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CAN GAY AND BISEXUAL MEN PREDICT WHEN THEY WILL HAVE SEX?

NEW CHEST STUDY HAS MAJOR IMPLICATIONS FOR “AS NEEDED” PrEP DOSING STRATEGIES

Slowly but surely, word is spreading about Pre-Exposure Prophylaxis (PrEP), the exciting new strategy for HIV prevention for HIV-negative men and women at risk, principally in the form of the once-daily Truvada pill by Gilead.  Current studies of once-daily PrEP dosing find it to be effective, with the iPrEX trial reporting 92% efficacy when taken every day. One of the biggest criticisms of PrEP has been that asking people who consider themselves otherwise healthy to take a pill every day is an unrealistic expectation.  Scientists are currently studying if less frequent Truvada dosing is still effective.   Earlier this year, for instance, an extension phase of the iPrEx study found that those who took Truvada at least four times a week still avoided infection. More recently, the IPERGAY study has stopped giving placebo treatments ahead of schedule because of the high effectiveness of PrEP taken on an “as needed” schedule.  Rather than ask participants to take the pill every day, IPERGAY had participants take two pills up to 24 hours before having sex, one pill in the 24 hours after sex, and an additional pill 48 hours after.  This dosing may be less burdensome than daily pill taking, but it demands further behavioral research on how often and how accurately individuals can predict when they will have sex, and then adhere to the guidelines of their regimen appropriately. Other less-than-daily dosing strategies are also currently being tested, including the ADAPT trial.

“We may find that alternate dosing strategies work, especially ones where someone is expected to take a pill before they have sex. But the strategy will only work for gay and bisexual men if they can actually predict when they will have sex,” said Dr. Jeffrey Parsons, lead researcher on a new study by the Hunter College Center for HIV/AIDS Educational Studies and Training (CHEST).  Parsons and his team analyzed behavioral data on gay and bisexual men’s sexual practices and behaviors. This included using an online daily diary that asked men to predict whether they would have sex the next day, and then following up to see whether or not they did for a total of 30 days each. This was a unique sample, in that they were all highly sexually active, with men reporting an average of nearly 13 male partners in the 6 weeks prior to enrollment. Given the sheer frequency of their sexual behavior, highly sexually active gay and bisexual men would be ideal candidates for PrEP.

“Interestingly, we found that gay and bisexual men were not very good at predicting when they would have sex. They often overestimated their likelihood of having anal sex with casual partners.” said Parsons. “Instead, we found that they were much better at predicting when they wouldn’t have sex,” he continued. So, basically, even if a guy is sure he is going to get laid, chances aren’t much better than flipping a coin. On the other hand, when a guy is certain he won’t have sex, chances are, he’s right! 

For example, according to the study’s modeling, even when men predicted that they were 100% likely to have sex the next day, they only sealed the deal 59% of the time. In comparison, when men believed they had a 0% chance of having sex the next day—which only happened 14% of the time!—results showed they were right 96% of the time.

These findings may seem intuitive, especially for gay and bisexual men who’ve ever been on the prowl, but they illustrate the fact that gay and bisexual men may not get a lot of warning time for taking doses of PrEP prior to sex.  The problem here is that gay and bisexual men are likely to miss necessary pre-sex doses if they are required to anticipate sex too far in advance or if they’re relying on the likelihood of sex being high before taking a dose. “Should event-based dosing prove equally effective, our findings have implications for how providers talk to their patients about PrEP,” said Parsons. Rather than only taking a pre-sex dose when they think they will have sex, the data suggest counseling the opposite—providers might consider counseling men that they should take a dose of PrEP every day unless they think the chances of sex within the next 24 hours are 0%, in which case the dose could be skipped. With the estimated retail cost of Truvada at $25.86 per pill, this study suggested that even among this sample of highly sexually active men, this would result in more than 50 days of doses that could be safely skipped each year, leading to a cost savings of more than $1,300 per year. 

Although these findings provide some guidance for event-based dosing, ultimately more behavioral research on this innovative biomedical approach to HIV prevention is needed. Researchers need to understand if event-based dosing is easier than daily pill taking. And the potential for injectable PrEP (currently being tested) may make regular pill taking less critical.

  About the study:

The results of this study titled, “Accuracy of highly sexually active gay and bisexual men’s predictions of their daily likelihood of anal sex and its relevance for intermittent event-driven HIV Pre-Exposure Prophylaxis,” by Jeffrey T. Parsons, H. Jonathon Rendina, Christian Grov, Ana Ventuneac, and Brian Mustanski will be published in an upcoming issue of JAIDS (Journal of Acquired Immune Deficiency Syndromes).

CHEST’s mission is to conduct research to identify and promote strategies that prevent the spread of HIV and improve the lives of people living with HIV. We have been advocating for and working with the LGBT community since 1996. www.chestnyc.org

Contact:              

Dr. Jeffrey T. Parsons, Director – Center for HIV Educational Studies & Training

jparsons@chestnyc.org

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Trans Community Spotlight: Melissa Sklarz, Politician and Activist

By Leo Spychala with Special Thanks to Joshua Guthals & Divpreet Kaur

On February 22, 2012, Melissa Sklarz made history when she became the first transgender person elected President of The Stonewall Democratic Club of New York City, the largest LGBT Democratic political club in both the City and State of New York. This victory was just the latest in Ms. Sklarz’s long history of breaking barriers; in 1999, she was the first transgender person to run for and win political office in New York State when she was elected Judicial Delegate from the 66th Assembly District. In 2004, she became the first transgender person in the state to be appointed as a delegate at the Democratic National Convention. Though her two-year term as President ended this past February, Sklarz remains active in politics while maintaining a successful professional life as a director of the Actors Federal Credit Union.

Before her personal and professional success, Sklarz struggled with alcohol and substance abuse. She felt that she would never be able to transition successfully, “I didn’t have the language, I didn’t have a role model, I didn’t have a road map. I just had feelings that didn’t have words for them.” When she became homeless and jobless she felt she had to reevaluate the direction of her life.  After entering and completing a rehabilitation program, Sklarz joined the Gender Identity Project as a peer counselor at the LGBT Center in Greenwich Village. It was here that she met other transgender women she could relate to, having always felt different from the few transgender women she did know who she describes as being very glamorous. “It was profound, it was a shock, because I thought I was unique and that there were not people like me. And going there to the support groups, I found out that there were.” It was during this time that Sklarz got her start in public service when she passionately spoke out at a public hearing against the transphobia that was occurring in her neighborhood at the time, Manhattan’s Meatpacking District. “And they got even with me,” Sklarz jokes, “they put me on the community board.”

In 2002, New York State passed SONDA, the Sexual Orientation Non-Discrimination Act, which prohibits discrimination on the basis of sexual orientation. Language that would have included gender expression and identity was ultimately excluded from the final law, leaving transgender people open to legal discrimination in housing, employment, public accommodations and education. In the twelve years following, Sklarz has been fighting for the passage of GENDA, the Gender Expression Non-Discrimination Act, a similar bill that would outlaw discrimination based on gender expression or identity.Speaking on the bill, Sklarz states, “we’ve got to change the minds of New York State, almost literally one person at a time.” At the time of this interview Sklarz was gearing up to get GENDA passed in this year’s legislative session which runs from January to June. She expressed concern that the passage of the bill in an election year would be tough and so far she has been correct; with the legislative session coming to a close, the bill has  passed in the State assembly, but the State senate has yet again failed to bring the bill to the floor for a vote.

No matter the outcome, Melissa Sklarz will continue to fight for the rights of all New Yorkers, especially against those who try to distort the message of the non-discrimination law. She explains that laws like this will have no effect on 99% of people, but for those who are affected the outcome will be significant. “The enemies of transgender people use their talking points to frame our discussions as mostly bathroom oriented. We try to explain to them [that] transgender people have been using bathrooms for fifty years. That will not change. What changes is we will not be harassed when we use them.”

On her tenure as President of the Stonewall Democratic Club, Sklarz said her victory sent out a message that the initials LGBT do not just mean gay, white men. With the rise of more positive coverage by the media of transgender people, she hopes to see others follow in her footsteps. “My success took years. The goal of me being out and visible is that the next generation, their success, won’t take years.”

For more information about GENDA, check out http://www.prideagenda.org/igniting-equality/current-legislation/gender-expression-non-discrimination-act

  T-Talk is a transgender women’s project seeking to reduce sexual health risk, substance use, and internalized stigma affecting the community. If you’re a transwoman living in NYC, follow this link to see if you’re eligible to participate: https://chest.az1.qualtrics.com/SE/?SID=SV_bQHdE91Bfq9tvMM&Study=ttalk

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Study at CHEST for Women of TRANS Experience: T-Talk T-Talk is a peer-led intervention that was developed in response to the acute health prevention needs of our community of transgender women in New York City. Peer Health Navigators, who are members of the community, will facilitate the individual and group sessions to guide our participants through the process of learning more about common psychosocial health issues. Our participants will take part in seven sessions aimed at reducing sexual health risks, substance use, and internalized stigma. Peer Health Navigators will work along participants to develop coping skills, and to achieve their goals of gaining access to professional medical care, social support, and other critical services.

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The T-Talk team and CHEST invites you to "Gia Padilla: La Asesina de la Guajira" at Harlem United. Learn how to dance "Guajira" with Gia Padilla Live from Puerto Rico!

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NYC Anti-Violence Project's Community Heroes Award Ceremony

Today Wednesday, April 30th, 2014 from 6:00pm to 7:30pm

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CHEST Spotlight: Gay and Bisexual Men's Use of the Internet: Research from the 1990s through 2013

CHEST faculty affiliate Dr. Christian Grov is featured in the Annual Review of Sex Research published by The Journal of Sex Research with an article about gay and bisexual men's use of the internet from the 90's to today. From logging on via dial-up modem on a desktop computer to geo-social-sexual networking via handheld devices, Dr. Grov documents the historical and cultural shifts in how gay and bisexual men have used the Internet for sexuality.

The article is available for free until August. Click here to download!

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An Open letter to the AIDS Healthcare Foundation (AHF) President, Michael Weinstein

FOR IMMEDIATE RELEASE

April 28, 2014

Contact:             Dr. Jeffrey Parsons

Director of the Center for HIV Educational Studies and Training Distinguished Professor of Psychology and Public Health at Hunter College and the Graduate Center of the City University of New York (CUNY)

Email:                    jparsons@chestnyc.org 

April 28, 2014

Dear Mr. Weinstein:

We, the research team at The Hunter College Center for HIV Educational Studies and Training (CHEST) are deeply concerned about your recent inflammatory remarks about HIV Pre-Exposure Prophylaxis (PrEP), calling Truvada a “party drug” and “ineffective” in preventing HIV transmission.  We know that the AIDS Healthcare Foundation (AHF), as the largest HIV/AIDS services organization in the United States with a $300 million dollar budget, provides services to a diverse range of patients and clients. People who are at risk for HIV and who are HIV-positive often experience barriers due to intersecting factors in accessing HIV services. The AHF staff and Board are also quite diverse in their experiences and approaches to HIV work and in all likelihood, there are staff and volunteers at AHF that do not agree with your position on PrEP.  Your position on PrEP ignores the data on its effectiveness  and further fuels stigma around sexual behavior and HIV, especially amongst communities that are most at risk for HIV infection – young men of color who have sex with men and serodiscordant couples.  The AHF should represent the needs of all people at risk for or living with HIV/AIDS rather than catering only to those who engage in particular behaviors deemed “appropriate” (especially considering they are likely at less risk for HIV in the first place and thus in less need of the AHF’s services).

Mr. Weinstein, your position on PrEP is out of touch with the realities of HIV prevention.  PrEP is the most promising biomedical intervention to date for preventing new HIV infections in high-risk populations and is designed to provide protection against existing levels of HIV risk. In fact, there is no evidence that the use of PrEP will increase risk behaviors. Research suggests that a majority of people struggle to use condoms 100% of the time, and PrEP would provide an added layer of protection in the face of their existing risk. Men already engaged in bareback sex deserve and need an effective HIV prevention method – condoms should not be the only tool that people have to protect themselves from HIV infection.  There are also contributing factors that impact decisions around condom use, such as using substances and engaging in high risk sexual behavior.  Shaming non-mainstream sexual practices along with fueling stigma can potentially increase their risk and the difficulty of providing prevention for people engaged in such practices. 

Over the past couple of weeks, leading experts and activists working in the field of HIV prevention have spoken out against your position on PrEP, yet you continue to stand by your statements.  There is a significant amount of misinformation and confusion about PrEP – misleading information about its effectiveness, side effects, and health insurance coverage, to name a few, that can contribute to the relatively small numbers of people who are currently on PrEP.  As professionals working in HIV prevention and care, we need to focus on the realities of the HIV epidemic and work to make PrEP more widely available to those individuals who are at most risk for HIV infection. Further, we must focus on understanding and addressing barriers to PrEP uptake, factors that contribute to difficulties with PrEP adherence (e.g., drug use), issues with dissemination of accurate information regarding PrEP to community members and service providers, and the continued stigma that is associated with the sexual practices that put individuals at risk for HIV.  The continuation of the HIV epidemic both nationally and globally requires a shift in the HIV prevention paradigm, and it is clear that the position you have taken on behalf of AHF is dangerous, stigmatizing, and out of touch with such paradigm-shifting approaches to prevention.

Signed,

the CHEST Research Team

Center for HIV Educational Studies and Training (CHEST)

Hunter College of the City University of New York (CUNY)

Contact: Dr. Jeffrey Parsons – jparsons@chestnyc.org

  CHEST’s mission is to conduct research to identify and promote strategies that prevent the spread of HIV and improve the lives of people living with HIV. We have been advocating for and working with the LGBT community since 1996.

  # # #

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Research results from CHEST in collaboration with HOOK and Rentboy.com

Press Release: For Immediate Release

April 25, 2014

  New study of male escorts finds that what they want to know is not what you think

  Internet-based male escorts want to learn about ways to improve their business, found a new study from researchers at the Center for HIV Educational Studies and Training (CHEST.) They want services beyond safer sex and express high interest in being helped in ways that will improve their careers as escorts. “A lot of current research on male escorts has focused on HIV risk and looked at ways to help men stop being escorts. The assumption has always been that, because male escorts exchange sex for money, they are in dire need of safer sex training,” says Dr. Christian Grov, one of the study’s authors. “Instead, we found that over 70% reported using a condom with their last client and that services such as ‘Attracting the right client and keeping them,’ or learning how to navigate the legality of escorting, outranked being trained in how to negotiate safer sex with clients,” said Grov.

  The data were taken from a 2013 survey of 418 male escorts on Rentboy.com, one of the largest websites on which male escorts advertise themselves to other men. The research team partnered with HOOK (hook-online.com), one of the oldest grassroots organizations to provide services and advocacy for men in the sex industry. One of Hook’s most popular programs is “Rent University,” a series of workshops offered to men in the sex industry. “Rent University was started in 2004 and has offered a variety of workshops ranging from self-defense to substance use harm reduction,” says Hawk Kinkaid, HOOK’s President and founder. “We partnered with the research team at CHEST to gain greater insight about what courses and programs to plan for the next Rent U. sessions and articles on HOOK’s site. We wanted to know what interests men in the sex industry about healthy living through working smarter,” said Kinkaid.

  The CHEST survey asked men about 14 different workshops and those topping the list predominantly had to do with ways in which men could build their careers as escorts (managing money, marketing oneself). In fact, ending one’s career as an escort ranked 8th and negotiating safer sex ranked 12th. “This suggests that both researchers and providers really need to rethink how we are going to approach the topic of escorting,” says Grov. “Instead of trying to ‘save’ these men from being escorts and assuming HIV prevention is their chief interest, perhaps we really should be trying understand motivations for escorting and the intrinsic benefits men receive from being escorts,” continued Kinkaid.

  But this is not to suggest all male escorts are happy-go-lucky. “It is important to remember that exchanging sexual services for money is highly stigmatized and there isn’t an organized physical community of male escorts. Many of these men remain hidden among us,” said Grov. In fact, the study found more than 2/3rd of participants (69.7%) had not disclosed their escorting to a single family member and a quarter had not told a single friend. “And this is exactly why online grassroots organizations like Hook have proven so valuable for these men. Where there isn’t a physical place for escorts to gather, online communities like Hook have created a virtual space.” And while 70% of participants reported using a condom with their last male client, 30% did not. Although in the minority, the study identified areas for improvement.

  For more information:

Christian Grov. cgrov@chestnyc.org 212-206-7919

  The findings from this study are forthcoming in the journal Sexuality Research and Social Policy

  Grov, C., Rodriguez-Diaz, C. E., Ditmore, M. H., Restar, A., & Parsons, J. T. (2014). What kinds of workshops do Internet-based male escorts want? Implications for prevention and health promotion. Sexuality Research and Social Policy. doi: 10.1007/s13178-014-0151-z http://link.springer.com/article/10.1007%2Fs13178-014-0151-z 

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An observational study of how we date, have sex, and form relationships today

Dr. Tyrel Starks and Pace University is conducting an online study of how people date and form relationships. Participation includes an initial survey questionnaire about your feelings and attitudes towards relationships, your history with dating, current mental, emotional and social well-being, and recent substance use and sexual behavior. Then, you will return to the survey once a week for 6 weeks to update us about what is going on in your dating life. The survey is open to men and women who think of themselves as single. If you are interested, click here to learn more about the study https://v2.proofpilot.com/en/datingtoday/

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Project WISE Recruitment

The CUNY Hunter College Center for HIV Educational Studies and Training (CHEST) is currently recruiting for a compensated study with older adults (over the age of 50) who are living with HIV/AIDS, are substance users, and have issues with medication adherence. This study also incorporates spirituality as a determinant for coping and resiliency. If you are interested in learning more about Project WISE, please visit http://www.chest.org/wise/index.html . Also, feel free to reach out to the contacts listed below for additional information about WISE:

  Jonathan Lopez Matos, CHEST Retention Coordinator

                jlopez@chestnyc.org, 212-206-7919 ext 928

Ruben Jimenez, CHEST Director of Recruitment and Retention

                Rjimenez@chestnyc.org, 212-206-7919 ext 913

Bobby Preti, CHEST Hunter College social work intern (until May 16, 2014)

                bpreti@chestnyc.org, 212-206-7919

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Check out this recent article about the reality of being a gay male escort from the perspective of the men working within the sex work industry. The article also features quotes from CHEST Director, Dr. Jeffrey Parsons.

"People think you're just this f--king hooker, someone who's money-hungry, dirty and gross. But that's not my reality," said Boomer Banks on a recent March afternoon, looking up from his sewing machine. "It isn't my be-all, end-all. It's just a way for me to be able to get what I need for the rest of my career."

Click here to read more!

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Join us to celebrate the launch of the T-Talk study for women of trans experience!

Various agencies will be providing FREE consultation related to legal matters, name change, health matters, insurance, aesthetic empowerment, and more!

Trans woman and allies welcome!

Wednesday, April 2nd from 6PM to 9PM!

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Good News for those of you who live in the New York City area! The Anti-Violence Project (AVP), BOOM! Health, and the Audre Lorde Project (ALP) are hosting this wonderful event in which T-Talk from CHEST will be having a fabulous table! Come to this wonderful event and visit our table, It is all FREE of Charge!

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CHEST Debuts Newsletter!

Click here to check out our debut newsletter.

Click here to subscribe to our updates lists to receive researching findings, community news, and more.

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A Year-End Look at CHEST's Most Popular Research Findings of 2013

CHEST's research made a splash in 2013 - at public health conferences, on social media, and in national news. Here's a look at five of our most popular research findings.

1. 1 in 10 Grindr users reported to CHEST that they have never had an HIV test in their lifetime. CHEST researcher Jon Rendina says, "men [may be] sharing potentially inaccurate HIV status information with their partners on Grindr,” especially when one-third of these men reported that they were HIV-negative despite having never been tested. Click here to read more about our Grindr research findings on Huffington Post.

2. Penis size matters - especially the girth, which correlates strongly to reports of condom breakage and slippage. Condom comfort impacted men with smaller than average penises along with men with larger than average penises. “A one-size-fits-all approach to condom distribution may not be an ideal approach for many individuals,” says Dr. Grov. Click here for more information about CHEST's finding on penis size and sexual health from Psychology Today.

3. Gay and bi men continue to rank HIV as their top health concern. HIV/STDs ranked first, with mental health and substance use tied for second place. “These findings are promising for HIV prevention providers because they suggest many gay and bisexual men still recognize HIV as a top issue for the gay community,” says Dr. Grov. Click here for Queerty.com's article on these findings.

4. In gay couples, three isn't always a crowd. Our research into monogamy and commitment among gay and bisexual men found that many couples are not strictly monogamous - by choice. Dr. Parsons states, "Our findings suggest that certain types of non-monogamous relationships - especially 'monogamish' ones - are actually beneficial to gay men, contrary to assumptions that monogamous relationships are always somehow inherently better." Here's what Huffington Post wrote about our findings.

5. LGBT members of the US Military face harassment, victimization, and reduced job opportunities. CHEST presented the results of our LGBT Military Study at the 141st Annual Meeting of the American Public Health Association. Key findings included that a majority of gay and bisexual men in the military were engaging in safer sexual practices; however, experiencing harassment within the military was associated with a greater frequency of unprotected anal intercourse, particularly among those who were actively serving in the military in the past year. Click here to read more about CHEST's LGBT Military Study on our Tumblr Blog.

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Are you 50 or older and living with HIV? Are you concerned about your drug or alcohol use? Have you heard about Hunter College's Center for HIV Educational Studies & Training (CHEST)? CHEST was founded in 1996 by Dr. Jeffrey Parsons to conduct research about preventing HIV and about improving the well-being of those living with HIV/AIDS. It's a leading research organization that regularly collaborates with organizations you might spend time at, like the Momentum Project, GMHC, ASC, and the Positive Life Project. Perhaps you met some CHEST staff members at one of these organizations the last time you were there!

We want to tell you about an ongoing study at CHEST called Wellness In Spirituality and Education, otherwise known as Project WISE. WISE is an intervention based research study designed for people living with HIV who are age 50 and older and struggling with substance use (drugs or alcohol). WISE is designed to help decrease substance use, increase HIV medication adherence, and improve general well-being. People will receive up to $260 for their full participation in the study.

If you are interested to see if you might qualify to participate in Project WISE, you can call CHEST at 212 206-7919 or you can click HERE to answer some questions to see if you’re eligible for the study.

There are over a hundred people currently taking part in Project WISE and about 80 more people can enroll. So if you’re interested, or you know someone who might be interested in knowing more about WISE, take a moment and either visit CHEST’s website at: http://www.chestnyc.org/wise OR call 212-206-7919 and ask for more information about Project WISE

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CHEST Research Spotlight: LGBT Service Members in the US Military Still Face Harassment and Victimization

Harassment, victimization, mental health, substance abuse, and sexual risk behaviors of LGBT service members in the US military

November 20, 2013

Mental Health & Alcohol Use:

Increases in PTSD, anxiety, and depression were associated with increased odds of alcohol dependence, with PTSD and depression being most strongly associated with alcohol dependence.

Feeling a sense of growth as a result of coming to terms with one’s sexual identity was associated with decreased odds of alcohol dependence, perhaps indicating that this factor promotes coping in the face of difficult life experiences.

Experiences of Harassment:

Women and men reported similar levels of sexual orientation-based harassment in the military.

A greater number of lesbian and bisexual women reported being denied career opportunities and more incidents of sexual harassment inside the military than gay and bisexual men, though gay and bisexual men also reported experiencing sexual harassment.

HIV risks & testing:

Overall, a majority of gay and bisexual men in the military were engaging in safer sexual practices (i.e., condom use during anal sex).

Experiencing harassment within the military because of perceived sexual orientation was associated with a greater frequency of unprotected anal intercourse, particularly among those who were actively serving in the military in the past year.

Almost all service members reported having been tested for HIV at least once in their lifetime, with most having received a test within the previous 12 months. 

These findings highlight that, despite Department of Defense policy changes such as the dismissal of Don’t Ask, Don’t Tell (DADT), many LGBT military members still face harassment and victimization in the military. More work is needed to achieve adequate levels of safety and equity for LGBT individuals serving in the military. New programmatic initiatives spearheaded by the Military Partners and Families Coalition, the Center for American Progress, and the Palm Center are underway that may be tremendously helpful in reaching these objectives. These challenges notwithstanding, a majority of surveyed individuals reported no difficulties with mental health, substance use, or sexual risk behavior, suggesting that a variety of resilient factors may be protecting them from the adverse effects of gender and sexual orientation-based stigma and discrimination.

  The results of this study titled, “Serving Proud: Lesbian, Gay, Bisexual, and Transgender Service Members in the US” were presented at the APHA 141st Annual Meeting and Exposition held on November 2-6, 2013 in Boston, MA.

CHEST’s mission is to conduct research to identify and promote strategies that prevent the spread of HIV and improve the lives of people living with HIV. We have been advocating for and working with the LGBT community since 1996.

  Correspondence may be sent to CHEST’s director Jeffrey T. Parsons at: jeffrey.parsons@hunter.cuny.edu