Scaling Up Paediatric HIV Care with an Integrated, Family-Centred Approach: An Observational Case Study from Uganda
Family-Centred Approach: An
Observational Case Study from Uganda. PLoS ONE 8(8): e69548. doi:10.1371/journal.pone.0069548
Scaling Up Paediatric HIV Care with an Integrated, Family-Centred Approach: An Observational Case Study from Uganda
Emmanuel Luyirika 0 1
Megan S. Towle 0 1
Joyce Achan 0 1
Justus Muhangi 0 1
Catherine Senyimba 0 1
Frank Lule 0 1
Lulu Muhe 0 1
Sten H. Vermund, Vanderbilt University, United States of America
0 1 Mildmay Uganda , Kampala, Uganda, 2 Independent Health Consultant, Mumbai , India , 3 World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo, 4 World Health Organization Headquarters , Geneva , Switzerland
1 Scaling Up a Family-Centred Approach to HIV Care
Family-centred HIV care models have emerged as an approach to better target children and their caregivers for HIV testing and care, and further provide integrated health services for the family unit's range of care needs. While there is significant international interest in family-centred approaches, there is a dearth of research on operational experiences in implementation and scale-up. Our retrospective case study examined best practices and enabling factors during scale-up of family-centred care in ten health facilities and ten community clinics supported by a non-governmental organization, Mildmay, in Central Uganda. Methods included key informant interviews with programme management and families, and a desk review of hospital management information systems (HMIS) uptake data. In the 84 months following the scale-up of the family-centred approach in HIV care, Mildmay experienced a 50-fold increase of family units registered in HIV care, a 40fold increase of children enrolled in HIV care, and nearly universal coverage of paediatric cotrimoxazole prophylaxis. The Mildmay experience emphasizes the importance of streamlining care to maximize paediatric capture. This includes integrated service provision, incentivizing care-seeking as a family, creating child-friendly service environments, and minimizing missed paediatric testing opportunities by institutionalizing early infant diagnosis and provider-initiated testing and counselling. Task-shifting towards nurse-led clinics with community outreach support enabled rapid scale-up, as did an active management structure that allowed for real-time review and corrective action. The Mildmay experience suggests that family-centred approaches are operationally feasible, produce strong coverage outcomes, and can be well-managed during rapid scale-up.
Funding: World Health Organization Headquarters, Maternal, Newborn, Child and Adolescent Health Department provided financial support for the
documentation of best practices at Mildmay Uganda by the team, with the support of an external consultant. Author Dr. Lulu Muhe is a staff member at the WHO
Headquarters Maternal, Newborn, Child and Adolescent Health Department. The funders had no role in the 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.
Nearly 150,000 children are living with HIV in Uganda, and
the majority of children are under five years of age . Vertical
transmission accounts for an estimated 18% of new infections
nationally , and an estimated 53% of HIV-infected women
receive antiretroviral to prevent mother-to-child transmission
(PMTCT) . While nearly 60% of HIV-exposed infants are
tested within 1216 months after birth, there is high loss to
followup among exposed infants . Yet despite the clear need to
scaleup comprehensive prevention, care, and treatment for
HIVexposed and infected infants, paediatric services have lagged
behind adult care both in Uganda and internationally .
Challenges to scale-up have included: poor linkages from PMTCT
programmes and the subsequent missed opportunities for
identification during postnatal and child health care; challenges of early
infant diagnosis; the prioritization of adult treatment and
subsequent lag in availability of paediatric antiretroviral dosages;
and limited paediatric expertise amongst healthcare providers [4
Family-centred approaches to HIV care have emerged as an
effort to better target children and their caregivers for testing and
care, and to provide integrated, comprehensive HIV and health
services that support the range of a family units care needs. A
family-centred approach seeks to provide services within dynamic
familial relationships, particularly given that infection often occurs
in the familial context (e.g. sexual relations, pregnancy,
breastfeeding). Family members are also often responsible for chronic care
among HIV-infected individuals, and the impacts of HIV may
affect the family beyond the HIV-infected individual, and are
often intergenerational .
In the past, paediatric HIV care, PMTCT, and ART have been
funded and provided as stand-alone, parallel services .
Alternatively, family-centred care intends to integrate HIV
services within the broader primary healthcare system and provide
a comprehensive, one stop service package for families, and
increase access to paediatric services (Figure 1). Service
beneficiaries move beyond the index clients to include spouse and/or sexual
partners, children, family members, and community members in a
facilitys catchment area [1214,1718]. Family-centred HIV care
should include timely maternal and paediatric HIV diagnosis,
antiretroviral prophylaxis, co-trimoxazole prophylaxis, and
longterm antiretroviral therapy for an entire family. It can also include
a number of other health interventions, including treatment of
opportunistic infections (OIs), infant feeding, sick and well child
care, immunizations, malaria prevention and treatment, and
tuberculosis interventions including isoniazid preventive therapy
Thereby, a family-centred approach to HIV care is an
optimal opportunity to capture paediatric clients at key entry
points of care, including sexual and reproductive health services
(e.g. prevention of mother-to-child transmission, PMTCT),
postpartum care, paediatric and adult outpatient and inpatient
departments (e.g. integrated management of child illness, IMCI),
immunization clinics, and community-based health mobilization
. The challenge for family-centred approaches is to
integrate HIV care into a wide continuum of services,
particularly in an effort to capture children that are both
symptomatic and asymptomatic, as well as those living with
non-biological caregivers [15,19]. In doing so, integrated HIV
services are critical to progress in the Millennium Development
Goals, and particularly the incidence of child morbidity and
mortality (Goal 4), maternal mortality (Goal 5), and tuberculosis
(Goal 6) .
Preliminary evidence on family-centred approaches
demonstrates good outcomes in preventing mother-to-child transmission,
increasing paediatric referrals, improving paediatric clinical
outcomes, and supporting adherence and retention in HIV care
[12,15,1718]. Children, both HIV-infected and not, also
indirectly benefit when their caregivers are treated, as evidenced
by decreases in malarial and diarrhoeal episodes, hospitalizations,
and mortality, as well as improvements in school enrolment and
nutrition, and decreases in child labour . This said
familycentred HIV models vary widely in service delivery approach,
beneficiary recruitment targets and methods, and level of service
While there is interest in family-centred care models, there is a
dearth of research sharing operational experiences. This paper
seeks to examine good practices and enabling factors in a
familycentred model scaled up in Uganda by a non-governmental
organization, Mildmay Uganda, and identify key lessons and
recommendations for a family-centred approach targeting
paediatric care. By examining the operational model that contributed to
this rapid scale-up of family-centred, integrated HIV care, this
case aims to contribute to a wider discussion on increasing access
to high-quality HIV prevention, treatment, and care services for
children in resource-limited settings. Disseminating experiences in
translating policy into practice aims to benefit policy makers,
programme managers, implementation partners, and healthcare
Figure 1. Possibilities for integrated service package for family-centred care. Figure displays recommended services listed within four
subheadings: HIV and TB care, paediatric and adult primary care, psychosocial and economic support, and administrative services.
In 2003 Mildmay Uganda began using a family-centred
approach to integrate paediatric HIV care into adult HIV and
maternal and child health services in its own centre, nine partner
facilities, and ten community health facilities in six districts of
Ugandas Central region. These facilities included public and
private (non-governmental and faith-based) institutions. The
integrated package at Mildmay included the following services:
(a) HIV diagnosis, prevention, prophylaxis, and treatment services;
(b) reproductive and maternal health services, including PMTCT,
family planning, and cervical cancer screening; (c) paediatric
outpatient and inpatient services, including rehabilitation for
severe acute malnutrition; (d) adolescent and adult outpatient and
inpatient services; (e) commodity distribution for families enrolled
in care (e.g. insecticide treated nets, safe water supplies); (f)
specialist services including paediatric dental, adult and paediatric
ophthalmology, occupational therapy, physiotherapy, and mental
health; (g) TB screening and treatment; and (h) home-based
follow-up and counselling support from community-based
volunteers and community nurses.
Documentation efforts examined retrospectively how Mildmay
and its partners utilized the family-based care approach to
integrate HIV services in facilities. First, key informant interviews
with programme managers, care providers, and patient families
examined operational successes and challenges across sites.
Documentation particularly examined Mildmay problem-solving
around challenges noted in family-centred care literature and were
analyzed focusing on the changes in key services approaches. Key
informant interviews with patients are routinely conducted, with
consent, within patient satisfaction and programme review
processes. Given that it is routine and consent is obtained for
use in programme research and evaluation there are no IRB or
Uganda National Council for Science and Technology (UNCST)
Second, a key documents review examined programmatic
strategy pieces, national paediatric HIV care policies, technical
guidelines, and relevant memos, e.g. previous internal
documentation work on cotrimoxazole scale-up and disclosure to children
at Mildmay. Third, a desk study examined electronic Health
Management Information System data maintained at the
Mildmay main site between 1999 and 2010. Data collection tools
were developed by experienced technical staff, and the same data
set is used for reporting to the Ministry of Health, Centers for
Disease Control and Prevention, Monitoring and Evaluation of
the Emergency Plan Progress, monthly district reports, and other
stakeholders. Key data points available at the time of intervention
(2003) and at period of analysis (2010) were entered into Excel and
analyzed using simple frequency distribution. These included the
number of children enrolled in care and the number of children on
cotrimoxazole prophylaxis and/or ART. All Mildmay Uganda
clients provide informed consent for use of stored medical record
data for future programme research and evaluation. As we only
analysed aggregate, anonymous hospital administrative data, and
the research only documented best practice and lessons learnt
using routine data of consenting clients, no further ethics review
Results demonstrate a significant increase in demand for, and
utilization of, paediatric HIV care since the introduction of the
family-centred care strategy. After the 2003 introduction of the
family-centred approach at the Mildmay main site, the numbers of
children enrolled in HIV care, receiving cotrimoxazole
prophylaxis, and on antiretroviral treatment increased (Figure 2). The
approach resulted in a 50-fold increase of families registered in
HIV care at Mildmay and supported facilities (n = 70 to 3,653).
Family units enrolled in care average two adults and two children.
From 2003 to 2010, Mildmay experienced a 43-fold increase of
children actively enrolled in care (n = 86 to 3726) and a 23-fold
increase of children on ART (n = 86 to 2015). Mildmay was one of
the first organizations to begin providing antiretroviral treatment
for children in Uganda; between 1999 and 2003 a small number of
children were enrolled in HIV care and receiving antiretroviral
treatment. About half of these children at any given time during
the review period were eligible to receive ART given the initiation
criteria; of note, ART guidelines have since changed and all
infected children under five are eligible to initiate ART.
Additionally, the facility has achieved nearly universal paediatric
cotrimoxazole coverage after prophylaxis scale-up began in 2004.
Service uptake results suggest that the family-centred approach
captured numbers of HIV-infected children for enrolment in
integrated care. At the time of this evaluation, nineteen percent of
Mildmays clients (n = 22,000) were children, which is one of the
highest proportions among Ugandan health facilities and exceeds
the national target of 10% paediatric patients. It is certainly worth
beginning a discussion by noting that the availability of free ARVs
in Uganda in 2004 brought national momentum to treating both
adults and children. However, we argue that Mildmays approach
in encouraging families to access services together played a very
important role in increasing numbers of children in care. The
Mildmay paediatric caseload continues to exceed the national
average per site; districts where Mildmay is implementing health
systems strengthening support do not otherwise have an emphasis
on family-centred care, and still have very low paediatric care
coverage. Many sites in these districts with ART availabilityand
without the integrated family approachstill do not offer paediatric
As no facilities were offering paediatric HIV care at the time of
scale-up, several measures were required to build capacity to
provide paediatric care, to deliver comprehensive services, and to
operate within the new integrated delivery approach. In
supporting scale-up of family-centred care, Mildmay Uganda worked with
identified partner facilities to: conduct needs assessments, provide
capacity building for the multidisciplinary teams involved with
service provision (Figure 3), advise facility restructuring as required
for efficient patient capture and integrated service delivery, target
the family networks of HIV-infected clients for enrolment into
integrated health services, drive monitoring and evaluation, revise
programmatic guidelines, and prepare supportive exit strategies
with partner facilities.
As a retrospective and largely observational study, controls were
not available to study the specific causality of family-centred care
Operational Best Practices
Our qualitative examination of Mildmays approach highlights
a number of best practices and enabling factors that have
Figure 2. Cumulative trend of uptake of paediatric care after introduction of family-based approach at Mildmay main site in 2003.
Figure demonstrates uptake trends from 1999 to 2010 for three key indicators: number of children and adolescents enrolled in HIV care, number on
cotrimoxazole prophylaxis, and number on ART. Uptake data shows sharp increases for all three indicators at 2003, when the family-based
approached was introduced at Mildmay.
streamlined integrated care services provision at the facility,
supported access at the community level, and provided for active
management of the family-centred approach during rapid
Incentivizing care seeking as a family. Facilities have
reorganized their delivery approach to provide one stop
package of services that incentivizes care-seeking as a family
(Figure 4). Within the family-centred approach, beneficiaries
frequently cited client satisfaction during interviews as a key
reason for seeking services. Patients can be referred within the
same facility for different services, or re-scheduled as a family if
additional services will require prolonged waiting time or the
clinical services required are offered on another day of the
week. Beneficiaries are given same-day appointments if the
family chooses. Family members are also fast tracked for
treatment if they come with children, an incentive for parents to
initiate care with their children. Mildmay facilities also permit
alternate drug collection by approved family members, so that
families can acquire treatment when the index client is too weak
or unable to go to the facility, or the child is in school. Facilities
refer when necessary, and also link families to social support
services including livelihood projects and education support for
children. Integrated HIV services should also reduce household
costs for seeking services at multiple facilities, or multiple visits
for different service components; this data was not collected
from clients but could be the focus of future research.
Provider-facilitated disclosure. Mildmay experienced a
30% increase in partner testing, and the disclosure rates increased
from 30% to 70% in 72 months, following provider-assisted
partner disclosure as an entry point into HIV care. The
familycentred approach promotes provider-facilitated serostatus
disclosure to significant others when the client is prepared, thus further
enhancing the family support system. Counsellors provide a
number of disclosure methods; clients can disclose in the presence
of a counsellor, or can request the counsellor disclose to their
parents in their presence, or others request time to disclose on their
own. While index clients are encouraged to disclose to their family
members, contact with families only occurs when the index client
is ready. Additionally, 152 unique individuals in discordant
relationships have been identified and supported. Follow-up with
clients as family units has also enhanced continued counselling for
Provider-initiated testing and counselling and early
infant diagnosis integrated into triage. Routine
providerinitiated testing and counselling (PITC) has been integrated into
triage at key entry points to care, including antenatal care,
outpatient clinics, and inpatient facilities. All staff members are
trained on the client flow pathway for identified HIV-exposed and
infected children (Figure 5). In post-test counselling, there is a
strong focus on preparing the index client to bring other family
members in for testing, counselling, and care. As women more
women seek services in Mildmay facilitiesparticularly as primary
Figure 3. Capacity building for integrating family-centred care at partner facilities. Figure describes the courses designed by Mildmay and
made available during partner facility service integration, as needs assessments determine. These include short-term (week) courses on skills sets like
pediatric HIV nursing or laboratory skills, modular courses on more advanced subjects like community-based HIV care and health systems
approaches, and training for community volunteers on HIV/AIDS basics and counseling skills.
caregivers coming for their childs careemphasis is placed on
partners testing. Counselling urges family members to take drugs
together at the prescribed time, and to encourage each other to
observe care provider instructions and agreed plans with providers
(e.g. safer sex, nutrition, treatment adherence). Patients and
communities qualitatively attribute good adherence to supportive
Routine PITC is particularly strong with decentralized capacity
for early infant diagnosis (EID). All supported facilities have been
trained and equipped to collect dry blood spots, especially within
postnatal care services. Dry blood spots are collected every two
weeks from partner facilities, and sent centrally from Mildmay to
Kampala-based laboratories. Turnaround for laboratory results is
a maximum of 14 days. Staff members report that the timely
return of test results fosters client trust in the availability of
services, encouraging caregivers to bring children back for further
In addition to PITC strategies, free voluntary HIV testing and
counselling (HTC) services are provided regularly at each facility.
At every HTC encounter, the index client is encouraged to have
their partner(s) and children tested as well.
Multi-pronged strategy for capturing paediatric
referrals. Particular care is taken for parent-child and sibling
referrals. At enrolment into care, information is captured about
the index clients children and if they have been tested. At every
clinic visit, follow-up information regarding the childrens status is
collected as part of the client review form. Similarly, for any child
seen at Mildmay, reviews inquire about the siblings status and if
they are in care. Parents and guardians are encouraged and
supported to disclose HIV serostatus to older children. This has
enhanced adherence and retention amongst this age group .
There are additional strategies to capture HIV-infected children
living with non-parent or non-biological caregivers. Orphanages
bring children in their care for testing, as do some schools after
obtaining parental consent. Churches also liaise with Mildmay to
conduct HTC for their congregations. Community-based
volunteers target grandparent-run households to follow-up with children
in care. Lastly, Mildmays waiting rooms host morning health
talks in the facility waiting area to capture clients.
Child-friendly service environment. Mildmay Uganda has
created a child-friendly environment at its main health centre,
including furniture, toys, play equipment, and on-duty child
counsellors. Childrens play clubs organized at health facilities
bring children together on specific days to interact with other
children and receive support. The care at these play clubs varies
by age group, and children are encouraged to give feedback on
their experiences with treatment. Parents reported that the
childfriendly environment is encouraging for the families, and they
believe children are well-cared for centre.
Multi-disciplinary management team. A
multi-disciplinary team of clinicians, nurses, social workers, counsellors,
pharmacists, monitoring and evaluation team members, and
psychosocial programming staff meet weekly to review operations
and strengthen linkages across departments involved in delivering
family-centred care. Weekly reviews also determine follow-up with
clients who missed appointments, and also examine mortality data.
The multi-disciplinary management designed has facilitated a
number of innovations, including a particularly interesting
Figure 4. Service approach at health facilities before and after family-centred approach. Figure describes several service delivery
components (e.g. scheduling, counseling, medication refills, and community engagement) before and after the family-centred approach. The figure
demonstrates considerable effort to re-align the service approach to make it family-friendly, for example, same-day scheduling for families or
fasttracking families with children for services.
mortality tracking system. In an effort to monitor client outcomes,
while also recognizing the sensitivities around accurate mortality
data, the Mildmay management team has instituted a memorial
system to ensure mortality reporting. Throughout the year,
monitoring teams compile the families who have lost a family
member, and a memorial service is held each year for those who
have passed away. Mildmay reports that the value attached to the
memorial service has encouraged families to report deaths.
Task shifting in HIV care and community outreach
support. Task shifting towards a nurse-led approach with
community volunteer support has facilitated quality services,
especially as client loads increase, by addressing gaps in skilled
human resources, decentralizing services, facilitating service
integration, and monitoring uptake in the community. Nurse-led
community clinics can provide follow-up care to infants and
children that do not require physician review, and for
noncomplicated cases can reduce wait time at facilities and minimize
direct staff costs under management by nurse time instead of
medical officer time. The proportion of child reviews by the
nurseled clinic has risen from 5% to 12% between 2007 and 2010;
however wait times were not measured.
Mildmays family-centred care has trained community-based
volunteers (CBV) and volunteer nurses to provide outreach and
home-based care to a client load of ten patients, including
homebased care, drug adherence support, follow-up visits for pregnant
women and children, and mobilization for HTC. CBVs are often
members of the Village Health Teams created by the Ministry of
Health, some are local leaders, and many are expert patients.
CBVs are managed by a local head, who reports directly to the
health facility. CBV incentives include transport costs for
scheduled activities, limited days of work in an effort to not
overburden, and bicycles for CBVs who have served at least six
months and regularly follow-up with at least ten patients.
Mildmay has also created mechanisms to promote community
ownership. Community decision-making has been instituted at
some facilities, and community members serve on the facility
management committees that plan service integration. Quarterly
meetings between community members and service providers
review operations of the CBVs and health providers, clients drug
taking and readiness to start treatment, and general services
uptake. Additionally, local councils (LCs) provide political will and
key linkages to services. LCs vet children for services and formally
refer children to play clubs at the facility. Local authorities help
supervise CBV operations in their villages.
Figure 5. Client flow pathway into HIV care and treatment within family-centred approach. Figure demonstrates the patient flow at
integrated facilities; the pathway has been adapted from the WHO Integrated Management of Adult Illness sequence of care. Entry points into
familybased points including outpatient care, maternal and child health clinics, antenatal care, inpatient admissions, and community-based outreach.
Clients then proceed through triage assessments, education and support as required, assessment of client and family health status, care and
treatment as required, positive prevention for HIV-infected clients, and follow-up care services.
Considerations for Scale-up
These operational outcomes suggest that family-centred care is
a feasible and effective method for capturing paediatric clients and
providing comprehensive HIV care as a one stop model for the
family. While our case study highlights a number of best practices
and enabling factors in the Mildmay experience, there are also
noteworthy challenges and considerations for scaling up integrated
First, a number of resource investments are required for
scaleup of integrated, family-centred care. The model relies on a secure
procurement and supply chain system, and human resources for
care and follow-up support. The most critical human resource
requirement for scale-up was the creation of the multi-disciplinary
management team, but otherwise staff was not added. In settings
with limited staff numbers, clinics were encouraged to use task
shifting and volunteers. As this paper identifies, one significant
challenge to integrated care has been traditional funding of
vertical streams, e.g. paediatric HIV, maternal care, and adult
HTC. Resource requirements and costing have not been
systematically studied in this case study, but are an important
area for continued research.
Second, staffing levels and facility infrastructure must be
prepared to provide quality services for increased patient loads,
balance workloads for service providers, and minimize client
waiting time. Reorganization of space and patient flows may be
required to provide adequate triage, counselling, and waiting
space. As discussed, Mildmay utilized task-shifting for additional
human resources support, and also adopted additional clinical
days and a new scheduling system to better manage additional
Third, family-centred care requires staff training and support
for paediatric and family-oriented care, and attrition after
orientation to the approach hinders programme scale-up. As
discussed, Mildmay instituted a multi-disciplinary management
team to ensure more consistent communications and support
across facilities and provider units. The management team also
had to continue to identify emerging training needs (Figure 3) for
health workers, volunteers, and managers after the initial
Fourth, the approach required planned logistical support for
community-based activities like outreach and mobilization (e.g.
transport for community based volunteers, which was not
originally planned for). This is particularly challenging with
outreach for families requiring additional support due to extreme
poverty or difficult accessibility, and when children are living
among multiple households that require several points of contact
with caregivers. These situations may necessitate outreach clinics
and care provision. Finally, continued stigma and discrimination
around HIV and care seeking persists in some communitiesfor
example, reluctance to waste time on the care of HIV-infected
orphansand requires ongoing mobilization activities and local
The growing programmatic and policy interest around
familycentered care models emphasizes the need to share scale-up results
and challenges, as this paper aims to do. As an emerging model of
practice, there is considerable scope for further research in
effective delivery, including leadership and capacity building in
facilities that re-align service delivery towards the family-centred
model, and the impact of integrated care on paediatric clinical
The family-centred approach at Mildmay has integrated
paediatric early diagnosis, prevention, treatment, and care into
outpatient and inpatient care, maternal and child health services,
and HIV care. Operationally, a number of best practices have
facilitated high-quality services and decentralized access during
rapid-scale up in partner facilities. The Mildmay experience
highlights the critical need to re-align care provision towards
integrated service packages that incentivize care-seeking as a
family, and in child-friendly environments. Mildmays approach
was aided by provider-initiated or facilitated testing and
counselling to target index clients and families for care, and task-shifting
towards nurse-led clinics with community outreach support. These
community outreach mechanisms diversified service entry and
provided critical adherence support, including targeted volunteer
efforts at the household level; engagement with local leaders; and
service outreach to churches, schools, and orphanages.
Multidisciplinary team management and tracking mortalities through
an annual memorial service further enabled further facilitated
informed scale-up. The Mildmay scale-up experience emphasizes
that family-centred care approaches can be operationally feasible,
and it is a promising approach for producing positive
programmatic and uptake outcomes for paediatric HIV/AIDS care.
The authors would like to thank the following for their considerable efforts
during the project documentation: Dr. Lillian Nabiddo (Mildmay Uganda),
Dr. Christine Nabiryo (Uganda Christian University), Dr. Josephine
Nabukeera (formerly Mildmay Uganda, now CDC Uganda), and Dr.
Shaffiq Essajee (World Health Organization Department of HIV). The
authors also thank Dr. Eyerusalem Negussie and Dr. Amitabh Suthar
(World Health Organization Department of HIV) for written feedback on
Conceived and designed the experiments: EL FL LM. Performed the
experiments: EL JA JM CS. Analyzed the data: EL FL LM MT. Wrote the
paper: MT LM.
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