Entering the fourth decade of HIV/AIDS, the considerable individual and public-health benefits of regular HIV testing and early HIV diagnosis have been well established.1–4 Of persons at risk for HIV, men who have sex with men (MSM) arguably have the most to benefit from testing. Annual HIV incidence among MSM in the United States has increased steadily since the early 1990s, attributed in part, to the high proportion of HIV-infected MSM who are unaware of their infection.2,5–7 Although national guidelines recommend that MSM test for HIV annually, many test only infrequently, and of those <25 years of age, many have never tested for HIV.1,6–11 As a consequence, nearly half of HIV-infected MSM may be diagnosed late in the course of their HIV disease.12
Although considerable research has explored factors associated with ever, repeat, and recent testing among MSM in the United States, no reports have focused on those who have never tested for HIV (NTMSM).6–11,13–27 Thus, information on potential modes of delivery, relevant content, and priority of interventions to facilitate testing of NTMSM is not available. For example, although the internet is a promising new mode to deliver test-promotion interventions, the proportion of NTMSM who use the internet for HIV information (HIV internet-use) and who might access these interventions is unknown.28–30 Similarly, although outreach testing programs at MSM venues reach many high-risk MSM, the types of venues attended by NTMSM are also unknown.31–34
While several studies suggest that the main reasons for not HIV testing among MSM are perceived low risk for infection, fear of testing positive, and structural barriers such as not knowing where or not having the time or resources to test, the variation of these reasons among age, race/ethnic, risk, and HIV internet-use subgroups of NTMSM is unknown.6–9,24–27 Information about the variation of main reasons for not testing might help programs target more relevant test-promotion interventions and services for these important subgroups.35–37
Although most MSM eventually test for HIV, the magnitude and correlates of strong intentions to test in the upcoming year is also unknown for NTMSM.26 Information on subgroups of NTMSM who lack strong testing intentions might help prevention programs prioritize test-promotion interventions for MSM at risk for delayed testing and late HIV diagnosis. Finally, an over-the-counter rapid HIV test (OTCRT) is currently being evaluated and may soon be available in the United States market.38,39 Information on the potential use of an OTCRT among NTMSM, particularly among those who lack strong testing intentions, might help establish research needs on how OTCRT, if approved, might be used to increase the uptake of HIV testing among NTMSM.
To help meet these information needs, we evaluated among NTMSM who participated in the Centers for Disease Control and Prevention's Web-based HIV Behavioral Surveillance (WHBS) project (1) the magnitude and characteristics of subgroups that might be accessible to prevention services via the internet or at MSM venues; (2) the distribution of main reasons for not testing in age, racial/ethnic, risk, and HIV internet-use subgroups; and (3) the magnitude and correlates of strong intentions to test for HIV in the upcoming year and to use an OTCRT if it became available.
Conducted in collaboration with 6 public health departments over a 16-week period in 2007, WHBS was an internet-based survey of risk and preventive behaviors of MSM who reported residing in the following metropolitan (project) areas: Baltimore, Boston, Dallas, Los Angeles, New York, and San Francisco. Banner advertisements were used to recruit men who accessed 16 MSM web sites. Designed and approved by each participating health department, banner advertisements appeared systematically (e.g., to every third visitor) and encouraged men to participate. When an internet user clicked on the banner, the user was assigned a unique survey identification number and was sent directly to the WHBS eligibility web page. A count of banner advertisements appearances (impressions) was available from the following 7 websites that yielded 89.5% of the total number of completed MSM interviews: BGCOnlin, BigMuscle, Dlist, Friendster, Gay.com, Manhunt, and MySpace.
Persons who reported being male at birth, at least 18 years of age, and residing in one of the project areas were eligible to participate. Eligible persons were sent directly to a consent web page designed and approved by the health department of the reported city of residence. Ineligible persons were sent directly to a web page containing information about local HIV services. Ineligible persons could not use the “back” arrow on their internet browser to reenter the site and their assigned identification number expired immediately. A count of persons who began and who completed the eligibility screen was recorded, including reasons for ineligibility.
At the consent web page, eligible persons were asked to check a box stating that they read the information about WHBS and agreed to participate in a 10- to 15-minute anonymous survey without reimbursement. Survey questions were grouped on separate pages and participants were required to submit their responses to proceed to the next page. Participants could view and make corrections to any of their previous answers, and they could refuse to answer any survey question by selecting a “refuse to answer” option. All WHBS web pages were written in English at or below the seventh grade reading level.
The survey assessed participant characteristics within the following 7 domains: (1) socio-demographic (age, race/ethnicity, highest level of education achieved, sexual identity); (2) attendance at 12 types of MSM venues (e.g., bars, dance clubs, sex establishments); (3) internet usage and purpose (e.g., hours per week, to meet sex partners); (4) risk behavior (e.g., drug use; number of male sex partners met via the internet or with whom participants had unprotected anal intercourse (UAI); diagnosis of a sexually transmitted disease); (5) exposure to HIV-prevention services (Appendix); (6) HIV testing and the most important (main) reason for not testing (Appendix); and (7) HIV-testing intentions. All variables within domains 2 to 6 were assessed in the year before the date of interview; for domain 6, we also assessed whether participants had ever tested for HIV.
Two HIV-testing intentions were measured using the same 4-point response scale (“very likely,” “somewhat likely,” “somewhat unlikely,” “very unlikely”). Intention to test for HIV was assessed with the following question: “How likely is it that you will get tested for HIV in the next 12 months?” All participants except those who responded “very unlikely” were asked to respond to the second intention measure: “A new type of HIV home testing kit may soon be available in drug stores or by mail. This new home test kit would use a swab from your mouth (no blood) and would let you know at once if you were infected with HIV. If the new home test kit was available, how likely is it that you would use it?” Strong intention to test in the next year or to use an OTCRT was defined as responding “very likely” to the respective question.
All analyses were conducted using SAS version 9.1 (SAS Institute Inc., Cary, NC), and were restricted to participants who identified as male, and who reported having never tested for HIV and having had sex with another male in the past year. The univariate distribution of socio-demographic characteristics, internet usage, venue attendance, risk behavior, exposure to HIV-prevention services, main reasons for not testing, and testing intentions were first evaluated by city of residence. Because similar distributions were observed across cities, all subsequent analyses were conducted on the combined dataset.
Contingency table analyses using chi-squared tests, Cochran-Armitage trend tests, or odds ratios (OR) and 95% confidence intervals (CI) were performed to evaluate correlates of main reasons for not HIV testing, and strong intention to test for HIV in the next year and to use an OTCRT if it became available. The distributions of the 3 most frequently reported main reasons for not testing are provided in figures for the following identified correlates: age group, race/ethnicity, number of male UAI partners (0, 1, >1), and number of times website(s) were visited for HIV information (0, 1, >1).
Logistic-regression analyses were conducted to identify independent correlates of strong intention to test for HIV. Variables selected for inclusion in the full logistic-regression model included age group, race/ethnicity, and level of education, and other variables that were associated (P < 0.05) with strong intention in contingency-table analyses. A manual, stepwise procedure was used to remove statistically nonsignificant variables from the model only after meaningful confounding (≥10% change in adjusted OR) of retained covariates was ruled out. We report crude and adjusted OR and 95% CI for variables included in the full and final models, respectively.
To evaluate correlates of strong intention to use an OTCRT, contingency-table analyses were stratified by strength of intention to test for HIV in the next year (available strata: “very likely,” “somewhat likely,” “somewhat unlikely”). Strong intention to use an OTCRT was not reported for all data combined because it was not assessed of NTMSM who reported that it was “very unlikely” they would test for HIV in the next year.
Recruitment Outcomes and Derivation of Analytical Sample
Of 76,294 persons who accessed the WHBS website and began the eligibility screen, 44,801 (58.7%) completed the screen, of whom 31,016 (69.2%) were ineligible due to residence (n = 30,553; 98.5% of ineligible), or age <18 years or female at birth (n = 463; 1.5% of ineligible). Of 13,785 (30.8%) eligible persons, 7296 (52.9%) completed the survey, of whom 6015 (82.4%) identified as male and reported having sex with another man in the previous 12 months.
From 7 websites that tracked banner advertisements impressions, of 21,862,924 impressions, 38,431 (0.18%) persons completed the eligibility screen, 12,304 were eligible (32.0% of screened), 6523 completed the survey (53.0% of eligible), and 5385 identified as male and reported having sex with another man in the previous 12 months (89.5% of total MSM participants).
Of the 6015 MSM, 1038 (17.3%) reported that they had never tested for HIV—of whom 87 (8.4%) reported not knowing whether they would test for HIV in the next year and 5 (0.5%) refused to report their HIV-testing intentions. Analyses were restricted to the 946 NTMSM on whom analyzable responses to HIV-testing intentions were obtained.
Of the 946 NTMSM, most were <25 years of age, white, and college educated; nearly all identified as gay or bisexual; many used the internet to socialize and meet sex partners; and most had attended multiple types of MSM venues; 123 (13.0%) reported not attending any MSM venue in the past year (Table 1). Many NTMSM reported attending dance clubs (54.9%), bars (49.1%), and sex establishments (34.1%); few reported attending gay-pride events (12.3%) and raves or circuit parties (11.2%). Many NTMSM reported having multiple male sex partners and UAI, and although few had participated in in-person or online HIV-prevention sessions, approximately half had received free condoms and nearly half used the internet to obtain information about HIV and safer sex (Table 1).
Reasons for Not Testing
Among NTMSM, main reasons for not testing for HIV in the past year were low perceived risk for infection (32.2%), structural barriers (25.1%), fear of testing positive (18.1%), and worry about loss of confidentiality (5.8%) (Table 1). Of the 305 NTMSM who had not tested because of low perceived risk in the past year, during that year, 34.9% had used noninjection drugs, 52.5% had >1 male internet partners, 56.4% had ≥2 male sex partners, and 37.4% had UAI. Of the 237 NTMSM who reported structural barriers as their main reason for not testing, 42.2%, 27.4%, 25.3%, and 5.1% reported not knowing where, or not having the money, time, or transportation to test, respectively.
Reporting structural barriers as a main reason for not testing decreased with increasing age (trend test, P < 0.001) (Fig. 1). Not testing because of low perceived risk (P = 0.319) and fear of testing positive (P = 0.689) did not vary significantly by age group.
Compared with white NTMSM, proportionally more black (37.0% vs. 14.8%; OR, 3.38; 95% CI, 2.04–5.60) and Hispanic (21.3% vs. 14.8%; OR, 1.56; 95% CI, 1.02–2.39) NTMSM reported fear of testing positive as a main reason for not testing (Fig. 1). Not testing because of low perceived risk (P = 0.406) and structural barriers (P = 0.106) did not vary significantly by race/ethnicity.
Male UAI Partners.
Reporting low perceived risk decreased (trend test, P < 0.001), and reporting structural barriers (trend test, P = 0.008) and fear of testing positive (trend test, P < 0.001) increased, with increased number of UAI partners (Fig. 2).
Use of the Internet for HIV Information.
Reporting low perceived risk decreased (trend test, P = 0.018) and reporting fear of testing positive increased (trend test, P < 0.001) with increased HIV internet-use (Fig. 1). Reporting structural barriers did not vary significantly with increased HIV internet-use (P = 0.384).
Intention to Test for HIV
Approximately one-quarter of NTMSM reported that it was very likely they would test for HIV in the next year (Table 1). In the final logistic-regression model, increased adjusted odds for strong testing intention were observed among NTMSM aged 18 to 24 years or of black or Hispanic race/ethnicity, and among NTMSM who reported attending multiple types of MSM venues, participating in an in-person HIV-prevention session, visiting websites for HIV information more than once, using noninjection drugs, having multiple male sex partners, and main reasons for not testing other than low perceived risk (Table 2).
Potential Use of an OTCRT
Compared with NTMSM who were somewhat unlikely to test for HIV in the next year, proportionally more NTMSM who were somewhat likely (47.4% vs. 76.5%; OR, 3.62; 95% CI, 2.39–5.49) and very likely (47.4% vs. 85.6%; OR, 6.60; 95% CI, 4.09–10.66) to test reported strong intentions to use an OTCRT if it was available. In stratified analyses, no socio-demographic or risk variables were consistently associated with strong intentions to use an OTCRT across intentions to test in the upcoming year (Table 3).
In an internet survey of MSM from 6 US cities in 2007, we found that of a large sample of MSM who had never tested for HIV, most were under 25 years of age, many reported considerable HIV risks in the past year, and only one-quarter reported strong intentions to test for HIV in the upcoming year. Many NTMSM, however, attended multiple types of MSM venues and used the internet for HIV information, and are thus plausibly accessible to outreach-testing services and online interventions. Interestingly, even among NTMSM with low testing intentions, many reported they would use an OTCRT if it was available.
Similar to surveys that included ever-tested MSM, we also found that low perceived risk, structural barriers, and fear of testing positive were the most frequently reported main reasons for not testing, and that concern about loss of confidentiality was infrequently reported as a main reason.6–9,24–27 We also found, however, that the distribution of the 3 most important reasons for not testing varied considerably by socio-demographic, risk, and internet-use characteristics. Thus, to facilitate HIV testing of diverse NTMSM, only a minority of whom hold strong testing intentions, our findings suggest that prevention programs should expand testing services and interventions tailored to address this variation.35–37
Low Perceived Risk
Low perceived risk was the most frequently reported main reason for not testing among NTMSM of all age groups, and of white and Hispanic race/ethnicity. However, many NTMSM who reported low perceived risk as a main reason for not testing also reported considerable risk behavior, and among NTMSM who reported 1 male UAI partner in the past year, low perceived risk remained the most frequently reported reason for not testing. Notably, very few (14.8%) NTMSM who reported low perceived risk as the main reason for not testing in the past year held strong intentions to test for HIV in the upcoming year.
Many NTMSM who had 1 male UAI partner may have perceived being at low risk because their UAI partners were main partners or because they “knew” their UAI partners were HIV-negative.40–45 These NTMSM, however, remain at substantial HIV risk because of the high prevalence of undiagnosed HIV infection among MSM, and that many undiagnosed, HIV-infected MSM unintentionally disclose being “HIV- negative” and engage in UAI because they perceive themselves or their partners at low risk for infection.6,7,46–50
Collectively, these findings underscore the need for targeted test-promotion efforts for NTMSM who report not testing because of low perceived risk, particularly for those who engage in UAI. Interventions designed to heighten uncertainty of risk and perceived vulnerability might persuade some NTMSM who do not test because of perceived low risk; however, these interventions may only be effective when coupled with messages that convey the value of early HIV diagnosis on personal health and well being, and that have explicit information on available testing services.36,51,52 The increased uptake of HIV testing from the “Gimme 5 Minutes” social marketing campaign targeting young black MSM in London, for example, was attributed, in part, to the provision of detailed information on where and when to test, and how results would be made available.52
Many MSM may also report being at low risk as a rationalization for avoiding testing and as a coping strategy to reduce the stress and fear from knowingly engaging in HIV risks.27,53–56 Because messages designed to increase perceived vulnerability may threaten self-image and induce defensiveness,51,57 prevention programs should also consider alternative promotional strategies. Though further research is necessary, interventions that preserve self-image, induce hypocrisy, or incorporate affective outcomes such as anticipated regret have been effective in reducing risk behaviors and might also be effective in increasing the uptake of testing among NTMSM.57–62
Fear of Testing Positive
Fear of testing positive was the most frequently reported main reason for not testing among NTMSM who were of black race and who reported multiple male UAI partners, 2 groups of NTMSM at considerable risk for undiagnosed HIV infection.6,7,47 These findings underscore the need for programs to investigate and address underlying causes of fears about testing HIV-positive, particularly for these important subgroups.
Although heightened risk perception probably helps explain fear of testing positive among NTMSM with multiple UAI partners, one study suggests that risk perceptions of young black and white MSM are similar.6,63 Compared with young white MSM, however, young black and Hispanic MSM might be less aware of the efficacy and safety of antiretroviral therapy (ART), and of the availability of medical care for those with limited resources.64 Thus, prevention programs should consider increasing awareness of the benefits and availability ART, particularly targeting NTMSM of black and Hispanic race/ethnicity and who report multiple UAI partners. The ACT against AIDS campaign, for example, is designed to increase testing in specific populations such as black and Hispanic MSM by conveying, in part, the benefits of early HIV diagnosis, the efficacy of ART to prolong quality life, and information about treatment programs for those without health insurance.65
Not surprisingly, structural barriers were frequently reported as a main reason for not testing among younger and Hispanic NTMSM, groups that may have fewer resources to test or that might be less integrated in MSM communities and less aware of free HIV-testing services. We also found that structural barriers was 1 of 2 most frequently reported main reasons for not testing among NTMSM who reported UAI, suggesting that expanded delivery of testing services might benefit those NTMSM most in need of testing.
We were encouraged that most NTMSM attended multiple types of MSM venues and that attendance at multiple venues was associated with strong testing intentions. Attendance at diverse MSM venues could be a proxy for increased social integration within MSM communities or for greater acceptance or openness about homosexuality, factors known to be associated with HIV testing.8,11,23,27,66 Our findings suggest that expanding community-based testing at MSM venues, particularly those attended by young and Hispanic MSM, might be particularly helpful to facilitate testing of NTMSM who have not tested because of structural barriers. With the availability of rapid HIV tests, outreach testing has become more feasible. For example, over a 2-year period, 8 community-based organizations in 7 US cities provided rapid HIV testing services at bars, bathhouses, parks, and other outreach settings for 23,900 persons, 7037 (30%) of whom had never previously tested for HIV.34
Implications for Internet-Based Interventions
We found that approximately half of NTMSM used the internet to obtain information about HIV and that more frequent use of the internet for this purpose was (1) associated directly with strong testing intentions, and (2) associated inversely with low perceived risk and directly with fear of testing positive (as main reasons for not testing). These associations might be explained by several motivational health-behavior theories under which persons who perceive greater threat from HIV (i.e., greater perceived risk and fear) have greater motivation for protective behavior, and thus would be more likely to seek information about HIV and to formulate intentions to engage in protective behavior such as testing for HIV.35,36,51,67,68
Our findings, thus, suggest that internet-based test promotion programs might be effective in facilitating testing of many NTMSM.28–30 In the only study found of its kind, a recent randomized controlled trial found that an internet-based video intervention was more effective than a text-alone intervention in increasing both intentions and uptake of HIV testing among non-gay identified MSM in Lima, Peru. Notably, the majority of MSM who participated reported having never tested for HIV.69
Prevention programs should also consider how their websites might be adapted to facilitate testing of NTMSM. Home pages, for example, might encourage users who have not tested in the past year to enter portals specific to a main reason for not testing. Users entering these portals could then be provided more personally relevant information and motivational messages. Because structural barriers were a prevalent reason for not testing, prevention websites should also provide “one-click” access to pages that have information in both English and Spanish on the locations and hours of operation of free testing services.
The findings in this report are subject to several important limitations. First, since our survey was restricted to a convenience, internet-based sample of NTMSM from 6 US cities, the extent to which our findings may generalize to other groups of NTMSM is unknown. As in other internet surveys, the magnitude and direction of recruitment bias in our survey cannot be assessed because the number and characteristics of NTMSM who observed banner advertisements and who chose not to participate is unknown. However, because our survey employed standard banner advertisements that obtained a click-through rate (0.18%) commensurate with internet marketing (median click-through rate of 5 banner-size categories, 0.18%, range: 0.10%–0.37%),70 a systematic bias of recruiting only very experienced or savvy internet users is unlikely.
Second, because WHBS was an internet-based, anonymous survey, some individuals may have participated more than once. However, WHBS did not reimburse participants for their time, and thus avoided a major incentive for repeat participation. Other measures taken to avoid repeat participation included (1) conducting WHBS over a short 16-week period; (2) systematically, rather than uniformly, presenting banner advertisements to website visitors; (3) restricting participation to persons who clicked on banner advertisements rather than allowing persons to search for and access the WHBS website directly; and (4) restricting access to the WHBS website to those with a unique identification number that expired after survey completion and that could not be used twice.
Third, the validity of our measures to predict testing behavior is unknown. Because our measures did not include test costs or appeals for a realistic appraisal of testing intentions, it is possible that our reported intentions might overestimate testing behavior, particularly with an OTCRT which may be expensive to purchase. Additionally, some participants may have overestimated their intentions to use an OTCRT because our measure did not specify the requirement for supplemental confirmatory testing for those who test HIV-positive with an OTCRT.1,38,71 To help reduce bias, we provided the most conservative estimate our data allowed by excluding “somewhat likely” responses from our defined intention outcomes.
Fourth, because our survey was cross-sectional, identified correlates of testing intentions may not be causal. For example, prior exposure to in-person or online prevention services may reflect the fact that MSM with stronger testing intentions were more likely to seek out these services. Finally, we were unable to report potential use of an OTCRT among those NTMSM who held the weakest testing intention.
Public Health Significance and Potential Uptake of OTCRT
Our finding that approximately 1 in 6 (17%) predominately young MSM had never tested for HIV, similar to 22% of 15- to 25-year-old MSM surveyed in 10 US cities in 1999 and 16% of 18- to 24-year-old MSM in 15 US cities in 2003–2005, is remarkable in light of considerable investments in the past 2 decades to increase testing among MSM.11,26,72 Although we were encouraged that strong testing intention was associated with black and Hispanic race/ethnicity and increased risk behavior, findings that might be attributed, in part, to these investments, more effective efforts are clearly needed.72 Recent policy changes1 and new social-marketing campaigns65 will hopefully reduce the delay in testing among NTMSM; however, new HIV testing applications could also play an important role.38,39
In our large sample of NTMSM, many reported they would use an OTCRT if it was available, even among those who thought it was unlikely they would test in the upcoming year under currently available options. That an OTCRT might be used among many NTMSM who might not test otherwise is plausible given the large uptake of rapid tests in the United States, and that an inexpensive home test that provides accurate and rapid results are test attributes with the highest reported preference among MSM.20,21,73–75 Thus, our findings and those of others suggest potential value in evaluating public-health applications of OTCRT, if approved, to increase the uptake of testing among MSM. In the interim, to help reduce late HIV diagnoses and transmissions attributed to undiagnosed infection, prevention programs should expand delivery of interventions and services tailored to address the diversity of reasons for not testing among NTMSM.
Selected Measures and Variable Definitions
Exposure to HIV Prevention Services.
“Attended in-person session” was defined as responding “yes” to either of the following 2 questions: “In the past 12 months, not including when you may have been tested for HIV, have you had a one-on-one conversation with an outreach worker, counselor, or prevention program worker about ways to protect yourself or your partners from getting HIV or other sexually transmitted diseases?” “In the past 12 months, have you been a participant in any sessions involving a small group of people to talk about ways to protect yourself or your partners from getting HIV or other sexually transmitted diseases?”
“Received free condoms” was defined as responding “yes” to the following question: “In the past 12 months, have you received free condoms?”
“Visited website(s) for HIV information” was defined as responding “one time” or “more than one time” to the following question: “In the past 12 months, how often have you visited a website for information about HIV?”
“Visited website(s) for safer sex information” was defined as responding “one time” or “more than one time” to the following question: “In the past 12 months, how often have you visited a website for information about safer sex?”
“Approached online by HIV prevention worker” was defined as responding “one time” or “more than one time” to the following question: “In the past 12 months, how often have you been approached online by someone doing HIV prevention work?”
“Participated in online HIV prevention chat session” was defined as responding “one time” or “more than one time” to the following question: “In the past 12 months, how often have you participated in or observed an online chat session related to HIV prevention?”
Main Reason for Not Testing for HIV.
Main reason for not testing for HIV was defined as choosing “Yes” to 1 of 11 available reasons provided after the following statement: “Which of these reasons was the most important reason you have not been tested for HIV in the past 12 months?” “Yes” responses were grouped into 1 of 5 categories (noted in parentheses).
- “Because you haven't done anything to get HIV?” (Low perceived risk for HIV).
- “Because you don't know where to go to get tested?” (Structural barriers).
- “Because you couldn't get transportation to a testing place?” (Structural barriers).
- “Because you didn't have time?” (Structural barriers).
- “Because you didn't have the money or the insurance to pay for the test?” (Structural barriers).
- “Because you were afraid of finding out that you had HIV?” (Fear of testing positive).
- “Because you were worried your name would be reported to the government if you tested positive?” (Worried about loss of confidentiality).
- “Because you were worried someone would find out about your test results?” (Worried about loss of confidentiality).
- “Because you were afraid of losing your job, insurance, housing, family, or friends if people found out you tested positive?” (Worried about loss of confidentiality).
- “Because you don't like needles?” (Other reason).
- “Other important reason why you have not been tested for HIV in the past 12 months.” (Other reason).
- “Don't know.”
- “Refuse to answer.”
Note: Information on main reason for not testing was not provided by NTMSM (n = 66) who chose “No” to all of the above reasons including 11. These 66 NTMSM were also categorized as having an “other reason.”
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