Long-Term Financing Needs for HIV Control in Sub-Saharan Africa in 2015-2050

OBJECTIVES:

To estimate the present value of current and future funding needed for HIV treatment and prevention in 9 sub-Saharan African (SSA) countries that account for 70% of HIV burden in Africa under different scenarios of intervention scale-up. To analyse the gaps between current expenditures and funding obligation, and discuss the policy implications of future financing needs.

DESIGN:

We used the Goals module from Spectrum, and applied the most up-to-date cost and coverage data to provide a range of estimates for future financing obligations. The four different scale-up scenarios vary by treatment initiation threshold and service coverage level. We compared the model projections to current domestic and international financial sources available in selected SSA countries.

RESULTS:

In the 9 SSA countries, the estimated resources required for HIV prevention and treatment in 2015-2050 range from US$98 billion to maintain current coverage levels for treatment and prevention with eligibility for treatment initiation at CD4 count of <500/mm(3) to US$261 billion if treatment were to be extended to all HIV-positive individuals and prevention scaled up. With the addition of new funding obligations for HIV-which arise implicitly through commitment to achieve higher than current treatment coverage levels-overall financial obligations (sum of debt levels and the present value of the stock of future HIV funding obligations) would rise substantially.

CONCLUSIONS:

Investing upfront in scale-up of HIV services to achieve high coverage levels will reduce HIV incidence, prevention and future treatment expenditures by realising long-term preventive effects of ART to reduce HIV transmission. Future obligations are too substantial for most SSA countries to be met from domestic sources alone. New sources of funding, in addition to domestic sources, include innovative financing. Debt sustainability for sustained HIV response is an urgent imperative for affected countries and donors.

Below:  Annual resources required by nine sub-Saharan countries (US$ billions) from 2015 to 2050 (3% discounting).

Below:  Per capita annual resources required by nine sub-Saharan countries ($US) from 2015 to 2050 (3% discounting).

Below:  Total expenditures on HIV from domestic and international sources combined (current US$) in selected sub-Saharan African countries, compared with estimated resource needs for treatment, prevention and structural interventions in 2015 under different coverage levels and eligibility for treatment. EAE, external AIDS expenditure; GEA, Government Expenditure on AIDS; RNE, resource needs estimate. GEA and EAE estimates are from Resch et al 2015.

Full article at:   http://goo.gl/C2PXSW

By:  Atun R¹, Chang AY¹, Ogbuoji O¹, Silva S¹, Resch S¹, Hontelez J¹, Bärnighausen T¹.

¹Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.

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The Effect of Switching to Second-Line Antiretroviral Therapy on the Risk of Opportunistic Infections among Patients Infected with Human Immunodeficiency Virus in Northern Tanzania

Background.

Due to the unintended potential misclassifications of the World Health Organization (WHO) immunological failure criteria in predicting virological failure, limited availability of treatment options, poor laboratory infrastructure, and healthcare providers' confidence in making switches, physicians delay switching patients to second-line antiretroviral therapy (ART). Evaluating whether timely switching and delayed switching are associated with the risk of opportunistic infections (OI) among patients with unrecognized treatment failure is critical to improve patient outcomes. 

Methods. 

A retrospective review of 637 adolescents and adults meeting WHO immunological failure criteria was conducted. Timely and delayed switching to second-line ART were defined when switching happened at <3 and ≥3 months, respectively, after failure diagnosis was made. Cox proportional hazard marginal structural models were used to assess the effect of switching to second-line ART on the risk of developing OI. 

Results.

Of 637 patients meeting WHO immunological failure criteria, 396 (62.2%) switched to second-line ART. Of those switched, 230 (58.1%) were delayed. Switching to second-line ART reduced the risk of OI (adjusted hazards ratio [AHR], 0.4; 95% CI, .2-.6). Compared with patients who received timely switch after failure diagnosis was made, those who delayed switching were more likely to develop OI (AHR, 2.2; 95% CI, 1.1-4.3). 

Conclusion.

Delayed switching to second-line ART after failure diagnosis may increase the risk of OI. Serial immunological assessment for switching patients to second-line ART is critical to improve their outcomes.

Below:  Kaplan–Meier curves for 637 human immunodeficiency virus-infected adolescent and adult patients according to switching status

Full article at:   http://goo.gl/LP8ujr

By:  Ramadhani HO1, Bartlett JA2, Thielman NM2, Pence BW3, Kimani SM4, Maro VP5, Mwako MS6, Masaki LJ7, Mmbando CE8, Minja MG9, Lirhunde ES9, Miller WC3.

¹Kilimanjaro Christian Medical Centre, Moshi; Tanzania; Department of Epidemiology, University of North Carolina, Chapel Hill.

²Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, and; Duke Global Health Institute, Durham, North Carolina.

³Department of Epidemiology , University of North Carolina , Chapel Hill.

⁴Duke Global Health Institute , Durham, North Carolina.

⁵Kilimanjaro Christian Medical Centre , Moshi ; Tanzania.

⁶Mawenzi Regional Hospital .

⁷Machame Designated District Hospital .

⁸Kilema Designated District Hospital , and.

⁹Kibosho Designated District Hospital , Moshi , Tanzania.

Open Forum Infect Dis. 2016 Jan 29;3(1):ofw018. doi: 10.1093/ofid/ofw018. eCollection 2016.

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Depression & HIV Risk among Men Who Have Sex with Men in Tanzania

Studies have shown high rates of depression among men who have sex with men (MSM) in developed countries. Studies have also shown association between depression and HIV risk among MSM. However, very little research has been done on depression among African MSM. 

We assessed depression and HIV risk among a sample of MSM in Tanzania. We reviewed data on 205 MSM who were recruited from two Tanzanian cities using the respondent driven sampling method. Demographic and behavioral data were collected using a structured questionnaire. HIV and sexually transmitted infections data were determined from biological tests. Depression scores were assessed using the Patient Health Questionnaire (PHQ-9). For the analysis, depression scores were dichotomized as depressed (PHQ > 4) and not depressed (PHQ ≤ 4). Bivariate and multivariable Poisson regression analyses were conducted to assess factors associated with depression. 

The prevalence of depression in the sample was 46.3%. The mean (±SD) age of the sample was 25 (±5) years. In bivariate analysis, depression was associated with self-identifying as gay (p = .001), being HIV positive (p < .001: <8% of MSM knew they were HIV infected) and having a high number of sexual partners in the last 6 months (p = .001). 

Depression was also associated with sexual (p = .007), physical (p = .003) and verbal (p < .001) abuse. In the Poisson regression analysis, depression was associated with verbal abuse (APR = 1.91, CI = 1.30-2.81). Depression rates were high among MSM in Tanzania. It is also associated with abuse, HIV and HIV risk behaviors. Thus, reducing the risk of depression may be helpful in reducing the risk of HIV among MSM in Africa. 

We recommend the colocation of mental health and HIV preventive services as a cost-effective means of addressing both depression and HIV risk among MSM in Africa.

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By:  Ahaneku H1, Ross MW2, Nyoni JE3, Selwyn B1, Troisi C4, Mbwambo J5, Adeboye A6, McCurdy S6.

• 1 Department of Epidemiology, Human Genetics and Environmental Sciences , The University of Texas School of Public Health , Houston , TX , USA.
• 2 Department of Family Medicine and Community Health , University of Minnesota , Minneapolis , MN , USA.
• 3 Department of Sociology and Anthropology , University of Dar es Salaam , Dar es Salaam , Tanzania.
• 4 Department of Management, Policy and Community Health , The University of Texas School of Public Health , Houston , TX , USA.
• 5 Department of Psychiatry , Muhimbili University of Health Sciences , Dar es Salaam , Tanzania.
• 6 Department of Health Promotion and Behavioral Sciences , The University of Texas School of Public Health , Houston , TX , USA
• AIDS Care. 2016 Mar;28 Suppl 1:140-7. doi: 10.1080/09540121.2016.1146207. 

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Malaria & HIV among Pediatric Inpatients in Two Tanzanian Referral Hospitals

Malaria remains common in sub-Saharan Africa, but it is frequently over-diagnosed and over-treated in hospitalized children. HIV is prevalent in many malaria endemic areas and may delay parasite clearance and increase mortality among children with malaria. 

This prospective cohort study enrolled children with suspected malaria between 3 months and 12 years of age hospitalized at two referral hospitals in Tanzania. Both a thick blood smear (BS) and a malaria rapid diagnostic test (mRDT) were performed. If discordant results were obtained, PCR was performed for Plasmodium falciparum. Malaria was confirmed if two out of three tests were positive. Malaria parasite densities were determined for two consecutive days after diagnosis and treatment of malaria. All participants were tested for HIV. 

Among 1492 hospitalized children, 400 (26.8%) were enrolled with suspected malaria infection. There were 196/400 (49.0%) males, and the median age was 18 [9-36] months. BS was positive in 95/400 (23.8%), and mRDT was positive in 70/400 (17.5%), with moderate agreement (Kappa=0.598). Concordant results excluded malaria in 291/400 (72.8%) and confirmed malaria in 56/400 (14.0%). PCR performed on 53 discordant results confirmed malaria in 1/39 of the BS-positive/mRDT-negative cases, and 6/14 of the BS-negative/mRDT-positive cases. 

The prevalence of confirmed malaria was 63/400 (15.8%). In multivariable logistic regression, malaria was associated with HIV (OR 3.45 [1.65-7.20], p=0.001). Current breastfeeding (OR 0.25 [0.11-0.56], p=0.001) and higher hemoglobin (OR 0.70 [0.60-0.81], p<0.001 per 1g/dL) were associated with decreased odds of malaria. Malaria parasite clearance was delayed in HIV-infected participants (p<0.001). Malaria is over-diagnosed even at referral centers in high transmission areas. 

Hospitalized HIV-infected children are more likely to have malaria and exhibit delayed clearance of parasites. Hospitals should consider using mRDTs as a first step for malaria testing among hospitalized children in sub-Saharan Africa.

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By:  Smart LR1, Orgenes N2, Mazigo HD3, Minde M4, Hokororo A5, Shakir M6, Verweij JJ7, Downs JA8, Peck RN8.

• 1Department of Internal Medicine, Catholic University of Health & Allied Sciences, P.O. Box 1464, Mwanza, Tanzania; Department of Internal Medicine, Bugando Medical Centre, P.O. Box 1370, Mwanza, Tanzania; Center for Global Health, Weill Cornell Medical College, 402 East 67th Street, 2nd Floor, NewYork, NY 10065, USA. Electronic address: smart.luke@gmail.com.
• 2Department of Pediatrics, Catholic University of Health & Allied Sciences, P.O. box 1464, Mwanza, Tanzania.
• 3Department of Parasitology, Catholic University of Health & Allied Sciences, P.O. Box 1464, Mwanza, Tanzania.
• 4Department of Pediatrics, Bugando Medical Centre, P.O. Box 1370, Mwanza, Tanzania.
• 5Department of Pediatrics, Catholic University of Health & Allied Sciences, P.O. box 1464, Mwanza, Tanzania; Department of Pediatrics, Bugando Medical Centre, P.O. Box 1370, Mwanza, Tanzania.
• 6Weill Cornell Medical College in Qatar, Qatar Foundation-Education City, P.O. Box 24144, Doha, Qatar.
• 7Laboratory of Medical Microbiology and Immunology, St. Elisabeth Hospital, Tilburg, The Netherlands.
• 8Department of Internal Medicine, Catholic University of Health & Allied Sciences, P.O. Box 1464, Mwanza, Tanzania; Department of Internal Medicine, Bugando Medical Centre, P.O. Box 1370, Mwanza, Tanzania; Center for Global Health, Weill Cornell Medical College, 402 East 67th Street, 2nd Floor, NewYork, NY 10065, USA. 
• Acta Trop. 2016 Mar 18;159:36-43. doi: 10.1016/j.actatropica.2016.03.019.

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Improvements in Health-Related Quality of Life among Methadone Maintenance Clients in Dar Es Salaam, Tanzania

BACKGROUND:

Injection of heroin has become widespread in Dar es Salaam, Tanzania and is spreading throughout the country. To prevent potential bridging of HIV epidemics, the Tanzanian government established a methadone maintenance treatment (MMT) clinic in February 2011. We assess the effect of MMT on health-related quality of life (HRQOL) and examine factors, particularly HIV infection and methadone dose, associated with changes in HRQOL.

METHODS:

This study utilized routine data on clients enrolling in methadone from February 2011 to April 2012 at Muhimbili National Hospital. Change in physical (PCS) and mental health (MCS) composite scores, as measured by the SF-12 tool, were the primary outcomes. Backward stepwise linear regression, with a criterion of p<0.2 was used to identify baseline exposure variables for inclusion in multivariable models, while adjusting for baseline scores.

RESULTS:

A total of 288 MMT clients received baseline and follow-up assessments. Mean methadone dose administered was 45mg (SD±25) and 76 (27%) were confirmed HIV-positive. Significant improvements were observed in PCS and MCS, with mean increases of 15.7 and 3.3, respectively. In multivariable models, clients who had previous poly-substance use with cocaine [p=0.040] had a significantly higher mean change in PCS. Clients who were living with HIV [p=0.002]; satisfied with current marital situation [p=0.045]; had a history of suicidal thoughts [p=0.021]; and previously experienced cognitive difficulties [p=0.012] had significantly lower mean change in PCS. Clients with shorter history of heroin use [p=0.012] and who received higher methadone doses [p=0.028] had significantly higher mean change in MCS, compared to their counterparts.

CONCLUSION:

Aspects of mental and physical health, risk behaviors and quality of life among drug users are intertwined and complex. Our research revealed positive short-term effects of MMT on HRQOL and highlights the importance of sustained retention for optimal benefits. Comprehensive supportive services in addition to provision of methadone are needed to address the complex health needs of people who inject drugs.

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By:  Ubuguyu O1, Tran OC2, Bruce RD3, Masao F1, Nyandindi C1, Sabuni N4, McCurdy S5, Mbwambo J1, Lambdin BH6.

• 1Muhimbili University of Health and Allied Sciences, PO Box 65001, Dar es Salaam, Tanzania.
• 2Pangaea Global AIDS, 436 14th St, Suite 920, Oakland, CA 94612, USA.
• 3Yale University, New Haven, CT 06520, USA.
• 4Tanzania Ministry of Health and Social Welfare, 6 Samora Machel Ave, Dar es Salaam, Tanzania.
• 5University of Texas School of Public Health, 7000 Fannin St, Houston, TX, USA.
• 6RTI-International, 351 California St, Suite 500, San Francisco, CA 94104, USA; Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA. Electronic address: blambdin@rti.org. 
• Int J Drug Policy. 2016 Mar 11. pii: S0955-3959(16)30065-2. doi: 10.1016/j.drugpo.2016.03.005

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Sexual Violence Against Female and Male Children in the United Republic of Tanzania

During a household survey in Tanzania, a nationally representative sample of females and males aged 13-24 years reported any experiences of sexual violence that occurred before the age of 18 years. The authors explore the prevalence, circumstances, and health outcomes associated with childhood sexual violence. 

The results suggest that violence against children in Tanzania is pervasive, with roughly three in 10 females and one in eight males experiencing some form of childhood sexual violence, and its health consequences are severe. 

Results are being used by the Tanzanian government to implement a National Plan of Action.

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By:  Vagi KJ1, Brookmeyer KA2, Gladden RM2, Chiang LF2, Brooks A3, Nyunt MZ4, Kwesigabo G5, Mercy JA2, Dahlberg LL2.

• 1U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA kvagi@cdc.gov.
• 2U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
• 3UNICEF Afrique de l'Ouest et du Centre/West and Central Africa Regional Office, Dakar-Yoff, Sénégal.
• 4United Nations Children's Fund, Laos.
• 5Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. 
• Violence Against Women. 2016 Mar 14. pii: 1077801216634466

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Generating Trust: Programmatic Strategies to Reach Women Who Inject Drugs with Harm Reduction Services in Dar Es Salaam, Tanzania

BACKGROUND:

Strong evidence supports the effectiveness of methadone-assisted therapy (MAT) to treat opioid dependence, reduce the risk of HIV transmission, and improve HIV related health outcomes among people who inject drugs (PWID). HIV prevalence reaches 71% in women who inject drugs (WWID) in Dar es Salaam, Tanzania; creating an urgent need for access to MAT. Despite the availability and potential benefits of treatment, few women have enrolled in services. This formative research sought to identify programmatic strategies to increase women's participation in outreach and their subsequent enrollment in MAT.

METHODS:

We conducted twenty-five, in-depth interviews with patients and their providers at a MAT clinic. Open-ended interviews explored enrollment experiences, with a focus on contextual barriers and facilitators unique to women. Ethnographic observations of harm reduction education at outreach sites and the MAT clinic enriched interview data. Trust/mistrust emerged as an overarching theme cross cutting patient and provider accounts of the connective process to enroll PWID in the methadone program. We explore trust and mistrust in relationship to the interrelated themes of family loss, social isolation, vehement discrimination and motivation for treatment.

RESULTS:

Narratives delineated both the generation of mistrust against PWID and the generation of mistrust in PWID against outsiders and medical institutions. In order to enroll PWID in treatment, community base organizations engaged outreach strategies to overcome mistrust and connect eligible patients to care, which varied in their success at recruiting women and men. Greater discrimination against WWID pushed them into hiding, away from outreach teams that focus on outdoor areas where men who inject drugs congregate. Building trust through multiple encounters and making a personal connection facilitated entry into care for women. Only PWID were eligible for MAT, due to resource constraints and the higher risk associated with injection drug use. Many women smoke heroin, yet still face high risk of HIV, resulting from low condom use during sex work to fund drug use.

CONCLUSION:

Expanding outreach times and locations, by women peers, could increase women's enrollment in treatment. Allowing women who smoke heroin to enter the program could prevent onward transmission via sex work and reduce the chance of progressing from the lower risk smoking or sniffing to injection drug use.

Purchase full article at:   http://goo.gl/ZEjW8A

By:  Zamudio-Haas S1, Mahenge B2, Saleem H3, Mbwambo J4, Lambdin BH5.

• 1Department of Preventative Medicine, University of California, 550, 16th Street, San Francisco, CA 94143, United States. Electronic address: Sophia.Zamudio-Haas@ucsf.edu.
• 2Department of Psychology, University of Dodoma, P.O. Box 259, Dodoma, Tanzania.
• 3Pangaea Global AIDS, 436, 14th Street, Suite 920, Oakland, CA 94612, United States.
• 4Department of Psychiatry, Muhimbili University of Health and Allied Sciences, P.O. Box 65293, Dar es Salaam, Tanzania.
• 5Behavioral and Urban Health Program, RTI International, 351, California St, Suite 500, San Francisco, CA 94104, United States; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, United States; Department of Global Health, University of Washington, Seattle, WA, United States. 
• Int J Drug Policy. 2016 Jan 23. pii: S0955-3959(16)00035-9. doi: 10.1016/j.drugpo.2016.01.012.

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Rapid Acquisition of HPV Around the Time of Sexual Debut in Adolescent Girls in Tanzania

BACKGROUND:

No reports exist on genotype-specific human papillomavirus (HPV) acquisition in girls after first sex in sub-Saharan Africa, despite high HPV prevalence and cervical cancer incidence.

METHODS:

We followed 503 HP-unvaccinated girls aged 15-16 years in Mwanza, Tanzania, 3-monthly for 18 months with interviews and self-administered vaginal swabs. Swabs were tested for 13 higHRisk and 24 low-risk HPV genotypes. Incidence, clearance and duration of overall HPV and genotype-specific infections were calculated and associated factors evaluated.

RESULTS:

A total of 106 participants reported first sex prior to enrolment (N = 29) or during follow-up (N = 77). One was HIV-positive at the final visit. The remaining 105 girls contributed 323 adequate specimens. Incidence of any new HPV genotype was 225/100 person-years (pys), and incidence of vaccine types HPV-6, -11, -16 and -18 were 12, 2, 2 and 7/100 pys, respectively. Reporting sex in the past 3 months and knowing the most recent sexual partner for a longer period before sex were associated with HPV acquisition. Median time from reported sexual debut to first HPVinfection was 5 months, and infection duration was 6 months.

CONCLUSION:

This is the first description of HPV acquisition after first sex in sub-Saharan Africa where the incidence of cervical cancer is amongst the highest in the world. HPV incidence was very high after first sex, including some vaccine genotypes, and infection duration was short. This very high HPV incidence may help explain high cervical cancer rates, and supports recommendations that the HPV vaccine should be given to girls before first sex.

Below:  Time from sexual debut to first infection with any HPV, any HR HPV or any LR HPV, among 41 girls who reported sexual debut during follow-up and were HPV-naïve at time of reported sexual debut.  Kaplan Meier curves are calculated separately for each HPV group.

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

   

By:  Houlihan CF1, Baisley K2, Bravo IG3, Kapiga S4, de Sanjosé S5, Changalucha J6, Ross DA2, Hayes RJ2, Watson-Jones D7.

• 1Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK Mwanza Intervention Trials Unit, Mwanza, Tanzania catherine.houlihan@lshtm.ac.uk.
• 2MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK.
• 3Unit of Infections and Cancer, Institut Català d'Oncologia, Barcelona, Spain.
• 4Mwanza Intervention Trials Unit, Mwanza, Tanzania MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK.
• 5Unit of Infections and Cancer, Institut Català d'Oncologia, Barcelona, Spain CIBER ESP, Barcelona, Spain.
• 6National Institute for Medical Research, Mwanza, Tanzania.
• 7Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK Mwanza Intervention Trials Unit, Mwanza, Tanzania. 
• Int J Epidemiol. 2016 Mar 4. pii: dyv367.

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Prevalence & Risk Factors of Cervical Squamous Intraepithelial Lesions among HIV-Infected Women in Dar es Salaam, Tanzania

To determine the prevalence and predictors of cervical squamous intraepithelial lesions (SIL) among HIV-infected women in Tanzania, a cross-sectional study was conducted among HIV-infected women at HIV care and treatment clinics. 

A Papanicolaou (Pap) smear was used as a screening tool for detection of cervical SIL. From December 2006 to August 2009, 1365 HIV-infected women received cervical screening. The median age was 35 (interquartile range [IQR]: 30-42) years, and the median CD4 + cell count was 164 (IQR: 80-257) cells/mm(3). 

The prevalence of cervical SIL was 8.7% (119/1365). In multivariate analysis, older age (≥50 versus 30-<40 years: prevalence ratio [PR], 2.36; 95% confidence interval [CI], 1.45-3.84, p for trend = 0.001), lower CD4 + cell counts (<100 versus ≥200 cells/mm(3): PR, 1.55; 95% CI, 1.01-2.36, p for trend = 0.03) and cervical inflammation (PR, 1.73; 95% CI, 1.16-2.60, p = 0.008) were associated with an increased risk of cervical SIL. Women with advanced WHO HIV disease stage (IV versus I/II: PR, 3.45; 95% CI, 1.35-8.85, p for trend = 0.01) had an increased risk for high-grade SIL. 

In resource-limited settings where it is not feasible to provide cervical cancer prevention services to all HIV-infected women, greater efforts should focus on scaling-up services among those who are older than 50 years, with lower CD4 cell counts and advanced HIV disease stage.

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By:  Liu E1, McCree R2, Mtisi E3, Fawzi WW4, Aris E5, Lema IA5, Hertzmark E6, Chalamilla G5, Li N1, Vermund SH7, Spiegelman D8.

• 1Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA.
• 2National Cancer Institute, Center for Global Health, Rockville, MD, USA.
• 3Africa Academy for Public Health, Dar es Salaam, Tanzania.
• 4Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA Department of Nutrition, Harvard School of Public Health, Boston, MA, USA Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
• 5Management and Development for Health, Dar es Salaam, Tanzania.
• 6Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
• 7Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN, USA.
• 8Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA Department of Nutrition, Harvard School of Public Health, Boston, MA, USA Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA stdls@hsph.harvard.edu. 
• Int J STD AIDS. 2016 Mar;27(3):219-25. doi: 10.1177/0956462415584466. Epub 2015 May 7.

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