This pill allows you to have anxiety-free sex. So why aren't more people taking it? - Video

Acceptability of Three Novel HIV Prevention Methods among Young Male and Transgender Female Sex Workers in Puerto Rico

Sex workers need HIV-prevention methods they can control and incorporate easily in their work. We studied the acceptability of three methods: HIV self-test use with clients, oral pre-exposure prophylaxis (PrEP), and rectal microbicide gel. 

Four male and eight transgender female (TGF) sex workers in Puerto Rico completed a baseline survey with a quantitative measure of likelihood of use. From them, one male and four TGF also completed a 12-week study of rectal microbicide placebo gel use prior to receptive anal intercourse with male clients and evaluated via qualitative in-depth interviews and follow-up quantitative assessments how each method could be incorporated into their work. 

Most were interested in a rectal microbicide gel and able to use it covertly with clients. Challenges to using the HIV self-test with clients included the potential for both breach of confidentiality and confronting violent situations. Participants also expressed interest in oral PrEP, but raised concerns about side effects.

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By:  Giguere R1, Frasca T2, Dolezal C2, Febo I3, Cranston RD4, Mayer K5, McGowan I4, Carballo-Diéguez A2.

• 1Division of Gender, Sexuality and Health, HIV Center for Clinical and Behavioral Studies, Columbia University and NY State Psychiatric Institute, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA. giguere@nyspi.columbia.edu.
• 2Division of Gender, Sexuality and Health, HIV Center for Clinical and Behavioral Studies, Columbia University and NY State Psychiatric Institute, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA.
• 3Department of Pediatrics, Gama Project, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA.
• 4School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
• 5Fenway Health, Fenway Institute, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA.
• AIDS Behav. 2016 Apr 5. 

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HIV-negative male couples' attitudes about pre-exposure prophylaxis (PrEP) and using PrEP with a sexual agreement

One efficacious strategy to help prevent HIV is oral pre-exposure prophylaxis (PrEP), a daily regimen of antiretroviral treatment taken by HIV-negative individuals. Two of the recommendations of Centers for Disease Control and Prevention (CDC) guidelines for PrEP pertain to being in a relationship (i.e., male couples). 

Despite the recognition of how primary partners in male couples' relationships shape HIV risk and CDC's PrEP guidelines, there is a paucity of data that examine HIV-negative male couples' attitudes toward PrEP use and using PrEP with a sexual agreement. A sexual agreement is an explicit agreement made between two individuals about what sex and other related behaviors may occur within and outside of their relationship. In this qualitative study, we examine HIV-negative male couples' attitudes toward PrEP use and whether they thought PrEP could be integrated into a sexual agreement. 

Data for this study are drawn from couple-level interviews conducted in 2014 with 29 HIV-negative male couples who had a sexual agreement and were from Atlanta or Detroit. Both passive (e.g., flyers) and active (e.g., targeted Facebook advertisements) recruitment methods were used; the sample was stratified by agreement type. Thematic analysis was applied to identify the following themes regarding HIV-negative male couples' attitudes toward PrEP use: 

1. PrEP and condom use; 
2. concerns about PrEP (e.g., effectiveness, side effects, and promoting sexually risky behavior); and 
3. accessibility of PrEP. 

Some thought PrEP could be a part of couples' agreement because it could help reduce sexual anxiety and sexual risk, and would help keep the couple safe. Others described PrEP use with an agreement as something for "others". Some were also concerned that incorporating PrEP could usurp the need for a sexual agreement in a couples' relationship. 

These themes highlight the need to improve informational messaging and promotion efforts about PrEP among HIV-negative male couples who may benefit from using it.

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By:  Mitchell JW1, Lee JY1, Woodyatt C2, Bauermeister J3, Sullivan P2, Stephenson R4.

• 1 Department of Public Health Sciences , University of Miami Miller School of Medicine , Miami , FL , USA.
• 2 Department of Epidemiology, Rollins School of Public Health , Emory University , Atlanta , GA , USA.
• 3 Department of Health Behavior and Health Education, School of Public Health, and The Center for Sexuality and Health Disparities , University of Michigan , Ann Arbor , MI , USA.
• 4 Department of Health Behavior and Biological Sciences, School of Nursing, and The Center for Sexuality and Health Disparities , University of Michigan , Ann Arbor , MI , USA.
• AIDS Care. 2016 Apr 7:1-6. 

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Comparing the impact of increasing condom use or HIV pre-exposure prophylaxis (PrEP) use among female sex workers

Highlights

• To achieve the same impact on FSW HIV prevalence as increasing condom use by 1%, the coverage of PrEP has to increase by >2%.
• The relative impact of PrEP compared to condoms increases for scenarios where pimps contribute to HIV transmission.
• Condom promotion interventions should remain the mainstay HIV prevention strategy for FSWs.
• PrEP should only be implemented to fill prevention gaps where condoms cannot be used.

In many settings, interventions targeting female sex workers (FSWs) could significantly reduce the overall transmission of HIV. To understand the role HIV pre-exposure prophylaxis (PrEP) could play in controlling HIV transmission amongst FSWs, it is important to understand how its impact compares with scaling-up condom use-one of the proven HIV prevention strategies for FSWs. 

It is important to remember that condoms also have other benefits such as reducing the incidence of sexually transmitted infections and preventing pregnancy. A dynamic deterministic model of HIV transmission amongst FSWs, their clients and other male partners (termed 'pimps') was used to compare the protection provided by PrEP for HIV-negative FSWs with FSWs increasing their condom use with clients and/or pimps. For different HIV prevalence scenarios, levels of pimp interaction, and baseline condom use, we estimated the coverage of PrEP that gives the same reduction in endemic FSW HIV prevalence or HIV infections averted as different increases in condom use. 

To achieve the same impact on FSW HIV prevalence as increasing condom use by 1%, the coverage of PrEP has to increase by >2%. The relative impact of PrEP increases for scenarios where pimps contribute to HIV transmission, but not greatly, and decreases with higher baseline condom use. In terms of HIV infections averted over 10 years, the relative impact of PrEP compared to condoms was reduced, with a >3% increase in PrEP coverage achieving the same impact as a 1% increase in condom use. 

Condom promotion interventions should remain the mainstay HIV prevention strategy for FSWs, with PrEP only being implemented once condom interventions have been maximised or to fill prevention gaps where condoms cannot be used.

Below:  The relative impact of PrEP compared to condoms for decreasing the endemic FSW HIV prevalence (a) or averting HIV infections (b) after 10 years for different baseline FSW HIV prevalences, with no condom or PrEP use at baseline.

Below:  Sensitivity analysis on how the relative impact of PrEP changes for specific changes in model parameters

Full article at:   http://goo.gl/hsnL86

By:  Mukandavire Z1, Mitchell KM2, Vickerman P3.

• 1Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK. Electronic address: Zindoga.Mukandavire@lshtm.ac.uk.
• 2Department of Infectious Disease Epidemiology, Imperial College London, London, UK. Electronic address: Kate.Mitchell@imperial.ac.uk.
• 3School of Social and Community Medicine, University of Bristol, Bristol, UK. Electronic address: Peter.Vickerman@bristol.ac.uk. 
• Epidemics. 2016 Mar;14:62-70. doi: 10.1016/j.epidem.2015.10.002. Epub 2015 Nov 12.

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Pre-Exposure Prophylaxis for HIV Prevention: Concerns about PrEP: Adherence

Via:  http://goo.gl/eKIvSD

Familiarity with and Preferences for Oral and Long-Acting Injectable HIV Pre-exposure Prophylaxis (PrEP) in a National Sample of Gay and Bisexual Men in the U.S.

We sought to determine preferences for oral versus long-acting injectable (LAI) PrEP among gay and bisexual men (GBM). We surveyed a national U.S. sample of 1071 GBM about forms of PrEP. 

LAI PrEP was found to be acceptable among 43.2 % of men when injected monthly compared with 53.6 % of men when injected every 3 months. When asked to choose between forms of PrEP, 46.0 % preferred LAI, 14.3 % oral, 21.7 % whichever was most effective, 10.1 % had no preference, and 7.8 % would not take PrEP. There were no differences in PrEP preferences by race/ethnicity, income, region of residence, or relationship status. 

Those unwilling to take PrEP were significantly older than those who preferred LAI PrEP and those who would take either. Those who preferred the most effective form were younger, had less education, and reported more recent club drug use. Those who reported condomless anal sex and those who thought they were good PrEP candidates were more willing to take PrEP. Long-term health and side effects were of the greatest concern for both LAI and oral PrEP. The availability of LAI PrEP has the potential to increase uptake among GBM. 

The results of ongoing clinical trials of LAI PrEP will need to demonstrate similar or greater efficacy as daily Truvada for uptake to be maximized.

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By:  Parsons JT1,2,3, Rendina HJ4, Whitfield TH4,5, Grov C4,6.

• 1Center for HIV/AIDS Educational Studies & Training, Hunter College of the City University of New York (CUNY), New York, NY, USA. jeffrey.parsons@hunter.cuny.edu.
• 2Health Psychology and Clinical Sciences Doctoral Program, The Graduate Center of the City University of New York (CUNY), New York, NY, USA. jeffrey.parsons@hunter.cuny.edu.
• 3Department of Psychology, Hunter College of the City University of New York (CUNY), 695 Park Ave., New York, NY, 10065, USA. jeffrey.parsons@hunter.cuny.edu.
• 4Center for HIV/AIDS Educational Studies & Training, Hunter College of the City University of New York (CUNY), New York, NY, USA.
• 5Health Psychology and Clinical Sciences Doctoral Program, The Graduate Center of the City University of New York (CUNY), New York, NY, USA.
• 6CUNY Graduate School of Public Health and Health Policy, New York, NY, USA. 
• AIDS Behav. 2016 Mar 21. 

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The Role of Psychiatrists in HIV Prevention

Via:  http://goo.gl/Gg5hGd

PrEP Adherence Patterns Strongly Impact Individual HIV Risk & Observed Efficacy in Randomized Clinical Trials

BACKGROUND:

Randomized controlled trials (RCT) suggest that the efficacy of tenofovir-based pre-exposure prophylaxis (PrEP) strongly depends on consistency of PrEP use. We explore how patterns of pill-taking and waning of PrEP protection may affect PrEP efficacy for HIV prevention.

METHODS:

A two-arm RCT was simulated by mathematical models assuming that prescribed daily doses were skipped periodically, randomly or in large blocks. Risk-driven adherence, in which PrEP was taken when sex was expected, was also investigated. Three temporal PrEP protection profiles were explored: long (5 days), intermediate (3 days) and short (24 hours). Modeling results were compared to the efficacy observed in completed RCTs.

RESULTS:

Expected PrEP efficacy was 60% with periodic, 50% with random and 34% with block adherence when PrEP had a long protection profile and pills were taken only 50% of the days. Risk-driven pill-taking resulted in 29% and 37% daily pills taken and efficacy of 43% and 51% for long protection. High PrEP efficacy comparable with that observed in Partners PrEP and CDC Botswana trials was simulated under long protection, high overall adherence and limited block pill-taking; the moderate efficacy observed in iPrEx and Bangkok trials was comparable with the 50% adherence scenarios under random pill-taking and long protection.

CONCLUSIONS:

Pill-taking patterns may have a substantial impact on the protection provided by PrEP even when the same numbers of pills are taken. When PrEP retains protection for longer than a day, pill-taking patterns can explain a broad range of efficacies observed in PrEP RCTs.

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By:  Dimitrov DT1, MÂsse BR, Donnell D.

• 1Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center and Department of Applied Mathematics, University of Washington, Seattle, Washington, USA 
• 2 Sainte-Justine Research Centre, University of Montreal, Montreal, Quebec, Canada 
• 3 Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center and Department of Global Health, University of Washington, Seattle, Washington, USA.
• J Acquir Immune Defic Syndr. 2016 Mar 16. 

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PrEP as Peri-Conception HIV Prevention for Women and Men

Daily oral tenofovir (TDF)-based pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy and recommended for men and women with substantial risk of HIV acquisition. 

The peri-conception period, the stage prior to pregnancy when condom use is necessarily reduced, has elevated HIV risk that can be mitigated by PrEP use. Data from a randomized trial suggest that peri-conception PrEP use by HIV-seronegative women does not increase the risk of pregnancy loss, birth defects or congenital anomalies, preterm birth, or infant growth faltering. 

Women considering PrEP use throughout pregnancy must weigh the known increased risk of HIV acquisition with unknown risks of drug effects on infant growth. PrEP has been used safely by HIV-seronegative men with HIV-seropositive female partners who have become pregnant. 

As an effective user-controlled HIV prevention strategy, PrEP offers autonomy and empowerment for HIV prevention and can be recommended alongside antiretroviral therapy, fertility screening, vaginal self-insemination, intercourse timed to peak fertility, medically assisted reproduction, and other safer conception strategies to provide multiple options. 

The integration of PrEP into safer conception programs is warranted and will safely reduce HIV transmission to women, men, and children during the peri-conception period.

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By:  Heffron R1, Pintye J2, Matthews LT3, Weber S4, Mugo N5.

• 1Departments of Global Health and Epidemiology, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA, 98104, USA. rheffron@uw.edu.
• 2School of Nursing, University of Washington, 325 Ninth Avenue, Box 359909, Seattle, WA, 98104, USA.
• 3Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, 125 Nashua Street, Suite 722, Boston, MA, 02114, USA.
• 4University of California San Francisco, 1001 Potrero Ave, 6D-33, San Francisco, CA, 94110, USA.
• 5Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya. 
• Curr HIV/AIDS Rep. 2016 Mar 18. 

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HIV Incidence among Men Who Have Sex with Men After Diagnosis with Sexually Transmitted Infections

BACKGROUND:

Men who have sex with men (MSM) are at high risk for acquiring HIV infection after diagnosis with other sexually transmitted infections (STIs). Identifying the STIs associated with the greatest risk of subsequent HIV infection could help target prevention interventions, particularly preexposure prophylaxis (PrEP).

METHODS:

Using matched HIV and STI surveillance data from Washington State from January 1, 2007, to June 30, 2013, we calculated the incidence of new HIV diagnoses after different STI diagnoses among MSM. Men entered observation at the time of their first STI diagnosis during the study period and exited at HIV diagnosis or June 30, 2013. Cox proportional hazards regression was used to conduct a global comparison of rates.

RESULTS:

From January 1, 2007, to June 30, 2013, 6577 HIV-negative MSM were diagnosed as having 10,080 bacterial STIs at 8371 unique time points and followed for 17,419 person-years. Two hundred eighty (4.3%) men were subsequently diagnosed as having HIV infection for an overall incidence of 1.6 per 100 person-years (95% confidence interval, 1.4-1.8). The estimated incidence of HIV diagnoses among all MSM in the state was 0.4 per 100 person-years. Men who have sex with men were at the greatest risk for HIV diagnosis after being diagnosed as having rectal gonorrhea (HIV incidence, 4.1 per 100 person-years), followed by early syphilis (2.8), urethral gonorrhea (1.6), rectal chlamydial infection (1.6), pharyngeal gonorrhea (1.1), late syphilis (1.0), and urethral chlamydial infection (0.6; P < 0.0001 overall).

CONCLUSIONS:

Men who have sex with men diagnosed as having rectal gonorrhea and early syphilis were at the greatest risk for being diagnosed as having HIV infection after STI diagnosis. These men should be prioritized for more intensive prevention interventions, including PrEP.

Below:  Cumulative hazard of HIV diagnosis following bacterial STIs (STI) GC = gonorrhea. CT = chlamydial infection

Below:  Percent of 736 MSM newly diagnosed as having HIV infection from July 2011 to June 2013 with a reported STI diagnosis in the 2 years before HIV diagnosis GC indicates gonorrhea; CT, chlamydial infection.

Full article at:   http://goo.gl/N3Kb5L

By:  Katz DA1, Dombrowski JC, Bell TR, Kerani RP, Golden MR.

• 1From the Departments of *Medicine and †Epidemiology, University of Washington, Seattle, WA; ‡HIV/STD Program, Public Health-Seattle & King County, Seattle, WA; and §Infectious Disease Assessment Unit, Washington State Department of Health, Olympia, WA. 
• Sex Transm Dis. 2016 Apr;43(4):249-54. doi: 10.1097/OLQ.0000000000000423.

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Acceptability & Willingness to Use HIV Pre-Exposure Prophylaxis among HIV-Negative Men Who Have Sex with Men in Switzerland

Pre-exposure prophylaxis (PrEP) is discussed as an additional HIV prevention method targeting men who have sex with men (MSM). So far, PrEP has not been approved in Switzerland and only little is known about the acceptability of PrEP among MSM living in Switzerland. Given the slow uptake of PrEP among MSM in the USA, the objectives of the study were to investigate the acceptability for PrEP and to identify factors influencing the acceptability for this prevention method and the willingness to adopt it. 

During a 4-month period we conducted five focus group discussions with 23 consecutively sampled HIV-negative MSM aged 22-60 years living in Switzerland. We analyzed the data according to qualitative content analysis. The acceptability of PrEP varied considerably among the participants. 

Some would use PrEP immediately after its introduction in Switzerland because it provides an alternative to condoms which they are unable or unwilling to use. Others were more ambivalent towards PrEP but still considered it 

1. an additional or alternative protection to regular condom use, 
2. an option to engage in sexual activities with less worries and anxieties or 
3. a protection during receptive anal intercourse independently of the sexual partner's protective behaviour. 

Some participants would not consider using PrEP at all: they do not see any benefit in PrEP as they have adopted safer sex practices and did not mention any problems with condom use. Others are still undecided and could imagine using an improved form of PrEP. The results provide a valuable basis for a model explaining the acceptability of PrEP among MSM and suggest including the personal HIV protection strategy in the considerations adopted.

Full article at:   http://goo.gl/Bjn9An

By:   Gredig D1, Uggowitzer F1, Hassler B1, Weber P1, Nideröst S1.

• 1 School of Social Work , University of Applied Sciences and Arts Northwestern Switzerland , Olten , Switzerland. 
• AIDS Care. 2016 Mar 13:1-4.

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Beyond Condoms: Risk Reduction Strategies among Gay, Bisexual & Other Men Who Have Sex with Men Receiving Rapid HIV Testing in Montreal, Canada

Gay, bisexual, and other men who have sex with men (MSM) have adapted their sexual practices over the course of the HIV/AIDS epidemic based on available data and knowledge about HIV. This study sought to identify and compare patterns in condom use among gay, bisexual, and other MSM who were tested for HIV at a community-based testing site in Montreal, Canada. 

Results showed that while study participants use condoms to a certain extent with HIV-positive partners and partners of unknown HIV status, they also make use of various other strategies such as adjusting to a partner's presumed or known HIV status and viral load, avoiding certain types of partners, taking PEP, and getting tested for HIV. 

These findings suggest that MSM who use condoms less systematically are not necessarily taking fewer precautions but may instead be combining or replacing condom use with other approaches to risk reduction.

Full PDF article at:   http://goo.gl/HuCkMf

By:  Otis J1,2, McFadyen A3, Haig T3,4,5, Blais M3, Cox J6, Brenner B7, Rousseau R8, Émond G9, Roger M10, Wainberg M7; Spot Study Group.

• 1Department of Sexology, Université du Québec à Montréal, Case postale 8888, succursale Centre-ville, Montreal, QC, H3C 3P8, Canada. otis.joanne@uqam.ca.
• 2CIHR Canadian HIV Trials Network, Vancouver, Canada. otis.joanne@uqam.ca.
• 3Department of Sexology, Université du Québec à Montréal, Case postale 8888, succursale Centre-ville, Montreal, QC, H3C 3P8, Canada.
• 4CIHR Canadian HIV Trials Network, Vancouver, Canada.
• 5COCQ-SIDA, Montreal, QC, Canada.
• 6Direction de santé publique du CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montreal, QC, Canada.
• 7Faculty of Medicine, McGill University, Montreal, QC, Canada.
• 8RÉZO, Montreal, QC, Canada.
• 9Applied Human Sciences, Concordia University, Montreal, QC, Canada.
• 10Laboratoire de Biologie Moléculaire, Centre hospitalier de l'université de Montréal, Montreal, QC, Canada. 
• AIDS Behav. 2016 Mar 9

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Knowledge, Attitudes, and Acceptability of Pre-Exposure Prophylaxis among Individuals Living with HIV in an Urban HIV Clinic

Introduction

Pre-exposure prophylaxis (PrEP) is an effective tool to reduce HIV transmission. The primary objective of this study was to assess awareness of PrEP by individuals living with HIV (HIV+) and acceptance of its use for their HIV negative (HIV-) partners.

Methods

A cross sectional survey was conducted among individuals living with HIV who received care at an urban HIV clinic between January 2013 and June 2013. The survey examined knowledge, attitudes, and acceptability of PrEP, and perception of transmission risk of HIV. Chi-Square test and Fisher's Exact test were used to compare proportions.

Results

Among 206 subjects living with HIV, 15.3% (32) had heard of PrEP. Men who have sex with men (MSM) were more likely to be aware of PrEP than all others (p = 0.003). Once educated about PrEP those who believed PrEP would reduce their partner’s risk for HIV were more likely to recommend PrEP to their partner (p<0.001). 92% of all respondents said they would be “extremely likely/likely” to discuss PrEP use with their provider. Of 159 subjects whose main partner was HIV-, MSM (p = 0.007), male participants (p = 0.044), and those who were consistently taking meds (p = 0.049) were more likely to be aware of PrEP. Those who perceived they were at risk of transmitting HIV (p<0.001) and those who were consistently taking meds (0.049) were more likely to agree that PrEP could reduce the risk of HIV to their partners.

Conclusion

This study illustrates a low awareness of PrEP but once educated the willingness of a cohort of individuals living with HIV to recommend PrEP to their partners. Our findings demonstrate the importance of providers informing their patients living with HIV about PrEP, as these persons are an underutilized link to support the uptake of PrEP by their HIV- partners.

Factors Associated with PrEP Awareness and Acceptance (206).

Awareness: Have you ever heard of pre-exposure prophylaxis (PrEP) before?
		Yes N (%)	No N (%)	p-value
Sexual Orientation(Non MSM includes heterosexual, lesbian, and questioning/don’t’ know)	Non- MSM (153)	17(11.9)	135 (89%)	0.003
	MSM (53)	15 (28.8%)	43(74.1)
Gender	Male (117)	25 (21.4)	92 (78.6)	0.011
	Female (86)	7 (8.1)	79 (91.9)
Condom use during last sexual encounter	Yes (144)	19(13.2)	125(86.8)	0.093
	No (57)	13(22.8)	44 (77.2)
Have you missed any medicine in past 7 days?	Yes (62)	51 (82.3)	11 (17.7)	0.062
	No (129)	118(91.5)	11(8.5)
Acceptance: How likely would you be to recommend PrEP to an HIV—partner?
		Extremely Likely/Likely	Extremely Unlikely/ Unlikely/Unsure	p-value
Education	Finished High School (134)	122 (91.0)	12 (9.0)	0.170
	Did not finish High School (72)	61 (84.7)	11 (15.3)
I believe PrEP will reduce the risk of HIV transmission to my partner	Strongly Agree/Agree (170)	160 (94.1)	10 (5.9)	<0.001
	Strongly Disagree/ Disagree/ Undecided (35)	23 (65.7)	12 (34.3)

Boldface indicates statistical significance (p<0.05)

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

By:  Jenani Sarah Jayakumaran,^1,* Erika Aaron,² Ed J. Gracely,³ Emily Schriver,^3,¤ and Zsofia Szep²

Jesse Lawton Clark, Editor

¹Drexel University College of Medicine, Philadelphia, PA, United States of America

²Department of Infectious Diseases and HIV Medicine, Drexel University College of Medicine, Philadelphia, PA, United States of America

3Department of Epidemiology and Biostatistics, Drexel University School of Public Health, Philadelphia, PA, United States of America

David Geffen School of Medicine at UCLA, UNITED STATES

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: EA ZS. Performed the experiments: JSJ. Analyzed the data: EG ES. Contributed reagents/materials/analysis tools: EA JSJ ZS EG ES. Wrote the paper: JSJ EA ZS EG ES.

^¤Current address: AJ Drexel Autism Institute, Drexel University School of Public Health, Philadelphia, PA, United States of America

* E-mail: ude.lexerd@34jsJ

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