Open Access Archives - Page 6 of 35 - Implementation Science at UW

✪ Impact of a stakeholder selected implementation strategy package – fast tracking, provider re-training, and co-location – on PrEP implementation for pregnant women in antenatal care clinics in western Kenya

Abstract:

Background

Pre-exposure prophylaxis (PrEP) is recommended for HIV prevention in pregnant and postpartum women at substantial ongoing risk for HIV. In resource-limited settings, there exist gaps in the integration of PrEP into antenatal care.

Methods

We conducted a difference-in-differences analytic approach (3 months pre- and 3 months post) between January 2022 and July 2022 in 8 facilities (4 intervention and 4 comparison) in western Kenya. During the 6-month period, we tested a combination of 2 stakeholder selected implementation strategies – retraining health providers and fast tracking PrEP clients– to improve PrEP delivery. All study facilities dispensed PrEP in the Maternal and Child health clinics (MCH). We evaluated absolute changes in: PrEP penetration, PrEP fidelity, client PrEP knowledge, client satisfaction, and client waiting and service times as outcomes specified a priori while PrEP offer and HIV testing were outcomes specified post hoc. We measured acceptability and appropriateness by providers of the implementation strategies using AIM and IAM respectively.

Results

We observed statistically significant improvements in PrEP penetration and PrEP offer (p < 0.05) and non-significant improvements in fidelity. PrEP penetration increased 6 percent points (p = 0.002), PrEP offer increased nearly 6 percentage points (p = 0.002), and PrEP fidelity increased 4 percentage points (p = 0.202) in intervention vs comparison facilities. Client PrEP knowledge increased 0.45 out of 7 total points (p < 0.001) and PrEP screening increased 13 percentage points (p = 0.001). We observed no significant changes in service time (0.13-min increase; p = 0.249), waiting time (0.03-min decrease; p = 0.796), or client satisfaction (0.04/24 total point decrease; p = 0.849) in intervention vs comparison facilities. HIV testing did not significantly change (7 percentage point decrease, p = 0.305). The implementation strategy bundle was deemed appropriate and acceptable by the providers (appropriateness: 18.5/20; acceptability: 18.5/20). Overall, the implementation strategy bundle was associated with larger increases in implementation outcomes among women receiving a visit other than their first ANC visit, as well as among sites without stockouts of HIV test kits.

Conclusions

A stakeholder-selected implementation strategy bundle that included retraining healthcare workers, fast tracking PrEP clients to reduce waiting time, and PrEP dispensing in MCH improved several implementation outcomes without significantly affecting waiting time or reducing service time.

Contributions to the literature

Evidence is sparse on effective implementation strategies that focus on structural- and provider-level barriers to enhance delivery of integrated care in resource-limited settings.
Stakeholder-selected strategies are hypothesized to have a better fit to local context and potentially be more effective than externally selected strategies.
We tested a package of two stakeholder-selected implementation strategies – retraining health providers, fast tracking PrEP clients in a difference-in-differences study in 8 clinics in Kenya.
The package was associated with significant improvements in PrEP penetration, PrEP offer, PrEP knowledge, and PrEP screening. It was not associated with significant changes in PrEP fidelity, HIV testing, service time, waiting time, or client satisfaction.
The improvement associated with the package was most pronounced among clinics that did not experience substantial stockouts of supplies, suggesting that implementation strategies are not sufficient to overcome gaps in basic resourcing in the presence of critical events.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Can audit and feedback improve health service readiness and delivery outcomes in a low-resource setting? Effectiveness results of the IDEAs strategy from central Mozambique

Abstract:

Limited evidence exists on audit and feedback (A&F) in low-resource contexts. We tested the Integrated District Evidence-to-Action (IDEAs), a multicomponent A&F strategy in Mozambique’s maternal and child health (MCH) services. IDEAs include A&F meetings, readiness assessments, and facility support. We report the effectiveness results. IDEAs were implemented in 2016–2020 across two provinces, 12 districts, and 154 primary health facilities in Mozambique. We assessed 1) ten service delivery outcomes across antenatal, maternity, postpartum, childcare, and reproductive health services and 2) five service readiness outcomes (medicines, infrastructure, equipment, care, and staffing availability). We used propensity score matching to minimize bias and a controlled interrupted time series with a negative binomial mixed effects model for service delivery analysis, presenting incidence rate ratios (IRR) with 95% confidence intervals (95% CI). For service readiness outcomes, we created composite scores for each domain and a difference-in-difference analysis using an ordinal mixed effects model, reporting odds ratios (OR) and 95% CI. Significant associations were found with first at-risk child appointments (IRR = 1.06 [1.04, 1.07]), first polymerase chain reaction tests for HIV-exposed children (IRR = 1.02 [1.01, 1.03]), new contraceptive users (IRR = 0.95 [0.94, 0.96]), women starting long-lasting contraceptives (IRR = 0.94 [0.93, 0.95]), availability of infrastructure (OR = 5.84 [1.32, 25.88]) and essential care (OR = 0.13 [0.03, 0.54]). No significant associations were found between IDEAs and six of 10 service delivery outcomes (women with a fourth dose of preventive malaria treatment; women protected with tetanus vaccine; women with four+ antenatal visits; deliveries with active management of the third stage of labor; first postpartum consultations and fully vaccinated children) and on medicine, equipment, and staffing availability. We observed mixed effectiveness in implementing IDEAs, with null and sub-optimal effects suggesting the need to refine and adapt strategy components to more effectively address clinical and readiness outcomes.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Integrating behavioral health care into a low-barrier HIV clinic using the Collaborative Care Model: a mixed methods evaluation of patient care cascade outcomes and determinants

Abstract:

Background

Low-barrier HIV care is an evidence-based intervention to improve HIV outcomes among those who have complex barriers to care, but the walk-in model poses challenges to integrating behavioral health services. We evaluated the acceptability and feasibility of a Collaborative Care Model (CoCM) for treatment of depression and opioid use disorder in a low-barrier clinic.

Methods

In a sequential explanatory mixed methods pilot study, we accessed data from patient records to generate a care cascade for the number of patients enrolled in the first six months of the program and conducted individual interviews with patients and staff to interpret the care cascade findings.

Results

Among 175 patients who visited the clinic, 36% were screened for, 24% were referred to, 15% completed an intake for, and 9% engaged in CoCM. The interviews revealed that screening was limited by a lack of clarity among staff about services offered in CoCM, staff forgetting the screening process, and limited time during patent visits. Referrals were limited by low buy-in among staff and patient complexity. Intakes were limited by time and space constraints in the care setting and competing acute patient needs. The care manager’s ability to embody the clinic’s culture facilitated engagement among patients who completed intakes.

Conclusions

Staff perceived CoCM to be acceptable and feasible to implement, but only in the context of multiple barriers to implementation and challenges to systematic screening and measurement-based care.

Trial registration

Not applicable.

Contributions to the literature

We evaluated implementation of the Collaborative Care Model, an evidence-based model for integrating behavioral healthcare into primary care settings, for treating depression and opioid-use disorder in a low-barrier HIV clinic. To our knowledge, this is the first implementation of the Collaborative Care Model in a low-barrier HIV clinic.
By specifying a multi-component implementation strategy, our evaluation provides a foundation for selecting and tailoring implementation strategies for use with integrated behavioral healthcare interventions.
Through use of a joint visual display showing a care cascade with illustrative quotes, our evaluation demonstrates a novel approach to using explanatory mixed methods in implementation science.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Partnering with Policymakers to Design Suicide Care Research: Maximizing Impact in Adolescent Mental Health Policy

Abstract:

Outpatient medical settings are a critical source of mental health care for adolescents and young adults. This is due to the familiarity and accessibility of those settings and challenges accessing mental health care elsewhere. Adolescents and young adults who die by suicide are more likely to have seen a medical provider in the prior month than a mental health specialist, but few suicide care interventions have been developed to specifically address the challenges of working in these outpatient medical settings. This paper provides the perspective of the University of Washington Suicide Care Research Center on the importance of incorporating evidence into public policy decisions regarding workforce development and standards of care for adolescents and young adults experiencing suicidal thoughts and behaviors, their families, and their outpatient medical setting providers; and the equal importance of integrating policy and funding perspectives in clinical services and implementation science. The paper will review the trends in suicide care policy and funding structures as relevant to adolescents and young adults in outpatient medical settings, provide recommendations to advance the translation of research into evidence-based policy decisions for adolescents and young adults at risk of suicide, and recommendations for researchers on incorporating policy perspectives in the development and evaluation of evidence-based interventions. We will share how the University of Washington Suicide Care Research Center is operationalizing these recommendations.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Evaluating spoke facilitation costs of implementing TelePain in the Veterans Health Administration

Abstract:

Background

The high prevalence and significant morbidity and mortality associated with chronic pain among veterans has made expansion of pain services within the Veterans Health Administration (VHA) a key priority. TelePain, in which services are provided via telehealth from central “hub” sites to patients at decentralized “spoke” sites, is one such model with positive implementation findings to date. However, the staff effort and cost of implementation have yet to be examined when considering TelePain or similar virtual hub-and spoke models of specialty pain care, information that is critical for expansion of services.

Methods

Using an established time-based activity tracker designed for implementation facilitation, study staff tracked minutes spent on implementation activities at 11 spoke sites. Annual salaries were extracted to calculate an average cost per minute for each personnel type. Costs per personnel minute were combined with activity data to calculate costs of implementation activities at spoke sites. Implementation reach outcomes for the first 36 months of implementation were extracted from the electronic health record. Service utilization data was combined with cost data to calculate cost per patient reached and per clinical encounter achieved at each site.

Results

Total facilitation costs (range: $1,746-$7,978) and unique patients reached (range: 2–46) varied considerably across spoke sites and greater staff implementation efforts (measured in time or cost) were not associated with greater numbers of patients reached. Therefore, costs per patient reached also varied widely (range: $120–2,569) across spoke sites. Key challenges included high rurality and small clinic size; insufficient engagement of frontline providers; lack of referral options for high acuity patients; and lack of existing programming within which to situate pain services.

Conclusions

At spoke sites where patients were consistently referred and reached, costs were relatively modest, particularly compared to the high cost of untreated chronic pain, suggesting the potential impact of this model at scale. However, in spoke sites where referrals and encounters were low during initial implementation, cost per patient was high. Findings highlight the need for better methods for tailoring of facilitation interventions to spoke site’s individual needs to maximize impact.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Finding the balance between rigour and relevance: implementing adaptations to the implementation of a pragmatic randomised controlled trial of a two-way texting intervention for voluntary medical male circumcision in South Africa

Abstract:

Objectives

To document adaptations that were made to the implementation of the two-way texting (2wT) randomised controlled trial (RCT) for voluntary medical male circumcision (VMMC) in South Africa and to provide a nuanced discussion on the differences between adaptations and fidelity in this context.

Design

We conducted a qualitative study using the Framework for Reporting Adaptations and Modifications in Evidence-based Implementation Strategies (FRAME-IS) to examine 2wT adaptations. We reported adaptations to the 2wT intervention using two steps. First, we categorised adaptations in a shared study-specific Google Docs that documented participant engagement with the 2wT system, tracked daily RCT implementation notes, reported software bugs and noted reminder emails about adaptations for the research team. Second, we conducted a qualitative assessment of the influence of adaptations on project outcomes via 10 periodic reflection meetings with VMMC implementers. Reflection documentation included notes from field observations, meeting minutes and informal partner check-ins to complete adaptation documentation. Using the FRAME-IS as a codebook, adaptations were categorised.

Settings

The RCT was conducted in rural and urban VMMC clinics in the North West and Gauteng districts of South Africa.

Participants

Implementation scientists and VMMC implementers who implemented the 2wT pragmatic randomised controlled trial (pRCT) were participants for the adaptation study.

Primary and secondary outcome measures

The primary outcome measure was the adaptations that were made during the implementation of the 2wT pRCT. The secondary outcome measures were fidelity and rigour of implementing adaptations to the 2wT pRCT.

Results

Between June 2021 and February 2022, 13 adaptations were identified in three phases during the implementation of the 2wT pRCT. The first phase of adaptations aimed to augment study recruitment, including conducting weekend VMMC recruitment camps, using mobile outreach services in the rural site, adding two urban sites to increase recruitment, using weekly WhatsApp calls for updates with all implementing teams, using virtual meetings to implement the 2wT strategy remotely during COVID-19 restrictions and allocating one clinician to work outside of normal working hours. The second phase of adaptations further enhanced enrolments, including adding two local language translations in the usability survey for 2wT men and contributing a portion towards the salary of the implementing staff by the research partner. The third phase included the exclusion of two rural clinics as recruitment sites due to inconsistent mobile phone networks, adding another layer of data quality checks to ensure data quality, training non-clinical counsellors to help with enrolling clients, retraining of staff in the rural site with high staff turnover and using both primary and alternative phone numbers for enrolment to reduce loss to follow-up.

Conclusions

This study made adaptations to the 2wT pRCT without compromising the fidelity of the study. The 2wT pRCT balances rigour (fidelity) and relevance (adaptation). Adaptations should not be confined by rigour but should also not go unchallenged or unverified. We conclude that fidelity can be maintained with adaptations that are implemented to close the gap between research in the laboratory and practice.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Towards development of guidelines for harnessing implementation science for suicide prevention: an international Delphi expert consensus study

Authors:

Sadhvi Krishnamoorthy, Gregory Armstrong, Victoria Ross, Lennart Reifels, Hayley Purdon, Jillian Francis, Jacinta Hawgood, Sharna Mathieu, Alexandr Kasal, Allison Crawford, Allison M. Gustavson, András Székely, Anna Baran, Annette Erlangsen, Ashley Nemiro, Chez Curnow, Daniel Reidenberg, Daria Biechowska, Ella Arensman, Emmanuel Nii-Boye Quarshie, Fiona Shand, Caroline Mae Ramirez, Isabel Zbukvic, Jorgen Gullestrup, Katherine McGill, Kylie King, Lakshmi Vijayakumar, Lauren White, Loraine Barnaby, Mark Sinyor, Marlena Sokół-Szawłowska, Maryke Van Zyl, Merike Sisask, Michael Phillips, Mohsen Rezaeian, Naohiro Yonemoto, Nathaniel Pollock, Nikhil Jain, Paul Siu Fai Yip, Ping Qin, Piotr Toczyski, Rakhi Dandona, Ricardo Gusmão, Samah Jabr, Sarah Spafford, Tae-Yeon Hwang, Thomas Niederkrotenthaler, Ulrich Hegerl, Vita Poštuvan, Yutaka Motohashi, Kairi Kõlves

^{University of Washington affiliated authors are displayed in bold.}

✪ Open Access

Published: April 2025

Read the full text in the open access journal BMJ Public Health

Abstract:

Objectives

Suicide research and prevention are complex. Many practical, methodological and ethical challenges must be overcome to implement effective suicide prevention interventions. Implementation science can offer insights into what works, why and in what context. Yet, there are limited real-world examples of the application of implementation science in suicide prevention. This study aimed to identify approaches to employ principles of implementation science to tackle important challenges in suicide prevention.

Methods

A questionnaire about promoting implementation science for suicide prevention was developed through thematic analysis of stakeholder narratives. Statements were categorised into six domains: research priorities, practical considerations, approach to intervention design and delivery, lived experience engagement, dissemination and the way forward. The questionnaire (n=52 statements—round 1; n=44 statements—round 2; n=9 statements—round 3) was administered electronically to a panel (n=62—round 1, n=48—round 2; n=45—round 3) of international experts (suicide researchers, leaders, project team members, lived experience advocates). Statements were rated on a Likert scale based on an understanding of importance and priority of each item. Statements endorsed by at least 85% of the panel would be included in the final guidelines.

Results

Eighty-two of the 90 statements were endorsed. Recommendations included broadening research inquiries to understand overall programme impact; accounting for resources in the translation of evidence into practice; embedding implementation science in intervention delivery and design; meaningfully engaging lived experience; considering channels for dissemination of implementation-related findings and focusing on next steps needed to routinely harness the strengths of implementation science in suicide prevention research, practice and training.

Conclusion

An interdisciplinary panel of suicide prevention experts reached a consensus on optimal strategies for using implementation science to enhance the effectiveness of policies and programmes aimed at reducing suicide.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Study protocol for testing the efficacy of the Helping Educational Leaders Mobilize Evidence (HELM) implementation strategy in elementary schools: a hybrid type 3 effectiveness-implementation randomized controlled trial

Abstract:

Background

Schools need to implement universal student supports that prevent social, emotional, and behavioral difficulties; minimize associated risks; and promote social, emotional, and behavioral competencies. The purpose of this study is to examine the efficacy of the Helping Educational Leaders Mobilize Evidence (HELM) implementation strategy for promoting school-level implementation leadership, implementation climate, and high-fidelity delivery of an evidence-based practice. We will test HELM with an exemplar EBP, Positive Behavioral Interventions and Supports (PBIS). The specific aims of the study are to: 1) experimentally evaluate the effects of HELM versus PBIS training and technical assistance only (control condition); and 2) explore for whom, under what conditions, how equitably, and through which processes HELM works to improve outcomes, as well as its cost-effectiveness.

Methods

This study will use a hybrid type 3 effectiveness-implementation trial to provide a rigorous test of the effects of HELM in elementary schools. Schools will be randomly assigned to HELM + PBIS training and technical assistance (n = 21 schools; n = 210 educators) or PBIS training and technical assistance only (n = 21 schools; n = 210 educators) in a 1:1 ratio within cohorts using covariate constrained randomization that accounts for degree of prior PBIS exposure (measured using the Tiered Fidelity Inventory at baseline) and school size. A series of mixed effects models (time within educator, educator within school) will test within-subject/between-subject interactions across three timepoints (12 months total) to examine whether HELM will show steeper gains than the control on implementation leadership (primary outcome), implementation climate, PBIS fidelity, and student outcomes. Mediational analyses will test hypothesized mechanisms of change (i.e., implementation leadership and climate) of HELM on PBIS fidelity. Sequential mixed-methods data collection and analyses will further explore how organizational mechanisms are linked to implementation outcomes. Cost-effectiveness analyses will compare costs and outcomes of PBIS training and technical assistance only versus PBIS implementation with HELM.

Discussion

The nature of leadership support in schools can make the difference between successful and unsuccessful EBP implementation. Testing HELM within the context of PBIS implementation will provide rigorous evidence about whether and how HELM can equitably address important EBP and student outcomes.

Trial Registration

Clinical Trials ID: NCT06586723. Date of Registration: August 27, 2024. Prospectively registered. URL of Trial Registry Record: https://clinicaltrials.gov/study/NCT06586723?intr=helm&rank=1

Contributions to the Literature

Few effective strategies to enhance evidence-based practice implementation in schools address implementation leadership and climate, and those that do have only been evaluated qualitatively.
Schools have unique organizational characteristics, and it is important to test whether organizational implementation strategies developed in other contexts can be effective in improving implementation outcomes in schools.
This study will evaluate the effects of a tailored adaptation of the Leadership and Organizational Change for Implementation (LOCI) strategy for schools, entitled Helping Educational Leaders Mobilize Evidence (HELM), on implementation mechanisms (implementation leadership and implementation climate), PBIS fidelity, and student outcomes.
This study also will explore for whom, under what conditions, and how equitably HELM demonstrates its effects, providing critical information about influence on – and the limitations of – the impact of this organizational implementation strategy.
Finally, the study will evaluate the processes through which HELM works to improve outcomes, contributing to the emerging literature on implementation mechanisms, as well as its cost-effectiveness.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

Name of the registry
clinicaltrials.gov.

Peer Review reports

✪ Lessons learnt from the 2021 Pacific Northwest heat dome: a qualitative study of western Washington’s healthcare community response

Abstract:

Objective

The 2021 Pacific Northwest heat dome was Washington state’s deadliest recorded weather event and presented unprecedented response challenges to the state’s health sector. Understanding the impacts of this extreme heat event (EHE) on the sector as well as the barriers to and facilitators of implementing effective heat response is critical to preparing for future events, which are happening more frequently in the region due to climate change.

Design

Guided by an implementation science framework, we convened listening sessions and focus groups of the health sector in western Washington to reflect on regional response efforts.

Setting

Health sector organisations in 15 counties in western Washington State, USA: Clallam, Grays Harbor, Island, Jefferson, King, Kitsap, Lewis, Mason, Pacific, Pierce, San Juan, Skagit, Snohomish, Thurston and Whatcom.

Participants

A convenience sample of 109 listening group participants was recruited through the professional networks of the Northwest Healthcare Response Network, a regional healthcare coalition. 27 of the health sector professionals were recruited using purposive sampling to participate in seven focus groups organised by organisation type.

Results

The co-presence of the COVID-19 pandemic, limited staff capacity, resource acquisition challenges and inadequate regional collaboration emerged as key barriers, while advanced planning, indoor cooling capabilities, adapting strategies to local needs, robust internal relationships and strong external partnerships were reported to facilitate effective response. Establishing centralised coordination ahead of heat events, making improvements to the cooling capabilities of the built environment, developing plans and policies for EHEs that have co-benefits for other events, adopting evidence-informed response strategies, institutionalising the knowledge and relationships developed through prior events and improving evaluative processes (such as developing real-time monitoring capacity) will enable more effective response to future EHEs.

Conclusions

Western Washington’s health sector implemented EHE response activities that enabled essential service continuity, despite limited resources, unfamiliarity with EHEs and other systemic challenges. The recency of the heat dome presents an opportunity to incorporate lessons learnt into practice, policies, plans and built environment; these are necessary improvements ahead of future large-scale events the region may experience in the coming decades.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Strengthening the US Health Workforce to End the HIV Epidemic: Lessons Learned From 11 Ending the HIV Epidemic Jurisdictions

Authors:

Phillip L Marotta, Debbie Humphries, Daniel Escudero, David A Katz, Joseph G Rosen, Samantha Veronica Hill, Jennifer L Glick, Dennis H Li, Latosha Elopre, Fatemeh Ghadimi, Rinad S Beidas, Jose Bauermeister, Stephen Bonett, Drew B Cameron, LaRon E Nelson, Serena Rajabiun, Larry R Hearld, Mansoorah Kermani, Sarah Stoltman, Darjai Payne, Tobeya Ibitayo, Faiad Alam, Amanda Williams, Corilyn Ott, Emma Kay, Sarah Chrestman, Scott Batey, Laramie R Smith, Robin Gaines Lanzi, Karen Musgrove, Mayra Malagon, Jeannette Bailey-Webb, Florence Momplaisir, Robert Gross, Gregory Gross, Taylor Kaser, Tawnya Brown, Chelsey R Carter, Michael Mugavero , Tequetta Valeriano, Sarah Shaw, Anjuli D Wagner, Bakari Atiba, & Russell A Brewer

^{University of Washington affiliated authors are displayed in bold.}

✪ Open Access

Published: April 2025

Authors:

✪ Open Access

Read the full text in the open access journal Implementation Science Communications

Abstract:

Background

Methods

Results

Conclusions

Contributions to the literature

Authors:

✪ Open Access

Read the full text in the open access journal PLOS Global Public Health

Abstract:

Authors:

✪ Open Access

Read the full text in the open access journal Implementation Science Communications

Abstract:

Background

Methods

Results

Conclusions

Trial registration

Contributions to the literature

Authors:

✪ Open Access

Read the full text in the open access journal Evidence-Based Practice in Child and Adolescent Mental Health

Abstract:

Authors:

✪ Open Access

Read the full text in the open access journal Implementation Science Communications

Abstract:

Background

Methods

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal BMJ Open

Abstract:

Objectives

Design

Settings

Participants

Primary and secondary outcome measures

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal BMJ Public Health

Abstract:

Objectives

Methods

Results

Conclusion

Authors:

✪ Open Access

Read the full text in the open access journal Implementation Science

Abstract:

Background

Methods

Discussion

Trial Registration

Contributions to the Literature

Authors:

✪ Open Access

Read the full text in the open access journal BMJ Open

Abstract:

Objective

Design

Setting

Participants

Results

Conclusions

Authors:

✪ Open Access

Read the full text open access in the journal JAIDS: Journal of Acquired Immune Deficiency Syndrome