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Di Ciaccio M, Villes V, Delabre RM, Alain T, Morel S, Michels D, Schmidt AJ, Velter A, Rojas Castro D. When awareness is not a barrier to PrEP uptake among men who have sex with men who are eligible for PrEP in France. AIDS Care 2024; 36:390-399. [PMID: 37931594 DOI: 10.1080/09540121.2023.2268887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/04/2023] [Indexed: 11/08/2023]
Abstract
Despite PrEP being available and free of charge in France, a gap remains between the estimated number of men who have sex with men (MSM) with high-risk exposure to HIV and the number of MSM PrEP users. The objective of this study is to identify factors associated with non-intention to use PrEP among PrEP-eligible and PrEP-aware MSM in France, "non-intenders".European MSM Internet Survey (EMIS)-2017 was a cross-sectional survey conducted among MSM concerning their HIV prevention needs. Logistic regression models were used to identify factors associated with "non-intenders".Compared to PrEP users, factors associated with non-intention to use PrEP were: age (aOR[95%CI] = 3.80[2.21;6.53]); not being vaccinated against hepatitis B (2.20[1.45;3.34]); self-efficacy (1.84[1.29;2.60]); lower knowledge about on-demand PrEP (11.48[7.37;17.87]) and daily PrEP (2.58[1.27;5.25]); not having a PrEP discussion at a hospital (12.39[8.90;17.27]) or at a community service/drop-in (4.93[3.48;6.97]); living in a department with few PrEP access points (1.70[1.10;2.63]).On-demand PrEP may meet the prevention needs of "non-intenders" who have lower HIV risk perception. Increasing communication from health providers and community health workers to all MSM is needed.
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Affiliation(s)
| | - Virginie Villes
- Coalition PLUS, Community-based Research Laboratory, Pantin, France
| | | | - Tristan Alain
- Coalition PLUS, Community-based Research Laboratory, Pantin, France
- AIDES, Pantin, France
| | - Stéphane Morel
- Coalition PLUS, Community-based Research Laboratory, Pantin, France
- AIDES, Pantin, France
| | - David Michels
- Coalition PLUS, Community-based Research Laboratory, Pantin, France
- AIDES, Pantin, France
| | - Axel Jeremias Schmidt
- Sigma Research, Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Daniela Rojas Castro
- Coalition PLUS, Community-based Research Laboratory, Pantin, France
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
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Rungmaitree S, Werarak P, Pumpradit W, Phongsamart W, Lapphra K, Wittawatmongkol O, Durier Y, Maleesatharn A, Kuttiparambil B, Cressey TR, Hoffman RM, Chokephaibulkit K. A pilot program of HIV pre-exposure prophylaxis in Thai youth. PLoS One 2024; 19:e0298914. [PMID: 38386680 PMCID: PMC10883585 DOI: 10.1371/journal.pone.0298914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
INTRODUCTION There are gaps in knowledge and experience of antiretroviral pre-exposure prophylaxis (PrEP) delivery in adolescents. METHODS This pilot study enrolled Thai adolescents 14-20 year-old without HIV who reported risk behaviour. All participants were offered daily tenofovir/emtricitabine (TDF-FTC) and followed for 24 weeks. HIV testing, renal function, bone density scan, and sexually transmitted infection (STI) testing including syphilis serology and urine molecular testing for gonorrhoea and C. trachomatis were performed at baseline and weeks 12 and 24. Adherence was evaluated through intracellular tenofovir diphosphate (TFV-DP) levels in dried blood spots. RESULTS Of the 61 enrolled adolescents, median age 18.1 (IQR: 14.8-20.9) years, 46 (75.4%) were males and 36 (59%) were MSM. Retention to week 24 was 80.3%. One third (36%) had TFV-DP levels consistent with taking ≥6 pills/week at week 12 and 29% at week 24. The factors associated with taking ≥6 pills/week were being MSM (adjusted odds ratio [aOR]: 53.2, 95% CI: 1.6-1811; p = 0.027), presence of STI at baseline (aOR: 9.4, 95% CI: 1.5-58.5; p = 0.016), and self-report of decreased condom use while taking PrEP (aOR: 8.7, 95% CI: 1.4-56.6; p = 0.023). 31% had an STI at baseline and this declined to 18% at week 24. No renal or bone toxicity was observed and there were no HIV seroconversions. CONCLUSIONS Daily oral PrEP with FTC-TDF in high-risk Thai adolescents is feasible, accepted, well-tolerated, and had no increased risk compensation; however, low adherence was a major challenge. Adolescent-specific PrEP strategies including long-acting modalities are needed for successful HIV prevention.
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Affiliation(s)
- Supattra Rungmaitree
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Peerawong Werarak
- Department of preventive and social medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Wanatpreeya Phongsamart
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Keswadee Lapphra
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Orasri Wittawatmongkol
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yuitiang Durier
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Alan Maleesatharn
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Tim R. Cressey
- PHPT/IRD UMI 174, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Risa M. Hoffman
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, United States of America
| | - Kulkanya Chokephaibulkit
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Siriraj Institute of Clinical Research, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Blair KJ, Torres TS, Hoagland B, Bezerra DRB, Veloso VG, Grinsztejn B, Clark J, Luz PM. Moderating Effect of Pre-Exposure Prophylaxis Use on the Association Between Sexual Risk Behavior and Perceived Risk of HIV Among Brazilian Gay, Bisexual, and Other Men Who Have Sex With Men: Cross-Sectional Study. JMIR Public Health Surveill 2023; 9:e45134. [PMID: 37796573 PMCID: PMC10587815 DOI: 10.2196/45134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 07/14/2023] [Accepted: 07/31/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Gay, bisexual, and other men who have sex with men (MSM) with a higher perceived risk of HIV are more aware of and willing to use pre-exposure prophylaxis (PrEP). PrEP is an effective HIV prevention strategy, but there is a lack of data on how PrEP use might moderate the relationship between sexual risk behavior and perceived risk of HIV. Moreover, most studies measure perceived risk of HIV via a single question. OBJECTIVE We estimated the moderating effect of PrEP use on the association between sexual risk behavior and perceived risk of HIV, measured with the 8-item Perceived Risk of HIV Scale (PRHS), among Brazilian MSM. METHODS A cross-sectional, web-based survey was completed by Brazilian Hornet app users aged ≥18 years between February and March 2020. We included data from cisgender men who reported sex with men in the previous 6 months. We evaluated the moderating effect of current PrEP use on the association between sexual risk behavior, measured via the HIV Incidence Risk Index for MSM (HIRI-MSM), and perceived risk of HIV, measured by the PRHS. Higher HIRI-MSM (range 0-45) and PRHS (range 10-40) scores indicate greater sexual behavioral risk and perceived risk of HIV, respectively. Both were standardized to z scores for use in multivariable linear regression models. RESULTS Among 4344 cisgender MSM, 448 (10.3%) were currently taking PrEP. Current PrEP users had a higher mean HIRI-MSM score (mean 21.0, SD 9.4 vs mean 13.2, SD 8.1; P<.001) and a lower mean PRHS score (mean 24.6, SD 5.1 vs mean 25.9, SD 4.9; P<.001) compared to those not currently taking PrEP. In the multivariable model, greater HIRI-MSM scores significantly predicted increased PRHS scores (β=.26, 95% CI 0.22-0.29; P<.001). PrEP use moderated the association between HIRI-MSM and PRHS score (interaction term β=-.30, 95% CI -0.39 to -0.21; P<.001), such that higher HIRI-MSM score did not predict higher PRHS score among current PrEP users. CONCLUSIONS Our results suggest current PrEP users have confidence in PrEP's effectiveness as an HIV prevention strategy. PrEP's effectiveness, positive psychological impact, and the frequent HIV testing and interaction with health services required of PrEP users may jointly influence the relationship between sexual risk behavior and perceived risk of HIV among PrEP users.
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Affiliation(s)
- Kevin James Blair
- South American Program in HIV Prevention Research, Division of Infectious Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Thiago S Torres
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Brenda Hoagland
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Daniel R B Bezerra
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Valdilea G Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Jesse Clark
- South American Program in HIV Prevention Research, Division of Infectious Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Paula M Luz
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Ogaz D, Logan L, Curtis TJ, McDonagh L, Guerra L, Bradshaw D, Patel P, Macri C, Murphy G, Noel Gill O, Johnson AM, Nardone A, Burns F. PrEP use and unmet PrEP-need among men who have sex with men in London prior to the implementation of a national PrEP programme, a cross-sectional study from June to August 2019. BMC Public Health 2022; 22:1105. [PMID: 35659209 PMCID: PMC9163522 DOI: 10.1186/s12889-022-13425-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/12/2022] [Indexed: 11/30/2022] Open
Abstract
Background Access to prevention options, including HIV pre-exposure prophylaxis (PrEP), remains a public health priority for gay, bisexual, and other men who have sex with men (MSM), especially in London. We describe PrEP use in a London community sample of MSM before the introduction of a national PrEP programme in October 2020. Methods From June–August 2019, MSM aged ≥ 18 recruited from London commercial venues were asked to self-complete a sexual health questionnaire and provide an oral fluid sample for anonymous HIV antibody testing. Descriptive analyses of demographic characteristics, service engagement and outcomes, as well as sexual risk and prevention behaviours were examined in the survey population and in those reporting current PrEP use. We performed sequential, multivariate analyses examining current PrEP use in MSM of self-perceived HIV-negative/unknown status with identified PrEP-need defined as the report of condomless anal sex (CAS) in the last three months, or the report of CAS (in the last year) with an HIV-positive/unknown status partner not known to be on HIV treatment, in reflection of UK PrEP guidelines. Results One thousand five hundred and thirty-fifth questionnaires were completed across 34 venues, where 1408 were analysed. One in five MSM of self-perceived HIV-negative/unknown status reported current PrEP use (19.7%, 242/1230). In men with PrEP-need, 68.2% (431/632) did not report current use. Current PrEP use was associated with age (aOR: 3.52, 95% CI: 1.76–7.02 in men aged 40–44 vs men aged 18–25) and education (aOR: 1.72, 95% CI: 1.01–2.92 in men with ≥ 2 years/still full-time vs no/ < 2 years of education since age 16). Conclusion Among MSM in London, PrEP use is high but there is indication of unmet PrEP-need in men of younger age and lower levels of post-16 education. National programme monitoring and evaluation will require continued community monitoring to guide interventions ensuring equitable PrEP access and uptake in those who could most benefit from PrEP. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13425-0.
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Resnick D, Schapira MM, Andrews ME, Essoka-Lasenberry A, Davis-Voge A, Bauermeister JA, Wood SM. "I Think That I Have a Good Understanding of How to Protect Myself": A Qualitative Study About HIV Risk Perceptions Among Men and Gender Diverse Individuals Who Have Sex With Men. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2022; 34:82-S5. [PMID: 35192391 PMCID: PMC8992390 DOI: 10.1521/aeap.2022.34.1.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
This qualitative study aimed to determine how men and gender diverse individuals who have sex with men describe their perceived risk of HIV and what factors influence this risk assessment. We conducted in-depth, virtual interviews with 18 HIV-negative individuals from Philadelphia, eligible for or taking PrEP. The interviews assessed the participants' understanding of their HIV risk, using thematic analysis to deductively code and extract themes. Three themes emerged: (1) participants expressed both deliberative and affective risk perception before and after sexual encounters; (2) participants linked HIV knowledge to risk perception and stigma; (3) participants connected intrinsic and extrinsic factors to risk perception differently. Participants endorsed low overall risk perception, while also describing moments of high affective risk perception after sexual encounters in which they were not able to implement their preferred prevention strategies. Future research should explore helping individuals transform affective risk perception into empowerment around sexual health.
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Affiliation(s)
- Daniel Resnick
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
- Department of Medicine, Emory University School of Medicine, Atlanta GA
| | - Marilyn M Schapira
- The Center for Health Equity Research and Promotion, Michael J Crescenz VA Medical Center, Philadelphia PA
| | - Mary E. Andrews
- Annenberg School of Communication, the University of Pennsylvania, Philadelphia PA
| | - Amadi Essoka-Lasenberry
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Annet Davis-Voge
- HIV Research Prevention Division, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - José A. Bauermeister
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia PA
| | - Sarah M Wood
- Craig Dalsimer Division of Adolescent Medicine, Children Hospital of Philadelphia, Philadelphia PA
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Nalukwago GK, Isunju JB, Muwonge T, Katairo T, Bunani N, Semitala F, Kyambadde P, Matovu F. Adherence to oral HIV pre-exposure prophylaxis among female sex workers in Kampala, Uganda. Afr Health Sci 2021; 21:1048-1058. [PMID: 35222566 PMCID: PMC8843287 DOI: 10.4314/ahs.v21i3.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION In Kampala Uganda, female sex workers (FSWs) have high HIV prevalence (33%). Oral PrEP is a novel HIV prevention intervention that offers hope to decrease HIV incidence in key populations especially among FSWs. Studies have shown that with poor adherence, oral PrEP has no efficacy, and therefore adherence to PrEP is critical among FSWs to maximize HIV prevention. However, implementation data on adherence to PrEP among FSWs is limited so this study sought to assess adherence to PrEP. Specifically, we sought to 1) determine the level of adherence to PrEP among FSWs, and 2) determine factors associated with PrEP adherence. METHODS This cross-sectional study was conducted from November to December 2018; 126 FSWs using PrEP were interviewed using a questionnaire. Adherence was categorically defined as high adherence and low adherence. Logistic regression was done. RESULTS Using long-term contraception methods (OR 0.06, 95% CI: 0.04-0.77) and not using condoms with clients (OR 0.07, 95% CI: 0.01-0.42) were negatively associated with high PrEP adherence. CONCLUSION Barriers to PrEP adherence need to be addressed for successful PrEP implementation to improve adherence going forward. Service care providers should reinforce positive behaviors such as use of condoms devotedly during PrEP breaks.
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Affiliation(s)
- Grace Kakoola Nalukwago
- Makerere University College of Health Sciences, Public Health
- Makerere University Infectious Diseases Institute, Research
| | | | | | - Thomas Katairo
- Makerere University College of Health Sciences, School of Medicine, Clinical Epidemiology Unit
| | - Nelson Bunani
- Makerere University College of Health Sciences, Public Health
| | - Fred Semitala
- Makerere University College of Health Sciences, School of Medicine, Clinical Epidemiology Unit
| | | | - Flavia Matovu
- Makerere University School of Public Health, Epidemiology and Biostatistics
- MU-JHU Research Collaboration
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Alam N, Wahed T, Alam A, Dema P, Oishi SN, Nahar Q. Condom use, symptoms of suggestive sexually transmitted infections, and health care seeking among female sex workers in Bangladesh. Int J STD AIDS 2021; 32:1114-1122. [PMID: 34125631 DOI: 10.1177/09564624211021312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article presents a mixed-method cross-sectional study reporting condom use, sexually transmitted infection (STI) symptoms, and care seeking of female sex workers (FSWs) in Dhaka, Bangladesh. A survey of 1228 FSWs, in-depth interviews (n = 24), and key informants' interviews (n = 26) were used for data collection. Among the 1228 FSWs included in this study, 50% of them were illiterate and 39.3% were married, and their mean age was 27.1 years. The consistent use of condoms was reported by 75.6% of the FSWs, 88.7% reported having STI symptoms in the last 6 months, while 91.8% visited one of the drop-in centers for services. FSWs without formal education had lower odds of using condoms consistently (AOR: 0.72; 95% CI: 0.55-0.95), and those working elsewhere than in the streets showed higher odds (AOR: 1.63; 95% CI: 1.23-2.15) to use condoms. Stigma to access health care services, poor knowledge about STI/HIV, and low perceived risk were mentioned as causes of having STI symptoms in the survey as well as in qualitative in-depth interviews. Self-reported condom use, STI symptoms, and care-seeking practices were found to be high among the FSWs. Inconsistent condom use and a high number of sex partners could be the reasons for high levels of STI symptoms. Innovative objectively verifiable approaches should be tested to collect condom use data.
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Affiliation(s)
- Nazmul Alam
- Department of Public Health, 141014Asian University for Women, Chittagong, Bangladesh
| | - Tasnuva Wahed
- Research to Policy Limited, Mirpur, Dhaka, Bangladesh
| | - Anadil Alam
- 56291International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), Mohakhali, Bangladesh
| | - Passang Dema
- Department of Public Health, 141014Asian University for Women, Chittagong, Bangladesh
| | - Shafiqua N Oishi
- Department of Public Health, 141014Asian University for Women, Chittagong, Bangladesh
| | - Quamrun Nahar
- 56291International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), Mohakhali, Bangladesh
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Resnick D, Morales K, Gross R, Petsis D, Fiore D, Davis-Vogel A, Metzger D, Frank I, Wood S. Prior Sexually Transmitted Infection and Human Immunodeficiency Virus Risk Perception in a Diverse At-Risk Population of Men Who Have Sex with Men and Transgender Individuals. AIDS Patient Care STDS 2021; 35:15-22. [PMID: 33400589 DOI: 10.1089/apc.2020.0179] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Prior sexually transmitted infections (STIs) are associated with higher rates of subsequent human immunodeficiency virus (HIV) infection, but the influence of prior STIs on perceived vulnerability to HIV remains unclear. We aimed to assess this relationship, hypothesizing that a prior STI diagnosis is associated with higher self-assessed vulnerability to HIV. We performed a cross-sectional study of men and transgender individuals who have sex with men screening for HIV prevention trials in Philadelphia. An unadjusted regression analysis found no significant association between prior STI and HIV risk perception (p = 0.71) or HIV anxiety (p = 0.32). Multivariate logistic regression models that controlled for predetermined potential cofounders known to impact HIV risk-such as condom use, preexposure prophylaxis use, and demographics-also failed to show statistically significant associations between prior STI and HIV risk perception (p = 0.87) or HIV anxiety (p = 0.10). Furthermore, there was no effect modification by HIV preventive behaviors on the relationship between prior STI and HIV vulnerability. These data suggest that a gap exists between how clinicians may attribute individual HIV risk and how individuals view their own vulnerability at a given moment in time. Future research should focus on the dynamic relationship between perceived HIV vulnerability, STI diagnosis, and adoption of preventive behavior to determine better, individualized targets for HIV prevention interventions.
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Affiliation(s)
- Daniel Resnick
- HIV Research Prevention Division, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Knashawn Morales
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Robert Gross
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Danielle Petsis
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Danielle Fiore
- HIV Research Prevention Division, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Annet Davis-Vogel
- HIV Research Prevention Division, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David Metzger
- HIV Research Prevention Division, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ian Frank
- HIV Research Prevention Division, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sarah Wood
- HIV Research Prevention Division, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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