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Wynn A, Mussa A, Ryan R, Babalola CM, Hansman E, Ramontshonyana K, Tamuthiba L, Ndlovu N, Wilson ML, Ramogola-Masire D, Klausner JD, Morroni C. Evaluating Chlamydia trachomatis and Neisseria gonorrhoeae screening and treatment among asymptomatic pregnant women to prevent preterm birth and low birthweight in Gaborone, Botswana: A secondary analysis from a non-randomised, cluster-controlled trial. BJOG 2024; 131:1259-1269. [PMID: 38351649 DOI: 10.1111/1471-0528.17775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 01/05/2024] [Accepted: 01/18/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVE To evaluate the impact of screening and treating asymptomatic pregnant women for Chlamydia (C.) trachomatis and Neisseria (N.) gonorrhoeae infections on the frequency of preterm birth or low birthweight infants in Botswana. DESIGN Non-randomised, cluster-controlled trial. SETTING Four antenatal care clinics in Gaborone, Botswana. POPULATION Pregnant women aged ≥15 years, attending a first antenatal care visit, ≤27 weeks of gestation and without urogenital symptoms were eligible. METHODS Participants in the intervention clinics received screening (GeneXpert®, Cepheid) during pregnancy and at the postnatal visit. Participants in the standard-of-care clinics received screening at the postnatal visit only. We used multivariable logistic regression and post-estimation predictive margins analysis. Post-hoc analysis was conducted among sub-samples stratified by parity. MAIN OUTCOME MEASURES Preterm birth (<37 weeks of gestation) and low birthweight (<2500 g). RESULTS After controlling for parity, hypertension, antenatal care visits and clinic site, the predicted prevalence of preterm birth or low birthweight was lower in the intervention arm (11%) compared with the standard-of-care arm (16%) (adjusted odds ratio [aOR] 0.59; 95% confidence interval [CI] 0.28-1.24). In post-hoc analysis, the intervention was more effective than the standard-of-care (aOR 0.20; 95% CI 0.07-0.64) among nulliparous participants. CONCLUSION A C. trachomatis and N. gonorrhoeae infection screening and treatment intervention among asymptomatic pregnant women may have reduced preterm birth or low birthweight outcomes, but results were not statistically significant. Post-hoc analysis found that the intervention reduced adverse outcomes among nulliparous participants.
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Affiliation(s)
- Adriane Wynn
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, La Jolla, California, USA
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
| | - Aamirah Mussa
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
- Old Medical School, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Rebecca Ryan
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
| | - Chibuzor M Babalola
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Emily Hansman
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Lefhela Tamuthiba
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
| | - Neo Ndlovu
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
| | - Melissa L Wilson
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynaecology, University of Botswana, Sir Ketumile Masire Teaching Hospital/G5038, Gaborone, Botswana
| | - Jeffrey D Klausner
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Chelsea Morroni
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
- MRC Centre for Reproductive Health, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
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Ju I, Elhindi J, Hook M, Melov SJ, Sawleshwarkar S, Yapa HM, Zablotska I, Pasupathy D. Sexually transmitted infections: Prevalence and clinical outcomes among pregnant women in Western Sydney. Int J Gynaecol Obstet 2024; 166:107-114. [PMID: 38654697 DOI: 10.1002/ijgo.15548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/18/2024] [Accepted: 04/05/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE We report the prevalence, characteristics and clinical outcomes of women with sexually transmitted infections (STIs) in pregnancy in the Western Sydney Local Health District (WSLHD) serving a large culturally and socio-economically diverse community in New South Wales (NSW), Australia, over the last 10 years. METHODS A retrospective cohort study of all pregnant women booked for antenatal care at three hospitals in WSLHD between September 2012 and August 2022 inclusive. Characteristics and birth outcomes associated with STIs diagnosed in pregnancy (chlamydia, gonorrhea, and syphilis) are reported using multivariable logistic regression adjusting for relevant confounders. RESULTS During 2012-2022, there were 102 905 births and 451 women (0.44%) with an STI diagnosis during pregnancy. The number of women with a history of chlamydia prior to their current pregnancy has increased over the last 10 years (P < 0.001). STIs in pregnancy were more common in younger women aged <20 years (adjusted odds ratio [aOR] 7.30, 95% confidence interval [CI] 5.04-10.57), 20-24 years (aOR 3.12, 95% CI 2.46-3.96), and >40 years (adj OR 1.67, 95% CI 1.07-2.59), in women with body mass index >30 (aOR 1.73, 95%CI 1.37-2.19), and those who smoked (aOR 2.24, 95% CI 1.71-2.94) and consumed alcohol (aOR 3.14, 95% CI 1.88-5.23) and illicit drugs (aOR 2.10, 95% CI 1.31-3.36). STIs in pregnancy were borderline associated with stillbirth (aOR 2.19 95% CI 0.90-5.36) but did not have a significant impact on preterm birth (aOR 1.21, 95% CI 0.87-1.68), admission to neonatal intensive care unit (NICU) (aOR 1.02, 95% CI 0.77-1.34), or having a small-for-gestational-age (SGA) baby (aOR 0.97, 95% CI 0.74-1.27). CONCLUSIONS Sociodemographic factors such as age, weight, smoking, and alcohol and drug use, were associated with the STI incidence in pregnancy. While the latter did not have an impact on preterm birth, NICU admission, and SGA in our cohort, there was a borderline association with stillbirth. Future research should identify barriers and facilitators to testing in a multicultural population and understanding the drivers of higher rates of STIs in certain population groups.
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Affiliation(s)
- I Ju
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Obstetrics and Gynaecology, Westmead Hospital, Sydney, New South Wales, Australia
| | - J Elhindi
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - M Hook
- Department of Obstetrics and Gynaecology, Westmead Hospital, Sydney, New South Wales, Australia
| | - S J Melov
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Institute of Maternal Fetal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - S Sawleshwarkar
- Western Sydney Sexual Health Centre, Sydney, New South Wales, Australia
| | - H M Yapa
- Sydney Infectious Diseases Institute, Faculty of Medicine & Health, University of Sydney, Sydney, New South Wales, Australia
| | - I Zablotska
- Western Sydney Sexual Health Centre, Sydney, New South Wales, Australia
| | - D Pasupathy
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Institute of Maternal Fetal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
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Shiluli C, Kamath S, N. Kanoi B, Kimani R, Maina M, Waweru H, Kamita M, Ndirangu I, M. Abkallo H, Oduor B, Pamme N, Dupaty J, M. Klapperich C, Raju Lolabattu S, Gitaka J. Multi-repeat sequences identification using genome mining techniques for developing highly sensitive molecular diagnostic assay for the detection of Chlamydia trachomatis. OPEN RESEARCH AFRICA 2024; 7:2. [PMID: 38783971 PMCID: PMC11109563 DOI: 10.12688/openresafrica.14316.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/22/2024] [Indexed: 05/25/2024]
Abstract
Chlamydia trachomatis ( C. trachomatis) is a common sexually transmitted infection (STI). In 2019, the World Health Organization reported about 131 million infections. The majority of infected patients are asymptomatic with cases remaining undetected. It is likely that missed C. trachomatis infections contribute to preventable adverse health outcomes in women and children. Consequently, there is an urgent need of developing efficient diagnostic methods. In this study, genome-mining approaches to identify identical multi-repeat sequences (IMRS) distributed throughout the C. trachomatis genome were used to design a primer pair that would target regions in the genome. Genomic DNA was 10-fold serially diluted (100pg/μL to 1×10 -3pg/μL) and used as DNA template for PCR reactions. The gold standard PCR using 16S rRNA primers was also run as a comparative test, and products were resolved on agarose gel. The novel assay, C. trachomatis IMRS-PCR, had an analytical sensitivity of 4.31 pg/µL, representing better sensitivity compared with 16S rRNA PCR (9.5 fg/µL). Our experimental data demonstrate the successful development of lateral flow and isothermal assays for detecting C. trachomatis DNA with potential use in field settings. There is a potential to implement this concept in miniaturized, isothermal, microfluidic platforms, and laboratory-on-a-chip diagnostic devices for reliable point-of-care testing.
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Affiliation(s)
- Clement Shiluli
- Centre for Research in Infectious Diseases, College of Graduate Studies and Research, Mount Kenya University, Thika, Kiambu County, Kenya
| | - Shwetha Kamath
- Division of Research and Development, Jigsaw Bio Solutions Private Limited, Bangalore, India
| | - Bernard N. Kanoi
- Centre for Research in Infectious Diseases, College of Graduate Studies and Research, Mount Kenya University, Thika, Kiambu County, Kenya
| | - Racheal Kimani
- Centre for Research in Infectious Diseases, College of Graduate Studies and Research, Mount Kenya University, Thika, Kiambu County, Kenya
| | - Michael Maina
- Centre for Research in Infectious Diseases, College of Graduate Studies and Research, Mount Kenya University, Thika, Kiambu County, Kenya
| | - Harrison Waweru
- Centre for Research in Infectious Diseases, College of Graduate Studies and Research, Mount Kenya University, Thika, Kiambu County, Kenya
| | - Moses Kamita
- Centre for Research in Infectious Diseases, College of Graduate Studies and Research, Mount Kenya University, Thika, Kiambu County, Kenya
| | - Ibrahim Ndirangu
- Centre for Research in Infectious Diseases, College of Graduate Studies and Research, Mount Kenya University, Thika, Kiambu County, Kenya
| | - Hussein M. Abkallo
- Animal and Human Health Program, International Livestock Research Institute, Nairobi, Nairobi County, Kenya
| | - Bernard Oduor
- Animal and Human Health Program, International Livestock Research Institute, Nairobi, Nairobi County, Kenya
| | - Nicole Pamme
- Department of Materials and Environmental Chemistry, Stockholm University, Stockholm, Stockholm County, Sweden
| | - Joshua Dupaty
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, USA
| | | | | | - Jesse Gitaka
- Centre for Research in Infectious Diseases, College of Graduate Studies and Research, Mount Kenya University, Thika, Kiambu County, Kenya
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Hansman E, Mussa A, Ryan R, Babalola CM, Ramontshonyana K, Tamuthiba L, Ndlovu N, Bame B, Klausner JD, Morroni C, Wynn A. Use of Expedited Partner Therapy for Pregnant Women Treated for Sexually Transmitted Infections in Gaborone, Botswana. Sex Transm Dis 2024; 51:331-336. [PMID: 38301627 DOI: 10.1097/olq.0000000000001928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
BACKGROUND Partner notification and treatment for sexually transmitted infections are critical to prevent reinfection and reduce transmission. However, partner treatment rates are low globally. Expedited partner therapy (EPT), in which the patient delivers treatment directly to their partner, may result in more partners treated. We assessed partner notification and treatment outcomes among pregnant women in Gaborone, Botswana, including EPT intent, uptake, and effectiveness. METHODS The Maduo study was a cluster-controlled trial evaluating the effect of antenatal Chlamydia trachomatis and Neisseria gonorrhoeae infection screening in pregnant women. The intervention arm received screening at first antenatal care (ANC), third-trimester, and postnatal care visits. The standard-of-care arm received screening postnatally. Participants screening positive were given options for partner treatment: contact slips, in-clinic treatment, or EPT. Self-reported partner notification and treatment outcomes were assessed at test-of-cure visit. RESULTS Of 51 women who screened positive for C. trachomatis / N. gonorrhoeae at first ANC and returned for test of cure, 100% reported notifying their partner and 48 (94.1%) reported their partner received treatment. At third trimester 100% (n = 5), reported partners were treated. Before testing, EPT intent was lower than EPT uptake at all time points (first ANC: 17.9% vs. 80.4%; third-trimester: 57.1% vs. 71.4%; postnatal care: 0% vs. 80.0%). Partner treatment success was 100% among EPT users compared with 70% among nonusers ( P = 0.006). CONCLUSIONS Partner notification and treatment success was high in this population. Despite low pretest intent to use EPT, uptake was high and associated with greater partner treatment success. Our findings suggest that EPT may be a successful partner treatment strategy to pursue in low- and middle-income countries.
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Affiliation(s)
| | | | - Rebecca Ryan
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
| | - Chibuzor M Babalola
- Keck School of Medicine, University of Southern California, 1845 N. Soto Street, Los Angeles, CA
| | | | - Lefhela Tamuthiba
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
| | - Neo Ndlovu
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
| | - Bame Bame
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
| | - Jeffrey D Klausner
- Keck School of Medicine, University of Southern California, 1845 N. Soto Street, Los Angeles, CA
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5
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Wynn A, Morroni C, Klausner JD. Further Considerations Regarding Molecular Screening and Treatment of Bacterial Vaginosis. JAMA Pediatr 2024; 178:94-95. [PMID: 37930708 DOI: 10.1001/jamapediatrics.2023.4755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Adriane Wynn
- Division of Infectious Diseases and Global Public Health, University of California, San Diego
| | - Chelsea Morroni
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
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Mussa A, Wynn A, Ryan R, Babalola CM, Hansman E, Simon S, Bame B, Tamuthiba L, Ramontshonyana K, Ndlovu N, Moshashane N, Masole M, Klausner JD, Morroni C. Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infection and associated factors among asymptomatic pregnant women in Botswana. Int J STD AIDS 2023:9564624231163203. [PMID: 36930946 DOI: 10.1177/09564624231163203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
BACKGROUND Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae) are curable sexually transmitted infections (STIs) that cause adverse pregnancy and neonatal outcomes. Most countries, including Botswana, do not offer C. trachomatis or N. gonorrhoeae screening during antenatal care (ANC) and instead use a syndromic approach for management of STIs. METHODS The Maduo Study is a prospective, cluster-controlled trial in Botswana evaluating the impact of diagnostic screening for antenatal C. trachomatis and N. gonorrhoeae infections to prevent adverse neonatal outcomes. Using baseline data from the Maduo Study (March 2021-March 2022), we determined the prevalence of C. trachomatis and N. gonorrhoeae infection among asymptomatic pregnant women in Botswana and correlates of infection using multivariable logistic regression. RESULTS Of 251 women who underwent C. trachomatis and N. gonorrhoeae screening at first ANC visit, 55 (21.9%, 95%CI 17.0-27.5) tested positive for C. trachomatis, 1 (0.4%, 95%CI 0-2.2) for N. gonorrhoeae; and 2 (0.8%, 95%CI 0-2.8) for dual C. trachomatis and N. gonorrhoeae infection. Older age was associated with lower odds (aOR 0.93; 95%CI 0.88-0.98; p = 0.011) while any alcohol use during pregnancy was associated with higher odds (aOR = 3.53; 95%CI 1.22-10.16; p = 0.020) of testing positive for C. trachomatis or N. gonorrhoeae. CONCLUSIONS A high frequency of C. trachomatis infections was detected among asymptomatic pregnant women in Botswana indicating that many antenatal STIs are missed by the syndromic management approach. Our results highlight the need for diagnostic C. trachomatis screening during ANC in Botswana and other low- and middle-income countries that rely solely on the syndromic approach for management of STIs.
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Affiliation(s)
- Aamirah Mussa
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Adriane Wynn
- Division of Infectious Diseases and Global Public Health, 8784University of California San Diego, La Jolla, CA, USA
| | - Rebecca Ryan
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Emily Hansman
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,University of California, Los Angeles, CA, USA
| | - Selebaleng Simon
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Bame Bame
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Lefhela Tamuthiba
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Neo Ndlovu
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Neo Moshashane
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Maitumelo Masole
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Chelsea Morroni
- 292006Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
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7
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Mussa A, Wynn A, Ryan R, Babalola C, Simon S, Ramontshonyana K, Tamuthiba L, Ndlovu N, Moshashane N, Klausner JD, Morroni C. High Cure Rate Among Pregnant Women in a Chlamydia trachomatis and Neisseria gonorrhoeae Testing and Treatment Intervention Study in Gaborone, Botswana. Sex Transm Dis 2023; 50:124-127. [PMID: 36630419 DOI: 10.1097/olq.0000000000001725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Abstract
A high cure rate was observed after testing and treatment of Chlamydia trachomatis and Neisseria gonorrhoeae infection among pregnant women in a nonrandomized cluster trial in Gaborone, Botswana.
Between March 2021 and March 2022, 251 pregnant women were tested for Chlamydia trachomatis and Neisseria gonorrhoeae infection in Botswana. Fifty-eight (23%) tested positive for at least 1 infection, and 57 (98%) were treated. No participants tested positive at test of cure. In some settings, cost of test of cure may outweigh the benefits.
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Affiliation(s)
| | - Adriane Wynn
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, La Jolla
| | - Rebecca Ryan
- From the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Selebaleng Simon
- From the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Lefhela Tamuthiba
- From the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Neo Ndlovu
- From the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Neo Moshashane
- From the Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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8
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Babalola CM, Siebert JC, Kallapur SG, Maecker HT, Rosenberg-Hasson Y, Hansman E, Wynn A, Mussa A, Ryan R, Simon S, Morroni C, Klausner JD. Discrete Plasma Cytokine Profiles among Pregnant Women in Botswana by Chlamydia trachomatis infection, HIV status, and Gestational age. J Infect Dis 2022; 226:1298-1299. [PMID: 35876733 DOI: 10.1093/infdis/jiac302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Chibuzor M Babalola
- Keck School of Medicine Department of Population and Public Health Sciences at University of Southern California, Los Angeles, CA 90033, USA
| | | | - Suhas G Kallapur
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles 90095, USA.,University of California, Los Angeles Mattel Children's Hospital, 10833 Le Conte Avenue, Los Angeles, CA 90095
| | - Holden T Maecker
- Institute for Immunity, Transplantation, and Infection, Stanford University School of Medicine, Stanford, CA 94305USA
| | - Yael Rosenberg-Hasson
- Institute for Immunity, Transplantation, and Infection, Stanford University School of Medicine, Stanford, CA 94305USA
| | - Emily Hansman
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles 90095, USA
| | - Adriane Wynn
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA 92093USA
| | - Aamirah Mussa
- Botswana Sexual and Reproductive Health Research Initiative, Botswana-Harvard AIDS Institute Partnership, Gaborone, Private Bag BO 320.,Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Rebecca Ryan
- Botswana Sexual and Reproductive Health Research Initiative, Botswana-Harvard AIDS Institute Partnership, Gaborone, Private Bag BO 320
| | - Selebaleng Simon
- Botswana Sexual and Reproductive Health Research Initiative, Botswana-Harvard AIDS Institute Partnership, Gaborone, Private Bag BO 320
| | - Chelsea Morroni
- Botswana Sexual and Reproductive Health Research Initiative, Botswana-Harvard AIDS Institute Partnership, Gaborone, Private Bag BO 320.,Medical Research Council Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom UK EH16 4TJ
| | - Jeffrey D Klausner
- Keck School of Medicine Department of Population and Public Health Sciences at University of Southern California, Los Angeles, CA 90033, USA
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