documented to have become HIV-positive, and it appears he was taking the drug correctly and had levels of it in his blood that are usually effective at preventing HIV infection.

What that means is that, in this one case, PrEP didn’t work. This first-ever event is important news when it comes to communicating about prevention because it means we can no longer say “there has never been a documented case in which PrEP failed to prevent an HIV infection” through sexual contact. Now there is one documented case. But we still know from extensive empirical studies that Truvada taken daily as PrEP prevents a lot of HIV infections—a 92 to 99 percent reduction in risk of infection. It remains a highly-effective prevention tool for those at risk of exposure to HIV. That hasn’t changed.

We also know that this individual was infected by a strain of HIV that was already resistant to the drugs in Truvada before he was exposed to it. Indeed, we know from other studies that about 1 percent of new HIV infections in circulation are resistant to tenofovir, one of the drugs in Truvada, and that a higher number of infections are resistant to the other drug, emtricitabine. This is the first-ever incident in which a single infection was found to be resistant to both at the same time.

Fortunately, because those on PrEP continue to receive HIV tests as they refill the drug, an HIV infection like this will be caught and treated early to reduce the chance of it spreading to someone else. This case certainly reiterates the importance of ongoing testing while on PrEP. Another bit of good news in this case is that the individual’s HIV infection is now fully suppressed with an undetectable viral load, thanks to some of the many other HIV drugs available.

PrEP remains an excellent tool for lowering your risk of acquiring HIV. When considering PrEP or any other HIV prevention method, it’s up to every individual to decide the level of risk they can live with. PrEP is more effective at preventing HIV infections than condoms alone, and extremely effective when used in combination with condoms. That said, PrEP is a risk reduction tool, not a risk elimination tool. No prevention method (aside from abstaining from all risk) is known to be 100 percent effective with 100 percent certainty, and PrEP does not protect against other sexually-transmitted infections such as chlamydia, gonorrhea, herpes or syphilis.

We now know that HIV transmission can happen while on PrEP. What we don’t know from this is just how likely it is; this is the only known transmission to occur in someone who was taking Truvada daily from among the more than 40,000 people who have used PrEP. So although it is unfortunate that this kind of incident can happen, we can still be confident that it is very rare.

National Black HIV and AIDS Awareness Day is Saturday


Cascade AIDS Project is honoring National Black HIV/AIDS Awareness Day with public community celebration this Saturday at Charles Jordan Community Center in North Portland.

There will be food, music, activities and free rapid HIV testing and incentives for those who get tested at the event, which is designed to raise awareness of HIV/AIDS in the Black community and encourage testing, community engagement and treatment for those living with HIV.

2016 marks the 16th year for National Black HIV/AIDS Awareness Day, a national HIV testing and treatment community mobilization initiative targeted at Blacks in the United States and the Diaspora. NBHAAD was founded in 1999 as a national response to the growing HIV and AIDS epidemic in African American communities.

Despite the incredible progress that medical science and informed communities have made countering the HIV epidemic in the United States, black Americans are still being infected with HIV at an worrying rate. In 2014, 44 percent of all new HIV diagnoses in the U.S. were African-Americans, who comprise 12 percent of the general population. In an even more alarming figure, the CDC recently estimated that half of all black MSM (men who have sex with men) in the United States will end up infected with HIV. Much of this gap can be explained by disparities in access to health care.

But when those living with HIV gain access to treatment, the vast majority will live healthy, normal lifespans—and are unlikely to infect others when they regularly see a healthcare provider and follow a consistent regimen of HIV-suppressing medications.

The celebration is from 2 p.m. to 4:30 p.m. at 9009 N. Foss Ave. Get more info about the event on Facebook here.

Meet the PrEPpies: CAP’s PrEP Coordinators answer common questions about the new blue pill


Today I’m here with Pivot’s PrEP Coordinators Morgan Jade and Carlos Negrete to talk about some of the frequently asked questions they’re getting about PrEP, and explore what Cascade AIDS Project can do to help you find out whether PrEP is right for you and get connected to a provider.

PrEP stands for Pre-Exposure Prophylaxis, an HIV-prevention strategy that entails taking a daily pill that reduces your risk of becoming infected with HIV. Currently, the only medication approved as PrEP is Truvada, one pill that is a combination of two HIV-fighting drugs.

Morgan and Carlos work full-time at CAP helping people who want to know more about PrEP. They can give you basic information about how it works, help you figure out how to pay for it (they’re able to help many people get it for free) or get connected through a medical provider who is familiar with prescribing PrEP to patients. They can follow up with you after you start PrEP to provide any other support you need.

Matt: If someone is interested in getting on PrEP, what do they need to do?

Carlos: First, if you do have insurance and a medical provider (doctor), talk to your provider and figure out what they require to start the process. If you don’t have insurance or a medical provider, you can contact us at CAP so we can help determine the best way for you to get PrEP.

Morgan: The first thing your provider might do is talk to you about your risk for acquiring HIV to determine whether PrEP is a good option. Then you’ll get a test for HIV and a full STD screening panel. They’ll also test you for Hepatitis B and kidney function to prevent potential complications.

Carlos: Those tests Morgan mentioned are to make sure PrEP is right for you, and your body. Your doctor will assess the results and make the best plan with you.

Matt: How much does PrEP cost?

Morgan: If you were to pay for a month of Truvada yourself, the cost would be between $1,300 and $1,500, but there are a lot of options for getting PrEP at reduced cost or for free. That’s why it’s so important to contact us to talk about your insurance or drug assistance program options.

Matt: How much of the cost does the person have to pay out-of-pocket?

Carlos: It really depends on the person and the insurance plan they have, but depending on income and drug assistance programs, many people can get Truvada fully covered. Gilead, the drug company that makes Truvada, offers a couple of different assistance programs to help you cover the cost of Truvada. They have options for individuals who are insured and uninsured.

Matt: Let’s say I’m interested in PrEP but I’m not sure if I’m at a very high risk for HIV. Am I using up resources that could be going to somebody who needs it more?

Morgan: If you’re eligible for PrEP, it’s definitely not a waste of resources. It’s never a waste to want to take care of your health.

Carlos: Determining if you’re at risk for HIV infection is an important conversation between you and your medical provider. There’s also a website called “is PrEP right for me” ( that can help guide that decision. As PrEP coordinators, we can also talk to you about different things to consider when making the decision.

Matt: When someone contacts Cascade AIDS Project about going on PrEP, what can they expect?

Morgan: We’ll answer your questions over email, phone, Grindr or Facebook, or if you need something more in-depth we’ll schedule an appointment to meet with us 1-on-1.

Carlos: In our appointment, we go over the client’s specific needs—anything from insurance navigation to financial assistance programs to education on PrEP and some of the side-effects.

Morgan: We’ll try to make the process as smooth as possible, and help you find the right provider for you and your specific needs. We’re both PrEP nerds and we always welcome anybody who wants to talk about this topic.

Matt: If someone’s not sure whether they should be on PrEP or not and decides to tell you about their sexual history, will you tell them whether they should be on it or not?

Morgan: We’re happy to talk to you about what makes a person eligible for PrEP, such as things you might do that put you at risk for HIV, but we can’t make the decision for you. Our goal is more to empower you with the information so you can make informed choices going forward.

Matt: Will a health care provider be able to give a definite yes or no answer?

Carlos: First of all, PrEP is a relatively new treatment and some providers still need to catch up. If your provider is not willing to prescribe it, ask for a referral or come talk to us. We have a list of providers who are knowledgeable and comfortable providing PrEP.

Morgan: Educating yourself about PrEP, understanding why you want to consider PrEP and learning to advocate for yourself is so important so you can have a meaningful conversation with your provider.

Matt: Does going on PrEP mean someone no longer has to use condoms?

Morgan: That’s an important decision that only you and your partner or partners can make together. Some people will continue to use condoms when they’re on PrEP, some will stop, and some never used condoms in the first place. With that said, condoms provide an extra layer of protection on top of PrEP.

Carlos: PrEP is very effective at preventing HIV infections, but it doesn’t protect you against other STIs, like chlamydia, syphilis, gonorrhea or herpes, or pregnancy. It’s up to you to decide whether you are only worried about HIV, or you want to reduce your risk of getting any STI or getting pregnant. People who are concerned about things other than HIV may decide to continue using condoms.

Matt: If you still have to use condoms, then why use PrEP?

Carlos: PrEP gives individuals an added layer of protection, and there are many personal reasons why someone chooses PrEP. It can allow you to feel more empowered about your health, your sex life, and your life overall, whether or not you choose to use condoms.

Matt: How easy is it to quit PrEP if someone gets on it and then changes their mind?

Morgan: You can stop PrEP at any time if you feel you don’t need it anymore. However, it’s recommended that you take PrEP for 28 days after your last potential exposure to HIV.

Carlos: Also, if you want to start again, and still have a half a bottle left, don’t just start taking it. Go back to your doctor and get tested again to start PrEP again.

Matt: Will PrEP stop working if someone takes it for a long time, or goes off for a while and gets back on it later?

Carlos: No. It doesn’t make any difference if I stop and start again a year later. But make sure you go through your provider when you do.

Matt: How many days in a row do I have to take PrEP before it starts protecting me?

Carlos: For anal sex, it starts working after seven days. For vaginal sex, 21 days. That’s how long it takes the drug to build up to an effective level in that part of your body.

Matt: If I’m on PrEP is it possible to still get HIV?

Carlos: There hasn’t yet been a known case where someone taking PrEP as prescribed was infected with HIV. That said, there there are still reasons why you’ll get regular HIV tests even while you’re on PrEP to continue receiving the medication. Let’s say I started PrEP today and was exposed to HIV tomorrow. Or, let’s say I skipped several days of the medication and was exposed to HIV during that time, when I didn’t have full protection from PrEP.

Also, if an initial HIV test was done during the window period, there could be a chance that the test did not detect the virus yet even though the person was already infected before starting PrEP. Our test here at CAP is a fourth-generation test; it looks for both HIV antibodies and antigens. Antigens are foreign substances that cause your immune system to activate. The antigen is part of the virus itself and is present during acute HIV infection (the phase of infection right after people are infected but before they develop antibodies to HIV) and they can be detected after 4 weeks of exposure to HIV. So we call those four weeks when the virus cannot be detected the window period.

Morgan: Nothing is 100% guaranteed, but when taken consistently and correctly it can provide up to 99% protection against HIV infection. The more consistently you take it, the less likely it is you’ll contract HIV.

Matt: Thanks Morgan and Carlos, that’s all the questions I have about PrEP. Now how can people get a hold of you if they’re thinking of going on PrEP and want some help?

Morgan: Folks can call, email, or stop by Cascade AIDS Project. We look forward to talking with you!

Contact Morgan at:, 503-278-3873 or stop by 208 SW 5th Ave. suite 800.

Contact Carlos at:, 503-278-3874 or on the Grindr account “PrEP Questions” or on Facebook.

Pivot’s health enrollment fair this Saturday: Walk in with questions, walk out with health insurance.


Don’t forget that there are just a few days left to sign up for health insurance for 2016 through the insurance exchange at Sunday, January 31 is the last day to enroll and CAP staff will help walk you through the process if you need help.

To enroll after January 31, you’d have to purchase a plan from somewhere other than the exchange, qualify for Medicaid, or else have a non-health-related “qualifying life event” such as losing a job or being dropped from a partner’s plan (see a list of qualifying events here. Otherwise, the exchange—and its generous discounts on premiums—won’t be open to you again until November to sign up for coverage that would start in 2017.

Pivot’s Public workshop this Saturday from 10 a.m. to 2 p.m. at Pivot, 209 SW 4th Ave., is an opportunity to connect with CAP staff and get all your questions answered about the process. There will also be refreshments and raffle prizes for anyone who participates.

If you can’t make it to Pivot, the Coalition for Community Health Clinics will be holding a similar enrollment fair from 10 a.m. to 3 p.m. the same day at 3920 N. Kearby Ave.

You can also call Cascade AIDS Project to speak to CAP’s health insurance coordinators. Call Michael Lee Howard at 503-278-3878 or Nashoba Temperly at 503-278-3877 any time during business hours, Monday through Friday. Even after the health exchange enrollment period has closed, they’ll still be here to help you find alternative ways of getting health insurance or see whether you qualify for free healthcare through Medicaid/Oregon Health Plan.

It can’t be stressed enough how how much it benefits you to carry health insurance, both financially and for your health. Even minor unexpected injuries or emergency events—such as a broken arm, a minor car accident or appendicitis—can run up medical bills in the tens of thousands of dollars, leading to medical debt you’ll have to pay off if you’re uninsured. Having health insurance also enables you to receive preventative health care for free and can pay for otherwise-expensive medications like PrEP.

Fortunately the health insurance exchange limits premiums to what you are able to pay based on your income, and you may discover that you qualify for free health care through Oregon Health Plan. If you’re not sure how to navigate the process, the best way you can find out how this works for you is to talk to someone, so come in Saturday!

Who should or shouldn’t be on PrEP? A physician explains

It could be the most promising—and controversial—HIV prevention tool yet. When used correctly, pre-exposure prophylaxis (PrEP), the daily pill that blocks an HIV infection from taking root in the body, can ensure that HIV-negative people stay that way. Combined with other safer sex strategies such as condom use, PrEP transforms the HIV prevention landscape, but not without a dose of scrutiny as well.

What, exactly, is the relationship between PrEP and other risk-reduction strategies like condoms? To understand how a medical doctor thinks about PrEP and discusses it with patients, we spoke to Dr. Christopher Evans, a physician and infectious disease specialist at Oregon Health and Sciences University who works with PrEP patients daily.

Matt Pizzuti: Can you tell me a little about what you do and your expertise in PrEP?

Christopher Evans, M.D.,M.P.H., AAHIVM

Christopher Evans, M.D.,M.P.H., AAHIVM

Christopher Evans, M.D.: I am an infectious disease trained physician, I trained in New York, and now I work at OHSU doing primary care and also infectious disease consultation. Within the clinic that’s HIV care. I also see patients that are at risk for HIV, partners of HIV-positive patients, etc, as well as the public at large.

MP: Who is PrEP recommended for?

CE: PrEP is recommended for anyone who is at risk for HIV; someone who has had possible previous STIs, which may mean you are at higher risk, and high-risk groups, such as someone with an HIV-positive partner, or someone with a partner or number of partners of unknown serostatus (in other words, someone who has sex with people without being able to verify that they are all HIV-negative).

MP: Many of the people currently receiving messages about PrEP are men who have sex with men, and I think it’s sometimes hard for individuals in that category to know whether they, individually, should be considering it. To make this a little simpler, who among at-risk populations would you NOT recommend PrEP for?

CE: First of all PrEP’s not recommended for anyone who’s not going to take it the way it’s prescribed. There also may be people in a long-term monogamous relationship who know the serostatus of their partners and know their partners don’t have HIV. There’s a gray area around monogamous serodiscordant couples (couples with one HIV-positive partner and one HIV-negative partner) when the HIV-positive partner has an undetectable viral load; we know the risk of transmission to the negative partner is low even with unprotected sex. I would add that the CDC still recommends PrEP for serodiscordant couples.

In every relationship everyone has to make their own decisions, though. I’m not there to dictate, I’m there to give you the options and talk about your risk.

In more specific cases, PrEP may not be recommended for pregnant women, although we do know that in some cases some women are pregnant when they get HIV. There are some gray zones for people who have chronic hepatitis B because of the risk of a viral flare-up if you discontinue PrEP.

MP: Out in the community there are a lot of strong opinions about PrEP; it’s pretty common to hear people say that PrEP is being used as an “excuse” to have unprotected sex or that it’s leading to riskier behavior.

At the same time, people in public health roles are saying that PrEP is not a substitute for condoms, although it does make sex much safer if you’re not using condoms consistently. In your view, what’s the relationship between PrEP and condoms?

CE: So there are personal comments, and then there’s evidence. Even in big studies, there’s evidence that the incidence of risky behavior decreases in people on PrEP. The big one was iPrEx, a study on gay, bisexual and transgender women who have sex with men, one of the first that looked at using Truvada for PrEP and was used for FDA approval.

Subsequent studies looked at risky behaviors again and found that risky behaviors, over time, went down, in both those on PrEP and those receiving placebo. But both groups also got safe-sex messages while they are coming in, just as in a patient setting, where it’s not like it’s being just given to people without any counseling.

The analogy I use is, if you have a seat belt would you drive faster? Most people would say they would continue to drive the speed limit even with a seatbelt on because it’s the more prudent thing to do.

Regardless, I always talk to my patients about using condoms. Condom use has a lot of different steps, though, and it’s not just putting on the condom; it’s negotiating using the condom, it’s people going out and having a good time (drinking) and still having the wherewithal to use it, and condoms can break—so condoms as a strategy is not 100% effective because people are not 100% consistent. But I think condoms are a cornerstone of public health policy and still important. I’m not ready to throw them out the door and say you have this other option so we don’t need it anymore.

There’s also the issue that having one STD can increase your risk for others; getting syphilis will increase your risk for HIV. So I’ll talk about the way you can get syphilis or chlamydia or gonorrhea, which can be transmitted through oral sex, anal sex, etc, even while you’re on PrEP.

MP: A lot of us, when we go to get tested, have been counseled on the fact that unprotected oral sex is a safer sex option compared to unprotected anal sex, and that’s mainly because of the risk of HIV. Of course there’s still a risk for transmission of other sexually-transmitted infections. So If somebody is on PrEP, is there still a difference between unprotected anal sex and unprotected oral sex or are they about the same level of risk now?

CE: Anal sex is always going to the riskiest sex, especially if you are the receptive partner or the bottom. You could look at the scale of possible risks for HIV and I’d say that oral sex is at the very bottom, but I don’t think any public health official has said there is no risk for HIV from oral sex—it’s just at the very bottom risk.

MP: Right, but when it comes to other STIs—syphilis, gonorrhea, chlamydia—is there a difference between unprotected oral sex and unprotected anal sex? Most of the population that PrEP pertains to was already at risk for other STIs because, whether or not it’s ill-advised, very few people use condoms for oral sex.

And here’s why I mention that. One concern I see brought up again and again in the community is this idea that PrEP is driving a spike in sexually-transmitted infections because people are getting on PrEP and no longer using condoms. But one thing I’m not sure about is whether the increase in STIs is in the same population as PrEP users, and if unprotected anal sex would make all that much difference when most were already at risk for those infections through oral sex.

CE: I don’t know because there hasn’t been studies done. I don’t think anyone has explained the recent increase in STI rates and I don’t think anyone has linked it to PrEP. That would be a great study to be done, but at this point, nobody knows that to be the case.

For more information about PrEP or first steps if you are interested in getting on PrEP, email Find Dr. Christopher Evans’ info at OHSU here

Intestinal bug affecting Portland men can be transmitted by food or sex

You may have heard about an intestinal infection affecting men who have sex with men (MSM) in Portland. It’s called shigella, a bacterial infection that causes symptoms that resemble food poisoning—diarrhea, fever, nausea, vomiting, cramps, and sometimes more serious issues.

The recent cases affecting gay and bisexual men in the area have come from sexual contact. More commonly, though, shigella is spread between children or through contaminated water, or comes from contaminated food, such as the outbreak this fall that recently infected over a hundred people who ate at the same restaurant in San Jose, California. Fortunately, it’s treatable using antibiotics.

The most obvious way the shigella bacterium is transmitted sexually is through oral-anal contact (rimming). But the bacteria can also travel to your mouth on your hands or on genitals after playing with an infected person’s anus. The Multnomah Health Department is recommending washing up thoroughly before and after sex to clean the bacteria off. If you think you might be sick, you can protect others by taking a break from sex until you see your doctor for a diagnosis.

There are cases of shigella that stay mild, and some people never even know they are infected. But having only minor symptoms doesn’t mean someone else won’t get a serious illness if you pass it to them. Infections can be especially risky for people whose immune systems are compromised by other health concerns, who have untreated HIV, or the elderly.

If you are infected with the shigella bacteria the condition is called shigellosis, with symptoms that start 1-6 days after being exposed. The illness usually lasts about a week after that but in more severe cases can take much longer. It can be contagious before there are any symptoms, as well as for a few weeks after the symptoms go away.

Shigella is less common in North America these days, but the disease has existed since before people even knew about the bacteria that cause it. Shigella is one of the bugs that can cause dysentery—diarrhea with blood in it—which used to kill people through dehydration before oral rehydration therapy was developed. Since then, clinicians use a simple treatment called oral rehydration therapy, which is water containing a specific ratio of salt and glucose (sugar), that enables sick intestines to absorb fluids and electrolytes. But diarrheal diseases like shigella are still very serious illness in the developing world where people might not have access to treatment.

Get help signing up for health insurance

It was just a few years ago that people were still being blocked from getting health insurance because they couldn’t afford the premiums, or had a pre-existing condition used as a reason to deny coverage. Thanks to the Affordable Care Act (known as Obamacare) health insurance companies are now required to accept anyone who signs up between November and January no matter what your health status is. Beyond that, there are income-based caps limiting how much most people have to pay for coverage so that more people can afford it.

With these protections in place, for most people the biggest obstacle getting health insurance is simply not knowing what the benefits are or how to sign up. Cascade AIDS Project is working to increase access to health care for people living with HIV and also the broader LGBTQ community, and can help walk you through it.

First of all, what’s the benefit of health coverage?

As you probably already know, health care costs these days are getting extremely expensive. A doctor’s appointment for a sore throat can cost you $150 or more just to find out you don’t need antibiotics. Let’s say that sometime over the next year you—heaven forbid—break a bone and need surgery to repair it, or get in a minor car wreck and need to stay in a hospital overnight. For even a brief hospital stay you could end up with a bill in excess of $20,000. That can (more…)

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