Increased prevalence of pregnancy and comparative risk of program attrition among individuals starting HIV treatment in East Africa
Increased prevalence of pregnancy and comparative risk of program attrition among individuals starting HIV treatment in East Africa
Charles B. Holmes 0 1
Constantin T. Yiannoutsos 1
Batya Elul 1
Elizabeth Bukusi 1
John Ssali 1
Andrew Kambugu 1 2
Beverly S. Musick 1
Craig Cohen 1
Carolyn Williams 1
Lameck Diero 1
Nancy Padian 1 3
Kara K. Wools-Kaloustian 1
0 Centre for Infectious Disease Research in Zambia , Lusaka , Zambia , 2 Johns Hopkins University School of Medicine , Baltimore , Maryland, United States of America, 3 Georgetown University School of Medicine , Washington, DC , United States of America, 4 Indiana University R.M. Fairbanks School of Public Health , Indianapolis , Indiana, United States of America, 5 Mailman School of Public Health, Columbia University, ICAP at Columbia University , New York , New York, United States of America, 6 Centre for Microbiology Research, Kenya Medical Research Institute , Nairobi , Kenya , 7 Masaka Regional Hospital , Masaka , Uganda
1 Editor: Marcel Yotebieng, The Ohio State University , UNITED STATES
2 Infectious Diseases Institute , Kampala , Uganda , 9 Indiana University School of Medicine, Indianapolis, Indiana, United States of America, 10 University of California San Francisco , San Francisco , California, United States of America, 11 National Institute of Allergies and Infectious Diseases , Bethesda , Maryland, United States of America, 12 Academic Model Providing Access to Health Care (AMPATH) , Eldoret , Kenya
3 University of California , Berkeley, California , United States of America
Data Availability Statement: As the data comes
from several clinical programs, the authors do not
have local ethical approval from the participating
clinical programs or where applicable, national
permission to share the data beyond the scope of
this publication. Their data sharing agreements are
quite specific stating that all data sharing must
come in response to a concept sheet submitted to
the East Africa IeDEA Executive Committee for
review and approval (https://www.iedea.org/
working-groups/executive-committee/). For further
The World Health Organization now recommends initiating all pregnant women on life-long
antiretroviral therapy (ART), yet there is limited information about the characteristics and
program outcomes of pregnant women already on ART in Africa. Our hypothesis was that
pregnant women comprised an increasing proportion of those starting ART, and that
subgroups of these women were at higher risk for program attrition.
Methods and findings
We used the International Epidemiology Databases to Evaluate AIDS- East Africa
(IeDEAEA) to conduct a retrospective cohort study including HIV care and treatment programs in
Kenya, Uganda, and Tanzania. The cohort consecutively included HIV-infected individuals
13 years or older starting ART 2004±2014. We examined trends over time in the proportion
pregnant, their characteristics and program attrition rates compared to others initiating and
already receiving ART. 156,474 HIV-infected individuals (67.0% women) started ART. The
proportion of individuals starting ART who were pregnant women rose from 5.3% in 2004 to
12.2% in 2014. Mean CD4 cell counts at ART initiation, weighted for annual program size,
increased from 2004 to 2014, led by non-pregnant women (annual increase 20 cells/mm3)
and men (17 cells/mm3 annually), with lower rates of change in pregnant women (10 cells/
mm3 per year) (p<0.0001). There was no significant difference in the cumulative incidence
information about data sharing requirements and
the process for submitting concept sheets please
contact: Dr. Kara Wools-Kaloustian at kwools@iu.
Funding: The funders had no role in study design,
data collection and analysis, decision to publish, or
preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
of program attrition at 6 months among pregnant women starting ART and non-pregnant
women. However, healthy pregnant women starting ART (WHO stage 1/2) had a higher rate
of attrition rate (9.6%), compared with healthy non-pregnant women (6.5%); in contrast
among women with WHO stage 3/4 disease, pregnant women had lower attrition (8.4%)
than non-pregnant women (14.4%). Among women who initiated ART when healthy and
remained in care for six months, subsequent six-month attrition was slightly higher among
pregnant women at ART start (3.5%) compared to those who were not pregnant (2.4%),
(absolute difference 1.1%, 95% CI 0.7%-1.5%).
Pregnant women comprise an increasing proportion of those initiating ART in Africa, and
pregnant women starting ART while healthy are at higher risk for program attrition than
nonpregnant women. As ART programs further expand access to healthier pregnant women,
further studies are needed to better understand the drivers of loss among this high risk
group of women to optimize retention.
Antiretroviral treatment (ART) programs in sub-Saharan Africa are adding over one million
HIV-infected patients each year [
]. With WHO HIV Guidelines recommending universal
eligibility for treatment, these numbers are expected to rise substantially in coming years . These
recommendations follow closely those in 2013 calling for the initiation of lifetime ART for all
HIV-infected pregnant women. Even as efforts are undertaken to further expand treatment
access, it is important understand what we have learned about how pregnancy impacts retention
and care so that we can design programs that continue to support this vulnerable group.
However, because of the challenges of collecting high quality longitudinal data in these
settings, the biggest funders of these programs, the U.S. President's Emergency Plan for AIDS
Relief (PEPFAR) and the Global Fund for AIDS, TB and Malaria (Global Fund), have generally
not been able to report retention outcomes for pregnant women within national HIV
programs they support [
]. A series of single-clinic analyses, and multi-site studies from Malawi,
Mozambique and elsewhere have suggested that pregnant women starting ART may be at
higher risk of attrition compared to others at various time points, although the findings and
comparators have not been consistent [5±13]. As a consequence, there is a critical need for
large scale analyses of patient-level data focusing on pregnant women living with HIV.
We report here on data from the International epidemiologic Databases to Evaluate AIDS East
Africa consortium (IeDEA-EA), which, in this study, consolidates clinical data from six
PEPFARsupported programs in Kenya, Uganda and Tanzania. Because of its large size and quality of data,
IeDEA-EA can conduct detailed yet generalizable evaluations of program characteristics, clinical
trends and outcomes. We longitudinally assessed the proportion of patients initiating therapy
who were pregnant and compare their clinical characteristics with others initiating ART.
Materials and methods
The IeDEA-EA database was used to conduct a retrospective cohort study starting in 2004, the
start of PEPFAR funding, to 2014, to examine longitudinal changes in ART program
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characteristics and patient outcomes. Approval for this study was obtained from the regulatory
bodies at Moi University College of Health Sciences (MU/CHS) & Moi Teaching and Referral
Hospital (MT&RH) Institutional Research and Ethics Committee (IREC), the Kenya Medical
Research Institute/National Ethics Review Committee (ERC), Ugandan National Counsel of
Science and Technology, (UNCST), Makerere University School Medicine Research & Ethics
Committee (MUSOMREC), and the United Republic of Tanzania National Institute for
Medical Research Coordinating Committee, and the Indiana University Institutional Review Board.
All regulatory bodies waived patient consent as all data were collected in the course of routine
clinical care and only de-identified data were available for analyses.
Study sites and population
The IeDEA-EA Collaboration includes nine PEPFAR-funded HIV treatment programs in
which six have access to pregnancy data: The Academic Model Providing Access to Healthcare
(AMPATH) in western Kenya; the Family AIDS Care and Education Services (FACES) in
Nyanza Province, Kenya; the Masaka Regional Referral Hospital HIV Clinic in western
Uganda; the Infectious Diseases Institute (IDI) in Kampala, Uganda; and the Kisesa Health
Center in Tanzania. Masaka and IDI are Regional Hospitals; AMPATH included one Regional
Hospital, 12 District Hospitals, and 17 Health Centers; FACES included four Health Centers
and four District Hospitals; and Kisesa, is a large Tanzania Ministry of Health health center.
The majority of the clinics are rural (55%) though the majority of patients (62%) receive care
at urban clinics.
The programs included in the analysis are HIV care and treatment clinics within ministry
of health supported facilities. Some of these programs represent rapid adopters of new
guidelines, such as B+ while others have lagged in adoption of new WHO treatment guidelines.
Retention strategies differ between programs and have been dependent on funding and
program structure at various time points, strategies utilized have include peer supporters,
community outreach teams, and phone outreach.
Data from patients 13 years of age or older at enrollment who initiated antiretroviral
treatment between January 2004 and December 2014 were eligible for inclusion in this analysis.
Data collection and management
Data from initial and follow-up visits were collected on clinic-specific forms as part of clinical
care (www.iedea-ea.org,ªDocuments.&.Publicationsº link). WHO staging was determined by
the clinician based on history, physical exam and laboratory findings. CD4 cell counts were
measured in site supported clinical laboratories. An OpenMRS database (www.openmrs.org)
is used at AMPATH, FACES, and the Masaka Hospital while IDI uses a proprietary database
to manage their data. De-identified data are sent from programs biennially to the IeDEA-EA
Regional Data Center (RDC) where data were harmonized and quality checked. Periodic
audits of accuracy are conducted based on source verification of a random sample of records.
Pregnancy status was determined based on clinician ascertained pregnancy status, date of last
menstrual period (LMP), delivery dates, pregnancy outcome (term vs. pre-term) and estimated
Vital status was ascertained variably across sites. At AMPATH and IDI, deaths are
established passively (those deaths reported to the clinic) and through routine patient outreach per
clinic retention programs practices. At FACES, Kisesa and Masaka, vital status is established
only through passive reporting. All known deaths were included regardless of ascertainment
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Pregnancy at ART initiation. Three groups were compared to assess the temporal trends
of the proportion patients initiating ART: men, pregnant and non-pregnant women. The
proportion of patients pregnant at ART start was calculated by dividing the number of pregnant
women starting ART by the number of adult patients initiating therapy each month.
Pregnancy status was defined by any evidence of pregnancy in the database. Date of conception
was based on LMP, gestational age, date of delivery, or clinical notation, specifically: two
weeks after the LMP, or the current visit date minus the gestational age, or 37 weeks prior to a
pre-term deliveries or 40 weeks prior to a term delivery. For women whose conception date
could not be calculated, conception date was imputed based on the median gestational age
where pregnancy was first noted for women on whom data were available: 21 weeks. The
imputed conception date was then calculated as the visit at which pregnancy was first noted
minus 21 weeks.
Medians and inter-quartile ranges (IQR) for continuous or frequency percentages for
categorical factors were calculated. Comparisons between groups were tested by Kruskal-Wallis
and Pearson chi-square. Annual programmatic trends in the proportion of women pregnant
at ART initiation and WHO stage at the start of therapy, analyzed over the study period, were
based on a log-linear model to assess changes in relative risk over time (expressed in years
centered at 2008), (WHO stage 3/4 versus 1/2). The model of the proportion of women who were
pregnant by year is ªlog-linearº because the logarithm of the proportion of pregnant women
out of all patients enrolled is a linear (regression) equation of the year of enrollment in a
program, i.e log Tyi a bxi where yi is the number of pregnant women at time i = 1,2, ,k, Ti
is the total number of patients during that time point, and xi is the year of enrollment. Using
this model, the coefficient b is an estimate of the log relative risk of being pregnant for each
year of the program's existence. A regression model was used to assess changes in CD4 counts
(square-root transformed) over (the linear effect of) time (also expressed as above).
Pregnancy and program attrition. HIV program attrition was defined as the combined
endpoint of death or loss to program (defined as not having a visit within six months of the
database closure date of 31 December, 2014) [
We constructed time-varying dichotomous (yes/no) variables to define pregnancy status,
pregnant/not pregnant (assigned one at conception and remaining equal to one until
completion of follow-up), and pregnant at ART initiation. WHO stage at ART initiation was
dichotomized as having stage 1/2 disease, versus having stage 3/4 disease. Cumulative incidence rates
of attrition were produced according to the Aalen-Johansen estimator stratified for pregnancy
status and dichotomized WHO stage at ART initiation. In addition, a similar analysis was
carried out, based on the left-truncated data of women who received at least six months of ART,
addressing the possibility that cumulative ART exposure may result in reduced cumulative
incidence of attrition compared to those seen among women just starting therapy.
Analyses were carried out with SAS version 9.3 (SAS Institute, Cary, NC) and STATA
version 14 (STATA Corp., College Station, TX).
Patient and program characteristics
156,474 HIV-infected adults started ART between 2004 and 2014, 104,791(67.0%) of whom
were women. Of these, 72,776 (69.4%) were never observed to have a pregnancy
(never-pregnant women), and 32,015 (30.6%) were pregnant at least once during follow-up (ever pregnant
women). Among women who were ever pregnant, 19,130 (59.8%) were pregnant at ART
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initiation (Table 1). 72.5% of individuals initiating ART were enrolled at sites in Kenya
(AMPATH and FACES), 26.7% were enrolled in programs in Uganda (Masaka, IDI, Mbarara),
and 1% from Kisesa, Tanzania (Table 1).
Women who were pregnant at ART initiation were substantially younger (median age 27.5
years, inter-quartile range±IQR± 23.6±31.8) than women who were not pregnant at ART start
(34.6 years [IQR 28.5±41.9]) and men (38.4 years [IQR 32.4±45.6]). Pregnant women we also
healthier, both by WHO stage (12.2% WHO stage 3/4 vs. 48.2% and 56.7% among women
who were not pregnant at ART initiation and men respectively; p<0.001) and median CD4
cell count (350 cells/mm3 [IQR 216±521] versus 157 cells/mm3 [IQR 69±255] and 131 cells/
mm3 [IQR 49±225] respectively; (p<0.001). Non-pregnant women were also healthier than
men, based WHO stage and CD4 cell count (p<0.001).
Temporal trends of pregnancy, WHO stage and immune status at ART
Among all individuals starting ART between 2004 and 2014, the proportion who were
pregnant women rose from 5.3% to 12.2%, with the greatest increase occurring between 2005 and
2008 (S1 Fig). During the same time period, the proportion starting ART with WHO stage 3/4
disease declined significantly from 65.9% to 26.0% respectively, (p<0.0001). The largest
absolute declines in the proportion starting ART with WHO stage 3/4 disease were among men
(41.7%) and non-pregnant women (40.2%), compared with pregnant women (4.7%; Fig 1). In
a log-linear regression model, the annual relative decline in the proportion of patients starting
ART with WHO stage 3/4, from 2004 to 2014, weighted for annual program size, was slightly
faster among non-pregnant women (7.0% per annum), and a bit slower for men (5.8%)
compared to pregnant women (6.3%). In addition to the overall decline, the improvement in
WHO stage accelerated in 2011, a trend seen in pregnant women starting in 2014. Mean CD4
cell counts at ART initiation, weighted for annual program size, increased from 2004 to 2014,
led by non-pregnant women (annual increase 20 cells/mm3), with somewhat lower increases
seen in men (17 cells/mm3 annually), and much lower in pregnant women (10 cells/mm3 per
year) (p<0.0001 in both cases; Fig 2). CD4 cell counts appear to rise at a higher rate starting
during the period of 2011 to 2013 for both pregnant and non-pregnant women and men.
Fig 1. Temporal trends of patients starting ART with advanced HIV disease (WHO stage 3/4).
Pregnancy and cumulative incidence of program attrition
Overall, there was no significant difference in the cumulative incidence of program attrition
over two years after ART start between pregnant women starting ART and non-pregnant
women (Fig 3A). However, among women starting ART while healthy (WHO Stage 1/2),
pregnant women experienced a 9.6% cumulative incidence of program attrition at 6 months,
Fig 2. Temporal trends of the average CD4 count at ART initiation. Reference line shows the 350 cells/mm3 CD4 count threshold.
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Fig 3. Cumulative incidence of attrition among (a) women starting ART while pregnant versus non-pregnant women,
and (b) women starting ART while pregnant with and without advanced disease versus non-pregnant women during
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compared to 6.5% in non-pregnant women (absolute difference 3.1% 95% confidence
interval±CI± 2.6%-3.6%), a difference that increased by two years of follow-up (Fig 3B). By contrast,
among women starting ART with advanced disease (WHO stage 3/4), pregnant women had
lower 6-month attrition rates (8.4%) compared to non-pregnant women (14.4%) (absolute
difference 6.0%, 95% CI 4.7%-7.2%) (Fig 3B).
Among the subset of women remaining in care six months after ART initiation, subsequent
program attrition at the next six months (i.e., one year after starting ART) was similar in those
who started ART while pregnant, and those who were not pregnant (3.5% and 3.6%
respectively). However, attrition among women starting ART while healthy was slightly higher
among those who were pregnant at ART start (3.5%) compared to those who were not
pregnant at ART (2.4%), (absolute difference 1.1%, 95% CI 0.7%-1.5%), and attrition among
women who started ART with more advanced disease was somewhat higher among those who
were not pregnant at the start of therapy (4.8%) compared to those who were pregnant (3.8%),
(absolute difference 1%, 95% CI 0.01%-1.9%; Fig 4).
Fig 4. Among women in care after 6 months on ART, cumulative incidence of attrition of pregnant women at ART initiation compared with non-pregnant
women, with and without advanced disease.
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This analysis of more than 150,000 people initiating ART over 11 years in East Africa found
that pregnant women constituted an increasing proportion of patients initiating ART, even
prior to the introduction of WHO Option B+. Consistent with earlier reports, we found that
pregnant women starting ART were healthier than men or women who were not pregnant,
and that patients overall are increasingly starting ART in a healthier state [
]. The rise in
CD4 cell counts and the falling WHO stage at treatment initiation appear to mirror the
increasing CD4 cell count thresholds in the 2010 and 2013 WHO guidelines, along with
emergence of recommendations for treating pregnant women with ART regardless of CD4 cell
count (Options B and B+). We demonstrated for the first time that absolute decreases over
time in the proportion of individuals starting treatment while ill (WHO stage 3/4) were driven
largely by non-pregnant women and men.
Although attrition rates were similar between pregnant and non-pregnant women overall,
our analyses have identified higher programmatic loss for healthy women initiating ART while
pregnant, compared to healthy non-pregnant women. Conversely, among those with advanced
disease (WHO stage 3/4), pregnant women had lower rates of attrition.
Our overall retention findings, drawn from an exceptionally large clinical database
multicountry analysis, generally confirm those of Toro and colleagues, who did not find elevated
attrition among pregnant women starting ART [
]. However, higher rates of attrition among
pregnant women starting ART (not differentiated by disease stage) have been reported in
several single-clinic analyses from South Africa [5±7,9]. When differentiating by disease stage at
ART initiation, sicker (WHO stage 3/4) non-pregnant women had the highest attrition overall,
a result that is likely driven by unascertained mortality among late presenters. The next highest
attrition rates were in healthy pregnant women (whose attrition is more likely attributable to
disengagement rather than death). Sicker pregnant women and healthy non-pregnant women
attrition rates were even lower. Although our study was conducted just prior to the
introduction of Option B+, women starting with Stage 1/2 disease are likely similar to those in other
studies of WHO Option B+. A small study conducted in rural northern Mozambique reported
higher overall rates of loss (consistent with other reports from that region) and found that
women starting ART under Option B+ had higher attrition compared with women starting
ART for their own health (WHO stage 3/4), essentially the converse of our findings [
authors pointed out that the poor retention among those starting under Option B+ could have
been attributable in part to the short period between HIV diagnosis and ART start, along with
inadequate staff training. Pregnant women starting ART under Option B+ guidelines in
Malawi were also found to have elevated early attrition rates (1.8 to 5 times higher) than
nonpregnant women starting ART with WHO Stage 3/4 or with CD4 cell count 350 [
Twoyear cumulative incidence rates for loss to follow-up in Malawi were generally consistent with
our findings, demonstrating higher rates of loss among pregnant women starting ART under
B+ guidelines (most starting ART while WHO Stage 1/2), than among non-pregnant women
(24.5% vs. 17%) [
]. It is not known the extent to which WHO option B, in which women
were advised to stop therapy following delivery and breastfeeding, could have differentially
affected our results. It is conceivable that women becoming pregnant while WHO stage 1/2
would have been more likely to start ART for PMTCT Option B, and not as indicated for their
own health, which could have led to higher rates of discontinuation/attrition. However,
Option B was only fleetingly applied in most settings, and in reality, women were infrequently
advised to discontinue ART. Also under Option B women were still recommended to continue
ART during breast feeding, and the substantial attrition we report starts immediately after
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While not explicitly evaluated here, it is possible that in some cases, with limited time for
behavioral readiness, healthy pregnant women may not be effectively counseled on the
importance of ARVs for their own health and transmission risk and may underestimate their
importance in the setting of the competing priorities of parenthood [
]. In-depth interviews
conducted with women stopping ART (under Option B+) in Malawi noted that feeling healthy
and side effects were among the common causes, which could conceivably contribute to the
program attrition demonstrated in our study [
]. We believe that the lower rates of attrition
among pregnant women with advanced disease, compared with non-pregnant women in our
cohort, may be driven in part by comparatively lower rates of mortality in this group due to
higher rates of pregnancy-associated healthcare utilization.
Based on our observations, and given the double risk to the mother's health and increases
in the risk of HIV transmission to the baby, there is urgent need for the application and
rigorous evaluation of retention interventions tailored to the needs of pregnant women, particularly
of those who are relatively healthier when initiating ART [
]. These could include
community-based models of care delivery to reduce travel time and enhance adherence support, peer
mentorship, electronic messaging, and incentives [21±23]. Furthermore, integrating ART into
antenatal care, may be necessary but not sufficient to ease access for pregnant women and its
impact on attrition is unclear . In order to secure better outcomes, programs must
intensify outcome monitoring for pregnant women initiating ART and be vigilant for, and
responsive to, poorer outcomes in this vulnerable population.
A potential limitation of our analyses is that IeDEA-EA may not be fully representative of
national programs. However, IeDEA-EA does include a substantial proportion of patients
receiving care under PEPFAR within the three countries; thus, we would expect that our
findings are generalizable to similarly resourced programs. Determining pregnancy status
was a challenge for programs included in the analysis, as cultural differences in pregnancy
acknowledgment make it harder to ascertain conception dates. We estimated conception dates
by synthesizing all available data, and are confident we have reasonably approximated the
conception date; any under-ascertainment of pregnancy would bias the results towards a null
effect, so the differences as presented may be conservative. A further limitation is that we were
not able to distinguish program attrition due to mortality, transfer to another program or
disengagement from care, among those lost. This in turn prevented us from distinguishing
whether attrition of women with advanced disease was qualitatively different (i.e., it included
many more unreported deaths) compared to attrition of pregnant women who did not have
advanced disease (most of which was almost certainly due to disengagement from care). The
sites included in the study also did not routinely collect viral loads, so our analyses were not
able to examine trends in viral load suppression. With many programs in our region
increasingly devolving care of pregnant women to mother-child clinics, attrition due to incompletely
documented transfer to other programs will be an increasing problem for future assessments
of outcomes among pregnant women. This limitation is common to clinical studies in this
setting, and can only be corrected by strengthening national data systems to track transfers or by
correcting estimates using sampling methods of those lost to follow-up [
We report on one of the largest and most comprehensive database of patients starting ART
during the first decade of the ART roll-out in sub-Saharan Africa, just prior to the
implementation of Option B+. We have demonstrated the growing impact of pregnancy on the
characteristics and outcomes of ART programs, and have documented a critical period of high risk of
attrition for healthy women during pregnancy. These findings should motivate the public
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health community to intensify monitoring and evaluation of ART programs to identify
retention issues among pregnant women in routine program settings. Research is also needed to
identify effective individual, programmatic and structural interventions to achieve the highest
levels of retention in care and other treatment outcomes in pregnant women. Failure to
address suboptimal retention in pregnant women will not only threaten global goals, but the
lives of both mothers and their children.
S1 Fig. Temporal trends in the proportion of patients pregnant at ART start.
The authors would like to acknowledge the many committed healthcare providers on the
front-lines of providing care to individuals within this cohort.
Conceptualization: Charles B. Holmes, Batya Elul, Elizabeth Bukusi, John Ssali, Andrew
Kambugu, Craig Cohen, Carolyn Williams, Lameck Diero, Nancy Padian, Kara K.
Data curation: Beverly S. Musick.
Formal analysis: Constantin T. Yiannoutsos, Beverly S. Musick, Carolyn Williams, Kara K.
Funding acquisition: Craig Cohen.
Investigation: Charles B. Holmes, Constantin T. Yiannoutsos, Batya Elul, Elizabeth Bukusi,
John Ssali, Andrew Kambugu, Beverly S. Musick, Craig Cohen, Carolyn Williams, Lameck
Diero, Nancy Padian, Kara K. Wools-Kaloustian.
Methodology: Constantin T. Yiannoutsos, Batya Elul, Beverly S. Musick, Carolyn Williams,
Nancy Padian, Kara K. Wools-Kaloustian.
Project administration: Charles B. Holmes, Elizabeth Bukusi, Andrew Kambugu, Craig
Cohen, Carolyn Williams, Lameck Diero, Nancy Padian, Kara K. Wools-Kaloustian.
Resources: Batya Elul, Elizabeth Bukusi, John Ssali, Craig Cohen, Carolyn Williams, Lameck
Diero, Nancy Padian, Kara K. Wools-Kaloustian.
Software: Constantin T. Yiannoutsos, Beverly S. Musick.
Supervision: Charles B. Holmes, John Ssali, Andrew Kambugu, Carolyn Williams, Lameck
Diero, Nancy Padian, Kara K. Wools-Kaloustian.
Visualization: Constantin T. Yiannoutsos, Batya Elul, Beverly S. Musick.
Writing ± original draft: Charles B. Holmes.
Writing ± review & editing: Charles B. Holmes, Constantin T. Yiannoutsos, Batya Elul,
Elizabeth Bukusi, John Ssali, Andrew Kambugu, Beverly S. Musick, Craig Cohen, Carolyn
Williams, Lameck Diero, Nancy Padian, Kara K. Wools-Kaloustian.
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2016; 11(2):e0149527. Epub 2016/02/24. https://doi.org/10.1371/journal.pone.0149527 PMID:
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