Exposure to Violence & Psychological Well-Being Over Time in Children Affected by HIV/AIDS in South Africa & Malawi

Many of the risk factors for violence against children are particularly prevalent in families and communities affected by HIV/AIDS. Yet, in sub-Saharan Africa, where HIV rates are high, efforts to prevent or address violence against children and its long-lasting effects are hampered by a lack of evidence. 

We assessed the relationship between violence exposure and mental health among HIV-affected children attending community-based organisations in South Africa (n = 834) and Malawi (n = 155, total sample n = 989) at baseline and 12-15-month follow-up. Exposure to violence in the home and in the community was high. HIV-negative children who lived with an HIV-positive person experienced most violence overall, followed by HIV-positive children. Children unaffected by HIV experienced least violence (all p < .05). 

Interpersonal violence in the home predicted child depression, trauma symptoms, lower self-esteem, and internalising and externalising behavioural problems, while exposure to community violence predicted trauma symptoms and behavioural problems. Harsh physical discipline predicted lower self-esteem and behavioural problems for children. Exposure to home and community violence predicted risk behaviour. Over time, there was a decrease in depressed mood and problem behaviours, and an increase in self-esteem for children experiencing different types of violence at baseline. This may have been due to ongoing participation in the community-based programme. 

These data highlight the burden of violence in these communities and possibilities for programmes to include violence prevention to improve psychosocial well-being in HIV-affected children.

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

By:  Skeen S1,2, Macedo A3, Tomlinson M1, Hensels IS3, Sherr L3.

• 1 Department of Psychology , Stellenbosch University , Stellenbosch , South Africa.
• 2 Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa.
• 3 Department of Infection and Population Health , University College London , London , UK.
• AIDS Care. 2016 Mar;28 Suppl 1:16-25. doi: 10.1080/09540121.2016.1146219.

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Adolescent Sexual Minority Girls Are at Elevated Risk for Use of Multiple Substances

This summary is not available. Please click here to view the post.

Relations among Internalizing and Externalizing Symptoms and Drinking Frequency During Adolescence

Background

In adolescence, internalizing (e.g., anxious, depressive, and withdrawn) and externalizing (e.g., aggressive, oppositional, delinquent, and hyper-active) symptoms are related with alcohol use. However, the directionality among internalizing symptoms, externalizing symptoms, and alcohol use during adolescence is equivocal. Moreover, gender differences and similarities among these behaviors are not definitive in existing literature.

Objectives

This study examined longitudinal relationships between internalizing and externalizing symptoms and past-month alcohol use among adolescent boys and girls.

Methods

Using longitudinal survey data from a study of community-dwelling adolescents (n = 724), we estimated cross-lagged structural equation models to test relations between internalizing and externalizing symptoms (as measured by the Youth Self Report, YSR [Achenbach, 1991]) and self-report alcohol use in the past month among adolescents. Gender differences were tested in a multiple group structural equation model.

Results

Alcohol use at age 12 was a predictor of internalizing and externalizing symptoms at age 15 for both boys and girls. With regard to gender differences, girls demonstrated an association between internalizing symptoms and drinking at age 12, whereas boys showed a stronger association between externalizing symptoms and drinking at age 18.

Conclusions/Importance

Early alcohol use is problematic for youth, and results of this study lend support to prevention programs for youth. Preventing or curbing early drinking may offset later externalizing and internalizing symptoms, as well as ongoing alcohol use, regardless of gender.

Below:  Cross-lagged model of internalizing and externalizing symptoms and alcohol use

Full article at:   http://goo.gl/2kdCDB

By:  Hyun-Jin Jun, Paul Sacco, Charlotte Lyn Bright, and Elizabeth A. S. Camlin

School of Social Work, University of Maryland, Baltimore, Baltimore, Maryland, USA

Address correspondence to Hyun-Jin Jun, University of Maryland, School of Social Work, 525 West Redwood Street, Baltimore, MD 21201, USA;Email: ude.dnalyramu.wss@nujh

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

HIV Risk Behavior & Internalizing/Externalizing Psychopathology among Adolescents in Court-Ordered Treatment

BACKGROUND:

The confluence of drug use behaviors, sexual risk, and psychopathology may complicate human immunodeficiency virus (HIV) prevention intervention for adolescents engaging in substance use and criminal behavior. However, few studies have examined these risk associations.

OBJECTIVE:

This study identified HIV risk behavior subgroups among adolescents in court-ordered substance abuse treatment and examined linkages with dimensions of internalizing and externalizing psychopathology.

METHODS:

Internalizing and externalizing behaviors were assessed with the Millon Adolescent Clinical Inventory (MACI). Latent class analysis was used to identify subgroups on the basis of involvement in substance use proximal to sex, number of partners, and consistency of condom use.

RESULTS:

Participants (n = 301) were identified as demonstrating high, medium, or low levels of sexual risk behavior. Greater externalizing psychopathology distinguished the high risk class from the medium risk class and from the low risk class.

CONCLUSION:

Detained youth with particularly serious oppositional-defiant behavioral characteristics, substance use, and sex risk behavior likely require intensive interventions that address the multiple systemic factors that contribute to the development and maintenance of this pattern.

Purchase full article at:   http://goo.gl/2bAzC9

By:  McMahon RC1, Stanforth ET1, Dévieux JG2, Jean-Gilles M2.

• 1 Department of Educational and Psychological Studies , University of Miami , Coral Gables , FL , USA.
• 2 Department of Health Promotion and Disease Prevention , Florida International University , Miami , FL , USA.
• Am J Drug Alcohol Abuse. 2016 Feb 10:1-9. 

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Children's Night Waking among Toddlers: Relationships with Mothers' & Fathers' Parenting Approaches & Children's Behavioural Difficulties

AIMS:

To explore associations between children's sleep problems, and behavioural difficulties and parenting approaches.

BACKGROUND:

Children commonly have problematic night waking; however, relationships between parenting cognitions and behaviours and children's sleep problems are rarely examined.

DESIGN:

Longitudinal children's cohort study from 5-29 months post birth.

METHODS:

Data were taken from the Quebec Longitudinal Study of Child Development (1998-2007) at three phases: 5, 17 and 29 months of age. Thousand four hundred and eighty-seven families were included in our study based on: participation from phase 1 (5-months old), both parents' reports on parenting cognitions/behaviours and child behavioural difficulties at 29 months, and mothers' reports of children's sleep at 29 months. In 2013, we conducted repeated measures anovas and manovas including children's gender.

RESULTS:

Extended night-time waking patterns (wakes of ≥ 20 minutes) were associated with mothers' and fathers' lower sense of parenting impact and higher over protectiveness and mothers' lower self-efficacy and higher coerciveness for 29-month-old children. In the extended waking group, mothers consistently reported lower self-efficacy, higher over protectiveness and lower parenting impact at 5, 17 and 29 months. For those children, fathers were only more overprotective at 5 and 29 months. Regarding 29-month-old children's behaviour, children in the extended night waking group had highest scores on externalizing and internalizing behaviours. Girls had higher scores on shyness/inhibition and boys had higher scores on aggression/hyperactivity.

CONCLUSION:

Mothers' and fathers' parenting cognitions and behaviours are affected by 29-month-old children's night waking patterns and night waking patterns are associated with children's behavioural problems.

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

By:  Zaidman-Zait A1,2, Hall WA3.

• 1Department of School Counseling and Special Education, Constantiner School of Education, Tel-Aviv University, Israel.
• 2Department of Human Early Learning Partnership (HELP), University of British Columbia (http://earlylearning.ubc.ca/), Vancouver, British Columbia, Canada.
• 3University of British Columbia School of Nursing, Vancouver, British Columbia, Canada.
• J Adv Nurs. 2015 Jul;71(7):1639-49. doi: 10.1111/jan.12636. Epub 2015 Feb 18.

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Bidirectional Associations between Externalizing Behavior Problems and Maladaptive Parenting within Parent-Son Dyads Across Childhood

Coercive parent-child interaction models posit that an escalating cycle of negative, bidirectional interchanges influences the development of boys' externalizing problems and caregivers' maladaptive parenting over time. However, longitudinal studies examining this hypothesis have been unable to rule out the possibility that between-individual factors account for bidirectional associations between child externalizing problems and maladaptive parenting. 

Using a longitudinal sample of boys (N = 503) repeatedly assessed eight times across 6-month intervals in childhood (in a range between 6 and 13 years), the current study is the first to use novel within-individual change (fixed effects) models to examine whether parents tend to increase their use of maladaptive parenting strategies following an increase in their son's externalizing problems, or vice versa. These bidirectional associations were examined using multiple facets of externalizing problems (i.e., interpersonal callousness, conduct and oppositional defiant problems, hyperactivity/impulsivity) and parenting behaviors (i.e., physical punishment, involvement, parent-child communication). 

Analyses failed to support the notion that when boys increase their typical level of problem behaviors, their parents show an increase in their typical level of maladaptive parenting across the subsequent 6 month period, and vice versa. Instead, across 6-month intervals, within parent-son dyads, changes in maladaptive parenting and child externalizing problems waxed and waned in concert. Fixed effects models to address the topic of bidirectional relations between parent and child behavior are severely underrepresented. 

We recommend that other researchers who have found significant bidirectional parent-child associations using rank-order change models reexamine their data to determine whether these findings hold when examining changes within parent-child dyads.

Purchase full article at:   http://goo.gl/DVqrJ3

By:  Besemer S1, Loeber R2, Hinshaw SP3, Pardini DA4.

• 1University of California, Berkeley, Institute of Human Development (http://ihd.berkeley.edu/), 1205 Tolman Hall, Berkeley, CA, 94720, USA. besemer@berkeley.edu.
• 2Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
• 3Department of Psychology, University of California Berkeley, Berkeley, CA, USA.
• 4School of Criminology & Criminal Justice, Arizona State University, Phoenix, AZ, USA.
• J Abnorm Child Psychol. 2016 Jan 18. 

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

The Predictive Utility of Conduct Disorder Symptoms in Preschool Children: A 3-Year Follow-Up Study

Conduct disorder (CD) symptoms often emerge during the preschool years, but it is not clear whether they predict later symptoms. 

The present study examined whether age 3 CD symptoms predict age 6 CD symptoms beyond oppositional defiant disorder (ODD) and attention-deficit/hyperactivity disorder—hyperactive/impulsive (ADHD HI) symptoms. Participants were 216 preschool children (M_Age = 44.19 months), including an externalizing sample (n = 161) and a comparison group (n = 55). Parents were administered a diagnostic interview when children were 3 years old and again three years later. 

The externalizing sample exhibited more CD symptoms than the comparison sample. In the externalizing sample, initial CD symptoms predicted later CD symptoms above and beyond ODD and ADHD HI symptoms; this relation was stronger for boys than girls. Stealing, property destruction, and fighting independently predicted later CD symptoms. CD symptoms also predicted subsequent ADHD HI symptoms and predicted ODD symptoms at level that approached significance. 

Results support the predictive validity of CD symptoms in preschool.

...First, CD symptoms significantly discriminated 3-year-old children with and without externalizing problems, and were quite rare among children without problems, suggesting these behaviors are not developmentally normative. Second, consistent with recent findings that early CD diagnosis predicts later diagnosis [13,16], CD symptoms at age 3 predicted CD symptoms three years later, even above baseline ODD and ADHD HI symptoms. This result further suggests that early CD symptoms may be of clinical concern and not merely a normative developmental phase. Third, results suggested that three symptoms were particularly useful in predicting later CD symptoms: breaking things, stealing, and fighting. These results are consistent with Loeber et al.’s finding that fighting is an important symptom in school-age children [38]. Fourth, CD symptoms appear to have utility not only in predicting future CD, but also in predicting subsequent ADHD HI and ODD symptoms. In contrast, children with more early symptoms of ADHD HI and ODD were not more likely to show later symptoms of CD. Finally, consistent with previous research [13,16], early CD symptoms more strongly predicted later problems for boys than for girls, though the relationship between early and later CD symptoms was also significant for girls.

The results of this study did not support existing theory and research on older children that suggest that either ODD or ADHD are developmental precursors to CD [3,23–24]. The findings in relation to ADHD HI are in line with a number of studies with younger [42] and older children [28] that suggest that hyperactivity may not predict future CD/aggression once early symptoms are controlled. In fact, for boys in this study, there was an unexpected negative relation between ADHD HI symptoms at age 3 and CD symptoms at age 6 once initial ODD and CD symptoms were controlled. We are not sure how to account for this surprising finding, but we propose two possibilities. First, this could be an instance of suppressor variables. That is, because initial ODD and CD symptoms were controlled for in this analysis, our finding estimates the relation between ADHD HI symptoms and later CD symptoms in boys with equivalent levels of ODD and CD. When early problem behaviors exist, perhaps it is better if these are due to impulsivity that might be somewhat outgrown, than to other, perhaps even more entrenched causes. Second, given the unexpected nature of this finding, it could simply be a Type I error. This study also does not support the notion that ODD may be a developmental precursor to CD, at least during the preschool years. Co-occurrences among these problem types may be the result of common influences, such as coercive parenting cycles or biological risk factors, rather than heterotypic continuity. If in fact ODD and CD develop in parallel, rather than sequentially, it is not clear that CD should preclude a diagnosis of ODD, as is currently specified in DSM-5 [43]. More research is needed to better understand the developmental progression of ADHD HI, ODD, and CD symptoms... 

Full article at:  http://goo.gl/wIei8A

By:  Benjamin Rolon-Arroyo, David H. Arnold, and Elizabeth A. Harvey

University of Massachusetts Amherst

Rolon-Arroyo, B. Department of Psychology (http://www.psych.umass.edu/), University of Massachusetts, 135 Hicks Way, Amherst, 01003, USA ude.ssamu.hcysp@ranolorb

Arnold, D. H. Department of Psychology, University of Massachusetts, 135 Hicks Way, Amherst, 01003, USA ude.ssamu.hcysp@dlonrad

Harvey, E. A. Department of Psychology, University of Massachusetts, 135 Hicks Way, Amherst, 01003, USA ude.ssamu.hcysp@yevrahe

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Does The Impact of Child Sexual Abuse Differ from Maltreated But Non-Sexually Abused Children?

Child sexual abuse (CSA) continues to be a significant problem with significant short and long term consequences. However, extant literature is limited by the reliance on retrospective recall of adult samples, single-time assessments, and lack of longitudinal data during the childhood and adolescent years. 

The purpose of this study was to compare internalizing and externalizing behavior problems of those with a history of sexual abuse to those with a history of maltreatment, but not sexual abuse. We examined whether gender moderated problems over time. Data were drawn from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) at ages 4, 6, 8, 10, 12, 14, and 16 (N=977). The Child Behavior Checklist was used to assess internalizing and externalizing problems. Maltreatment history and types were obtained from official Child Protective Services (CPS) records. Generalized Estimating Equations (GEE) were used to assess behavior problems over time by maltreatment group. 

Findings indicated significantly more problems in the CSA group than the maltreated group without CSA over time. Internalizing problems were higher for sexually abused boys compared to girls. For sexually abused girls internalizing problems, but not externalizing problems increased with age relative to boys. This pattern was similar among maltreated but not sexually abused youth. 

Further efforts are needed to examine the psychological effects of maltreatment, particularly CSA longitudinally as well as better understand possible gender differences in order to best guide treatment efforts.

Purchase full article at:   http://goo.gl/S2scBk

By:   Lewis T1, McElroy E1, Harlaar N1, Runyan D1.

• 1The Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado, Department of Pediatrics, School of Medicine, USA. 

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Masculine Traits and Depressive Symptoms in Older and Younger Men and Women

Evidence suggests that men who strongly endorse masculine traits display an atypical presentation of depression, including more externalizing symptoms (e.g., anger or substance use), but fewer typical, internalizing symptoms (e.g., depressed mood or crying). This phenomenon has not been adequately explored in older adults or women. 

The current study used the externalizing subscale of the Masculine Depression Scale in older and younger men and women to detect atypical symptoms. It was predicted that individuals who more strongly endorsed masculine traits would have higher scores on the measure of externalizing symptoms relative to a measure of typical depressive symptoms Center for Epidemiologic Studies-Depression Scale. It was anticipated that results would differ by age-group but not by gender. 

Multigroup path analysis was used to test the hypothesis. The hypothesized path model, in which endorsement of masculine traits was associated with lower scores on the Center for Epidemiologic Studies-Depression Scale and with scores on the externalizing, but not internalizing, factor of the Masculine Depression Scale, fit the data well. Results differed significantly by age-group and gender. 

Masculine individuals reported lower levels of typical depressive symptoms relative to externalizing symptoms, but further research is needed within age- and gender groups. 

Results are consistent with the gendered responding framework and suggest that current assessment tools, which tend to focus on internalizing symptoms of depression, may not detect depression in individuals who endorse masculine traits.

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

By:   Price EC1, Gregg JJ2, Smith MD3, Fiske A4.

• 1West Virginia University, Morgantown, WV, USA Michael E. Debakey VA Medical Center, Houston, TX, USA eprice2@mix.wvu.edu.
• 2West Virginia University, Morgantown, WV, USA Durham VA Medical Center, Durham, NC, USA.
• 3West Virginia University, Morgantown, WV, USA PSIMED Corrections, LLC, Charleston, WV, USA.
• 4West Virginia University, Morgantown, WV, USA. 

More at:  https://twitter.com/hiv_insight

And: http://twitter.com/Prison_Health

Trajectories of Internalizing & Externalizing Symptoms among Adults with Autism Spectrum Disorders

Individuals with autism spectrum disorder (ASD) experience higher rates of psychopathology than their typically developing peers or peers with other intellectual or developmental disabilities. Little is known about the developmental course of psychiatric symptoms such as internalizing and externalizing behaviors in this population. 

Individual characteristics and aspects of the family environment may explain variability in outcomes for adults with ASD. The present study extends our current understanding of psychopathology among individuals with ASD by examining group-based trajectories of internalizing and externalizing symptoms in adulthood. Overall, the results showed that symptoms became less severe over time. Distinct patterns of change in psychopathology were observed and associated with differential profiles of psychotropic medication use, comorbid mental health diagnoses, and residential placement. The likelihood of following each developmental trajectory was estimated based on characteristics of the adults with ASD (gender, adaptive behavior, and autistic symptoms) and maternal expressed emotion (criticism and warmth). 

Maternal criticism and warmth were identified as key risk and protective factors, respectively, with important implications for future research and intervention for individuals with ASD.

Purchase full article at:   http://goo.gl/0aAj2Y

By:  Woodman AC1, Mailick MR2, Greenberg JS2.

• 1University of Massachusetts-Amherst.
• 2University of Wisconsin-Madison. 

More at:  https://twitter.com/hiv_insight

And:        http://twitter.com/Prison_Health

Early Callous-Unemotional Behavior, Theory-of-Mind, and a Fearful/Inhibited Temperament Predict Externalizing Problems in Middle and Late Childhood

Childhood externalizing problems are more likely to be severe and persistent when combined with high levels of callous-unemotional (CU) behavior. A handful of recent studies have shown that CU behavior can also be reliably measured in the early preschool years, which may help to identify young children who are less likely to desist from early externalizing behaviors. 

The current study extends previous literature by examining the role of CU behavior in very early childhood in the prediction of externalizing problems in both middle and late childhood, and tests whether other relevant child characteristics, including Theory-of-Mind (ToM) and fearful/inhibited temperament moderate these pathways. 

Multi-method data, including parent reports of child CU behavior and fearful/inhibited temperament, observations of ToM, and teacher-reported externalizing problems were drawn from a prospective, longitudinal study of children assessed at ages 3, 6, and 10 (N = 241; 48 % female). Results demonstrated that high levels of CU behavior predicted externalizing problems at ages 6 and 10 over and above the effect of earlier externalizing problems at age 3, but that these main effects were qualified by two interactions. High CU behavior was related to higher levels of externalizing problems specifically for children with low ToM and a low fearful/inhibited temperament. 

The results show that a multitude of child characteristics likely interact across development to increase or buffer risk for child externalizing problems. These findings can inform the development of targeted early prevention and intervention for children with high CU behavior.

Purchase full article at:  http://goo.gl/p4s8Wn

By:   Song JH1, Waller R2, Hyde LW3, Olson SL3.

• 1Center for Human Growth and Development, University of Michigan, Ann Arbor, MI, USA. jjhsong@umich.edu.
• 2Department of Psychology, University of Michigan, Ann Arbor, MI, USA.
• 3Department of Psychology, Center for Human Growth and Development, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA. 

More at:  https://twitter.com/hiv_insight

And: http://twitter.com/Prison_Health

Family Context and Externalizing Correlates of Childhood Animal Cruelty in Adjudicated Delinquents

The purpose of this study was to determine whether childhood animal cruelty is primarily a feature of family context or of externalizing behavior. 

Twenty measures of family context and proactive (fearlessness) and reactive (disinhibition) externalizing behavior were correlated with the retrospective accounts of childhood animal cruelty provided by 1,354 adjudicated delinquents. A cross-sectional analysis revealed that all 20 family context, proactive externalizing, and reactive externalizing variables correlated significantly with animal cruelty. 

Prospective analyses showed that when the animal cruelty variable was included in a regression equation with the 10 family context variables (parental arguing and fighting, parental drug use, parental hostility, and parental knowledge and monitoring of offspring behavior) or in a regression equation with the five reactive externalizing variables (interpersonal hostility, secondary psychopathy, weak impulse control, weak suppression of aggression, and short time horizon), it continued to predict future violent and income (property + drug) offending. 

The animal cruelty variable no longer predicted offending, however, when included in a regression equation with the five proactive externalizing variables (early onset behavioral problems, primary psychopathy, moral disengagement, positive outcome expectancies for crime, and lack of consideration for others). 

These findings suggest that while animal cruelty correlates with a wide range of family context and externalizing variables, it may serve as a marker of violent and nonviolent offending by virtue of its position on the proactive subdimension of the externalizing spectrum.

Purchase full article at:  http://goo.gl/4vUWkW

By:  Walters GD1, Noon A2.

• 1Kutztown University, PA, USA walters@kutztown.edu.
• 2Kutztown University, PA, USA. 

More at:  https://twitter.com/hiv_insight

And: http://twitter.com/Prison_Health

Factors Promoting Mental Health of Adolescents Who Have a Parent with Mental Illness: A Longitudinal Study

Children of parents with mental illness have an elevated risk of developing a range of mental health and psychosocial problems. Yet many of these children remain mentally healthy.

The present study aimed to get insight into factors that protect these children from developing internalizing and externalizing problems.

Several possible individual, parent–child, and family protective factors were examined cross-sectionally and longitudinally in a sample of 112 adolescents. A control group of 122 adolescents whose parents have no mental illness was included to explore whether the protective factors were different between adolescents with and without a parent with mental illness.

Cross-sectional analyses revealed that high self-esteem and low use of passive coping strategies were related to fewer internalizing and externalizing problems. Greater self-disclosure was related to fewer internalizing problems and more parental monitoring was related to fewer externalizing problems. Active coping strategies, parental support, and family factors such as cohesion were unrelated to adolescent problem behavior. Longitudinal analyses showed that active coping, parental monitoring, and self-disclosure were protective against developing internalizing problems 2 years later. We found no protective factors for externalizing problems. Moderation analyses showed that the relationships between possible protective factors and adolescent problem behavior were not different for adolescents with and without a parent with mental illness.

The findings suggest that adolescents’ active coping strategies and parent–child communication may be promising factors to focus on in interventions aimed at preventing the development of internalizing problems by adolescents who have a parent with mental illness.

  

Full article at: http://goo.gl/eEUXr9

By:  L. M. A. Van Loon, M. O. M. Van De Ven, K. T. M. Van Doesum, C. M. H. Hosman, and C. L. M. Witteman

Behavioural Science Institute, Radboud University Nijmegen, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands

Community Mental Health Centre Dimence, Deventer, The Netherlands

L. M. A. Van Loon, Phone: +31 24 36 12 661, Email: ln.ur.hcysp@noolnav.l.

   

More at:  https://twitter.com/hiv_insight