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Medeiros DSD, Magno L, Crosland Guimarães MD, Grangeiro A, Filho ME, Soares F, Greco D, Westin M, Ferraz D, Zucchi EM, Dourado I. Violence, Discrimination, and High Levels of Symptoms of Depression Among Adolescent Men Who Have Sex With Men and Transgender Women in Brazil. J Adolesc Health 2023; 73:S19-S25. [PMID: 37953004 DOI: 10.1016/j.jadohealth.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE This study aimed at describing the prevalence of symptoms of depression among 15-19 year old adolescent men who have sex with men (aMSM) and transgender women (aTGW), who were recruited in an HIV pre-exposure prophylaxis cohort study in three Brazilian capital cities. The study also examined potential associations, including violence and discrimination, with severe symptoms of depression among aMSM. METHODS This is a cross-sectional study of baseline data among 730 aMSM and 56 aTGW recruited between February 2019 and February 2021. Sociodemographic and behavioral data were collected. The 20-item Center for Epidemiologic Studies Depression scale was used to screen for symptoms of depression. Scores of ≥22 points indicate the presence of severe symptoms associated with major depression. Logistic regression was used to assess independent associations among aMSM, adjusting for sociodemographic variables. RESULTS Our findings indicate a high prevalence of symptoms of depression (overall prevalence = 58.5% and 69.6%; 21.2% and 25.0% for mild/moderate, and 37.3% and 44.6% for severe) among these aMSM and aTGW, respectively. Psychological violence (aOR = 1.74; 95% CI = 1.12-2.70), sexual violence (aOR = 1.79; 95% CI = 1.07-2.98), and discrimination due to sexual orientation (aOR = 1.71; 95% CI = 1.23-2.38) were independently associated with severe symptoms of depression in aMSM. DISCUSSION The high prevalence of severe symptoms of depression and its association with psychological and sexual violence and discrimination creates cycles of vulnerability and carries important public health implications. Thus, our findings indicate public policies should consider assessing depression, psychological and sexual violence, as well as discrimination, especially in populations that will be targeted by interventions, such as the use of pre-exposure prophylaxis.
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Affiliation(s)
- Danielle Souto de Medeiros
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista, Bahia, Brazil.
| | - Laio Magno
- Departmento de Ciências da Saúde, Universidade do Estado da Bahia, Salvador, Bahia, Brazil
| | | | - Alexandre Grangeiro
- Departmento de Medicina Preventiva, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Marcos Eustorgio Filho
- Instituto de Matemática e Estatística, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | - Fabiane Soares
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | - Dirceu Greco
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Mateus Westin
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Dulce Ferraz
- Fundação Oswaldo Cruz (Fiocruz), Diretoria Regional de Brasília, Brasília, Brazil; gUMR Inserm 1296 - Radiations: Défense Santé Environnement, Université Lumière Lyon 2, Lyon, France
| | - Eliana Miura Zucchi
- Programa de Pós-Graduação em Saúde Coletiva, Universidade Católica de Santos, Santos, São Paulo, Brazil
| | - Inês Dourado
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Bahia, Brazil
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Ferraz D, Rossi TA, Zucchi EM, de Deus LFA, Mabire X, Ferguson L, Magno L, Grangeiro A, Préau M, Botelho FC, Rodrigues A, Steele S, Dourado I. "I Can't Take This Shitty Quarantine Anymore": Sexual Behavior and PrEP Use Among Young Men Who Have Sex with Men and Transgender Women in Brazil During the COVID-19 Pandemic. Arch Sex Behav 2023; 52:689-702. [PMID: 35881251 PMCID: PMC9321283 DOI: 10.1007/s10508-022-02364-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 06/15/2023]
Abstract
This study analyzes how the COVID-19 pandemic affected sexual behavior and use of HIV prevention methods among young transgender women (YTGW) and young gay, bisexual and other men who have sex with men (YGBMSM) participating in an HIV pre-exposure prophylaxis (PrEP) demonstration study in Brazil. Online interviews with 39 participants aged 15-22 years old were conducted between September and November 2020 and analyzed based on social constructionism and human rights-based approaches to health. The pandemic disrupted interviewees' routines, negatively affecting their life conditions. Among those who did not have a steady partner, social distance measures led to temporary interruption of sexual encounters and increased sexting and solo sex. Conversely, for those who had a steady relationship such measures contributed to increasing sexual practices and intimacy. Participants who had sexual encounters during the pandemic reported having continued to use PrEP. However, home confinement with family, lack of privacy, loss of daily routines and changes in housing impaired PrEP adherence and attendance at follow-up consultations. These results highlight the importance of maintaining HIV-service delivery for these groups during a public health crisis, as well as to address the structural drivers of the epidemic with comprehensive HIV prevention policies and by ensuring access of YGBMSM and YTGW to social protection policies.
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Affiliation(s)
- Dulce Ferraz
- UMR 1296 "Radiations: Défense, Santé, Environnement", Université Lyon 2, Lyon, France.
- Institut de Psychologie, Université de Lausanne, Lausanne, Switzerland.
- Escola FIOCRUZ de Governo, Fundação Oswaldo Cruz (FIOCRUZ), Brasília, Brazil.
| | - Thais Aranha Rossi
- Departamento de Ciências da Vida, Universidade do Estado da Bahia (UNEB), Salvador, Brazil
| | - Eliana Miura Zucchi
- Programa de Pós-Graduação em Saúde Coletiva, Mestrado Profissional em Psicologia e Políticas Públicas, Universidade Católica de Santos (UniSantos), Santos, Brazil
| | - Luiz Fabio Alves de Deus
- Programa de Pós-Graduação em Psicologia Social e Institucional, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Xavier Mabire
- UMR 1296 "Radiations: Défense, Santé, Environnement", Université Lyon 2, Lyon, France
- Institut de Psychologie, Université de Lausanne, Lausanne, Switzerland
| | - Laura Ferguson
- Institute on Inequalities in Global Health, University of Southern California, Los Angeles, CA, USA
| | - Laio Magno
- Departamento de Ciências da Vida, Universidade do Estado da Bahia (UNEB), Salvador, Brazil
| | - Alexandre Grangeiro
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marie Préau
- UMR 1296 "Radiations: Défense, Santé, Environnement", Université Lyon 2, Lyon, France
| | - Fernanda Cangussu Botelho
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Ayra Rodrigues
- Programa de Pós-Graduação em Saúde Coletiva, Mestrado Profissional em Psicologia e Políticas Públicas, Universidade Católica de Santos (UniSantos), Santos, Brazil
| | - Sabrina Steele
- Departamento de Ciências da Vida, Universidade do Estado da Bahia (UNEB), Salvador, Brazil
| | - Inês Dourado
- Instituto de Saúde Coletiva, Universidade Federal da Bahia (UFBA), Salvador, Brazil
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Lin B, Liu J, He W, Pan H, Zhong X. Psychological Status of Men Who Have Sex with Men during COVID-19: An Online Cross-Sectional Study in Western China. Int J Environ Res Public Health 2023; 20:1333. [PMID: 36674087 PMCID: PMC9858883 DOI: 10.3390/ijerph20021333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/03/2023] [Accepted: 01/07/2023] [Indexed: 06/17/2023]
Abstract
Background: The psychological status of men who have sex with men (MSM) as a vulnerable population during COVID-19 is worthy of attention. However, studies of Chinese MSM are limited. The aim of this study was to investigate the psychological status and influencing factors of MSM population and to provide a scientific basis for this group to actively respond to public health emergencies. Methods: From June to September 2020, we conducted an online survey. MSMs were recruited through collaboration with non-governmental organizations (NGOs) and peer recommendations. The variables we collected included four aspects: demographic and HIV-related characteristics; COVID-19-related knowledge, attitudes, and behaviors; COVID-19-related risk perception; epidemic exposure. The psychological status was assessed by the Psychological Questionnaire for Emergent Events of Public Health (PQEEPH), which defined the psychological status as five primary disorders: depression, neurasthenia, fear, anxiety, and hypochondria. Multivariate logistic regression was used to explore the influences of COVID-19-related factors on the psychological status. Results: We surveyed 412 MSM online during COVID-19. The five psychological status of high-risk states accounted for 16.99% (depression), 14.08% (neurasthenia), 16.75% (fear), 16.50% (anxiety), and 18.20% (hypochondria), respectively. Not being well-informed about the causes of COVID-19 (p = 0.020) and having experienced epidemic exposure (p = 0.006) were able to promote the occurrence of depression. Lack of knowledge of the curative effect of COVID-19 has a higher risk of occurrence neurasthenia (p < 0.001). Being afraid of the novel coronavirus (p < 0.001) promoted fear. The perceived prevalence of the epidemic (p = 0.003), being more susceptible to COVID-19 (p < 0.001), and not being well-informed about the causes of COVID-19 (p = 0.005) had a positive effect on anxiety. Considering that the epidemic was not effectively controlled (p = 0.017), being more susceptible to COVID-19 (p < 0.001) was a contributing factor to the hypochondria. Conclusions: The incidence of psychological disorders in Chinese MSM was higher than that in other groups during COVID-19. Factors associated with COVID-19 may cause a range of mental health problems in this population. Greater attention should be paid to the mental health status of special populations during the epidemic, and effective preventive education and intervention measures should be taken.
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Affiliation(s)
- Bing Lin
- School of Public Health, Chongqing Medical University, Chongqing 400016, China
- Research Center for Medicine and Social Development, Chongqing 400010, China
| | - Jiaxiu Liu
- School of Medical Informatics, Chongqing Medical University, Chongqing 400016, China
| | - Wei He
- School of Public Health, Chongqing Medical University, Chongqing 400016, China
- Research Center for Medicine and Social Development, Chongqing 400010, China
| | - Haiying Pan
- School of Public Health, Chongqing Medical University, Chongqing 400016, China
- Research Center for Medicine and Social Development, Chongqing 400010, China
| | - Xiaoni Zhong
- School of Public Health, Chongqing Medical University, Chongqing 400016, China
- Research Center for Medicine and Social Development, Chongqing 400010, China
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Santos CC, de M. Lima FW, Magno L, Soares F, Ferraz D, Grangeiro A, Zucchi EM, Préau M, Mabire X, Matos HRSS, Dourado I. Seroprevalence of anti-SARS-CoV-2 antibodies and factors associated with infection among adolescent men who have sex with men and transgender women in Salvador, Brazil. BMC Public Health 2023; 23:61. [PMID: 36624484 PMCID: PMC9829219 DOI: 10.1186/s12889-022-14969-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/29/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Brazil was strongly affected by the COVID-19 pandemic and the impact of the pandemic on sexual and gender minorities' youth remains unknown. This study aimed to estimate the seroprevalence of SARS-CoV-2 antibodies and associated factors among adolescent men who have sex with men (AMSM) and transgender women (ATGW) participants of a human immunodeficiency virus (HIV) pre-exposure prophylaxis cohort study (PrEP1519). METHODS This is a cross-sectional design conducted between June and October 2020 in Salvador, Brazil. Serum samples were collected from AMSM and ATGW aged 16-21 years between June-October 2020. IgG and IgM anti-SARS-CoV-2 were detected by chemiluminescence immunoassay, and data were collected through a socio-behavioral questionnaire. RESULTS Among the 137 participants, the seroprevalence of anti-SARS-CoV-2 IgG and IgM was 20.4%; 16.8% of the participants were positive for IgG, and 11.7% for IgM. In the multivariable analysis, the seroprevalence was two times higher among those who never wore masks (OR= 2.22; 95% CI: 1.08-4.57) and among those who believed that they could be easily cured of the disease (OR= 2.05; 95% CI: 1.05-4.01). CONCLUSIONS The high seroprevalence of SARS-CoV-2 antibodies among gender and sexual minority youth seems to be informed by behaviors and attitudes that contrast with public health measures and the potential severity of the disease when vaccination was still not available.
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Affiliation(s)
- Carina C. Santos
- grid.8399.b0000 0004 0372 8259Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal da Bahia, Salvador, Brazil
| | - Fernanda W. de M. Lima
- grid.8399.b0000 0004 0372 8259Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal da Bahia, Salvador, Brazil
| | - Laio Magno
- grid.442053.40000 0001 0420 1676Departamento de Ciências da Vida, Universidade do Estado da Bahia, Salvador, Brazil ,grid.8399.b0000 0004 0372 8259Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil
| | - Fabiane Soares
- grid.8399.b0000 0004 0372 8259Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil
| | - Dulce Ferraz
- grid.418068.30000 0001 0723 0931Escola FIOCRUZ de Governo, Fundação Oswaldo Cruz, Brasília, Brazil ,Pole of Social Psychology, UMR 1296 Radiations: Défense, Santé, Environnement, Université Lyon 2, Lyon, France ,grid.9851.50000 0001 2165 4204PHASE (Psychology of Health, Aging and Sport Examination), Faculty of Social and Political Science, University of Lausanne, Lausanne, Switzerland
| | - Alexandre Grangeiro
- grid.11899.380000 0004 1937 0722Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eliana Miura Zucchi
- grid.412267.40000 0000 9074 7896Programa de Pós-Graduação em Saúde Coletiva, Universidade Católica de Santos, Santos, Brazil
| | - Marie Préau
- Pole of Social Psychology, UMR 1296 Radiations: Défense, Santé, Environnement, Université Lyon 2, Lyon, France ,grid.9851.50000 0001 2165 4204Institut de Psychologie, Université de Lausanne, Lausanne, Switzerland
| | - Xavier Mabire
- Pole of Social Psychology, UMR 1296 Radiations: Défense, Santé, Environnement, Université Lyon 2, Lyon, France ,grid.9851.50000 0001 2165 4204PHASE (Psychology of Health, Aging and Sport Examination), Faculty of Social and Political Science, University of Lausanne, Lausanne, Switzerland
| | - Helen R. S. S. Matos
- grid.8399.b0000 0004 0372 8259Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal da Bahia, Salvador, Brazil
| | - Inês Dourado
- grid.8399.b0000 0004 0372 8259Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil
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Cluver LD, Sherr L, Toska E, Zhou S, Mellins CA, Omigbodun O, Li X, Bojo S, Thurman T, Ameyan W, Desmond C, Willis N, Laurenzi C, Nombewu A, Tomlinson M, Myeketsi N. From surviving to thriving: integrating mental health care into HIV, community, and family services for adolescents living with HIV. Lancet Child Adolesc Health 2022; 6:582-592. [PMID: 35750063 DOI: 10.1016/s2352-4642(22)00101-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 01/10/2023]
Abstract
Adolescents are a crucial generation, with the potential to bring future social and economic success for themselves and their countries. More than 90% of adolescents living with HIV reside in sub-Saharan Africa, where their mental health is set against a background of poverty, familial stress, service gaps, and an HIV epidemic that is now intertwined with the COVID-19 pandemic. In this Series paper, we review systematic reviews, randomised trials, and cohort studies of adolescents living with and affected by HIV. We provide a detailed overview of mental health provision and collate evidence for future approaches. We find that the mental health burden for adolescents living with HIV is high, contributing to low quality of life and challenges with adherence to antiretroviral therapy. Mental health provision is scarce, infrastructure and skilled providers are missing, and leadership is needed. Evidence of effective interventions is emerging, including specific provisions for mental health (eg, cognitive behavioural therapy, problem-solving, mindfulness, and parenting programmes) and broader provisions to prevent drivers of poor mental health (eg, social protection and violence prevention). We provide evidence of longitudinal associations between unconditional government grants and improved mental health. Combinations of economic and social interventions (known as cash plus care) could increase mental health benefits. Scalable delivery models include task sharing, primary care integration, strengthening families, and a pyramid of provision that differentiates between levels of need, from prevention to the care of severe disorders. A turning point has now been reached, from which complacency cannot persist. We conclude that there is substantial need, available frameworks, and a growing evidence base for action while infrastructure and skill acquisition is built.
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Affiliation(s)
- Lucie D Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
| | - Lorraine Sherr
- Institute of Global Health, University College London, London, UK
| | - Elona Toska
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK; Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
| | - Siyanai Zhou
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Claude-Ann Mellins
- HIV Center for Clinical and Behavioral Studies, Department of Psychiatry, New York State Psychiatric Institute, New York, NY, USA; Columbia University Irving Medical Center, New York, NY, USA
| | - Olayinka Omigbodun
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Xiaoming Li
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Samuel Bojo
- Agency for Research and Development Initiative, Juba, South Sudan
| | - Tonya Thurman
- Highly Vulnerable Children Research Center, Cape Town, South Africa; Tulane University School of Public Health, New Orleans, LA, USA
| | - Wole Ameyan
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Chris Desmond
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | | | - Christina Laurenzi
- Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Amahle Nombewu
- Teen Advisory Group, University of Cape Town, Cape Town, South Africa
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa; School of Nursing and Midwifery, Queens University, Belfast, UK
| | - Noxolo Myeketsi
- Department of Information Systems, University of the Western Cape, Cape Town, South Africa
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Rusley JC, Tao J, Koinis-Mitchell D, Rosenthal AE, Montgomery MC, Nunez H, Chan PA. Trends in risk behaviors and sexually transmitted infections among youth presenting to a sexually transmitted infection clinic in the United States, 2013-2017. Int J STD AIDS 2022; 33:634-640. [PMID: 35387518 DOI: 10.1177/09564624221077785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Sexually transmitted infections (STIs) are increasing among adolescents and young adults (AYA) across the United States. However, data are scarce on trends in condom use, number of partners, and other STI risk factors among AYA. The present study evaluated associations between sexual behaviors and STI diagnoses over time among AYA. Methods: We evaluated linked encounters of AYA aged 13-26 attending an urban Northeast public STI clinic from 2013-2017. Demographics, risk behaviors, self-reported past year and lifetime STI, and STI diagnosis during clinic encounter (positive test for urine, oral, or anal chlamydia; urine, oral, or anal gonorrhea; urine trichomonas; HIV; and syphilis) were extracted from electronic health records. We estimated prevalence and performed trend analyses of the repeated cross-sectional data. Cochran-Armitage and Kruskal-Wallis trend test were conducted for categorical and continuous variables, respectively. Results: Among 3822 encounters, clinical STIs demonstrated statistically significant increases including chlamydia (+9%, p = 0.001), gonorrhea (+5%, p = 0.008), and syphilis (+3%, p = 0.006) all of which significantly increased over time, as did any STI (+10%, p < 0.001). HIV and trichomonas rates remained low and unchanged. Self-reported STI increased as well, both past year (+9%) and lifetime (+14%). Greater proportions of AYA reported multiple partners (+9%, p < 0.001), and condomless oral (+12%, p = 0.001) and vaginal/anal (+7%, p = 0.001) sex. Conclusion: Among AYA presenting to a STI clinic, the proportion who engaged in condomless sex and had multiple partners increased over a 5 year period, which corresponded to increased STI prevalence during this period. Preventions efforts for AYA should continue to emphasize the importance of condoms and partner selection.
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Affiliation(s)
- Jack C Rusley
- Department of Pediatrics, Division of Adolescent Medicine, RinggoldID:12321Alpert Medical School of Brown University, Providence, RI, USA.,Department of Health Services, Policy, and Practice, RinggoldID:12321Brown University School of Public Health, Providence RI
| | - Jun Tao
- Department of Pediatrics, Division of Adolescent Medicine, RinggoldID:12321Alpert Medical School of Brown University, Providence, RI, USA
| | - Daphne Koinis-Mitchell
- Department of Pediatrics, Department of Psychiatry and Human Behavior, 174610Alpert Medical School of Brown University, Providence, RI, USA
| | - Alex E Rosenthal
- Department of Pediatrics, Division of Adolescent Medicine, RinggoldID:12321Alpert Medical School of Brown University, Providence, RI, USA
| | - Madeline C Montgomery
- Department of Medicine, Division of Infectious Diseases, RinggoldID:12321Alpert Medical School of Brown University, Providence, RI, USA.,Department of Behavioral and Social Sciences, 12321Brown University School of Public Health, Providence RI
| | - Hector Nunez
- Department of Medicine, Division of Infectious Diseases, RinggoldID:12321Alpert Medical School of Brown University, Providence, RI, USA
| | - Philip A Chan
- Department of Medicine, Division of Infectious Diseases, RinggoldID:12321Alpert Medical School of Brown University, Providence, RI, USA
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