RISING RATES OF SYPHILIS1–4 and human immunodeficiency virus (HIV)5 among men who have sex with men (MSM) and increases in unsafe sexual behaviors in these same populations6–8 have directed attention towards the commercial sex industry and its potential for facilitating HIV/sexually transmitted disease (STD) transmission. The commercial sex industry includes venues that are patronized for a fee or services that are purchased for sexual activity: commercial sex venues (CSVs) such as bathhouses, sex clubs, and some adult bookstores; organized MSM gatherings such as circuit parties and private parties; the adult film industry; and male commercial sex workers (CSWs).
Bathhouses and sex clubs have faced increased media attention due to reports of unsafe sexual behaviors and high rates of drug use.9,10 Case control data from Los Angeles revealed an increased risk of syphilis among MSM bathhouse/sex club attendees as compared to those that reported no attendance at these venues (43% versus 14%) (OR, 4.5; 95% CI, 1.6–12.9).11 Additional data collected from bathhouses/sex clubs in Los Angeles found HIV prevalence rates of 11% among MSM presenting for onsite testing, a proportion considerably higher than prevalence rates found at other outreach counseling and testing sites.12 Reports of HIV/STD transmission, sex with anonymous partners, and sexual stimulant drug use (i.e., Viagra, crystal methamphetamine, poppers, ecstasy) in bathhouses/sex clubs suggest prevention interventions may be of benefit in these venues.13–16 Interventions among male sex workers may influence this bridge population and prevent STD transmission among other sexual and drug-using networks.17 Prevention interventions are also needed to effectively reduce unsafe sexual behaviors among Internet sex solicitors, as well as those MSM that advertise sex for pay using this medium.18–22
Circuit parties are multisite weekend events that attract thousands of MSM. These parties have been associated with unsafe sex and drug use, suggesting that they might serve as prevention intervention sites.23–24 Many of these gatherings and activities such as circuit parties require financial contributions for participation; thus, MSM engaging in sexual activities at these venues may be in higher socioeconomic strata than other populations traditionally at risk for HIV/STD transmission. For example, some attendees of the annual White Party in Palm Springs, CA, one of the largest circuit parties in the United States, purchased event tickets for $450, not including airfare or hotel accommodation.25 Attendance at national and international circuit parties and use of the Internet to meet sexual partners in other cities and countries supports growing concern over the mobility of these MSM populations engaging in unsafe sexual behaviors as it relates to STD transmission and control.
This report summarizes how health departments and community-based organizations (CBO) in 8 cities address STD prevention in the commercial sex industry.
For the purposes of this report, the commercial sex industry was limited to venues patronized by MSM or services that are purchased by MSM and included CSVs (bathhouses, sex clubs, and bookstores), the adult film industry, male commercial sex work, circuit parties, and commercial sex solicitation via the Internet. Cities included in this summary are Atlanta, Miami, New York (NY), Los Angeles (LA), San Francisco (SF), Fort Lauderdale, Houston, and Chicago.
Descriptive and quantifiable data were contributed by representatives of public health programs and CBO from the 8 cities. These representatives were asked the open-ended question: “What types of interventions are being practiced in commercial sex environments in your jurisdiction?” Representatives were then asked to describe these interventions. Public health department (PHD) representatives were asked to provide the number of syphilis cases that reported meeting a sex partner in a commercial sex environment during the period 2001–2003. Per US Department of Health and Human Services guidelines, data collection, evaluation, and analysis are part of ongoing public health surveillance activities and thus are not subject to review by institutional review boards but are governed by state laws.
Syphilis Cases Reporting Meeting Partners at CSVs
Available data from 6 of the cities demonstrate a moderate proportion of MSM early syphilis (ES) cases report meeting sex partners at CSVs. Houston reported the highest percentage of ES CSV patrons (61%), followed by LA (28%) and SF (22%). Data collection methods vary considerably among study sites, thus limiting between-city comparisons (Table 1).
Collaboration With Owners.
PHD have collaborated with CSV owners to promote awareness of the syphilis epidemic, to promote safer sex, and to provide HIV/STD testing on site. LA has conducted meetings with CSV owners since the start of the syphilis outbreak in December 2000 that have resulted in free condom and lubricant distribution in these venues, as well as agreements to post safer sex guidelines and educational materials regarding syphilis. Additional meetings conducted by the LA PHD with club owners and CBOs in LA resulted in the provision of testing for syphilis, gonorrhea, and chlamydia in 3 of the larger bathhouses.
NY PHD met with CSV owners/managers in May 2004 and administered a survey about the type of establishment, patron demographics, current prevention services, and prevention services owners would be interested in implementing. Surveys were collected from 1 sex club, 1 bathhouse, and 4 private party managers. Two of these venues catered to nongay-identified MSM that were mostly black. All representatives were interested in some form of onsite educational messages. This forum led to discussions about onsite HIV/STD testing, and outreach educational for venue staff, and educational packages for patrons.
Chicago PHD has collaborated with the manager of the largest bathhouse in the Chicago area for the previous 6 years. This collaboration has resulted in consistent onsite HIV/STD counseling and testing, as well as ongoing and active cooperation with syphilis elimination efforts such as provision of condoms, lubricants, and syphilis education materials in the bathhouse. In addition, representatives from this bathhouse regularly attend the Chicago Syphilis Elimination Taskforce meetings.
Collaboration With CBOs.
In some cities, PHDs collaborate with CBO liaisons to facilitate interventions at CSVs. In LA, collaboration with a large CBO led to the establishment of a liaison with owners representing 8 of 11 known CSVs, coordination of onsite HIV/STD testing services by CBOs, and initiation of a peer-to-peer program to promote safer sex norms26,27 that included training peer “sexperts,” CSV staff, and CBO staff; a patron needs assessment; and CSV profiles.
NY CBOs have been involved in outreach in the CSVs since the early days of the HIV/AIDS epidemic. In response to the syphilis epidemic in 2003, the Syphilis Advisory Group of the NY PHD convened a Commercial Sex Venue Working Group composed of staff from CBOs, health care providers from the NY PHD, and other government agencies. The goals of this working group are to coordinate activities among CBOs and to develop innovative strategies that go beyond traditional outreach. Other CBOs in NY have distributed NY PHD syphilis palm cards, along with safer sex packets in CSVs. Street outreach workers near NY CSVs report that patrons were often willing to accept condoms but were less willing to discuss safe sex.
Houston PHD works closely with a large CBO-supported MSM clinic in Houston that has served as a liaison to the 2 bathhouses in the area and has provided educational outreach and counseling for over 10 years. The CBO supplies CSVs with syphilis brochures, palm cards, fliers, and condoms and has provided one bathhouse with a safer-sex videotape for use in an area of the bathhouse devoted to providing of safer-sex information. Additional collaborative efforts between the Houston PHD and this CBO have included outreach counseling, education, HIV/syphilis testing, and the distribution of syphilis awareness campaign materials to MSM in 2 popular MSM adult bookstores.
Legislation and Public Health Monitoring
The most controversial interventions pertaining to CSVs have been related to formal regulation of these businesses. Bathhouse closures in 1984 in SF in response to the emerging HIV/AIDS epidemic prompted an outcry from gay rights’ activists regarding the civil liberties of MSM attending these venues.28 Additional cities such as LA and NY imposed injunctions and/or ordinances that required CSV owners to provide safer sex materials such as lubricants and condoms and to post safer-sex guidelines for patron viewing. In 1990, 2 LA bathhouses were accused of permitting unsafe sexual conduct by patrons. This resulted in permanent injunctions calling for owners to implement and enforce a protocol to reduce the risk of HIV transmission. Quarterly inspections of these venues by public health investigators took place to insure that elements of this ordinance were being implemented. These elements included but were not limited to the provision of condoms, lubricants, and educational materials and the prohibition of anal intercourse without a condom. Due to the overt (i.e., announced) nature of these inspections, this injunction has done little to curb the unsafe sexual behaviors. Consequently, bathhouse and sex club owners have at best variably implemented the injunction requirements. Indeed, none have prohibited unprotected anal intercourse.
Since 1991, SF DPH has required CSVs to post its “Recommended Standards for the Operation of Commercial Sex Establishments.” These standards include recommendations for the physical setup and operations, as well as basic safe sex guidelines. These guidelines were developed by the SF DPH in collaboration with HIV/STD educators, CBO, and sex-club operators. Adherence to these guidelines is monitored through monthly, voluntary inspections of these venues by STD Prevention Services Outreach staff. Letters outlining areas of noncompliance, suggestions for environmental and safety improvements, and acknowledgement of areas of adherence are mailed to owners and/or managers subsequent to the visits. There are no penalties for noncompliance.
Renewed interest on the part of SF and LA departments of health in response to the syphilis epidemic among MSM and rising rates of HIV in the MSM population have resulted in county supervisory board motions calling for the licensing and formal regulation of CSVs. LA has drafted recommendations that include requirements for adequate lighting and provision of condoms and lubricants, prohibiting unprotected oral and anal sex, monthly public health inspections, and fines or closure of the establishments for nonadherence. Components of these recommendations are listed in Table 2. In 2003, the SF Board of Supervisors transferred licensing of the massage industry (which includes some illicit commercial sex activity) from the police department to the health department, effective June 2004.
Onsite Prevention and Education Materials
Most CSV owners in LA, Chicago, Houston, and SF provide condoms and lubricants, occasionally with assistance from the health departments or CBOs. Posters and other materials describing syphilis signs and symptoms, risks associated with oral sex, and other STD/HIV prevention messages have been displayed in CSVs in SF, Miami, Houston, and Chicago. A newer establishment in SF that rents out space for private parties has permitted the SF PHD and CBOs to perform onsite STD/HIV testing and to distribute partner-delivered syphilis prophylaxis (azithromycin packets) on the premises to interested patrons.
Syphilis campaign materials to increase awareness have been distributed in CSVs in SF, LA, Chicago, Miami, and Houston. These media campaign materials have included palm cards, miniflashlights, posters, and promotional stress grips distributed to patrons in the CSVs. In LA and SF, the linked media campaigns Stop the Sores and Healthy Penis have been shown to be effective in increasing syphilis testing and syphilis knowledge related to symptoms, modes of transmission, and risk-reduction strategies.29,30
The media campaign developed in Houston targeted gay and nongay-identified MSM. This campaign distributed 31,000 condom packs, as well as palm cards and/or posters in venues frequented by MSM. Palm cards have been created for 3 media campaigns in Miami: these include the Got Syph? campaign that focuses on the risk of syphilis transmission related to oral sex, the Don’t be a Sore Loser campaign, focusing on syphilis symptom recognition and the Kiss and Tell campaign, stressing the importance of discussion of STD transmission and disclosure with sexual partners. Palm cards from these campaigns have been distributed, along with towels at the entrance to bathhouses/sex clubs in the Miami and Fort Lauderdale areas. Posters from these campaigns have been used at these sites as well.
Media campaigns conducted in Chicago during 2000–2002 focused on the symptoms of primary and secondary syphilis and the association with acquisition of HIV. Surveys conducted in 2000 versus 2002 revealed an increased awareness regarding symptoms of syphilis, as well as knowledge of syphilis as a facilitator of HIV transmission.31 During this time, the ratio of primary cases versus secondary cases increased from 0.2 in 2001 to 0.34 in 2002, suggesting increased recognition of primary symptoms.
Onsite Counseling and Testing
All 8 of the STD programs have attempted to provide onsite STD/HIV testing and counseling, either directly using disease intervention specialist (DIS) staff or in collaboration with CBOs. Presently, CBOs in LA, SF, Chicago, and Houston conduct onsite HIV/STD counseling and testing. SF DPH staff performs onsite testing for bacterial STDs (including syphilis). The largest Houston MSM CBO has continued its collaboration with the CSV management of the 2 Houston area bathhouses where it has coordinated outreach education and free HIV/syphilis counseling and testing in these venues for the previous 10 years. Recent collaboration with the management of 2 MSM adult bookstores has resulted in the organization of outreach counseling and HIV/syphilis testing at these venues 2 nights a week. NY and Atlanta are initiating efforts to begin onsite STD/HIV testing in CSVs. Chicago DPH has worked closely with a CBO health center to provide onsite “mini-STD clinics” at 2 of the main bathhouses in Chicago. These miniclinics include HIV/STD counseling and testing, as well as treatment administered by a Chicago DPH-funded nurse. Testing and treatment services are provided during evening and weekend hours. These onsite testing efforts have been described in an earlier article in this journal by Ciesielski et al.4a
Circuit parties are organized social events within the gay community that typically take place over a long weekend. They have been associated with high rates of drug use and sexual activity.22–24 Circuit parties occur each year at the same time in a particular town or city. One of the largest circuit parties, the White Party, is held in Palm Springs, CA, and attracts up to 30,000 MSM per year. Interventions undertaken at this event in 2003 and 2004 have involved multicounty collaboration with the production company to distribute safer-sex packets at the major hotels and events that contain condoms, lubricant, and syphilis educational palm cards.
In 2003 and 2004, media campaign mascots Phil the Syphilis Sore and Healthy Penis advertised booths containing educational information and condoms. Outreach staff and educational materials were strategically positioned and placed in high-traffic areas of the events. A face-to-face survey conducted during the White Party in 2003 found that of 185 men surveyed, 80% had seen educational materials or outreach workers promoting syphilis awareness during the weekend events. This was considered evidence of the successful efforts of collaborating health departments and CBOs from 5 different counties in California. Forty percent of this group reported being tested for syphilis during the previous 6 months. This sample of 185 White Party attendees included MSM from 15 states and 2 countries (Patel P, unpublished data).
Chicago Health Department (CPHD) collaborates with local CBOs to provide educational outreach and safer sex packets during the International Men of Leather (IML), a circuit party held annually in Chicago that attracts between 5000 and 8000 MSM from the United States and abroad. In 2000 and 2002, CPHD collaborated with a CBO to conduct a survey of over 900 IML participants to gather information on HIV, STDs, and general knowledge of syphilis symptoms. In 2002 and 2003, CPHD collaborated with the IML host hotel to distribute thousands of condoms, lubricants, and palm cards alerting the participants of the local syphilis outbreak among MSM. These palm cards included basic syphilis symptom information and encouraged attendees to “leave our city with nothing more than good memories.” The Chicago Syphilis Elimination Coalition partners distributed condoms and syphilis prevention literature in the registration packets of the circuit party attracting black MSM, Release 2002. Street and club outreach was conducted at Chicago’s Halloween Pumpkinhead circuit party in association with distribution of condoms, lubricant, and literature, as well as onsite syphilis testing in mobile medical units parked outside the venues. Collaboration with hotel housekeeping personnel for Chicago’s circuit party, Fireball 2003, resulted in placement of safer-sex kits on the beds of participant’s rooms each time rooms were cleaned over the weekend.
Miami also hosts a White Party that takes place near Thanksgiving, attracting approximately 11,000 MSM. The Miami Health Department (MPHD) collaborated with the sponsors of this circuit party to include and distribute syphilis awareness palm cards in welcome packages for attendees. In addition, MPHD collaborated with local CBOs to create a slide show that was presented to attendees that included HIV/STD prevention messages. Media notices were posted in popular gay magazines, gyms, and barbershops before the White Party events, notifying MSM of the high rates of syphilis occurring in the Miami area. Houston hosts Jungle Party, the LUEY Weekend, and Splash, among other circuit parties. The largest MSM CBO has collaborated with circuit party organizers to distribute condoms and syphilis information to the attendees of these events for several years. Evaluative data on these circuit party efforts are not available.
Male CSWs may provide epidemiologic bridges for disease transmission between disparate HIV/STD at-risk populations. Williams et al.17,18 have collected information on a group of 399 male sex workers in the Houston area. These data demonstrate high rates of unprotected sex among those sex workers that are HIV positive. In addition, high rates of illicit drug use were reported by this sample of HIV-positive and HIV-negative sex workers, with approximately one third reporting injection drug use and, of these, approximately 39% reported sharing needles or other paraphernalia. There was significant mixing across age and race/ethnicity groups among drug-using and nonordrug-using male sex workers. The evaluation also revealed that male sex workers engaging in sex with patrons in cities other than Houston (intercity bridgers) had more sex-for-money partners as compared to sex workers engaging in sex within the city limits of Houston. These intercity bridgers were more likely to report recent use of powdered cocaine, methamphetamines, and injection drugs. These findings demonstrate a possible mechanism for introducing emerging and reemerging sexually transmitted diseases into networks of those engaged in the sex trade and groups connected to them by drug use and sex.17,18
The largest MSM CBO in Houston performs outreach counseling and testing services to male and transgender CSWs at 3 bar locations where the CSWs are picked up by their patrons. Many of these sex workers seek counseling and testing services at the clinic maintained by this CBO that provides HIV-infected and HIV noninfected MSM with HIV and STD testing, counseling, and clinical services.
A CBO in NYC targets young CSWs that are of black and Hispanic ethnicity and some transgender youth that frequent the meatpacking district of the city and specific CSVs where men solicit sex with other men. Condoms, lubricant, and educational information are offered, though the educational information is sometimes refused. These outreach events have resulted in teaching opportunities and discussions with younger CSWs. These informal discourses have revealed that many do not consider themselves gay as long as they are the insertive partner and also do not consider themselves at risk for HIV/STD transmission. Intergenerational sex is known to occur (many older men with youth) at these venues.
A SF DPH-supported clinic in SF offers HIV and STD counseling, testing, and treatment to male and female sex workers. Recent data show approximately 160 MSM sex workers are offered STD-testing services per year in this clinic. Other SF CBOs conduct syphilis educational outreach among male sex workers in the Castro and Polk districts.
Other cities such as LA and Miami have found it difficult to reach populations of male sex workers. Available information suggests that these populations use the Internet and MSM magazines as a medium for sexual solicitation. In LA, these male CSWs advertise as masseurs, escorts, and/or housekeepers. These service “fronts” make it difficult to reach and address high-risk behaviors in the CSW population. The recent legislation in SF to transfer licensing and inspection of the massage industry from the police department to the SF DPH may facilitate STD control in this industry.
Adult Film Industry
The adult film industry is a nonunionized multibillion-dollar industry that encompasses heterosexual, or “straight,” pornography and productions portraying men having sex with men, or “gay porn.” There is minimal if any crossover of actors or “talent” from straight to gay pornography or vice versa; however, anecdotal information suggests that this group of actors attends other CSVs and/or engages in other types of commercial sex work that may create opportunities for disease transmission across extended sexual networks.
Gay pornography is divided between productions where condoms are used for anal sex and productions where condoms are not used for anal sex, also known as barebacking films. Unlike the heterosexual adult film industry, the homosexual industry allows HIV-positive actors to work and does not require performers to undergo HIV and STD testing before filming. This is largely the result of high condom use rates for anal sex on homosexual production sites and the high number of HIV-positive performers (40%–50%). Condoms are not routinely used during the filming of oral sex scenes.
MSM performers in condom-only productions are provided with limited educational materials on set and undergo routine visual inspections of the anus, penis, scrotum, and foreskin for visual signs of STDs such as syphilis, warts, herpes, or molluscum before filming to insure that there are no unsightly blemishes. For oral sex scenes that are generally filmed without condoms, performers are sometimes required to rinse their mouth with a solution of 13% hydrogen peroxide, a practice that has never been systematically evaluated. No illicit drugs are permitted; however, erection-enhancing medications are allowed on sets. Efforts are made to eroticize condom use where possible.
Following media attention addressing the adult film industry, and recommendations from the straight pornography industry and the LA PHD, some producers in the gay pornography industry recently agreed to require actors to be tested for HIV, STD, and hepatitis on a routine basis. One CBO in LA provides HIV PCR testing and STD testing and treatment to male and female film workers. This CBO works closely with adult film industry producers to maintain a confidential database of results and to notify film industry partners of exposure to STDs and/or HIV. Most of the US adult heterosexual film industry is based in San Fernando Valley, CA; however the homosexual pornography industry includes companies in several states. This makes for a more challenging goal of implementing mandatory screening rules and makes it easier for adult film producers to go “underground” in response to increasing filming requirements.
The barebacking industry has been reluctant to engage in discussion of voluntary HIV and STD testing of its performers. “Condom only” producers of gay pornography openly chastise the eroticizing of barebacking, and the largest producer of gay pornography does not allow actors who have previously worked in the bareback industry to work in their films. Efforts to engage the barebacking industry in discussion of routine HIV/STD testing have been met with prompt refusal and denial of need. Information on HIV disclosure practices among bareback performers is not available.
The Internet as a CSV
There has been an increase in use of the Internet to meet sex partners reported by persons diagnosed with STDs.19,20 McFarlane et al. describe on-line public health interventions targeting Internet users in a separate article in this issue.20a Only anecdotal information is available regarding use of the Internet as a CSV. Multiple national websites advertise male escort services, male masseurs, and/or male housekeepers. These pseudonyms for male sex workers are also advertised in popular MSM magazines. Minimal data on interventions to reach these populations of male sex workers advertising on-line are available.
The Internet is also used as a tool to promote private sex parties. Potential attendees meet and are invited to these events through popular MSM chat rooms. CBOs in multiple cities have initiated online outreach programs targeting MSM who solicit sex partners through the Internet. In NY, CBOs enter into popular websites such as AOL.com and Gay.com and initiate conversations inside chat rooms with sex seekers. The CBO workers use names such as “sexhealtheducator” and “letstalkaboutsex.” The response varies, though these NY CBOs report good response rates, with many persons asking questions about barebacking and whether it can be done safely. Information provided to “chatters” includes symptoms of STDs and places where HIV/STD testing can be obtained. Another NY CBO was able to target young high-risk Latino men online and refer them for HIV/STD testing and counseling.
Houston, in collaboration with CBOs in SF, Miami, and New Orleans, has helped to develop an educational Internet outreach intervention targeting MSM. This intervention, called Project CORE (Cyber Outreach Education), will provide information and referrals to MSM using 3 popular Internet MSM chat rooms. Evaluative data on this project are pending. An Internet-based risk reduction assessment and education tool has been developed by another NY CBO targeting men who use “party” drugs such as methamphetamines. A CBO in Miami performs Internet-based prevention interventions targeting methamphetamine-using MSM. This CBO attends Internet-organized private parties and distributes condoms and syphilis palm cards.
The overall contribution of the commercial sex industry to the MSM syphilis epidemic has not been estimated. However, the contribution may be considerable, based on the number of MSM with syphilis who report meeting partners at CSVs. All PHDs should gather information as part of syphilis surveillance to help assess the effects of the local commercial sex industry.
Interventions undertaken at CSVs require collaboration between PHDs, CBOs, and owners/managers of these venues. PHDs should develop or foster community advisory bodies that include representatives from the affected populations, venue owners, CBOs, and public health agencies. These advisory boards should develop tactical and strategic response plans that include needs assessments of CSVs and their patrons to help direct interventions.
Many interventions have involved media campaigns with posters and palm cards for distribution at CSVs. Three cities (SF, LA, Chicago) have demonstrated increases in syphilis awareness among persons exposed to the campaigns. The costs of developing a media campaign may be too high for smaller PHDs. These PHDs should consider borrowing materials from other cities or collaborating with other areas to develop media campaigns. These campaigns should include simple messages that promote testing and/or treatment and information on sites providing these services. These social marketing campaigns should be developed using formative research with the target group (MSM). Most importantly, the campaign should be evaluated before and after it has been launched to assess effectiveness and make refinements.
CSV owners are wary of interventions that interrupt patrons’ activities and may be hesitant to allow HIV/STD counseling and testing services onsite. Even if testing is allowed, patrons may not be interested. Despite these limitations, targeted screening paired with educational outreach should be considered. Collaboration with CSV staff to serve as safer-sex advocates may be a more efficient way to reach these populations, but this approach has not been evaluated.
Public health officials should consider exercising public health authority in venues where disease transmission is occurring (CSVs, adult film industry). This authority may be in the form of abatements or regulation through legislation. Regulations may require significant public health oversight to insure compliance. PHDs pursuing this form of CSV intervention should collaborate with the MSM community, CSV owners, and CBO. Current laws in NYC and LA prohibit vaginal, anal, or oral intercourse at any commercial establishment. These PHD are attempting to regulate CSVs that are prohibited by these ordinances.
Male CSWs have sex partners from different age, race, gender, and drug-use groups.17,18,32 Further work is needed to understand the sexual networks created by these encounters, as well as those created by circuit parties.
Most of the described interventions have not been evaluated. Evaluations based on syphilis rates among patrons in the commercial sex industry would require large sample sizes and prolonged time measurements. Evaluations based on reported behavior are feasible but often difficult to interpret. Future efforts should be directed on the systematic collection of qualitative and quantitative data to inform the design of effective intervention programs and assess their impact on the commercial sex industry.
Many PHDs facing syphilis epidemics among MSM have included CSVs in their response. The interventions undertaken in those areas should help other PHDs that are considering working with CSVs. However, most interventions have not been evaluated for effectiveness.
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