1
|
Lejone TI, Mahomed O. Magnitude and Determinants of Virological Failure Among Patients >15 Years on Anti-Retroviral Therapy in Rural Lesotho Between 2015 and 2019 - A Retrospective Cohort Study. HIV AIDS (Auckl) 2023; 15:611-620. [PMID: 37849794 PMCID: PMC10577259 DOI: 10.2147/hiv.s424277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/10/2023] [Indexed: 10/19/2023] Open
Abstract
Background Lesotho has the second-highest HIV prevalence globally at an estimated 23%, with approximately 87% of the population between 15 and 59 years of age reported to be receiving antiretroviral treatment. There is an urgent need to increase access to effective ART due to increasing rates of first- and second-line treatment failure. Sustaining successful treatment and limiting the development of virological failure is essential, hence the need for early detection of increased viral load indicating drug resistance or rapid progression of viral replication. Aim The aim of the study was to determine the proportion of patients with HIV with virological failure and to identify factors associated with virological failure in two districts of Lesotho. Methods A retrospective cohort study was conducted in two districts (Butha-Buthe and Mokhotlong) in Lesotho. Data for all patients (age ≥15 years) in the viral load (VL) monitoring database with at least two consecutive viral load results between December 2015 and December 2019 from 22 health facilities were extracted. Descriptive data were presented using tables and figures. Bivariate and multivariate analyses were performed. A p-value < 0.05 was considered a statistically significant association. Results Only 4% (n = 913) of the study participants had virological failure. Longer time on treatment >65 months (AOR: 1.85 CI: 1.59-2.15) and being on second-line ART regimen (AOR: 75.23 95% CI: 75.00-99.15) were significantly (p < 0.001) associated with virological failure. Conclusion Virological failure among the study participants is lower compared to other settings. The study identified duration on treatment, treatment regimen as high risk for virological failure. Targeted interventions should be developed for these high-risk group individuals, with continuous monitoring of virological response and appropriate drug switching to clients to achieve improved outcomes.
Collapse
Affiliation(s)
- Thabo Ishmael Lejone
- SolidarMed, Lesotho, South Africa
- Discipline of Public Health Medicine, University of KwaZulu Natal, Durban, South Africa
| | | |
Collapse
|
2
|
Roy K, Himelfarb A, Karrah K, Porterfield L, Paremoer L, Serag H, Lee WC. The Social, Behavioral, and Ethical Modalities of COVID-19 on HIV Care in South Africa: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:9766. [PMID: 35955119 PMCID: PMC9368207 DOI: 10.3390/ijerph19159766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 06/15/2023]
Abstract
The profound public health impact of the novel outbreak of the SARS-CoV-2 virus in 2019 has been unparalleled in the last century. Rapid spread of the disease and a high death toll fueled the development and global rollout of effective vaccines regardless of the massive inequitable access. However, some public health measures intended to control COVID-19 have had collateral effects on the control of other infectious diseases. In this systematic review, we analyze the impact of the COVID-19 pandemic on efforts to control HIV in South Africa, emphasizing the social, ethical, and behavioral ramifications. The SCOPUS, PubMed, Ovid, PsychINFO, and Cochrane Library databases were searched for publications between March 2020 and January 2022. Of the 854 articles identified, 245 were found duplicated, and 609 were screened, 241 of which were potentially eligible, and 15 of which were ultimately included. Although no studies on the ethical implications were eligible for our study criteria due to insufficient primary data to perform an analysis on, we explored this topic in the Discussion section of this paper. We confirm declines in ART, PrEP, and HIV testing during the initial lockdown period, with slight variations across the South African provinces. Protecting routine services and reducing the disease burden on high-risk nations such as South Africa is imperative moving forward with the pandemic.
Collapse
Affiliation(s)
- Khushali Roy
- School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Aliayah Himelfarb
- Department of Psychiatry, Weill Cornell Medicine, New York, NY 10021, USA
| | - Kapil Karrah
- Medical College, MedCiti Medical Institute, Ghanpur 501401, Telangana, India
| | - Laura Porterfield
- Department of Family Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Lauren Paremoer
- Department of Political Studies, University of Cape Town, Cape Town 7700, South Africa
| | - Hani Serag
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Wei-Chen Lee
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| |
Collapse
|
3
|
Pharmacy Data as an Alternative Data Source for Implementation of a Data to Care Strategy. J Acquir Immune Defic Syndr 2020; 82 Suppl 1:S53-S56. [PMID: 31425396 DOI: 10.1097/qai.0000000000001969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Data to Care (D2C) is a strategy for using health departments' HIV surveillance data (HIV viral load and CD4 laboratory reports) to identify and re-engage not-in-care persons with HIV. In the current D2C model, there is a delay in the identification of persons not in care due to the time interval between recommended monitoring tests (ie, every 3-6 months) and the subsequent reporting of these tests to the health department. METHODS Pharmacy claims and fulfillment data can be used to identify persons with HIV who have stopped filling antiretroviral therapy and are at risk of falling out of care. Because most antiretrovirals (ARVs) are prescribed as a 30-day supply of medication, these data can be used to identify persons who are not filling their medications on a monthly basis. The use of pharmacy claims data to identify persons not filling ARV prescriptions is an example of how "big data" can be used to conduct a modified D2C model. RESULTS Although a D2C strategy using pharmacy data has not been broadly implemented, a few health departments are implementing demonstration projects using this strategy. As the projects progress, processes and outcomes can be evaluated. CONCLUSIONS Tracking ARV refill data can be a more real-time indicator of poor adherence and can help identify HIV-infected persons at risk of falling out of HIV medical care.
Collapse
|
4
|
Bijker R, Kiertiburanakul S, Kumarasamy N, Pujari S, Sun LP, Ng OT, Lee MP, Choi JY, Nguyen KV, Chan YJ, Merati TP, Cuong DD, Ross J, Jiamsakul A. Survival after long-term ART exposure: findings from an Asian patient population retained in care beyond 5 years on ART. Antivir Ther 2020; 25:131-142. [PMID: 32369040 DOI: 10.3851/imp3358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study investigated survival in people living with HIV being followed-up from 5 and 10 years after antiretroviral therapy (ART) initiation in a multi-country Asian cohort. METHODS We included patients in follow-up >5 years after ART initiation. Factors associated with mortality beyond 5 and 10 years on ART were analysed using competing risk regression with time-updated variables. RESULTS Of 13,495 patients retained after 5 years on ART, 279 subsequently died (0.56/100 person-years). Increased mortality was associated with age >50 years (sub-hazard ratio [sHR] 2.24, 95% CI 1.58, 3.15, compared with ≤40 years), HIV exposure through injecting drug use (sHR 2.17, 95% CI 1.32, 3.56), HIV viral load ≥1,000 copies/ml: sHR 1.52, 95% CI 1.05, 2.21, compared with <400), regimen (second-line regimen: sHR 2.11, 95% CI 1.52, 2.94, and third-line regimen: sHR 2.82, 95% CI 2.00, 3.98, compared with first-line regimen), HBV coinfection (sHR 2.23, 95% CI 1.49, 3.33), fasting plasma glucose ≥126 mg/dl (sHR 1.98, 95% CI 1.22, 3.21, compared with <100 mg/dl) and estimated glomerular filtration rate <60 ml/min/1.73 m2 (sHR 2.57, 95% CI 1.56, 4.22). Decreased mortality was associated with transmission through male-to-male sexual contact (sHR 0.44, 95% CI 0.22, 0.88, compared with heterosexual transmission) and higher CD4+ T-cell count (200-349 cells/µl: sHR 0.27, 95% CI 0.20, 0.38, 350-499 cells/µl: sHR 0.10, 95% CI 0.07, 0.16 and ≥500 cells/µl: sHR 0.09, 95% CI 0.06, 0.13, compared with <200 cells/µl). Results after 10 years were similar, but most associations were weaker due to limited power. CONCLUSIONS Next to preventing ART failure, HIV programmes should carefully monitor and treat comorbidities, including hepatitis, kidney disease and diabetes, to optimize survival after long-term ART exposure.
Collapse
Affiliation(s)
- Rimke Bijker
- The Kirby Institute, UNSW Sydney, Kensington, NSW, Australia
| | | | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site (CART CRS), VHS-Infectious Diseases Medical Centre, VHS, Chennai, India
| | | | - Ly P Sun
- National Center for HIV/AIDS, Dermatology & STDs, and University of Health Sciences, Phnom Penh, Cambodia
| | - Oon T Ng
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
| | - Man P Lee
- Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Jun Y Choi
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kinh V Nguyen
- National Hospital for Tropical Diseases, Hanoi, Vietnam
| | - Yu J Chan
- Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tuti P Merati
- Faculty of Medicine Udayana University & Sanglah Hospital, Bali, Indonesia
| | | | - Jeremy Ross
- TREAT Asia, amfAR - The Foundation for AIDS Research, Bangkok, Thailand
| | | | | |
Collapse
|
5
|
Rahmalia A, Price MH, Hartantri Y, Alisjahbana B, Wisaksana R, van Crevel R, van der Ven AJAM. Are there differences in HIV retention in care between female and male patients in Indonesia? A multi-state analysis of a retrospective cohort study. PLoS One 2019; 14:e0218781. [PMID: 31237899 PMCID: PMC6592601 DOI: 10.1371/journal.pone.0218781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 06/11/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Little is known about HIV treatment outcomes in Indonesia, which has one of the most rapidly growing HIV epidemics worldwide. METHODS We examined possible differences in loss to follow-up (LTFU) and survival between HIV-infected females and males over a 7-year period in an HIV clinic in Bandung, West Java. Data imputation was performed on missing covariates and a multi-state Cox regression was used to investigate the effects of sex and other covariates on patient transitions among four states: (1) clinic enrollment with HIV, (2) initiation/continuation/re-initiation of antiretroviral therapy (ART), (3) LTFU, and (4) death. RESULTS We followed 3215 patients (33% females), for a total of 8430 person-years. ART was used by 59% of patients at some point. One-year retention was 73% for females and 77% for males (p = 0.06). One-year survival was 98% for both females and males (p = 0.15). Females experienced a higher relative hazard to transition from HIV to LTFU (adjusted hazard ratio 1.21; 95% confidence interval 1.00-1.45), but this decreased after adjustments for clinical variables (aHR 0.94; 95% CI 0.79-1.11). Similarly, a lower relative hazard in females to transition from ART to death (aHR 0.59; 95% CI 0.35-0.99) decreased after adjustments for demographic variables. CONCLUSION This Indonesian cohort has low ART uptake and poor overall pre- and post-ART retention. Female-male differences in survival and retention were gone after adjusting for clinical and sociodemographic factors such as CD4 count and education level. Efforts should be made to improve retention among patients with lower education.
Collapse
Affiliation(s)
- Annisa Rahmalia
- Infectious Disease Research Center, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michael Holton Price
- Department of Anthropology, Pennsylvania State University, University Park, Pennsylvania, United States of America
- Santa Fe Institute, Santa Fe, New Mexico, United States of America
| | - Yovita Hartantri
- Infectious Disease Research Center, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
- Department of Internal Medicine, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Bachti Alisjahbana
- Infectious Disease Research Center, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
- Department of Internal Medicine, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Rudi Wisaksana
- Infectious Disease Research Center, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
- Department of Internal Medicine, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | |
Collapse
|
6
|
Dubrocq G, Rakhmanina N. Antiretroviral therapy interruptions: impact on HIV treatment and transmission. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2018; 10:91-101. [PMID: 29942160 PMCID: PMC6005325 DOI: 10.2147/hiv.s141965] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction Successful management of pediatric and adult human immunodeficiency virus (HIV) disease includes lifelong administration of antiretroviral therapy (ART). The need for the continuous use of antiretroviral drugs throughout the life course poses a challenge to children, adolescents, and adults living with HIV and their caregivers. Historically, treatment interruptions have been viewed as a negative therapeutic strategy. Recently, however, treatment interruptions or treatment reduction strategies have become a focus of investigations as innovative approaches to the long-term management of HIV disease. Current challenges with treatment interruptions include identifying an appropriate timeframe for length of interruptions and identifying HIV patient populations in whom the treatment interruption can be successful. Objective In this review, we aimed at summarizing recent studies of planned and unplanned treatment interruptions in children and adults living with HIV. Materials and methods We searched two databases (PubMed and Cochrane Controlled Trials Register) using keywords (HIV OR AIDS OR acquired immunodeficiency syndrome OR HIV-1 OR antiretroviral) AND (treatment interruption OR planned interruption OR therapeutic interruption OR unplanned interruption), for published randomized and nonrandomized clinical trials and observational cohort studies in children and adults (from birth to 99 years of age) in global settings covering a period from 2012 to 2018. In this review, only the studies that contained pediatric and adolescent populations with baseline immunological, virological, and clinical characteristics and outcomes after treatment interruption were included. Results A total of 174 eligible citations from the two databases were identified. We identified 10 prospective treatment interruption studies on children (five studies) and adults (five studies) during 2012–2018 with a total of 863 pediatric and 273 adult subjects. Collectively, recent studies on children and adults with HIV infection suggest that treatment interruptions with proper monitoring can be successful by instituting well-defined immunological and virological parameters or thresholds such as CD4 count, CD4%, and HIV RNA viral load that identify low-risk populations with treatment failure. In addition to standard virological and immunological outcome measurements, selected biomarkers that help detect early immune activation may also be useful in the monitoring of treatment interruption. Conclusion Treatment interruptions in adult and especially pediatric patients with well-controlled HIV disease may provide an alternative opportunity to optimize long-term HIV management by minimizing drug-associated toxicity and improving long-term adherence and quality of life.
Collapse
Affiliation(s)
- Gueorgui Dubrocq
- Division of Pediatric Infectious Diseases, Baylor Scott & White McLane Children's Medical Center, Temple, TX, USA.,Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, TX, USA
| | - Natella Rakhmanina
- Division of Pediatric Infectious Diseases, Children's National Health System, Washington, DC, USA.,Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| |
Collapse
|
7
|
Gils T, Bossard C, Verdonck K, Owiti P, Casteels I, Mashako M, Van Cutsem G, Ellman T. Stockouts of HIV commodities in public health facilities in Kinshasa: Barriers to end HIV. PLoS One 2018; 13:e0191294. [PMID: 29351338 PMCID: PMC5774776 DOI: 10.1371/journal.pone.0191294] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/01/2018] [Indexed: 11/22/2022] Open
Abstract
Stockouts of HIV commodities increase the risk of treatment interruption, antiretroviral resistance, treatment failure, morbidity and mortality. The study objective was to assess the magnitude and duration of stockouts of HIV medicines and diagnostic tests in public facilities in Kinshasa, Democratic Republic of the Congo. This was a cross-sectional survey involving visits to facilities and warehouses in April and May 2015. All zonal warehouses, all public facilities with more than 200 patients on antiretroviral treatment (ART) (high-burden facilities) and a purposive sample of facilities with 200 or fewer patients (low-burden facilities) in Kinshasa were selected. We focused on three adult ART formulations, cotrimoxazole tablets, and HIV diagnostic tests. Availability of items was determined by physical check, while stockout duration until the day of the survey visit was verified with stock cards. In case of ART stockouts, we asked the pharmacist in charge what the facility coping strategy was for patients needing those medicines. The study included 28 high-burden facilities and 64 low-burden facilities, together serving around 22000 ART patients. During the study period, a national shortage of the newly introduced first-line regimen Tenofovir-Lamivudine-Efavirenz resulted in stockouts of this regimen in 56% of high-burden and 43% of low-burden facilities, lasting a median of 36 (interquartile range 29-90) and 44 days (interquartile range 24-90) until the day of the survey visit, respectively. Each of the other investigated commodities were found out of stock in at least two low-burden and two high-burden facilities. In 30/41 (73%) of stockout cases, the commodity was absent at the facility but present at the upstream warehouse. In 30/57 (54%) of ART stockout cases, patients did not receive any medicines. In some cases, patients were switched to different ART formulations or regimens. Stockouts of HIV commodities were common in the visited facilities. Introduction of new ART regimens needs additional planning.
Collapse
Affiliation(s)
- Tinne Gils
- Médecins sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa
| | - Claire Bossard
- Médecins sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa
| | | | - Philip Owiti
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Ilse Casteels
- Médecins sans Frontières, Operational Centre Brussels, Kinshasa, DRC
| | - Maria Mashako
- Médecins sans Frontières, Operational Centre Brussels, Kinshasa, DRC
| | - Gilles Van Cutsem
- Médecins sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa
| | - Tom Ellman
- Médecins sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa
| |
Collapse
|
8
|
Gag P2/NC and pol genetic diversity, polymorphism, and drug resistance mutations in HIV-1 CRF02_AG- and non-CRF02_AG-infected patients in Yaoundé, Cameroon. Sci Rep 2017; 7:14136. [PMID: 29074854 PMCID: PMC5658410 DOI: 10.1038/s41598-017-14095-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 09/29/2017] [Indexed: 12/21/2022] Open
Abstract
In HIV-1 subtype-B, specific mutations in Gag cleavage sites (CS) are associated with treatment failure, with limited knowledge among non-B subtypes. We analyzed non-B HIV-1 gag and pol (protease/reverse-transcriptase) sequences from Cameroonians for drug resistance mutations (DRMs) in the gag P2/NC CS, and pol major DRMs. Phylogeny of the 141 sequences revealed a high genetic diversity (12 subtypes): 67.37% CRF02_AG versus 32.6% non-CRF02_AG. Overall, 7.3% transmitted and 34.3% acquired DRMs were found, including M184V, thymidine analogue mutations (T215F, D67N, K70R, K219Q), NNRTIs (L100I, Y181C, K103N, V108I, Y188L), and PIs (V82L). Twelve subjects [10 with HIV-1 CRF02_AG, 8 treatment-naïve and 4 on 3TC-AZT-NVP] showed 3 to 4 mutations in the Gag P2/NC CS: S373Q/T/A, A374T/S/G/N, T375S/A/N/G, I376V, G381S, and R380K. Subjects with or without Gag P2/NC CS mutations showed no significant difference in viral loads. Treatment-naïve subjects harboring NRTI-DRMs had significantly lower CD4 cells than those with NRTI-DRMs on ART (p = 0.042). Interestingly, two subjects had major DRMs to NRTIs, NNRTIs, and 4 mutations in the Gag P2/NC CS. In this prevailing CRF02_AG population with little exposure to PIs (~3%), mutations in the Gag P2/NC CS could increase the risk of treatment failure if there is increased use of PIs-based therapy.
Collapse
|
9
|
Byrd KK, Bush T, Gardner LI. Do Persons Living with HIV Continue to Fill Prescriptions for Antiretroviral Drugs during a Gap in Care? Analysis of a Large Commercial Claims Database. J Int Assoc Provid AIDS Care 2017; 16:632-638. [PMID: 28899258 DOI: 10.1177/2325957417729750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The significance of a gap in HIV care depends, at least partially, on whether patients continue to fill prescriptions for antiretroviral (ARV) drugs during the gap in care. We used a billing claims database to determine the proportion of persons who filled ≥1 prescription for ARV drugs during a gap in care (no clinic visit in >6 months). Persons were stratified into 3 groups: "never" (prescriptions never filled), "sometimes" (prescriptions filled >0%-<100% of months), and "always" (prescriptions filled monthly). Logistic regression analyses were conducted to determine factors associated with "never" filling ARV drugs. Of 14 308 persons, 69% (n = 9817), 13% (n = 1928), and 18% (n = 2563) "never," "sometimes," and "always" filled ARV drugs during the gap in care. Persons aged 18 to 29 years (odds ratio [OR] = 1.56, 95% confidence interval [CI] 1.39-1.74), women (OR = 1.67, CI 1.52-1.83), and persons from the Northeast region of the United States (OR = 1.86, CI 1.69-2.03) were more likely to never fill ARV drugs than persons aged ≥30 years, men, and persons outside the Northeast, respectively. Efforts should be made to minimize gaps in care, emphasize importance of therapy, and provide adherence support.
Collapse
Affiliation(s)
- Kathy K Byrd
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tim Bush
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lytt I Gardner
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| |
Collapse
|