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Psaros C, Hill-Rorie J, Quint M, Horvitz C, Dormitzer J, Biello KB, Krakower DS, Safren SA, Mimiaga MJ, Sullivan P, Hightow-Weidman LB, Mayer KH. A qualitative exploration of how to support PrEP adherence among young men who have sex with men. AIDS Care 2024; 36:732-743. [PMID: 37748111 PMCID: PMC10961251 DOI: 10.1080/09540121.2023.2240070] [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: 02/23/2023] [Accepted: 07/18/2023] [Indexed: 09/27/2023]
Abstract
New HIV infections disproportionately affect young men who have sex with men (YMSM). PrEP is effective in preventing HIV acquisition; however, adherence is critical and is often suboptimal among YMSM. Interventions addressing the unique PrEP adherence challenges faced by YMSM are needed. We conducted qualitative interviews with 20 HIV-negative, YMSM (ages 15-24) with a PrEP indication and 11 healthcare professionals to inform adaption of a PrEP adherence intervention (Life-Steps for PrEP) for YMSM. We explored environmental, healthcare, and individual factors influencing uptake, adherence, attitudes, and perspectives (including desired modifications) on the Life-Steps intervention. Interviews were analyzed using content analysis. Of YMSM study participants (mean age 21.6) 55% were White, 15% Hispanic, and 5% Black. Most YMSM were PrEP-experienced (70%). Healthcare professionals (6 prescribers, 1 nurse, 2 health educators, 2 other/unspecified) averaged 6.9 years of experience caring for YMSM. All described stigma as a barrier to PrEP; YMSM expressed concern around being perceived as "risky" and concern about inadvertent PrEP disclosure if family/friends found their medication, or if parental insurance was used. Difficulty with planning for potential adherence challenges were identified by both groups. YMSM highlighted benefits of a nurse-led intervention (i.e., adding "legitimacy"), but stressed need for nonjudgmental, "savvy" interventionists. YMSM expressed a desire for comprehensive YMSM-specific sexual health information. These findings informed modification and expansion of Life-Steps content. Results highlight key potential barriers, many of which center around privacy. Content that addresses PrEP stigma, disclosing PrEP use, navigating insurance, and planning ahead in a nonjudgmental environment by trusted providers emerged as important components of a YMSM-focused delivery of Life-Steps for PrEP.
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Affiliation(s)
- Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- The Fenway Institute, Fenway Health, Boston, MA, United States
| | | | - Meg Quint
- The Fenway Institute, Fenway Health, Boston, MA, United States
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Casey Horvitz
- Behavior and Technology Lab, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Katie B. Biello
- The Fenway Institute, Fenway Health, Boston, MA, United States
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, RI, United States
- Department of Behavioral & Social Sciences, Brown University School of Public Health, Providence, RI, United States
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States
| | - Douglas S. Krakower
- The Fenway Institute, Fenway Health, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Steven A. Safren
- Department of Psychology, University of Miami, Coral Gables, FL, United States
| | - Matthew J. Mimiaga
- The Fenway Institute, Fenway Health, Boston, MA, United States
- UCLA Center for LGBTQ+ Advocacy, Research & Health, Los Angeles, CA, United States
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, United States
- Department of Psychiatry & Biobehavioral Sciences, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Patrick Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Lisa B. Hightow-Weidman
- Institute on Digital Health and Innovation, College of Nursing, Florida State University, Tallahassee, FL, United States
| | - Kenneth H. Mayer
- The Fenway Institute, Fenway Health, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, United States
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2
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Mukherjee TI, Zerbe A, Falcao J, Carey S, Iaccarino A, Kolada B, Olmedo B, Shadwick C, Singhal H, Weinstein L, Vitale M, De Gusmao EDP, Abrams EJ. Human-Centered Design for Public Health Innovation: Codesigning a Multicomponent Intervention to Support Youth Across the HIV Care Continuum in Mozambique. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100664. [PMID: 35487546 PMCID: PMC9053144 DOI: 10.9745/ghsp-d-21-00664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/08/2022] [Indexed: 11/15/2022]
Abstract
Adolescents and young people represent a growing proportion of people living with HIV (AYAHIV), and there is an urgent need to design, implement, and test interventions that retain AYAHIV in care. Using a human-centered design (HCD) approach, we codesigned CombinADO, an intervention to promote HIV viral suppression and improve antiretroviral therapy (ART) adherence and retention in care among AYAHIV in Nampula, Mozambique. The HCD process involves formative design research with AYAHIV, health care providers, parents/caretakers, and experts in adolescent HIV; synthesis of findings to generate action-oriented insights; ideation and prototyping of intervention components; and a pilot study to assess feasibility, acceptability, and uptake of intervention components.CombinADO promotes ART adherence and retention in care by fostering peer connectedness and belonging, providing accessible medical knowledge, demystifying and destigmatizing HIV, and cultivating a sense of hope among AYAHIV. Successful prototypes included a media campaign to reduce HIV stigma and increase medical literacy; a toolkit to help providers communicate and address the unique needs of AYAHIV clients; peer-support groups to improve medical literacy, empower youth, and provide positive role models for people living with HIV; support groups for parents/caregivers; and discreet pill containers to promote adherence outside the home. In the next phase, the effectiveness of CombinaADO on retention in care, ART adherence, and viral suppression will be evaluated using a cluster-randomized control trial.We demonstrate the utility of using HCD to cocreate a multicomponent intervention to retain AYAHIV in care. We also discuss how the HCD methodology enriches participatory methods and community engagement. This is then illustrated by the youth-driven intervention development of CombinADO by fostering youth empowerment, addressing power imbalances between youth and adult stakeholders, and ensuring that language and content remain adolescent friendly.
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Affiliation(s)
- Trena I Mukherjee
- Department of Epidemiology, Columbia Mailman School of Public Health, New York, NY, USA.
| | - Allison Zerbe
- ICAP at Columbia University Mailman School of Public Health, New York, NY, USA
| | | | | | | | | | | | | | | | | | | | | | - Elaine J Abrams
- Department of Epidemiology, Columbia Mailman School of Public Health, New York, NY, USA
- ICAP at Columbia University Mailman School of Public Health, New York, NY, USA
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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3
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Klasko-Foster LB, Biello KB, Lodge W, Olson J, Mimiaga MJ. Transitioning from Face to Face to the Digital Space: Best Practices and Lessons Learned Leveraging Technology to Conduct HIV-Focused Interventions. Telemed J E Health 2022; 28:1070-1073. [PMID: 34995162 DOI: 10.1089/tmj.2021.0190] [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: 11/13/2022] Open
Abstract
Introduction: Coronavirus disease 2019 (COVID-19) has impacted researchers' ability to continue to deliver HIV prevention and treatment interventions face to face. Although telehealth has been an important strategy to maintain research operations during the current pandemic, participants at increased risk of or living with HIV are often at higher risk of also experiencing poverty, housing instability, and other challenges that may present obstacles to successful remote delivery. Methods: We provide descriptions of remote adaptations to two randomized controlled efficacy trials of behavioral interventions for primary and secondary HIV prevention with descriptive enrollment and retention data. Results and Conclusions: Best practices for implementing telemedicine and e-health procedures are discussed, including procedures for addressing remote participation barriers (economic, health literacy, etc.) and other challenges, such as building rapport and staff support (NCT03092531 and NCT03175159).
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Affiliation(s)
- Lynne B Klasko-Foster
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA.,Department of Behavioral and Social Health Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Katie B Biello
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Behavioral and Social Health Sciences, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA.,The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - William Lodge
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Behavioral and Social Health Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jennifer Olson
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Matthew J Mimiaga
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA.,The Fenway Institute, Fenway Health, Boston, Massachusetts, USA.,Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California, USA.,Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, Los Angeles, California, USA.,UCLA Center for LGBTQ Advocacy, Research and Health, Los Angeles, California, USA
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Mehra N, Tunje A, Hallström IK, Jerene D. Effectiveness of mobile phone text message reminder interventions to improve adherence to antiretroviral therapy among adolescents living with HIV: A systematic review and meta-analysis. PLoS One 2021; 16:e0254890. [PMID: 34293033 PMCID: PMC8297901 DOI: 10.1371/journal.pone.0254890] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 07/07/2021] [Indexed: 11/23/2022] Open
Abstract
Background Poor adherence to antiretroviral therapy in adolescents living with HIV is a global challenge. One of the key strategies to improve adherence is believed to be the use of digital adherence tools. However, evidence is limited in this area. Our objective was to investigate the effectiveness of mobile phone text message reminders in improving ART adherence for adolescents. Methods The preferred reporting item for systematic review and meta-analysis guideline was followed. A literature search was done in five databases (PubMed, Web of Science, Embase, Global Health and Cochrane) in August 2020. Additional searches for studies and grey literature were performed manually. We included studies with quantitative design exploring the effectiveness of text message reminders, targeting adolescents aged 10–19 years. Studies were excluded if the intervention involved phone calls, phone-based applications, or other complex tech services. Mean differences between intervention and standard of care were computed using a random effects model. Subgroup analyses were performed to identify sources of heterogeneity between one-way and two-way text messages. Results Of 2517 study titles screened, seven eligible studies were included in the systematic review. The total number of participants in the included studies was 987, and the study sample varied from 14 to 332. Five studies showed a positive impact of text messaging in improving adherence, while no significant difference was found between the intervention and the control (standard of care) group in the remaining two studies. The pooled mean difference between the intervention and the control group was 0.05 (95% CI: –0.08 to 0.17). There was considerable heterogeneity among the studies (I2 = 78%). Conclusion and recommendation The meta-analysis of text message reminder interventions did not show a statistically significant difference in the improvement of ART adherence among adolescents living with HIV. The included studies were heterogeneous in the reported clinical outcomes, where the effectiveness of the intervention was identified in small studies which had a short follow-up period. Studies with bigger sample size and a longer follow-up period are needed.
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Affiliation(s)
- Nishant Mehra
- Child and Family Health Unit, Department of Health Science, Faculty of Medicine, Lund University, Lund, Sweden
- * E-mail:
| | - Abayneh Tunje
- Child and Family Health Unit, Department of Health Science, Faculty of Medicine, Lund University, Lund, Sweden
- School of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Inger Kristensson Hallström
- Child and Family Health Unit, Department of Health Science, Faculty of Medicine, Lund University, Lund, Sweden
| | - Degu Jerene
- KNCV Tuberculosis Foundation, The Hague, Netherlands
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Crowley T, Rohwer A. Self-management interventions for adolescents living with HIV: a systematic review. BMC Infect Dis 2021; 21:431. [PMID: 33962558 PMCID: PMC8105944 DOI: 10.1186/s12879-021-06072-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/09/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Self-management interventions aim to enable people living with chronic conditions to increase control over their condition in order to achieve optimal health and may be pertinent for young people with chronic illnesses such as HIV. Our aim was to evaluate the effectiveness of self-management interventions for improving health-related outcomes of adolescents living with HIV (ALHIV) and identify the components that are most effective, particularly in low-resource settings with a high HIV burden. METHODS We considered randomised controlled trials (RCTs), cluster RCTs, non-randomised controlled trials (non-RCTs) and controlled before-after (CBA) studies. We did a comprehensive search up to 1 August 2019. Two authors independently screened titles, abstracts and full texts, extracted data and assessed the risk of bias. We synthesised results in a meta-analysis where studies were sufficiently homogenous. In case of substantial heterogeneity, we synthesised results narratively. We assessed the certainty of evidence using GRADE and presented our findings as summaries in tabulated form. RESULTS We included 14 studies, comprising 12 RCTs and two non-RCTs. Most studies were conducted in the United States, one in Thailand and four in Africa. Interventions were diverse, addressing a variety of self-management domains and including a combination of individual, group, face-to-face, cell phone or information communication technology mediated approaches. Delivery agents varied from trained counsellors to healthcare workers and peers. Self-management interventions compared to usual care for ALHIV made little to no difference to most health-related outcomes, but the evidence is very uncertain. Self-management interventions may increase adherence and decrease HIV viral load, but the evidence is very uncertain. We could not identify any particular components of interventions that were more effective for improving certain outcomes. CONCLUSION Existing evidence on the effectiveness of self-management interventions for improving health-related outcomes of ALHIV is very uncertain. Self-management interventions for ALHIV should take into account the individual, social and health system contexts. Intervention components need to be aligned to the desired outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019126313.
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Affiliation(s)
- Talitha Crowley
- Department of Nursing and Midwifery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anke Rohwer
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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6
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Murphy E, Keller J, Argani C, Milio L, Powell A, Sheffield J, Agwu A, Anderson J. Pregnancy in an Urban Cohort of Adolescents Living with Human Immunodeficiency Virus: Characteristics and Outcomes in Comparison to Adults. AIDS Patient Care STDS 2021; 35:103-109. [PMID: 33835849 DOI: 10.1089/apc.2020.0262] [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: 11/12/2022] Open
Abstract
Adolescents (13-24 years of age) account for more than one-fifth of new HIV diagnoses yearly, and the United States has one of the highest rates of adolescent pregnancy among high resource countries. However, there is limited information on the characteristics and outcomes of adolescents living with HIV (ALWHIV) during pregnancy and differences with pregnancy in adults living with HIV. We performed a retrospective cohort study to compare demographic characteristics, HIV viral suppression, and pregnancy outcomes in adolescents (n = 90) as compared with adults (n = 250) in an urban HIV pregnancy clinic from 2003 to 2015. Seventy-one women overall were diagnosed with HIV during pregnancy (adolescents, 25/90; adults, 46/250). One-fifth of adolescents acquired HIV perinatally. Adolescents were more likely than adults to have unintended pregnancy (83.6% vs. 68.7%, p = 0.016) and were less likely to be virally suppressed at delivery (50.0% vs. 69.7% overall, p = 0.001; 48.0% vs. 78.2% in postuniversal antiretroviral therapy era, p = 0.007%). Over one-third of adolescents reported a history of any illicit substance use, and adolescents were more likely than adults to use marijuana during pregnancy (29.2% vs. 16.9%, p = 0.013). Adolescents were less likely to experience preterm labor (11.0% vs. 24.1%, p = 0.012) or preterm premature rupture of membranes (3.7% vs. 16.7%, p = 0.003). There was one case of maternal-fetal transmission, which occurred in an adult pregnancy. Despite the high rate of unintended pregnancy, one-third of adolescents were discharged without an identified contraception plan. We identify several opportunities for intervention to improve reproductive health outcomes in ALWHIV.
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Affiliation(s)
- Emily Murphy
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jean Keller
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cynthia Argani
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lorraine Milio
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anna Powell
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeanne Sheffield
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Allison Agwu
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jean Anderson
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Approaches to Objectively Measure Antiretroviral Medication Adherence and Drive Adherence Interventions. Curr HIV/AIDS Rep 2020; 17:301-314. [PMID: 32424549 PMCID: PMC7363551 DOI: 10.1007/s11904-020-00502-5] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Traditional methods to assess antiretroviral adherence, such as self-report, pill counts, and pharmacy refill data, may be inaccurate in determining actual pill-taking to both antiretroviral therapy (ART) or pre-exposure prophylaxis (PrEP). HIV viral loads serve as surrogates of adherence on ART, but loss of virologic control may occur well after decreases in adherence and viral loads are not relevant to PrEP. RECENT FINDINGS Pharmacologic measures of adherence, electronic adherence monitors, and ingestible electronic pills all serve as more objective metrics of adherence, surpassing self-report in predicting outcomes. Pharmacologic metrics can identify either recent adherence or cumulative adherence. Recent dosing measures include antiretroviral levels in plasma or urine, as well as emtricitabine-triphosphate in dried blood spots (DBS) for those on tenofovir-emtricitabine-based therapy. A urine tenofovir test has recently been developed into a point-of-care test for bedside adherence monitoring. Cumulative adherence metrics assess adherence over weeks to months and include measurement of tenofovir-diphosphate in peripheral blood mononuclear cells or DBS, as well as ART levels in hair. Electronic adherence monitors and ingestible electronic pills can track pill bottle openings or medication ingestion, respectively. New and objective approaches in adherence monitoring can be used to detect nonadherence prior to loss of prevention efficacy or virologic control with PrEP or ART, respectively.
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Quinn KG, Voisin DR. ART Adherence Among Men Who Have Sex with Men Living with HIV: Key Challenges and Opportunities. Curr HIV/AIDS Rep 2020; 17:290-300. [PMID: 32557117 DOI: 10.1007/s11904-020-00510-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW In the USA, gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by HIV. High levels of adherence to antiretroviral therapy (ART) can dramatically improve outcomes for persons living with HIV and reduce the risk of HIV transmission to others. Yet, there are numerous individual, social, and structural barriers to optimal ART adherence. Many of these factors disproportionately impact Black MSM and may contribute to their poorer rates of ART adherence. This review synthesizes the key challenges and intervention opportunities to improve ART adherence among MSM in the USA. RECENT FINDINGS Key challenges to ART adherence include stigma, violence, depression, and substance use. Black MSM are significantly disadvantaged by several of these factors. There are several promising interventions to improve ART adherence among MSM, and there remains an opportunity to culturally tailor these to the needs of Black MSM populations to enhance adherence. Despite high rates of HIV among MSM, there continues to be a paucity of research on the various contributors to poor ART adherence among this population. Similarly, few interventions have been tested that lead to increased and sustained ART adherence among Black MSM.
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Affiliation(s)
- Katherine G Quinn
- Center for AIDS Intervention Research (CAIR), Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, 2071 N. Summit, Milwaukee, WI, 53202, USA.
| | - Dexter R Voisin
- Factor-Intwentash School of Social Work, University of Toronto, Toronto, Canada
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Reif LK, Abrams EJ, Arpadi S, Elul B, McNairy ML, Fitzgerald DW, Kuhn L. Interventions to Improve Antiretroviral Therapy Adherence Among Adolescents and Youth in Low- and Middle-Income Countries: A Systematic Review 2015-2019. AIDS Behav 2020; 24:2797-2810. [PMID: 32152815 PMCID: PMC7223708 DOI: 10.1007/s10461-020-02822-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Adolescents and youth living with HIV have poorer antiretroviral treatment (ART) adherence and viral suppression outcomes than all other age groups. Effective interventions promoting adherence are urgently needed. We reviewed and synthesized recent literature on interventions to improve ART adherence among this vulnerable population. We focus on studies conducted in low- and middle-income countries (LMIC) where the adolescent and youth HIV burden is greatest. Articles published between September 2015 and January 2019 were identified through PubMed. Inclusion criteria were: [1] included participants ages 10-24 years; [2] assessed the efficacy of an intervention to improve ART adherence; [3] reported an ART adherence measurement or viral load; [4] conducted in a LMIC. Articles were reviewed for study population characteristics, intervention type, study design, outcomes measured, and intervention effect. Strength of each study's evidence was evaluated according to an adapted World Health Organization GRADE system. Articles meeting all inclusion criteria except being conducted in an LMIC were reviewed for results and potential transportability to a LMIC setting. Of 108 articles identified, 7 met criteria for inclusion. Three evaluated patient-level interventions and four evaluated health services interventions. Of the patient-level interventions, two were experimental designs and one was a retrospective cohort study. None of these interventions improved ART adherence or viral suppression. Of the four health services interventions, two targeted stable patients and reduced the amount of time spent in the clinic or grouped patients together for bi-monthly meetings, and two targeted patients newly diagnosed with HIV or not yet deemed clinically stable and augmented clinical care with home-based case-management. The two studies targeting stable patients used retrospective cohort designs and found that adolescents and youth were less likely to maintain viral suppression than children or adults. The two studies targeting patients not yet deemed clinically stable included one experimental and one retrospective cohort design and showed improved ART adherence and viral suppression outcomes. ART adherence and viral suppression outcomes remain a major challenge among adolescents and youth. Intensive home-based case management models of care hold promise for improving outcomes in this population and warrant further research.
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Affiliation(s)
- Lindsey K. Reif
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY USA
| | - Elaine J. Abrams
- ICAP At Columbia University, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY USA
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY USA
| | - Stephen Arpadi
- Gertrude H. Sergievsky Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY USA
- ICAP At Columbia University, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY USA
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY USA
| | - Batya Elul
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY USA
| | - Margaret L. McNairy
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY USA
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY USA
| | - Daniel W. Fitzgerald
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY USA
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY USA
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10
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Brooks RA, Nieto O, Swendeman D, Myers J, Lepe RM, Cabral A, Kao U, Donohoe T, Comulada WS. Qualitative Evaluation of Social Media and Mobile Technology Interventions Designed to Improve HIV Health Outcomes for Youth and Young Adults Living With HIV: A HRSA SPNS Initiative. Health Promot Pract 2020; 21:693-704. [PMID: 32757839 PMCID: PMC7646559 DOI: 10.1177/1524839920938704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Youth and young adults living with HIV (YYALH) are less likely to be engaged in HIV care, adhere to their medications, and achieve viral suppression compared to older adult populations. In the United States, the majority of YYALH belong to racial/ethnic, sexual, and gender minority groups. HIV care interventions are needed that specifically target YYALH and that exploit the use of social media and mobile technology (SMMT) platforms, where youth and young adults have a ubiquitous presence. We conducted a qualitative evaluation of SMMT interventions included in a Health Resources and Services Administration Special Projects of National Significance initiative designed to improve medical care engagement, retention, and medication adherence to achieve viral suppression among YYALH. However, in this study, only young adults living with HIV (YALH) ages 18 to 34 years participated. A total of 48 YALH were interviewed. The data were analyzed using thematic analysis and revealed three main themes supporting the usefulness of the SMMT interventions, which included (1) acceptability of SMMT interventions in managing HIV care with subthemes of medical information accessibility, reminders, and self-efficacy; (2) feelings of support and personal connection afforded by SMMT interventions; and (3) SMMT interventions help to alleviate negative feelings about status and mitigate HIV-related stigma. A few participants identified problems with using their respective intervention, primarily related to the functionality of the technologies. Overall, findings from our qualitative evaluation suggest that SMMT-based interventions have the potential to increase engagement and retention in care, support YALH in adhering to medication, and help them adjust to their diagnosis.
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Affiliation(s)
| | - Omar Nieto
- University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Janet Myers
- University of California, San Francisco, San Francisco, CA, USA
| | | | | | - Uyen Kao
- University of California, Los Angeles, Los Angeles, CA, USA
| | - Thomas Donohoe
- University of California, Los Angeles, Los Angeles, CA, USA
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11
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Lucero R, Williams R, Esalomi T, Alexander-Delpech P, Cook C, Bjarnadottir RI. Using an Electronic Medication Event-Monitoring System for Antiretroviral Therapy Self-Management Among African American Women Living With HIV in Rural Florida: Cohort Study. JMIR Form Res 2020; 4:e14888. [PMID: 32130114 PMCID: PMC7057821 DOI: 10.2196/14888] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/31/2019] [Accepted: 12/16/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND HIV remains a significant health issue in the United States and disproportionately affects African Americans. African American women living with HIV (AAWH) experience a particularly high number of barriers when attempting to manage their HIV care, including antiretroviral therapy (ART) adherence. To enable the development and assessment of effective interventions that address these barriers to support ART adherence, there is a critical need to understand more fully the use of objective measures of ART adherence among AAWH, including electronic medication dispensers for real-time surveillance. OBJECTIVE This study aimed to evaluate the use of the Wisepill medication event-monitoring system (MEMS) and compare the objective and subjective measures of ART adherence. METHODS We conducted a 30-day exploratory pilot study of the MEMS among a convenience sample of community-dwelling AAWH (N=14) in rural Florida. AAWH were trained on the use of the MEMS to determine the feasibility of collecting, capturing, and manipulating the MEMS data for an objective measure of ART adherence. Self-reported sociodemographic information, including a self-reported measure of ART adherence, was also collected from AAWH. RESULTS We found that the majority of participants were successful at using the electronic MEMS. Daily use of the MEMS tended to be outside of the usual time participants took their medication. Three 30-day medication event patterns were found that characterized ART adherence, specifically uniform and nonuniform medication adherence and nonuniform medication nonadherence. There were relatively few MEMS disruptions among study participants. Overall, adjusted daily ART adherence was 81.08% and subjective ART adherence was 77.78%. CONCLUSIONS This pilot study on the use and evaluation of the Wisepill MEMS among AAWH in rural Florida is the first such study in the United States. The findings of this study are encouraging because 10 out of 12 participants consistently used the MEMS, there were relatively few failures, and objective adjusted daily and overall subjective ART adherence were very similar. On the basis of these findings, we think researchers should consider using the Wisepill MEMS in future studies of AAWH and people living with HIV in the United States after taking into account our practical suggestions. The following practical considerations are suggested when measuring objective medication adherence: (1) before using an MEMS, be familiar with the targeted populations' characteristics; (2) choose an MEMS that aligns with the participants' day-to-day activities; (3) ensure the MEMS' features and resulting data support the research goals; (4) assess the match among the user's ability, wireless features of the MEMS, and the geographic location of the participants; and (5) consider the cost of MEMS and the research budget.
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Affiliation(s)
- Robert Lucero
- Department of Family, Community, and Health Systems Science, Southern HIV & Alcohol Research Consortium, University of Florida, College of Nursing, Gainesville, FL, United States
| | - Renessa Williams
- Department of Family, Community, and Health Systems Science, Southern HIV & Alcohol Research Consortium, University of Florida, College of Nursing, Gainesville, FL, United States
| | - Tanisia Esalomi
- Department of Family, Community, and Health Systems Science, University of Florida, College of Nursing, Gainesville, FL, United States
| | - Paula Alexander-Delpech
- Department of Family, Community, and Health Systems Science, University of Florida, College of Nursing, Gainesville, FL, United States
| | - Christa Cook
- College of Nursing, University of Central Florida, Orlando, FL, United States
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12
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Masters MC, Krueger KM, Williams JL, Morrison L, Cohn SE. Beyond one pill, once daily: current challenges of antiretroviral therapy management in the United States. Expert Rev Clin Pharmacol 2019; 12:1129-1143. [PMID: 31774001 DOI: 10.1080/17512433.2019.1698946] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Modern antiretroviral therapy (ART) has revolutionized HIV treatment. ART regimens are now highly efficacious, well-tolerated, safe, often with one multi-drug pill, once-daily regimens available. However, clinical challenges persist in managing ART in persons with HIV (PWH), such as drug-drug interactions, side effects, pregnancy, co-morbidities, and adherence.Areas Covered: In this review, we discuss the ongoing challenges of ART for adults in the United States. We review the difficulties of initiating ART and maintaining therapy throughout adulthood and discuss new agents and strategies under investigation to address these issues. A PubMed search was utilized to identify relevant publications and guidelines through July 2019.Expert Opinion: Challenges persist in initiation and maintenance of ART. An individual's coexisting medical, social and personal factors must be considered in selecting and continuing ART to ensure safety, tolerability, and efficacy throughout adulthood. Continued development of new therapeutics and novel approaches to ART, such as long acting drugs or dual therapy, are needed to respond to many of these challenges. In addition, future research must address therapeutic disparities for populations historically underrepresented in clinical trials, including women, people aging with HIV, and those with complex comorbidities.
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Affiliation(s)
- Mary Clare Masters
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karen M Krueger
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Janna L Williams
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lindsay Morrison
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Susan E Cohn
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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13
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Dunn Navarra AM, Viorst Gwadz M, Bakken S, Whittemore R, Cleland CM, D'Eramo Melkus G. Adherence Connection for Counseling, Education, and Support: Research Protocol for a Proof-of-Concept Study. JMIR Res Protoc 2019; 8:e12543. [PMID: 30920377 PMCID: PMC6458537 DOI: 10.2196/12543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 12/16/2022] Open
Abstract
Background The highest rates of new HIV infections are observed in African Americans and Hispanics/Latinos (ethnic minority) adolescents and young adults (youth). HIV-infected ethnic minority youth are less likely to initiate and maintain adherence to antiretroviral treatment (ART) and medical care, as compared with their adult counterparts. Objective The objective of this research protocol was to describe our proposed methods for testing a peer-led mobile health cognitive behavioral intervention, delivered via remote videoconferencing and smartphones with HIV-infected ethnic minority youth, Adherence Connection for Counseling, Education, and Support (ACCESS). Our secondary aim was to obtain initial estimates of the biobehavioral impact of ACCESS on HIV virologic outcomes and self-reported ART adherence, beliefs and knowledge about ART treatment, adherence self-efficacy, and health care utilization (retention in care). Methods An exploratory, sequential mixed-methods study design will be used with conceptual determinants of adherence behavior informed by the information-motivation-behavioral skills model. HIV-infected ethnic minority youth aged 16 to 29 years with a detectable HIV serum viral load of more than 200 copies/ml (N=25) will be recruited. Qualitative pretesting will be conducted, including semistructured, in-depth, individual interviews with a convenience sample meeting the study inclusion criteria. Preliminary analysis of qualitative data will be used to inform and tailor the ACCESS intervention. Testing and implementation will include a one-group pre-posttest pilot, delivered by a trained successful peer health coach who lives with HIV and is well-engaged in HIV care and taking ART. A total of 5 peer-led remote videoconferencing sessions will be delivered using study-funded smartphones and targeting adherence information (HIV knowledge), motivation (beliefs and perceptions), and behavioral skills (self-efficacy). Participant satisfaction will be assessed with poststudy focus groups and quantitative survey methodology. Bivariate analyses will be computed to compare pre- and postintervention changes in HIV biomarkers, self-reported ART adherence, beliefs and knowledge about ART, adherence self-efficacy, and retention in care. Results As of December 2018, we are in the data analysis phase of this pilot and anticipate completion with dissemination of final study findings by spring/summer 2019. The major outcomes will include intervention feasibility, acceptability, and preliminary evidence of impact on serum HIV RNA quantitative viral load (primary adherence outcome variable). Self-reported ART adherence and retention in care will be assessed as secondary outcomes. Findings from the qualitative pretesting will contribute to an improved understanding of adherence behavior. Conclusions Should the ACCESS intervention prove feasible and acceptable, this research protocol will contribute to a shift in existent HIV research paradigms by offering a blueprint for technology-enabled peer-led interventions and models. International Registered Report Identifier (IRRID) DERR1-10.2196/12543
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Affiliation(s)
| | - Marya Viorst Gwadz
- Silver School of Social Work, New York University, New York, NY, United States
| | - Suzanne Bakken
- School of Nursing, Columbia University, New York, NY, United States
| | - Robin Whittemore
- School of Nursing, Yale University, New Haven, CT, United States
| | - Charles M Cleland
- Rory Meyers College of Nursing, New York University, New York, NY, United States
| | - Gail D'Eramo Melkus
- Rory Meyers College of Nursing, New York University, New York, NY, United States
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14
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Arnold EM, Swendeman D, Harris D, Fournier J, Kozina L, Abdalian S, Rotheram MJ. The Stepped Care Intervention to Suppress Viral Load in Youth Living With HIV: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e10791. [PMID: 30810536 PMCID: PMC6414817 DOI: 10.2196/10791] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 10/30/2018] [Accepted: 12/13/2018] [Indexed: 12/16/2022] Open
Abstract
Background Among youth living with HIV (YLH) aged 12-24 years who have health care in the United States, only 30% to 40% are virally suppressed. YLH must achieve viral suppression in order to reduce the probability of infecting others as well as increasing the length and quality of their own life. Objective This randomized controlled trial aimed to evaluate the efficacy of an Enhanced Standard Care condition (n=110) compared to an Enhanced Stepped Care intervention condition (n=110) to increase viral suppression among YLH aged 12-24 years with established infection (not acutely infected). Methods YLH (N=220) who are not virally suppressed will be identified at homeless shelters, health clinics, and gay-identified community-based organizations in Los Angeles, CA, and New Orleans, LA. Informed consent will be obtained from all participants. YLH will be randomly assigned to one of two study conditions: Enhanced Standard Care, which includes standard clinical care plus an automated messaging and monitoring intervention (AMMI), or an Enhanced Stepped Care, which includes three levels of intervention (AMMI, Peer Support via social media plus AMMI, or Coaching plus Peer Support and AMMI). The primary outcome is viral suppression of HIV, and YLH will be assessed at 4-month intervals for 24 months. For the Enhanced Stepped Care intervention group, those who do not achieve viral suppression (via blood draw, viral load<200 copies/mL) at any 4-month assessment will “step up” to the next level of intervention. Secondary outcomes will be retention in care, antiretroviral therapy adherence, alcohol use, substance use, sexual behavior, and mental health symptoms. Results Recruitment for this study began in June 2017 and is ongoing. We estimate data collection to be completed by the end of 2020. Conclusions This is the first known application of an Enhanced Stepped Care intervention model for YLH. By providing the lowest level of intervention needed to achieve viral suppression, this model has the potential to be a cost-effective method of helping YLH achieve viral suppression and improve their quality of life. Trial Registration ClinicalTrials.gov NCT03109431; https://clinicaltrials.gov/ct2/show/NCT03109431 International Registered Report Identifier (IRRID) DERR1-10.2196/10791
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Affiliation(s)
- Elizabeth Mayfield Arnold
- Department of Family and Community Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Dallas Swendeman
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States
| | - Danielle Harris
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States
| | - Jasmine Fournier
- Section of Adolescent Medicine, Department of Pediatrics, Tulane University, New Orleans, LA, United States
| | - Leslie Kozina
- Section of Adolescent Medicine, Department of Pediatrics, Tulane University, New Orleans, LA, United States
| | - Susan Abdalian
- Section of Adolescent Medicine, Department of Pediatrics, Tulane University, New Orleans, LA, United States
| | - Mary Jane Rotheram
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States
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15
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Medich M, Swendeman DT, Comulada WS, Kao UH, Myers JJ, Brooks RA. Promising Approaches for Engaging Youth and Young Adults Living with HIV in HIV Primary Care Using Social Media and Mobile Technology Interventions: Protocol for the SPNS Social Media Initiative. JMIR Res Protoc 2019; 8:e10681. [PMID: 30702434 PMCID: PMC6374729 DOI: 10.2196/10681] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 10/04/2018] [Accepted: 10/13/2018] [Indexed: 12/16/2022] Open
Abstract
Background In the United States, disparities in the rates of HIV care among youth and young adults result from the intersections of factors that include stigma, substance use, homelessness or marginal housing, institutional neglect, and mental health issues. Novel interventions are needed that are geared to youth and young adults. Objective In this paper, we aim to describe the interventions used by participating sites for Using Social Media initiative, the process for classifying the intervention components, and the methods for conducting a comprehensive evaluation of the interventions. Methods In 2015, the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau, Special Projects of National Significance (SPNS) funded the Evaluation and Technical Assistance Center (ETAC) at the University of California, Los Angeles and 10 demonstration projects at sites across the United States that incorporated innovative approaches using a variety of social media and mobile technology strategies designed specifically for youth and young adults living with HIV. The ETAC developed a typology, or a classification system, that systematically summarizes the principal components of the interventions into broader groups and developed a multisite, mixed-methods approach to evaluate them based on the Department of Health and Human Services HIV health outcomes along the HIV care continuum. The mixed-methods approach is key to remove potential biases in assessing the effectiveness of demonstration projects. Results This SPNS project was funded in September 2015, and enrollment was completed on May 31, 2018. A total of 984 participants have been enrolled in the multisite evaluation. Data collection will continue until August 2019. However, data analysis is currently underway, and the first results are expected to be submitted for publication in 2019. Conclusions This HRSA-funded initiative seeks to increase engagement in HIV medical care, improve health outcomes for people living with HIV, and reduce HIV-related health disparities and health inequities that affect HIV-positive youth and young adults. International Registered Report Identifier (IRRID) DERR1-10.2196/10681
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Affiliation(s)
- Melissa Medich
- Department of Family Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Dallas T Swendeman
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States
| | - W Scott Comulada
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States
| | - Uyen H Kao
- Department of Family Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Janet J Myers
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Ronald A Brooks
- Department of Family Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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16
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Linder LA, Wu YP, Macpherson CF, Fowler B, Wilson A, Jo Y, Jung SH, Parsons B, Johnson R. Oral Medication Adherence Among Adolescents and Young Adults with Cancer Before and Following Use of a Smartphone-Based Medication Reminder App. J Adolesc Young Adult Oncol 2018; 8:122-130. [PMID: 30307778 DOI: 10.1089/jayao.2018.0072] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE This study evaluated oral medication adherence among adolescents and young adults (AYAs) with cancer during a trial of a smartphone-based medication reminder application (app). METHODS Twenty-three AYAs receiving at least one prescribed, scheduled oral medication related to their outpatient cancer treatment participated in this 12-week single-group interrupted time series longitudinal design study. Baseline oral medication adherence was monitored using electronic monitoring caps for 4 weeks. Participants then used a medication reminder app and continued to have their oral medication adherence monitored for 8 weeks. Participants completed an electronically administered weekly survey addressing perceived adherence and reasons for nonadherence. RESULTS Four adherence phenotypes were identified using visual graphical analysis of individual participants' weekly adherence: (1) high adherence during the preintervention and intervention periods (n = 13), (2) low preintervention adherence and improved adherence during the intervention period (n = 3), (3) low adherence during both periods (n = 6), and (4) high preintervention adherence and low adherence during the intervention period (n = 1). Growth curve models did not show significant changes in adherence by preintervention versus intervention trajectories (p > 0.05); however, the variance in adherence during the intervention narrowed for more highly adherent AYAs. "Forgetfulness" was the most frequently reported reason for nonadherence. CONCLUSION Although overall adherence did not improve following use of the app, the variance decreased for more highly adherent participants. Additional or alternative interventions are needed for AYAs with persistently poor adherence. Assessment of adherence patterns may support individualized recommendation of tailored interventions.
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Affiliation(s)
- Lauri A Linder
- 1 College of Nursing, University of Utah , Salt Lake City, Utah.,2 Cancer Blood and Transplant Service, Primary Children's Hospital , Salt Lake City, Utah.,3 Cancer Control and Population Sciences, Huntsman Cancer Institute, University of Utah , Salt Lake City, Utah
| | - Yelena P Wu
- 3 Cancer Control and Population Sciences, Huntsman Cancer Institute, University of Utah , Salt Lake City, Utah.,4 Department of Dermatology, University of Utah , Salt Lake City, Utah
| | | | - Brynn Fowler
- 6 Comer Children's Hospital, University of Chicago , Chicago, Illinois
| | - Andrew Wilson
- 1 College of Nursing, University of Utah , Salt Lake City, Utah.,7 Department of Family & Preventive Medicine, University of Utah , Salt Lake City, Utah.,8 Real World Data Services, PAREXEL International Corporation , Waltham, Massachusetts
| | - Yeonjung Jo
- 1 College of Nursing, University of Utah , Salt Lake City, Utah
| | - Se-Hee Jung
- 1 College of Nursing, University of Utah , Salt Lake City, Utah
| | - Bridget Parsons
- 3 Cancer Control and Population Sciences, Huntsman Cancer Institute, University of Utah , Salt Lake City, Utah
| | - Rebecca Johnson
- 9 Multicare Health System, Mary Bridge Children's Hospital , Tacoma, Washington
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