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Dietrich JJ, Hornschuh S, Madi P, Ramsammy CW, Tsotetsi L, Tshabalala G, Nkala-Dlamini B, Violari A, Kidman R. Implementing ecological momentary assessments to measure violence and adolescent HIV transmission risk: Lessons from Johannesburg, South Africa. PLOS DIGITAL HEALTH 2024; 3:e0000283. [PMID: 38306387 PMCID: PMC10836659 DOI: 10.1371/journal.pdig.0000283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 12/04/2023] [Indexed: 02/04/2024]
Abstract
Ecological Momentary Assessment (EMA) is an important methodology to understand risky behaviour and holds promise for HIV research. EMA is still novel in sub-Saharan Africa. We describe challenges and lessons learned on a novel study implementing mobile phone EMAs with adolescent boys in South Africa. The Tsamaisano study was a longitudinal study from 2020-2023 to recruit adolescent boys aged 15-19 years; including those without HIV and those perinatally infected and living with HIV. Participants were prompted to complete 52 weekly mobile phone survey on emotional state, exposure to and perpetration of violence, and sexual risk behaviour. Surveys were delivered using a random algorithm to choose the day. We incorporated mechanisms to assess challenges and optimize survey completion: weekly team meetings with youth representation and real-time data monitoring. Additionally, 20 frequent vs infrequent survey submitters participated in qualitative interviews about barriers and recommendations. Real-time monitoring indicated low (defined as <50%) survey completion in the first months of study implementation. To ensure that both the adolescent participant and their caregiver understood the commitment required for successful EMA, we created and implemented a guided discussion around mobile phone access during the enrolment visit. We identified a need for increased and ongoing technical support; addressed by creating technical guides, implementing a standard two-week check-in call after enrolment, adding an automated request button for call-back assistance, creating a WhatsApp messaging stream, and reaching out to all participants failing to submit two sequential surveys. Entry-level smartphones, including those initially distributed by the study, did not have capacity for certain updates and had to be replaced with more expensive models. Participants struggled with randomly allocated survey days; completion improved with set completion days and targeted reminder messages. Together, these steps improved survey completion from 40% in December 2020 to 65% in April 2022. We describe key lessons learned to inform future study designs with mobile phone EMAs, drawing on our experience implementing such among adolescent boys, including persons living with HIV, in a low-and-middle income setting. The key lessons learned through the Tsamaisano study are important to inform future study designs with EMA utilizing mobile phone, electronic data collection among adolescent boys in low-and-middle-income settings.
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Affiliation(s)
- Janan Janine Dietrich
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Bellville, South Africa
- African Social Sciences Unit of Research and Evaluation (ASSURE), a division of the Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | - Stefanie Hornschuh
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Phumla Madi
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Candice W. Ramsammy
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lerato Tsotetsi
- African Social Sciences Unit of Research and Evaluation (ASSURE), a division of the Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Busisiwe Nkala-Dlamini
- Department of Social Work, Faculty of Humanities, University of the Witwatersrand, Johannesburg, South Africa
| | - Avy Violari
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rachel Kidman
- Program in Public Health, State University of New York at Stony Brook, Stony Brook, New York, United States of America
- Department of Family, Population and Preventive Medicine, State University of New York at Stony Brook, Stony Brook, New York, United States of America
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Zheng M, Chen W, Qian X, Tao R, Ma L, Zhou F, Zhu Z, Yao Y, Yang G. Awareness of mpox-related knowledge among men who have sex with men in China. BMC Public Health 2023; 23:600. [PMID: 36997990 PMCID: PMC10061892 DOI: 10.1186/s12889-023-15503-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 03/22/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND With the rapid spread of the mpox epidemic, cases have emerged in multiple countries, mainly among men who have sex with men. Because of the connectedness of today's world, countries have to be prepared to face risks in advance. Therefore, this study aimed to investigate awareness of mpox-related knowledge among men who have sex with men in China. METHODS With the assistance of the social organizations of men who have sex with men, a cross-sectional survey of men who have sex with men in China was conducted through an online questionnaire between July 1 and July 18, 2022. A nationwide sample of Chinese men who have sex with men (N = 3,257) was recruited. RESULTS Only 36.9% of participants had mpox-related knowledge. Awareness of mpox-related knowledge among respondents was positively associated with those in older age groups (33 to 42 years and 51 years or older) (adjusted odds ratio [AOR] = 1.31; 95% confidence interval [CI]: 1.03-1.67, AOR = 1.61; 95% CI: 1.16-2.24; respectively), married (AOR = 1.55; 95% CI: 1.09-2.19), and those with a graduate degree or above (AOR = 2.14; 95% CI: 1.11-4.13), while negatively associated with those living in the western parts of China (AOR = 0.74; 95% CI: 0.60-0.92), and those who were unsure of their history of Human Immunodeficiency Virus (HIV) status (AOR = 0.44; 95% CI: 0.30-0.63). CONCLUSION Mpox-related knowledge is fairly low among men who have sex with men in China. China needs to spread knowledge to the public through multiple channels, especially in key populations (men who have sex with men, HIV-infected, etc.), and take preventive measures to effectively avoid outbreaks of mpox.
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Affiliation(s)
- Min Zheng
- Guizhou Provincial Center for Disease Control and Prevention, Guiyang, 550004, Guizhou, China
| | - Wenyan Chen
- School of Public Health, the Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, 550025, Guizhou, China
| | - Xiaohan Qian
- Guizhou Provincial Center for Disease Control and Prevention, Guiyang, 550004, Guizhou, China
| | - Rui Tao
- Guizhou Provincial Center for Disease Control and Prevention, Guiyang, 550004, Guizhou, China
| | - Lin Ma
- Guizhou Provincial Center for Disease Control and Prevention, Guiyang, 550004, Guizhou, China
| | - Feng Zhou
- Guizhou Provincial Center for Disease Control and Prevention, Guiyang, 550004, Guizhou, China
- School of Public Health, the Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, 550025, Guizhou, China
| | - Zhilin Zhu
- Guizhou Provincial Center for Disease Control and Prevention, Guiyang, 550004, Guizhou, China
- School of Public Health, the Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, 550025, Guizhou, China
| | - Yongming Yao
- Guizhou Provincial Center for Disease Control and Prevention, Guiyang, 550004, Guizhou, China.
| | - Guanghong Yang
- Guizhou Provincial Center for Disease Control and Prevention, Guiyang, 550004, Guizhou, China.
- School of Public Health, the Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, 550025, Guizhou, China.
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Closson K, Zharima C, Kuchena M, Dietrich JJ, Gadermann A, Ogilvie G, Beksinska M, Kaida A. "I feel like it is asking if he is a stalker … but I also feel like it is asking if he cares": exploring young South African women and men's perceptions of the Sexual Relationship Power Scale. BMC Public Health 2022; 22:1368. [PMID: 35842627 PMCID: PMC9288208 DOI: 10.1186/s12889-022-13686-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 06/24/2022] [Indexed: 11/18/2022] Open
Abstract
Background Gender inequity and the subsequent health impacts disproportionately affect communities in the Global South. However, most gender equity measures, such as Pulerwitz’ (2000) Sexual Relationship Power Scale (SRPS), are developed and validated in the Global North and then applied in Global South settings without investigation of context applicability or validity. This study examines the SRPS’ validity evidence, comprehensiveness, and contemporary relevance for young South African women and men. Methods Between 2019 and 2021, 38 cognitive interviews (CIs) were conducted among previous participants of a South African youth cohort study ‘AYAZAZI’ (2015–2017) to explore youth’s perceptions of the SRPS. The SRPS measures women’s perceptions of their partner’s controlling behaviours, and men’s perceptions of their own controlling behaviours. Using CIs, participants responded to a 13-item adaptation of the SRPS for use among South African youth (strongly agree-strongly disagree), and then were asked to think-aloud their reasoning for responses, their understanding and perceived relevance of each item, and made overall suggestions for scale adaptations. An item appraisal coding process was applied, whereby Cognitive Coding assessed the types of cognitive problems youth had with understanding the items, and Question Feature Coding assessed which item features caused problems for participant understandings. Finally, youth recommendations for scale adaptations were summarized. Results Overall, 21 women and 17 men aged 21–30 participated in CIs in Durban and Soweto, South Africa. Cognitive Coding revealed 1. Comprehension issues, and 2. Judgements related to items’ applicability to lived experiences and identities (e.g., being unmarried). Question Feature Coding revealed items’ 1. Lack of clarity or vagueness in wording and 2. Logical problems in assumptions leading to multiple interpretations (e.g., item ‘my partner always need to know where I am’ interpreted as both controlling and caring behaviour). Multiple, overlapping issues revealed how many items failed to “fit” within the present-day living realities of South African youth. Youth recommended several item adaptations and additions, including strength-based items, to existing measures of gender equity and relationship power. Conclusion Given identified issues, several adaptations including revising items to be more inclusive, contemporary, context specific, relational, and strength-based are needed to validly measure gender equity and power dynamics within the relationships of South African youth. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13686-9.
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Affiliation(s)
- Kalysha Closson
- School of Population and Public Health, University of British Columbia, Vancouver, Canada.
| | - Campion Zharima
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa.,Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Michelle Kuchena
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Janan J Dietrich
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa.,African Social Sciences Unit of Research and Evaluation (ASSURE), a division of the Wits Health Consortium, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Health Systems Research Unit, South African Medical Research Council, Bellville, South Africa
| | - Anne Gadermann
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Gina Ogilvie
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Mags Beksinska
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
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Dietrich JJ, Benadé GL, Mulaudzi M, Kagee A, Hornschuh S, Makhale LM, Lemos MP, Lazarus E, Andrasik MP, Horvath KJ. "You Are on the Right Track With the App:" Qualitative Analysis of Mobile Phone Use and User Feedback Regarding Mobile Phone Sexual Risk Assessments for HIV Prevention Research. Front Digit Health 2021; 3:576514. [PMID: 34713080 PMCID: PMC8521804 DOI: 10.3389/fdgth.2021.576514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 02/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Accurate self-report of sexual behavior assists in identifying potential HIV exposure in HIV prevention trials. Brief mobile phone assessments, completed daily or after sexual activity, can improve the validity and reliability of self-reported sexual behavior and allow for remote survey completion outside of the clinic setting. We conducted a qualitative study to better understand participants mobile phone use and to explore their perspectives on how to improve an existing mobile application-based sexual risk assessment. Methods: Sexually active, HIV seronegative men (n = 14) and women (n = 15) aged 18–39 years were recruited through an HIV counseling and testing clinic and community outreach in Soweto, South Africa. We conducted qualitative research through four age-stratified focus group discussions (FGDs) and analyzed a brief socio-demographics and mobile phone access questionnaire. All participants completed a sexual risk assessment before the FGD. Using a framework analytic approach, data were coded with Nvivo software. Results: All participants had access to mobile phones and internet, and 27 (93.1%) were able to download applications on their personal phones. Participants preferred mobile risk assessments to be offered in a choice of South African languages, using formal language (as opposed to emojis), with straight-forward wording and limited to five to 10 questions. Most participants found it acceptable to complete the assessment once a week, on a weekday, while a few were willing to complete it after each sexual encounter. It was suggested that a message reminder to complete the assessment should be sent at least daily until it is completed. The majority agreed that a password-protected application with a discreet logo was ideal for privacy, ease of use and flexibility for completion in any setting. A concern with this format, however, was the potential data use requirement. Participants expressed privacy concerns with using SMS, WhatsApp and other social media for risk assessments. Most agreed on an airtime incentive between ZAR5-10 (USD 0.29–0.58) per survey. Participants encouraged researchers to provide feedback to them about their sexual risk. Conclusions: Completion of mobile phone sexual risk assessments can be optimized with minimal incentives by ensuring that questionnaires are simple, brief, infrequent and have trusted privacy measures.
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Affiliation(s)
- Janan J Dietrich
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Health Systems Research Unit, South African Medical Research Council, Bellville, South Africa
| | - Gabriella L Benadé
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mamakiri Mulaudzi
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ashraf Kagee
- Department of Psychology, Faculty of Arts and Social Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Stefanie Hornschuh
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lerato M Makhale
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maria P Lemos
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Erica Lazarus
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michele P Andrasik
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Keith J Horvath
- Department of Psychology, San Diego State University, San Diego, CA, United States
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Dietrich JJ, Otwombe K, Pakhomova TE, Horvath KJ, Hornschuh S, Hlongwane K, Closson K, Mulaudzi M, Smith P, Beksinska M, Gray GE, Brockman M, Smit J, Kaida A. High cellphone use associated with greater risk of depression among young women aged 15-24 years in Soweto and Durban, South Africa. Glob Health Action 2021; 14:1936792. [PMID: 34431754 PMCID: PMC8405067 DOI: 10.1080/16549716.2021.1936792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND The ubiquity of cellular phone (cellphone) use in young people's daily lives has emerged as a priority area of concern for youth mental health. OBJECTIVE This study measured the prevalence of depression and its association with high cellphone use among youth in Soweto and Durban, South Africa. METHODS We analysed cross-sectional, baseline survey data among youth aged 16-24 who participated in a dual-site cohort study, 'AYAZAZI', conducted from 2014 to 2017. The primary outcome was depression using the 10-item Center for Epidemiologic Studies Depression Scale, with a score of ≥ 10 indicating probable depression. Cellphone use was measured via self-reported average number of hours of active use, with 'high cellphone use' defined as daily usage of ≥ 8. Multivariable logistic regression models assessed the independent relationship between high cellphone use and probable depression, adjusting for potential confounders. RESULTS Of 425 participants with a median age of 19 years (IQR = 18-21), 59.5% were young women. Overall, 43.3% had probable depression, with a higher prevalence among women (49.0% vs. 34.9%, P = .004). Nearly all (94.6%) owned a cellphone. About one-third (29.5%) reported spending ≥ 8 hours per day using their cellphone (39.3% of women vs. 14.9% of men, P < .001). In the overall adjusted model, youth reporting high daily cellphone use had higher odds of probable depression (aOR: 1.83, 95% CI: 1.16-2.90). In gender-stratified models, high daily cellphone use was associated with probable depression among women (aOR: 2.51, 95% CI: 1.47-4.31), but not among men (aOR: 0.87, 95% CI: 0.35-2.16). CONCLUSIONS Among a cohort of South African youth, we found a high prevalence of probable depression and high cellphone use (30%). The findings indicate a need for intersectoral initiatives focused on meaningful mental health support for South African youth to support positive growth and development.
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Affiliation(s)
- Janan J Dietrich
- Perinatal HIV Research Unit (PHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,African Social Sciences Unit of Research and Evaluation (ASSURE), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa and Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit (PHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Keith J Horvath
- San Diego State University, Department of Psychology, San Diego, California, United States
| | - Stefanie Hornschuh
- Perinatal HIV Research Unit (PHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Khuthadzo Hlongwane
- Perinatal HIV Research Unit (PHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kalysha Closson
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Mamakiri Mulaudzi
- Perinatal HIV Research Unit (PHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Patricia Smith
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Mags Beksinska
- MatCH Research Unit (MRU), Department of Gynaecology and Obstetrics, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Glenda E Gray
- Perinatal HIV Research Unit (PHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Office of the President, South African Medical Research Council, Cape Town, South Africa
| | - Mark Brockman
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Jenni Smit
- MatCH Research Unit (MRU), Department of Gynaecology and Obstetrics, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
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Dietrich JJ, Lazarus E, Andrasik M, Hornschuh S, Otwombe K, Morgan C, Isaacs AJ, Huang Y, Laher F, Kublin JG, Gray GE. Mobile Phone Questionnaires for Sexual Risk Data Collection Among Young Women in Soweto, South Africa. AIDS Behav 2018; 22:2312-2321. [PMID: 29594618 DOI: 10.1007/s10461-018-2080-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Recall and social desirability bias undermine self-report of paper-and-pencil questionnaires. Mobile phone questionnaires may overcome these challenges. We assessed and compared sexual risk behavior reporting via in-clinic paper-and-pencil and mobile phone questionnaires. HVTN 915 was a prospective cohort study of 50 adult women in Soweto, who completed daily mobile phone, and eight interviewer-administered in-clinic questionnaires over 12 weeks to assess sexual risk. Daily mobile phone response rates were 82% (n = 3486/4500); 45% (n = 1565/3486) reported vaginal sex (median sex acts 2 (IQR: 1-3)) within 24 h and 40% (n = 618/1565) consistent condom. Vaginal sex reporting was significantly higher via mobile phone across all visits (p < 0.0001). There was no significant difference in condom use reporting by mobile phone and in-clinic paper-based questionnaires across all visits (p = 0.5134). The results show high adherence and reporting of sex on the mobile phone questionnaire. We demonstrate feasibility in collecting mobile phone sexual risk data.
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Affiliation(s)
- Janan J Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, PO BOX 114, Diepkloof, Soweto, Johannesburg, 1864, South Africa.
| | - Erica Lazarus
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, PO BOX 114, Diepkloof, Soweto, Johannesburg, 1864, South Africa
| | - Michele Andrasik
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Stefanie Hornschuh
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, PO BOX 114, Diepkloof, Soweto, Johannesburg, 1864, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, PO BOX 114, Diepkloof, Soweto, Johannesburg, 1864, South Africa
| | - Cecilia Morgan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Abby J Isaacs
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Yunda Huang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Fatima Laher
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, PO BOX 114, Diepkloof, Soweto, Johannesburg, 1864, South Africa
| | - James G Kublin
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Glenda E Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, PO BOX 114, Diepkloof, Soweto, Johannesburg, 1864, South Africa
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- South African Medical Research Council, Cape Town, South Africa
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