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Karlsson N, Kåberg M, Berglund T, Hammarberg A, Widman L, Ekström AM. A prospective cohort study of risk behaviours, retention and loss to follow-up over 5 years among women and men in a needle exchange program in Stockholm, Sweden. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 90:103059. [PMID: 33360734 DOI: 10.1016/j.drugpo.2020.103059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 11/09/2020] [Accepted: 11/18/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Needle exchange programs (NEP) are important in reducing risk behaviours among people who inject drugs (PWID), also exposed to HIV and hepatitis C (HCV) through injecting drug use (IDU). Women (WWID) compared to men who inject drugs (MWID), are particularly vulnerable with complex needs, however less is known about their risk determinants and NEP outcomes. METHODS In an open prospective NEP cohort, 697 WWID and 2122 MWID were followed, 2013-2018. Self-reported socio/drug-related determinants for receptive injection (needle/syringe and paraphernalia) and sexual risk behaviours at enrolment, lost to follow-up (LTFU) and probability of retention, were assessed for both groups. Multivariable logistic regression (adjusted odds ratios, aOR) for enrolment and Poisson regression (adjusted incidence rate ratios, aIRR) for LTFU, were used. Cumulative NEP-retention probability was analysed using a six- and 12-month scenario. RESULTS At NEP enrolment, injection risk behaviours among WWID were associated with: younger age; homelessness; amphetamine-IDU; non-participation in opioid substitution therapy (OST); history of custody and among MWID: lower education level; cohabitation; homelessness, being a tenant; amphetamine-IDU; non-participation in OST; history of being sectioned, HIV-negative and HCV-positive. Condomless sex among WWID was associated with: younger age; lower education-level; cohabitation; having a partner; amphetamine-IDU; non-participation in OST; being HIV-negative and HCV-positive and among MWID: younger age; married; cohabitation; having a partner; amphetamine-IDU; non-participation in OST; history of custody, prison and being HIV-negative. WWID had higher NEP-retention levels compared to MWID over time. Being LTFU among WWID was associated with being HIV-negative and reporting injection risk behaviours and among MWID, younger age, non-participation in OST, being HIV-negative and having protected sex. CONCLUSIONS Despite better NEP compliance among WWID, high injection and sexual risk behaviours in both gender-subgroups, especially in intimate relationships, suggests ongoing HCV and HIV-infection risks. Subgroup-variation in the NEP continuum of care warrants more gender-disaggregated research and tailoring gender-sensitive services may improve prevention, health and retention outcomes.
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Affiliation(s)
- Niklas Karlsson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; Department of Public Health Analysis and Development, Public Health Agency of Sweden (Folkhälsomyndigheten), Solna, Sweden.
| | - Martin Kåberg
- Department of Medicine Huddinge, Division of Infection and Dermatology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden; Stockholm Needle Exchange, Stockholm Centre for Dependency Disorders, Stockholm, Sweden
| | - Torsten Berglund
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; Department of Public Health Analysis and Development, Public Health Agency of Sweden (Folkhälsomyndigheten), Solna, Sweden
| | - Anders Hammarberg
- Stockholm Needle Exchange, Stockholm Centre for Dependency Disorders, Stockholm, Sweden; Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Centre for Dependency Disorders, Stockholm Health Care Services, Stockholm County Council, Sweden
| | - Linnea Widman
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Berg RC, Skogen V, Vinogradova N, Beloglazov A, Kazantseva T. Predictors of HIV Risk Behaviors Among a National Sample of Russian Men Who Have Sex with Men. AIDS Behav 2017; 21:2904-2912. [PMID: 27995434 DOI: 10.1007/s10461-016-1653-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Russia has one of the fastest growing HIV epidemics in the world and is at the point of transitioning from injection drug use to sexual transmissions. We sought to identify factors associated with unprotected sex among men who have sex with men (MSM) in Russia, separately for Moscow, St. Petersburg and the rest of the country. Multivariable data from a national cross-sectional study (n = 5035) demonstrate that significant correlates of unprotected anal intercourse (UAI) with a non-steady partner across all areas were visiting sex-related venues (AOR range 1.35-1.96) and access to condoms (AOR range 0.37-0.52). In Moscow and St. Petersburg, being HIV-positive was correlated with UAI (AOR 2.13 and 2.69). The dynamics of the HIV epidemic among MSM in Russia appear to be both similar, and different, across various areas and factors associated with unprotected sex should be seen as part of an environment of exogenous factors impacting MSM's sexual behaviors.
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Affiliation(s)
- Rigmor C Berg
- Knowledge Center for the Health Services, Norwegian Institute of Public Health, PO Box 4404, 0403, Nydalen, Oslo, Norway.
- Department of Community Medicine, University of Tromso, Tromso, Norway.
| | - Vegard Skogen
- Department of Community Medicine, University of Tromso, Tromso, Norway
| | - Nailya Vinogradova
- Department of Monitoring and Evaluation, Open Health Institute, Moscow, Russian Federation
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Sullivan DA, Rocha EM, Aragona P, Clayton JA, Ding J, Golebiowski B, Hampel U, McDermott AM, Schaumberg DA, Srinivasan S, Versura P, Willcox MDP. TFOS DEWS II Sex, Gender, and Hormones Report. Ocul Surf 2017; 15:284-333. [PMID: 28736336 DOI: 10.1016/j.jtos.2017.04.001] [Citation(s) in RCA: 236] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/16/2017] [Indexed: 12/21/2022]
Abstract
One of the most compelling features of dry eye disease (DED) is that it occurs more frequently in women than men. In fact, the female sex is a significant risk factor for the development of DED. This sex-related difference in DED prevalence is attributed in large part to the effects of sex steroids (e.g. androgens, estrogens), hypothalamic-pituitary hormones, glucocorticoids, insulin, insulin-like growth factor 1 and thyroid hormones, as well as to the sex chromosome complement, sex-specific autosomal factors and epigenetics (e.g. microRNAs). In addition to sex, gender also appears to be a risk factor for DED. "Gender" and "sex" are words that are often used interchangeably, but they have distinct meanings. "Gender" refers to a person's self-representation as a man or woman, whereas "sex" distinguishes males and females based on their biological characteristics. Both gender and sex affect DED risk, presentation of the disease, immune responses, pain, care-seeking behaviors, service utilization, and myriad other facets of eye health. Overall, sex, gender and hormones play a major role in the regulation of ocular surface and adnexal tissues, and in the difference in DED prevalence between women and men. The purpose of this Subcommittee report is to review and critique the nature of this role, as well as to recommend areas for future research to advance our understanding of the interrelationships between sex, gender, hormones and DED.
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Affiliation(s)
- David A Sullivan
- Schepens Eye Research Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA.
| | - Eduardo M Rocha
- Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Pasquale Aragona
- Department of Biomedical Sciences, Ocular Surface Diseases Unit, University of Messina, Messina, Sicily, Italy
| | - Janine A Clayton
- National Institutes of Health Office of Research on Women's Health, Bethesda, MD, USA
| | - Juan Ding
- Schepens Eye Research Institute, Massachusetts Eye & Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Blanka Golebiowski
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
| | - Ulrike Hampel
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alison M McDermott
- The Ocular Surface Institute, College of Optometry, University of Houston, Houston, TX, USA
| | - Debra A Schaumberg
- Harvard School of Public Health, Boston, MA, USA; University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sruthi Srinivasan
- Centre for Contact Lens Research, School of Optometry, University of Waterloo, Ontario, Canada
| | - Piera Versura
- Department of Specialized, Experimental, and Diagnostic Medicine, University of Bologna, Bologna, Italy
| | - Mark D P Willcox
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
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Lan CW, Scott-Sheldon LAJ, Carey KB, Johnson BT, Carey MP. Prevalence of Alcohol Use, Sexual Risk Behavior, and HIV Among Russians in High-Risk Settings: a Systematic Review and Meta-Analysis. Int J Behav Med 2017; 24:180-190. [PMID: 27730501 PMCID: PMC5638440 DOI: 10.1007/s12529-016-9596-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE The purpose of this study was to examine the (a) prevalence of and (b) association between alcohol, risky sex, and HIV among Russians at risk for primary or secondary HIV transmission. METHOD Electronic databases were searched to locate studies that sampled Russians, assessed alcohol use, and included either a behavioral measure of risk or a biological measure of HIV. Weighted mean (logit) effect sizes were calculated using random-effects assumptions. Moderator analyses were conducted using meta-regression. RESULTS Studies (19) sampled 12,916 Russians (M age = 29; 36 % women). Participants were recruited from clinical (52 %; e.g., sexually transmitted infection (STI) clinic, drug treatment), other high-risk community settings (32 %; e.g., sexual/drug networks), or both (16 %). Findings indicate that a substantial proportion of the participants used alcohol (77 %; 55 % heavy drinking). One half of participants reported using condoms (52 %), but only 29 % used condoms consistently. Most participants reported drinking before sex (64 %). Of the studies testing for HIV, 10 % of participants tested positive. Meta-regression analyses indicated that hazardous/harmful alcohol use was associated with increased risky behaviors (i.e., multiple partners, inconsistent condom use). CONCLUSION These findings support the need for and potential benefit of addressing alcohol use in HIV prevention programming in Russia.
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Affiliation(s)
- Chiao-Wen Lan
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, CORO West, Suite 309, 164 Summit Avenue, Providence, RI, 02906, USA
| | - Lori A J Scott-Sheldon
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, CORO West, Suite 309, 164 Summit Avenue, Providence, RI, 02906, USA.
- Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI, USA.
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA.
| | - Kate B Carey
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Blair T Johnson
- Department of Psychology, University of Connecticut, Storrs, CT, USA
| | - Michael P Carey
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, CORO West, Suite 309, 164 Summit Avenue, Providence, RI, 02906, USA
- Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI, USA
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
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Miller AC, Nelson AK, Livchits V, Greenfield SF, Yanova G, Yanov S, Connery HS, Atwood S, Lastimoso CS, Shin SS. Understanding HIV Risk Behavior among Tuberculosis Patients with Alcohol Use Disorders in Tomsk, Russian Federation. PLoS One 2016; 11:e0148910. [PMID: 26871943 PMCID: PMC4752500 DOI: 10.1371/journal.pone.0148910] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 01/23/2016] [Indexed: 11/22/2022] Open
Abstract
Russian Federation’s (RF) HIV epidemic is the fastest growing of any country. This study explores factors associated with high HIV risk behavior in tuberculosis (TB) patients with alcohol use disorders in Tomsk, RF. This analysis was nested within the Integrated Management of Physician-delivered Alcohol Care for TB Patients (IMPACT, trial number NCT00675961) randomized controlled study of integrating alcohol treatment into TB treatment in Tomsk. Demographics, HIV risk behavior (defined as participant report of high-risk intravenous drug use and/or multiple sexual partners with inconsistent condom use in the last six months), clinical data, alcohol use, depression and psychosocial factors were collected from 196 participants (161 male and 35 female) at baseline. Forty-six participants (23.5%) endorsed HIV risk behavior at baseline. Incarceration history(Odds Ratio (OR)3.93, 95% confidence interval (CI) 1.95, 7.95), age under 41 (OR:2.97, CI:1.46, 6.04), drug addiction(OR: 3.60 CI:1.10, 11.77), history of a sexually transmitted disease(STD)(OR 2.00 CI:1.02, 3.90), low social capital (OR:2.81 CI:0.99, 8.03) and heavier alcohol use (OR:2.56 CI: 1.02, 6.46) were significantly more likely to be associated with HIV risk behavior at baseline. In adjusted analysis, age under 41(OR: 4.93, CI: 2.10, 11.58), incarceration history(OR: 3.56 CI:1.55, 8.17) and STD history (OR: 3.48, CI: 1.5, 8.10) continued to be significantly associated with HIV risk behavior. Understanding HIV transmission dynamics in Russia remains an urgent priority to inform strategies to address the epidemic. Larger studies addressing sex differences in risks and barriers to protective behavior are needed.
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Affiliation(s)
- Ann C. Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- * E-mail:
| | - A. Katrina Nelson
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Viktoria Livchits
- Partners In Health Representative Office in Russian Federation, Moscow, Russia
| | - Shelly F. Greenfield
- Alcohol and Drug Abuse Treatment Program, McLean Hospital, Belmont, MA United States of America
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States of America
- Division of Women's Mental Health, McLean Hospital, Belmont, MA, United States of America
| | - Galina Yanova
- Tomsk Oblast Tuberculosis Hospital, Tomsk, Russian Federation
| | - Sergei Yanov
- Tomsk Oblast Tuberculosis Hospital, Tomsk, Russian Federation
| | - Hilary S. Connery
- Alcohol and Drug Abuse Treatment Program, McLean Hospital, Belmont, MA United States of America
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States of America
| | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Charmaine S. Lastimoso
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Sonya S. Shin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, United States of America
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Saadat VM. HIV Risks, Testing, and Treatment in the Former Soviet Union: Challenges and Future Directions in Research and Methodology. Cent Asian J Glob Health 2016; 4:225. [PMID: 29138724 PMCID: PMC5661207 DOI: 10.5195/cajgh.2015.225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background The dissolution of the USSR resulted in independence for constituent republics but left them battling an unstable economic environment and healthcare. Increases in injection drug use, prostitution, and migration were all widespread responses to this transition and have contributed to the emergence of an HIV epidemic in the countries of former Soviet Union. Researchers have begun to identify the risks of HIV infection as well as the barriers to HIV testing and treatment in the former Soviet Union. Significant methodological challenges have arisen and need to be addressed. The objective of this review is to determine common threads in HIV research in the former Soviet Union and provide useful recommendations for future research studies. Methods In this systematic review of the literature, Pubmed was searched for English-language studies using the key search terms "HIV", "AIDS", "human immunodeficiency virus", "acquired immune deficiency syndrome", "Central Asia", "Kazakhstan", "Kyrgyzstan", "Uzbekistan", "Tajikistan", "Turkmenistan", "Russia", "Ukraine", "Armenia", "Azerbaijan", and "Georgia". Studies were evaluated against eligibility criteria for inclusion. Results Thirty-nine studies were identified across the two main topic areas of HIV risk and barriers to testing and treatment, themes subsequently referred to as "risk" and "barriers". Study design was predominantly cross-sectional. The most frequently used sampling methods were peer-to-peer and non-probabilistic sampling. The most frequently reported risks were condom misuse, risky intercourse, and unsafe practices among injection drug users. Common barriers to testing included that testing was inconvenient, and that results would not remain confidential. Frequent barriers to treatment were based on a distrust in the treatment system. Conclusion The findings of this review reveal methodological limitations that span the existing studies. Small sample size, cross-sectional design, and non-probabilistic sampling methods were frequently reported limitations. Future work is needed to examine barriers to testing and treatment as well as longitudinal studies on HIV risk over time in most-at-risk populations.
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Affiliation(s)
- Victoria M Saadat
- Department of Health Research and Policy, Stanford University of Medicine, Stanford, CA
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Global Epidemiology of HIV Among Women and Girls Who Use or Inject Drugs: Current Knowledge and Limitations of Existing Data. J Acquir Immune Defic Syndr 2015; 69 Suppl 2:S100-9. [PMID: 25978476 DOI: 10.1097/qai.0000000000000623] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Women and girls who use and inject drugs are a critical population at risk of HIV. In this article, we review data on the epidemiology of drug use and injection among women globally and HIV prevalence among women and girls who use and inject drugs. RESULTS Women and girls comprise one-third of people who use and inject drugs globally. There is substantial variation in HIV prevalence in this population, between and within countries. There is a pronounced lack of data examining HIV risk among particularly vulnerable subpopulations of women who use and inject drugs, including women who have sex with women, transgender women, racial and ethnic minority women, and young women. Women who use and inject drugs experience stigma and discrimination that affect access to services, and high levels of sexual risk exposures. CONCLUSIONS There are significant gaps in our understanding of the epidemiology of drug use and injecting among women and girls and HIV risk and prevalence in this population. Women are frequently underrepresented in studies of drug use and HIV risk and prevalence among people who inject drugs, limiting our understanding of possible sex differences in this population. Most research originates from developed countries and may not be generalizable to other settings. A great deal of work is needed to improve understanding of HIV among particularly vulnerable subpopulations, such as transgender women who use drugs. Better data are critical to efforts to advocate for the needs of women and girls who use and inject drugs.
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DeHovitz J, Uuskula A, El-Bassel N. The HIV epidemic in Eastern Europe and Central Asia. Curr HIV/AIDS Rep 2015; 11:168-76. [PMID: 24652411 DOI: 10.1007/s11904-014-0202-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Eastern Europe and Central Asia represent one of the few regions globally where there is a continued increase in the incidence of HIV infection. For example, in Eastern Europe the rate of diagnosed cases of HIV infection per 100 000 population has increased from 11.7 in 2004 to 22.5 in 2011. Initially propelled by injection drug use, heterosexual transmission has now become a major driver of new infections in the region. Nonetheless substance use remains an important factor, with its control limited by challenges in scaling up harm reduction efforts. While most countries have implemented opioid substitution therapy programs, their scale remains very limited. Similarly, coverage of needles syringe programs across the region is variable. Complicating the control of HIV has been the emergence of non-injection drugs and inadequate access to antiretroviral therapy. In addition, structural barriers and stigma toward HIV infected people may contribute to the high proportion of late presentations for HIV care. Finally in the wake of the HIV epidemic, high rates of hepatitis C infection and tuberculosis have been noted.
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Affiliation(s)
- Jack DeHovitz
- SUNY Downstate Medical Center, 450 Clarkson Ave., MSC 1240, Brooklyn, NY, 11203, USA,
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Corsi KF, Dvoryak S, Garver-Apgar C, Davis JM, Brewster JT, Lisovska O, Booth RE. Gender differences between predictors of HIV status among PWID in Ukraine. Drug Alcohol Depend 2014; 138:103-8. [PMID: 24613219 PMCID: PMC4002293 DOI: 10.1016/j.drugalcdep.2014.02.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 02/06/2014] [Accepted: 02/06/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The HIV epidemic in Ukraine is among the largest in Europe. While traditionally the epidemic has spread through injection risk behavior, sexual transmission is becoming more common. Previous research has found that women in Ukraine have higher rates of HIV and engage in more HIV risk behavior than men. This study extended that work by identifying risk factors that differentially predict men and women's HIV status among people who inject drugs (PWID) in Ukraine. METHODS From July 2010 to July 2013, 2480 sexually active PWID with unknown HIV status were recruited from three cities in Ukraine through street outreach. The average age was 31 years old. RESULTS Women, who made up twenty-eight percent of the sample, had higher safe sex self-efficacy (p<.01) and HIV knowledge (p<.001) than men, but scored higher on both the risky injection (p<.001) and risky sex (p<.001) composite scores than men. Risky sex behaviors were associated with women's HIV status more than men's. We also report results identifying predictors of risky injection and sex behaviors. CONCLUSIONS Gender-specific interventions could address problem of HIV risk among women who inject drugs in a country with a growing HIV epidemic. Our findings suggest specific ways in which intervention efforts might focus on groups and individuals who are at the highest risk of contracting HIV (or who are already HIV positive) to halt the spread of HIV in Ukraine.
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Affiliation(s)
- K F Corsi
- Department of Psychiatry, University of Colorado School of Medicine, Denver, CO, United States.
| | - S Dvoryak
- Ukrainian Institute on Public Health Policy, Kiev, Ukraine
| | - C Garver-Apgar
- Department of Psychiatry, University of Colorado School of Medicine, Denver, CO, United States
| | - J M Davis
- Department of Psychiatry, University of Colorado School of Medicine, Denver, CO, United States
| | - J T Brewster
- Department of Psychiatry, University of Colorado School of Medicine, Denver, CO, United States
| | - O Lisovska
- Ukrainian Institute on Public Health Policy, Kiev, Ukraine
| | - R E Booth
- Department of Psychiatry, University of Colorado School of Medicine, Denver, CO, United States
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