Enrollment in HIV Care Two Years after HIV Diagnosis in the Kingdom of Swaziland: An Evaluation of a National Program of New Linkage Procedures

To improve early enrollment in HIV care, the Swaziland Ministry of Health implemented new linkage procedures for persons HIV diagnosed during the Soka Uncobe male circumcision campaign (SOKA, 2011–2012) and the Swaziland HIV Incidence Measurement Survey (SHIMS, 2011). 

Abstraction of clinical records and telephone interviews of a retrospective cohort of HIV-diagnosed SOKA and SHIMS clients were conducted in 2013–2014 to evaluate compliance with new linkage procedures and enrollment in HIV care at 92 facilities throughout Swaziland. 

Of 1,105 clients evaluated, within 3, 12, and 24 months of diagnosis, an estimated 14.0%, 24.3%, and 37.0% enrolled in HIV care, respectively, after adjusting for lost to follow-up and non-response. Kaplan-Meier functions indicated lower enrollment probability among clients 14–24 (P = 0.0001) and 25–29 (P = 0.001) years of age compared with clients >35 years of age. At 69 facilities to which clients were referred for HIV care, compliance with new linkage procedures was low: referral forms were located for less than half (46.8%) of the clients, and few (9.6%) were recorded in the appointment register or called either before (0.3%) or after (4.9%) their appointment. Of over one thousand clients newly HIV diagnosed in Swaziland in 2011 and 2012, few received linkage services in accordance with national procedures and most had not enrolled in HIV care two years after their diagnosis. 

Our findings are a call to action to improve linkage services and early enrollment in HIV care in Swaziland.

Below:  Distribution of 69 HIV care facilities to which eligible SHIMS and SOKA clients were referred at HIV diagnosis, by class of facility

Full article at:   http://goo.gl/W4JyJq

By:  

Duncan A. MacKellar, Daniel Williams, Jennifer Drummond, Simon Agolory, Andrew L. Baughman 

Division of Global HIV/AIDS, National Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

Nosipho Storer, Harriet Nuwagaba-Biribonwoha, Ruben Sahabo 

ICAP at Columbia University, Mbabane, Swaziland

Velephi Okello, Charles Azih 

Swaziland National AIDS Programme, Swaziland Ministry of Health, Mbabane, Swaziland

Harriet Nuwagaba-Biribonwoha, Margaret L. McNairy 

ICAP at Columbia University, New York, New York, United States of America

Peter Preko 

CTS Global assigned to Centers for Disease Control and Prevention Country Office, Mbabane, Swaziland

Rebecca L. Morgan 

McMaster University, Hamilton, Ontario, Canada

Makhosazana Dlamini 

Population Services International Country Program, Mbabane, Swaziland

Johnita Byrd 

ICF International, Atlanta, Georgia, United States of America

Peter Ehrenkranz 

Bill & Melinda Gates Foundation, Seattle, Washington, United States of America

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HIV Self-Testing in Peru: Questionable Availability, High Acceptability But Potential Low Linkage to Care among Men Who Have Sex with Men & Transgender Women

HIV status awareness is key to prevention, linkage-to-care and treatment. Our study evaluated the accessibility and potential willingness of HIV self-testing among men who have sex with men (MSM) and transgender women in Peru. 

We surveyed four pharmacy chains in Peru to ascertain the commercial availability of the oral HIV self-test. The pharmacies surveyed confirmed that HIV self-test kits were available; however, those available were not intended for individual use, but for clinician use. 

We interviewed 147 MSM and 45 transgender women; nearly all (82%) reported willingness to perform the oral HIV self-test. However, only 55% of participants would definitely seek a confirmatory test in a clinic after an HIV-positive test result. Further, price may be a barrier, as HIV self-test kits were available for 18 USD, and MSM and transgender women were only willing to pay an average of 5 USD. 

HIV self-testing may facilitate increased access to HIV testing among some MSM/transgender women in Peru. However, price may prevent use, and poor uptake of confirmatory testing may limit linkage to HIV treatment and care.

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By:  Bustamante MJ1, Konda KA2, Joseph Davey D3, León SR1, Calvo GM4, Salvatierra J5, Brown B6, Caceres CF1, Klausner JD7.

• 1Unit of Health, Sexuality and Human Development, and Laboratory of Sexual Health, Universidad Peruana Cayetano Heredia, Lima, Peru.
• 2Unit of Health, Sexuality and Human Development, and Laboratory of Sexual Health, Universidad Peruana Cayetano Heredia, Lima, Peru Division of Infectious Diseases, Department of Medicine, University of California Los Angeles, Los Angeles CA, USA.
• 3Department of Epidemiology, University of California, Los Angeles, Los Angeles, CA, USA dvoradavey@ucla.edu.
• 4Unit of Health, Sexuality and Human Development, and Laboratory of Sexual Health, Universidad Peruana Cayetano Heredia, Lima, Peru Epicentro Salud, Lima, Peru.
• 5Barton Health Center, Health Directorate of Callao, Lima, Peru.
• 6Center for Healthy Communities, Division of Clinical Sciences, UCR School of Medicine, Riverside, CA USA.
• 7Division of Infectious Diseases, Department of Medicine, University of California Los Angeles, Los Angeles CA, USA Department of Epidemiology, University of California, Los Angeles, Los Angeles, CA, USA. 
• Int J STD AIDS. 2016 Jan 29. pii: 0956462416630674.

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Systematic Assessment of Linkage to Care for Persons with HIV Released from Corrections Facilities Using Existing Datasets

Populations in corrections continue to have high prevalence of HIV. Expanded testing and treatment programs allow persons to be identified and stabilized on treatment while incarcerated. However, these gains and frequently lost on reentry. Systemic frameworks are needed to monitor linkage to care to guide programs supporting linkage to care. 

To assess the adequacy of linkage to care on reentry, incarceration data from the National Corrections Reporting Program and data from the Ryan White Services Report from 2010 to 2012 were linked using an encrypted client identification (eUCI). Time from release to the first visit and presence of detectable HIV RNA at linkage were assessed. Multivariate survival analyses were performed to identify associations between patient characteristics and time to linkage. 

Among those linking, only 43% in Rhode Island and 49% in North Carolina linked within 90 days, and 33% in both states had detectable viremia at the first visit. Those not previously in care and with shorter incarceration experiences longer linkage times. Persons identified as black, had median times greater than 1 year. 

Using existing datasets, significant gaps in linkage to care for persons with HIV on release from corrections were demonstrated in Rhode Island and North Carolina. Systemically implementing this monitoring to evaluate changes over time would provide important information to support interventions to improve linkage in high-risk populations. 

Using national datasets for both corrections and clinical data, this framework equally could be used to evaluate experiences of persons with HIV linking to care on release from corrections facilities nationwide.

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By:  Montague BT1, Rosen DL2, Sammartino C3, Costa M4, Gutman R3, Solomon L4, Rich J3,5.

• 1 Department of Infectious Diseases, University of Colorado , Aurora, Colorado.
• 2 University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.
• 3 School of Public Health, Brown University , Providence, Rhode Island.
• 4 Abt Associates , Cambridge, Massachusetts.
• 5 Warren Alpert School of Medicine, Brown University , Providence, Rhode Island.

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Results of a Rapid Hepatitis C Virus Screening and Diagnostic Testing Program in an Urban Emergency Department

STUDY OBJECTIVE:

We describe the results of an emergency department (ED) hepatitis C virus testing program that integrated birth cohort screening and screening of patients with a history of injection drug use, as well as physician diagnostic testing, according to national guidelines.

METHODS:

We conducted a retrospective cohort study using data collected as part of clinical care. The primary outcome was the hepatitis C virus prevalence among tested patients. We evaluated factors associated with testing positive with logistic regression.

RESULTS:

Of the 26,639 unique adults aged 18 years or older and presenting to the ED during the 6-month study, 2,581 (9.7%) completed hepatitis C virus screening (2,028) or diagnostic testing (553), of whom 267 were antibody positive (10.3% prevalence). Factors associated with testing positive for hepatitis C virus included injection drug use (38.4% prevalence; odds ratio [OR] 10.8; 95% confidence interval [CI] 7.5 to 15.5), homeless(25.5% prevalence; OR 3.1; 95% CI 1.5 to 6.8), diagnostic testing (14.8% prevalence; OR 2.6; 95% CI 1.7 to 3.9), birth cohort (13.7% prevalence; OR 3.6; 95% CI 2.4 to 5.3), and male sex (12.4% prevalence; OR 1.4; 95% CI 1.0 to 2.0). Of the 267 patients testing positive for hepatitis C virus antibody, 137 (51%) had documentation of result disclosure and 180 (67%) had confirmatory ribonucleic acid testing performed, of whom 126 (70%) had a positive result. Follow-up appointments at the hepatitis C virus clinic were arranged for 57 of the 126 (45%) patients with confirmed positive results, of which 30 attended.

CONCLUSION:

This ED screening and diagnostic testing program found a high prevalence of hepatitis C virus antibody positivity across all groups. Challenges encountered with hepatitis C virus screening included result disclosure, confirmatory testing, and linkage to care. Our results warrant continued efforts to develop and evaluate policies for ED-based hepatitis C virus screening.

Below:  Nurse triage template; HIV and hepatitis C virus screening questions

Full article at:   http://goo.gl/WsS6lp

By:  White DA1, Anderson ES2, Pfeil SK2, Trivedi TK2, Alter HJ2.

• 1Department of Emergency Medicine, Alameda Health System, Highland Hospital, Oakland, CA. Electronic address: dwhite@alamedahealthsystem.org.
• 2Department of Emergency Medicine, Alameda Health System, Highland Hospital, Oakland, CA.
• Ann Emerg Med. 2016 Jan;67(1):119-28. doi: 10.1016/j.annemergmed.2015.06.023. Epub 2015 Aug 4. 

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Linkage To & Retention in Care Following Healthcare Transition from Pediatric to Adult HIV Care

Outcomes following healthcare transition (HCT) from pediatric to adult HIV care are not well described. We sought to describe clinical outcomes following HCT within our institution among young adults with behavioral-acquired (N = 31) and perinatally-acquired (N = 19) HIV. 

We conducted a retrospective cohort study among HIV-infected adults who attempted transition from pediatric to adult HIV care within our institution. The primary end point was retention in care, defined as the completion of at least two visits over 12 months following linkage to adult care. Additional end points include time to linkage to adult care, and changes in CD4 + T cell count and HIV RNA across time. Outcomes were compared between perinatal and behavioral HIV cohorts. Binary data were analyzed using the Fisher exact test and continuous data were analyzed using the Mann-Whitney test. 

Forty-three (86%) of 50 patients were successfully linked to adult care. The median time to linkage was 98 days. Fifty percent of patients achieved full retention in care at 12 months post-linkage. Though those with behavioral-acquired HIV attempted transfer at an older age, the groups did not differ in rates of linkage and retention in adult care. CD4 + T cell counts and rates of viral suppression did not differ between pre- and post-HCT periods. 

Despite high rates of successful linkage to adult care in our study population, rates of retention in adult HIV care following HCT were low. These results imply that challenges remain in the adult HIV care setting toward improving the HCT process.

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By:  Ryscavage P1, Macharia T1, Patel D1, Palmeiro R1, Tepper V2.

• 1 Institute of Human Virology , University of Maryland School of Medicine (http://medschool.umaryland.edu/), Baltimore , MD , USA.
• 2 Division of Pediatrics , University of Maryland School of Medicine , Baltimore , MD , USA. 
• AIDS Care. 2016 Jan 13:1-5. 

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HIV Diagnoses and Care among Transgender Persons and Comparison with Men Who Have Sex with Men: New York City, 2006-2011

OBJECTIVES:

We measured HIV care outcomes of transgender persons, who have high HIV infection rates but are rarely distinguished from men who have sex with men (MSM) in HIV surveillance systems.

METHODS:

New York City's surveillance registry includes HIV diagnoses since 2000 and HIV laboratory test results for transgender persons since 2005. We determined immunological status at diagnosis, delayed linkage to care, and nonachievement of viral suppression 1 year after diagnosis for transgender persons diagnosed with HIV in 2006 to 2011 and compared transgender women with MSM.

RESULTS:

In 2006 to 2011, 264 of 23 805 persons diagnosed with HIV were transgender (1%): 98% transgender women and 2% transgender men. Compared with MSM, transgender women had similar CD4 counts at diagnosis and rates of concurrent HIV/AIDS and delayed linkage to care but increased odds of not achieving suppression (adjusted odds ratio = 1.56; 95% confidence interval = 1.13, 2.16).

CONCLUSIONS:

Compared with MSM, transgender women in New York City had similar immunological status at diagnosis but lagged in achieving viral suppression. To provide appropriate assistance along the HIV care continuum, HIV care providers should accurately identify transgender persons.

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By:   Wiewel EW1, Torian LV1, Merchant P1, Braunstein SL1, Shepard CW1.

• 1At the time of this analysis, all of the authors were with the HIV Epidemiology and Field Services Program, New York City Department of Health and Mental Hygiene, New York, NY. 

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#TestMeEast: A Campaign to Increase HIV Testing in Hospitals & to Reduce Late Diagnosis

Late diagnosis occurs in almost half of those diagnosed in the UK (HIV Prevention England, 2013. Retrieved June 22, 2014, from HIV Prevention England: http://www.hivpreventionengland.org.uk/Campaigns-Current/National-HIV-Testing-Week). Testing occurs mainly in sexual health and antenatal clinics despite recommendations to test more broadly 

We report the findings of an HIV-testing week campaign to offer testing to those who have blood tests as part of routine care within outpatient clinics and emergency departments of six London hospitals. The campaign target was to test 500 patients a day during the 2013 National HIV Testing Week (NHTW). Clinic staff and medical students were trained to offer routine HIV testing. Linkage to care was arranged for those who tested HIV-positive. 

During NHTW we tested 2402 of the planned 2500 test target. 2402/4317 (55.6% 95% CI 54.1-57.1%) of those who had routine blood tests were tested for HIV. There were eight HIV-positive tests; three were new diagnoses (all linked to care). The campaign hashtag #TestMeEast achieved a total Twitter "reach" of 238, 860 and the campaign had widespread news coverage. Our campaign showed that staff and students could be trained and mobilised to do thousands of routine HIV tests during a campaign.

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By:   Bath R1, O'Connell R1, Lascar M1, Ferrand R2, Strachan S3, Matin N1, Bassnet I1, Orkin C1,4.

• 1 Barts Health NHS Trust , London , UK.
• 2 London School of Hygiene and Tropical Medicine , London , UK.
• 3 Positively UK , London , UK.
• 4 HIV Medicine, Infection and Immunity , Royal London Hospital , London , UK. 

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HIV-Related Medical Admissions to a South African District Hospital Remain Frequent Despite Effective Antiretroviral Therapy Scale-Up

The public sector scale-up of antiretroviral therapy (ART) in South Africa commenced in 2004. We aimed to describe the hospital-level disease burden and factors contributing to morbidity and mortality among hospitalized HIV-positive patients in the era of widespread ART availability.

Between June 2012 and October 2013, unselected patients admitted to medical wards at a public sector district hospital in Cape Town were enrolled in this cross-sectional study with prospective follow-up. HIV testing was systematically offered and HIV-infected patients were systematically screened for TB. The spectrum of admission diagnoses among HIV-positive patients was documented, vital status at 90 and 180 days ascertained and factors independently associated with death determined.

Among 1018 medical admissions, HIV status was ascertained in 99.5%: 60.1% (n = 609) were HIV-positive and 96.1% (n = 585) were enrolled. Of these, 84.4% were aware of their HIV-positive status before admission. ART status was naive in 35.7%, current in 45.0%, and interrupted in 19.3%. The most frequent primary clinical diagnoses were newly diagnosed TB (n = 196, 33.5%), other bacterial infection (n = 100, 17.1%), and acquired immunodeficiency syndrome (AIDS)-defining illnesses other than TB (n = 64, 10.9%). 

By 90 days follow-up, 175 (29.9%) required readmission and 78 (13.3%) died. Commonest causes of death were TB (37.2%) and other AIDS-defining illnesses (24.4%). Independent predictors of mortality were AIDS-defining illnesses other than TB, low hemoglobin, and impaired renal function.HIV still accounts for nearly two-thirds of medical admissions in this South African hospital and is associated with high mortality. 

Strategies to improve linkage to care, ART adherence/retention and TB prevention are key to reducing HIV-related hospitalizations in this setting.

Full article at:   http://goo.gl/ExYwiQ

By:  Meintjes G1, Kerkhoff AD, Burton R, Schutz C, Boulle A, Van Wyk G, Blumenthal L, Nicol MP, Lawn SD.

• 1From the Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine (GM, CS, LB); Department of Medicine, Faculty of Health Sciences, University of Cape Town (GM, RB, CS, SDL); Department of Medicine, Khayelitsha District Hospital, South Africa (GM, RB); Department of Medicine, Imperial College London, London, UK (GM); The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, South Africa (ADK, SDL); Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA (ADK); Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, The Netherlands (ADK); School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town (AB); Health Impact Assessment Directorate, Western Cape Department of Health (AB); Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town (AB); Department of Medicine, Mitchells Plain Hospital (GVW); Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town (MPN); National Health Laboratory Service, South Africa (MPN); and Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK (SDL). 

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Quality of HIV Testing Data Before and After the Implementation of a National Data Quality Assessment and Feedback System

CONTEXT:

In 2010, the Centers for Disease Control and Prevention (CDC) implemented a national data quality assessment and feedback system for CDC-funded HIV testing program data.

OBJECTIVE:

Our objective was to analyze data quality before and after feedback.

DESIGN:

Coinciding with required quarterly data submissions to CDC, each health department received data quality feedback reports and a call with CDC to discuss the reports. Data from 2008 to 2011 were analyzed.

SETTING:

Fifty-nine state and local health departments that were funded for comprehensive HIV prevention services.

PARTICIPANTS:

Data collected by a service provider in conjunction with a client receiving HIV testing.

INTERVENTION:

National data quality assessment and feedback system.

MAIN OUTCOME MEASURES:

Before and after intervention implementation, quality was assessed through the number of new test records reported and the percentage of data values that were neither missing nor invalid. Generalized estimating equations were used to assess the effect of feedback in improving the completeness of variables.

RESULTS:

Data were included from 44 health departments. The average number of new records per submission period increased from 197 907 before feedback implementation to 497 753 afterward. Completeness was high before and after feedback for race/ethnicity (99.3% vs 99.3%), current test results (99.1% vs 99.7%), prior testing and results (97.4% vs 97.7%), and receipt of results (91.4% vs 91.2%). Completeness improved for HIV risk (83.6% vs 89.5%), linkage to HIV care (56.0% vs 64.0%), referral to HIV partner services (58.9% vs 62.8%), and referral to HIV prevention services (55.3% vs 63.9%). Calls as part of feedback were associated with improved completeness for HIV risk (adjusted odds ratio [AOR] = 2.28; 95% confidence interval [CI], 1.75-2.96), linkage to HIV care (AOR = 1.60; 95% CI, 1.31-1.96), referral to HIV partner services (AOR = 1.73; 95% CI, 1.43-2.09), and referral to HIV prevention services (AOR = 1.74; 95% CI, 1.43-2.10).

CONCLUSIONS:

Feedback contributed to increased data quality. CDC and health departments should continue monitoring the data and implement measures to improve variables of low completeness.

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By:   Beltrami J1, Wang G, Usman HR, Lin L.

• 1US Public Health Service and Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Beltrami and Mr Wang); Alberta Health Services, Surveillance and Reporting, Edmonton, Alberta, Canada (Dr Usman); and Department of Mathematical Sciences, Montana State University, Bozeman (Dr Lin). 

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Improvements in the Continuum of HIV Care in an Inner-City Emergency Department

Objective: The Johns Hopkins Hospital Emergency Department has served as a window on the HIV epidemic for 25 years, and as a pioneer in emergency department-based screening/linkage-to-care (LTC) programs. We document changes in the burden of HIV and HIV care metrics to the evolving HIV epidemic in inner-city Baltimore.

Design/methods: We analyzed seven serosurveys conducted on 18 144 adult Johns Hopkins Hospital Emergency Department patients between 1987 and 2013 as well as our HIV-screening/LTC program (2007, 2013) for trends in HIV prevalence, cross-sectional annual incidence estimates, undiagnosed HIV, LTC, antiretrovirals treatment, and viral suppression.

Results: HIV prevalence in 1987 was 5.2%, peaked at more than 11% from 1992 to 2003 and declined to 5.6% in 2013. Seroprevalence was highest for black men (initial 8.0%, peak 20.0%, last 9.9%) and lowest for white women. Among HIV-positive individuals, proportion of undiagnosed infection was 77% in 1987, 28% in 1992, and 12% by 2013 (P < 0.001). Cross-sectional annual HIV incidence estimates declined from 2.28% in 2001 to 0.16% in 2013. Thirty-day LTC improved from 32% (2007) to 72% (2013). In 2013, 80% of HIV-positive individuals had antiretrovirals ARVs detected in sera, markedly increased from 2007 (27%) (P < 0.001). Proportion of HIV-positive individuals with viral suppression (<400 copies/ml) increased from 23% (2001) to 59% (2013) (P < 0.001).

Conclusion: Emergency department-based HIV testing has evolved from describing the local epidemic to a strategic interventional role, serving as a model for early HIV detection and LTC. Our contribution to community-based HIV-screening and LTC program parallels declines in undiagnosed HIV infection and incidence, and increases in antiretroviral use with associated viral suppression in the community.

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By:  Kelen, Gabor D.^a; Hsieh, Yu-Hsiang^a; Rothman, Richard E.^a; Patel, Eshan U.^b; Laeyendecker, Oliver B.^b; Marzinke, Mark A.^c,d; Clarke, William^c; Parsons, Teresa^d; Manucci, Jordyn L.^d; Quinn, Thomas C.^b,d

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18 - 30-Year-Olds More Likely to Link to Hepatitis C Virus Care: An Opportunity to Decrease Transmission

Hepatitis C virus (HCV) infection incidence among 18- to 30-year-olds is increasing and guidelines recommend treatment of active injection drug users to limit transmission. 

We aimed to : measure linkage to HCV care among 18- to 30-year-olds and identify factors associated with linkage; compare linkage among 18- to 30-year-olds to that of patients >30 years. We used the electronic medical record at an urban safety net hospital to create a retrospective cohort with reactive HCV antibody between 2005 and 2010. We report seroprevalence and demographics of seropositive patients, and used multivariable logistic regression to identify factors associated with linkage to HCV care. We defined linkage as having evidence of HCV RNA testing after reactive antibody. 

Thirty two thousand four hundred and eighteen individuals were tested, including 8873 between 18 and 30 years. The seropositivity rate among those ages 18-30 was 10%. In multivariate analysis, among those 18-30, diagnosis location (Outpatient vs Inpatient/ED) (OR 1.78, 95% CI 1.28-2.49) and number of visits after diagnosis (OR 5.30, 95% CI 3.91-7.19) were associated with higher odds of linking to care. 

When we compared linkage in patients ages 18-30 to that among those older than 30, patients in the 18-30 years age group were more likely to link to HCV care than those in the older cohort even when controlling for gender, ethnicity, socioeconomic status, birthplace, diagnosis location and duration of follow-up. 

Eighteen- to 30-year-olds are more likely to link to HCV care than their older counterparts. During the interferon-free treatment era, there is an opportunity to prevent further HCV transmission in this population.

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By: Young KL1, Huang W2, Horsburgh CR1,3,4, Linas BP1,3,4,5, Assoumou SA1,3,5.

• 1Department of Medicine, Boston Medical Center, Boston, MA, USA.
• 2Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA.
• 3Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA.
• 4Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
• 5HIV Epidemiology and Outcomes Research Unit, Boston Medical Center, Boston, MA, US 

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