Experiences of Latinx sexual and gender minorities with access to healthcare during COVID-19 stay-at-home orders

Abstract

Purpose

The coronavirus disease 2019 (COVID-19) pandemic affected all social systems, but healthcare services were particularly disrupted. The pandemic also had a disproportionate impact on populations made socially vulnerable. In this study, we documented the experiences of Latinx sexual and gender minority (SGM) individuals with access to care during COVID-19 stay-at-home orders.

Methods

Semistructured qualitative interviews assessing experiences during the stay-at-home orders in response to the COVID-19 pandemic and patients’ experiences accessing healthcare during this period were conducted with 21 Latinx SGM individuals from the Washington, DC, area. Data were analyzed using rapid qualitative analysis (RQA), and salient themes were identified.

Results

The RQA revealed 3 themes reflecting participants’ experiences with pharmaceutical care during COVID-19 stay-at-home orders: (1) challenges in accessing HIV services; (2) community engagement; and (3) providers supporting access to care. Participants experienced problems with adherence to medication, transportation, and technology, as well as delays in care and miscommunication with providers. Latinx SGM individuals demonstrated engagement in response to this emergency as a community and valued their providers and their efforts to facilitate access to care.

Conclusion

The COVID-19 pandemic strained healthcare services. Findings from this study show that the impact of the pandemic on the provision of care increased the vulnerability of Latinx SGM people. Future research should explore the impact of public health emergencies on the health of populations historically made socially vulnerable, and innovative solutions should be identified to eliminate these barriers to health equity.

KEY POINTS.

• The challenges Latinx sexual and gender minorities had in accessing health services during the COVID-19 pandemic increased their vulnerability to adverse health outcomes.

• Technology, particularly e-health and telemedicine, played a significant role in keeping people in care during the COVID-19 pandemic. Among Latinxs in this study, the increased reliance on technology across various platforms was beneficial for some and challenging for others.

• Some accommodations made for healthcare provision during the pandemic should be studied to improve these services and provide sustainability.

Sexual and gender minority (SGM) people are a continually underserved and understudied population in US healthcare and public health. They are disproportionately affected by communicable and noncommunicable diseases, poverty, unemployment, and food security, among other determinants of health.^1,2 SGM individuals are significantly affected by the human immunodeficiency virus (HIV) epidemic and consequently are overrepresented among those using HIV prevention and care services. SGM people have also experienced adverse health outcomes as a result of the response to the coronavirus disease 2019 (COVID-19) pandemic,³ and racial and ethnic minority SGM individuals were disproportionately affected.⁴ Community-centered research is needed to improve access to and retention in healthcare services for these populations. Hence, studying their access to care and needs during the response to the COVID-19 pandemic could inform policies and practices to address specific barriers.

Current research on access to care needs for SGM individuals is primarily focused on HIV prevention (eg, preexposure prophylaxis, or PrEP) and care (eg, antiretroviral therapy), while there is some research about gender minorities’ access to gender-affirming care. Providers, particularly those in primary care, are essential for attention to the healthcare needs of SGM individuals. For example, research supports the idea that pharmacists’ knowledge of SGM patient needs plays a significant role in the health and well-being of SGM patients.^5,6 Doctor of pharmacy education programs have been found to either have only basic information about SGM-oriented health needs or completely lack SGM health competencies, yet pharmacists have been identified as key in facilitating linkage of SGM people to essential services such as primary care, counseling, HIV testing, and provision of PrEP.^7,8

As recommended by Del Río-González,⁹ in this report we use “Latinx” when referring to the community at large, “Latino” when referring to men, and “Latina” when referring to women. This is also consistent with how participants of the study self-identified. By 2020, Latinxs represented 18.9% of the US population.¹⁰ In 2019 estimates of new HIV infections in the US, Latinx SGM people accounted for 29% of new infections,¹¹ and, by the same year, Latinxs represented 30% of all people with HIV in the US.¹² HIV treatment requires medication adherence and is helping people with HIV live longer and healthier lives.¹³ The Ending the HIV Epidemic (EHE) initiative in the US encourages and facilitates access to and retention in care for people with HIV and integrates PrEP as an effective tool to reduce the incidence of new infections. Existing disparities in HIV treatment adherence and PrEP uptake among Latinx communities represent an area of priority for the EHE initiative in the 2030 target.^12–14 For example, the EHE initiative aims for 50% of eligible people to be on PrEP; while eligible White, non-Latinx people far surpass that goal, with 66% prescribed PrEP, Latinx populations—who, together with Black populations, account for the majority of people for whom PrEP is recommended—fall short of the EHE goals, with just 16% prescribed PrEP as of 2020.^13,15 Disparities in HIV incidence rates and accessibility to and use of PrEP make improving access to care for the Latinx population important to maintaining their health and preventing new HIV infections.

The COVID-19 pandemic greatly impacted SGM communities. In a study with a global sample of cisgender sexual minority men, gay and other men who have sex with men (MSM) reported negative economic and mental health outcomes and interruptions to HIV testing and treatment services.¹⁶ Challenges accessing HIV prevention and care services were also identified among sexual minority men in the US.¹⁷ In a study of SGM individuals in the US, increased incidence of anxiety and depression was found to coincide with the onset of the COVID-19 pandemic. Further, policies enacted in response to the pandemic increased vulnerability and experiences of violence among transgender women.¹⁸ Notably, Rhodes and colleagues¹⁹ documented that, in the early stages of the pandemic, sexual minority men with HIV faced new challenges accessing healthcare and adhering to medical regimens.

The COVID-19 pandemic has had a disproportionate impact on the morbidity and mortality of Latinx people, with Latinx SGM people facing an even more significant impact.^20,21 Early stay-at-home orders during the COVID-19 pandemic created both temporary and ongoing changes in healthcare delivery. These changes resulted in new barriers for Latinx SGM individuals when accessing HIV testing, prevention, or treatment services by altering and limiting how patients would receive services and inadequately informing patients of new service delivery methods.^22,23 Among all young sexual minority men, it was estimated that 1 in 7 stopped PrEP use, and 20% reported difficulty getting their medications as a result of the pandemic.²⁴ In a study with gay, bisexual, and other MSM, 32% said that COVID-19 prevented them from testing for HIV,²⁵ and 34.6% of Latinx SGM individuals received less medical care than usual.²¹ Moreover, Latinx SGM people were reported to be less likely than other racial or ethnic SGM groups to be interested in a future COVID-19 vaccine.²⁶

The pandemic additionally affected the finances of many households. Among Latinx SGM people, one study found that 50% had lost their jobs and 36.5% did not have enough food.²³ The financial stress led to increased alcohol use and worsened quality of mental health.²³ Similarly, 57.4% of Latinx SGM people reported personal financial loss, with disproportionate financial burdens for immigrants compared to US-born Latinx SGM individuals.²⁷ Another study found that social and financial changes resulted in 54.9% of Latinx SGM individuals experiencing changes in diet²⁸ and economic instability.

Despite the health disparities that exist for Latinx SGM people and the lower level of access to resources that this population experiences, research on the needs of this specific population is lacking in scope. Identifying the needs of SGM patients is important to remove barriers to access to care and improve access to fundamental services, especially in the context of public health emergencies. With this in mind, the goal of this study was to document the experiences of Latinx SGM people with pharmaceutical care during COVID-19 stay-at-home orders.

Methods

Population and recruitment.

Twenty-one Latinx SGM individuals in the Washington, DC, area were enrolled in this qualitative study. All participants were recruited using social media and with the support of local community partners. Eligible participants self-identified as gay, bisexual, MSM, or transgender; self-identified as Latinx, Latina, or Latino; self-reported their HIV status; lived in the Washington metropolitan area; and were at least 18 years old. Participants provided consent in English or Spanish and were scheduled for a remote interview (eg, by telephone or virtual call), and they received a $50 gift card as a token of appreciation. Participants provided demographic data at the beginning and end of the interview. All study procedures were reviewed and approved by the Office of Human Research at The George Washington University.

Data collection instrument.

Interviews were conducted remotely via video or telephone call between February 18 and June 25, 2021. During this period, Washington, DC, was under modified measures for phase 2 of the reopening process, which included limited seating in enclosed spaces, a limit to the number of people who could attend large events, and mandatory use of masks. Participants completed semistructured interviews with trained staff in English (n = 14) or Spanish (n = 7). The first author developed the semistructured interview guide, which included sections assessing participants’ general experiences during the COVID-19 pandemic, HIV prevention or HIV care, and overall health experiences as Latinx SGM individuals. Two bilingual Latinx researchers conducted the interviews, which took 30 to 60 minutes to complete.

Analytical approach.

We conducted a rapid qualitative analysis (RQA) of the interview data, following guidelines provided by Hamilton and colleagues.²⁹ We also integrated good practices developed explicitly for using RQA with Latinx populations to analyze qualitative data for implementation science research when the findings are needed to rapidly inform practice.³⁰ Our analytical procedures retained the scientific rigor and efficiency expected for qualitative analysis when compared to other qualitative methods, such as thematic analysis.³¹ When analyzing data, we started by developing an “interview summary” document, which was a structured template to summarize and organize key statements from each interview. The lead author created an “interview summary guidelines” document to ensure all analysts were consistent when completing their summaries. The lead author provided all analysts with training on completing the interview summaries, which included didactic and practice components. After each interview, the interviewer completed an interview summary that was integrated into the analysis. Interviewers also met regularly to exchange notes and their experiences during interviews.

Once each interview summary was completed, it was reviewed by separate analysts and then by the first author. Next, the first author and 3 team members created interview matrices to discover key themes. We used spreadsheets including participants’ responses to each question, allowing us to view responses across participants. Once responses were included in the matrix, 3 analysts extracted key themes. The first author conducted consensus meetings to determine the final themes. Data collected in Spanish were analyzed in Spanish, and only quotations used for dissemination purposes were translated to English. With a total of 21 interviews (including of 12 persons with HIV), we reached information power³² according to the aim and specificity of the study.

Results

The average age of the 21 participants was 34.5 years (range, 20-52 years), 14 identified as gay, bisexual, or MSM, and 7 identified as transgender women. All were born in Latin America, including in Colombia, El Salvador, Honduras, Mexico, Peru, and Puerto Rico. Most participants (n = 15; 71.4%) self-identified as Hispanic/Latino, Latino, or Latina. Other participants self-identified as Latin American, Indigenous (from Latin America), or White Latina. Almost half of the participants (n = 10; 47.6%) reported high school as their highest level of educational attainment, 57.1% (n = 12) were employed full-time, 52.3% (n = 11) had experienced a reduction in monthly income because of the COVID-19 pandemic, and 71.4% (n = 15) of the participants were single. Participants were receiving services from multiple organizations in the Washington, DC, area, including primary healthcare centers, community-based organizations, and other institutions serving persons with HIV.

The RQA revealed 3 themes reflecting participants’ experiences with access to care during the COVID-19 stay-at-home orders: (1) challenges in accessing HIV preventive or care services; (2) community engagement; and (3) providers supporting access to care. These themes are summarized with examples in Table 1.

Table 1.

Latinx Sexual and Gender Minorities’ Experiences With Access to Care During the Stay-at-Home Orders in Response to the COVID-19 Pandemic

Theme	Participant	Quotation
Challenges in accessing HIV preventive or care services	HIV-negative gay man, 25 years old	“At the beginning [of the pandemic], it was difficult to get appointments because they were not allowing too many people in the building. I was getting my meds by mail but not my labs done.”
	Gay man LWH, 52 years old	“There were some limitations. I did not get my laboratories for a few months. I think they [providers] were focused on other issues and were taking care of many people. There was very limited communication.”
	HIV-negative gay man, 35 years old	“I was very frustrated [with getting HIV medication]. There were problems with the pharmacy not having the medication I use, and then there were issues with my insurance that apparently was not covering the medications. The nurse changed me to a medication that is all the medications in one pill, and she gave me pills for 2 weeks. I appreciated her help because I was very frustrated.”
	Gay man LWH, 47 years old	“I missed my medication for a few weeks. I couldn’t communicate with my doctor because there was no one available. . . . They would try to send it [medication] to me by mail, and there was an issue with the post office and my provider. Time went by, and I was stressing out that I was in danger of developing resistance to that medication.”
	HIV-negative transgender woman, 30 years old	“It was difficult. It was a new way of doing things, but I always got my medications from the clinic to the pharmacy. They would call me every 2 months.”
	Gay man LWH, 38 years old	“My [HIV care] services got affected at some point, but they [providers] always found a way to give me my medication. . . . I use public transportation, and with the shutdown, it would take me double the time to get to the clinic. I had to lose too much time. Eventually, they started sending me the medications by mail.”
	Gay man LWH, 58 years old	“Communication with the providers is not great. Often, I feel isolated. You have to call multiple times, and you would expect they would call back or send an email, whether in English or another language.”
	HIV-negative gay man, 35 years old	“At the beginning [of the pandemic], we had many technological issues, including young people. To get an appointment, people had to register on a website, and for the Latino community, it was hard because just a few of us had access to technology. Even if people have smartphones, they do not know how to use them.”
	Gay man LWH, 52 years old	“I received my services through telemedicine, and it was very impersonal. It was not the same as when it was in person.”
Community engagement	Transgender women LWH, 29 years old (A)a	“When sharing her opinion about the HIV services available to transgender Latinas in the DMV area, . . . translatinas take care of each other’.”
	Gay man LWH, 52 years old	“Some people experience discrimination, and we need to change that. The language barrier, low levels of education—trouble reading or writing—those are the people we have to look for so they can access services.”
	Gay man LWH, 52 years old	“Our community [people with HIV] needed more information and to get our questions [related to COVID-19] answered.”
	Gay man LWH, 58 years old	“I called often about their plans to give us the [COVID-19] vaccine.”
	Gay man LWH, 42 years old	“It is good to know that some people in the clinic have lived experiences [of having HIV].”
Providers supporting access to care	Gay man LWH, 47 years old	“Something they did at my clinic was to provide services even if the patient had issues with the medical insurance or if they couldn’t pay.”
	HIV-negative transgender woman, 29 years old (B)a	“[My providers] were very nice. They sent me an [HIV] home test and condoms by mail.”
	Transgender women LWIH, 36 years old	“My doctor, she is like my second mother, . . . she is like an angel to me. At [name of the clinic] they’ve done their best to get me what I need.”
	Gay man LWH, 52 years old	“[My case manager] helped me get some supplemental financial support for transportation and food.”

Abbreviations: COVID-19, coronavirus disease 2019; HIV, human immunodeficiency virus; LWH, living with HIV.

^aA and B correspond to 2 distinct participants with the same HIV status, gender identity, and age.

Participants shared the main challenges encountered during the stay-at-home stage of the pandemic. Some of these barriers included difficulty getting appointments associated with physical access to the clinic, limited availability of providers, lack of communication, issues with access to medications, and challenges with technology. While the public health recommendations of physical distancing and limited numbers of people in indoor spaces may have helped reduce the spread of COVID-19, they also challenged access to HIV prevention and care services. Participants acknowledged that the pandemic required extraordinary attention and that providers were overwhelmed. They also recognized the efforts made by providers to ensure they had access to the medications or services they needed. Several participants mentioned that continuity of care was feasible because medication was mailed to them. However, participants documented the challenges associated with getting prescriptions mailed to them. In particular, those who were on HIV treatment experienced missing medication.

During the interviews, participants also reported how interaction with providers changed and the impact of technology on their access to care. For some participants, use of virtual appointments and websites to schedule appointments was a barrier. Some of the challenges documented were limited access to technology among Latinxs and the low technological literacy of some members of the Latinx community. For those who had access, some considered telemedicine to be impersonal. However, it is worth noting that 2 participants shared that technology facilitated their access to care. An HIV-negative 33-year-old gay man shared:

“Since the pandemic started, it has made it easier to make appointments. . . . So every other doctor, besides the dentist, I’ve done it over the computer. For me, it has made access more convenient. I do not have to go out of my way to go into the office or hospital.”

Participants also shared their experiences of community engagement in response to the needs of the Latinx community and people with HIV during the early stages of the COVID-19 pandemic. In this analysis, we defined community engagement as intentional interactions between community members and decision-makers, emphasizing the lived experiences of community members informing decision-making. For the transgender Latina community (translatinas), having each other and a support network was fundamental. Other participants shared how members of the Latinx community experienced inequities in the response to the pandemic due to the lack of information in Spanish or information that was consistent with their levels of literacy. Participants also voiced their interest in more information and support for those with HIV who may have had specific concerns about COVID-19 infection and vaccines. Some participants recognized having providers with lived experience as persons with HIV as an asset.

Research participants talked about providers’ support for access to HIV services. They documented specific instances in which providers’ support made a difference in their experience receiving HIV services during the early stages of the pandemic. Participants recognized the efforts of providers to keep patients in care and avoid delays in care by providing services even if medical insurance was not covering the services. Participants also documented the advantage of receiving preventive services, including at-home testing and condoms via the mail. Interviewees also shared the meaningful relationship they had developed with their providers and how their support went beyond clinical services.

Discussion

We interviewed 21 Latinx SGM individuals who shared their experiences accessing healthcare services during the stay-at-home phase of the response to the COVID-19 pandemic in the Washington, DC, metropolitan area. Their narratives helped us to describe 3 main themes that emerged from our analysis: their experiences accessing HIV prevention and care services, community engagement, and providers’ support for access to services. In their responses, participants also showed empathy for the overwhelming experience of many healthcare providers during the pandemic. Nonetheless, these stressors in the provision of services led to long waits to get appointments, limited access to care, and failure to adhere to the recommended use of medication.

Challenges in accessing HIV preventive or care services.

Challenges faced in seeking biomedical HIV prevention and care services were a major theme among the research participants. Studies documenting Latinx SGM access to HIV services during the COVID-19 pandemic have noted confusion and disruption to services as well as positive changes such as the introduction of telehealth and relaxed clinical protocols.¹⁹ Previous research describing challenges to HIV care for Latinx people has commonly identified language barriers, mistrust of the healthcare system, and lack of culturally relevant healthcare as barriers to access.^33–35 Findings from the interviews in this study suggest that these barriers continued to represent a challenge for the Latinx SGM community during the COVID-19 pandemic. For example, a participant shared their frustration and fear of not getting their HIV medications and complying with recommended adherence practices. This experience illustrates how challenges to HIV care adherence are not limited to individual behavior or choices but are also related to the structures that allow or challenge retention in care. Notwithstanding this, providers’ efforts to support continuity in HIV prevention and care services were recognized by participants. Challenges related to communication went beyond language incongruence, and at times communication was lacking altogether. Participants described bouncing between the pharmacy and their provider, not knowing whom to communicate with, or simply finding that no one was available to talk to regarding their medications. Our findings suggest that future research should include investigating communication between patients and their healthcare service providers throughout the care continuum to understand why communication problems occur and address how best to prevent them as a means to reduce delays in patients’ access to important care and prevention services. Organizations can also consider developing contingency communication plans that could be used in future public health emergencies.

Although transportation has been mentioned as a possible barrier to HIV services in other studies,³⁶ the participants in this study specifically described changes in transportation services brought on by the COVID-19 pandemic as a barrier to their ability to access HIV prevention and care services, noting that the time it took to get to the city from where they lived drastically increased. However, transportation was not the only barrier to accessing the medications participants needed. Participants who were able to get to their pharmacy described issues with the pharmacy not having their medications in stock, while, for those who received medication by mail, issues between the post office and their providers were new challenges experienced due to the pandemic. These findings are consistent with previous research documenting patterns for continuing and discontinuing medication during the early stages of the COVID-19 pandemic.³⁷ As a proactive measure, primary care services could be prepared with appropriate mechanisms for medication delivery and stocks to respond to public health emergencies and natural events that could alter the regular flow of service. Community pharmacies are well positioned for wider rollout of efficient local services such as mailing programs.

Technology, particularly e-health and telemedicine, played a significant role in keeping people in care in response to the COVID-19 pandemic. Among the Latinx SGM participants in this study, the increased reliance on technology across various platforms was beneficial for some and challenging for others. This finding expands on work by Harkness and colleagues²² with Latinx sexual minority men, in which they reported telehealth as a positive change experienced during the COVID-19 pandemic. This contrast reiterates the technological divide that must be considered when planning strategies for access to care³⁸ and that responses to health emergencies cannot rely exclusively on technology.

Community engagement.

Community engagement continues to be a supportive means for Latinx SGM people to better their health. Participants shared how they engaged with stakeholders. Some interviewees shared that they engaged with healthcare providers to advocate for the needs of their communities and peers, while others expressed that their community was their most significant source of support during the response to the COVID-19 pandemic and for their healthcare needs. During the COVID-19 pandemic response, the Latinx community called for increased community engagement to improve vaccine outreach and access,³⁹ which reflects the narrative of participants in this study when they discussed community engagement related to pharmaceutical care. These findings are consistent with evidence suggesting that peer-based strategies can lead to positive health outcomes and better engagement in care and research for Latinx populations affected by HIV.^26,40,41 There are gaps in research relating to community engagement during the COVID-19 pandemic among Latinx SGM people and access to care. The findings from this study highlight the successes of community engagement with Latinx SGM individuals, which suggests the need to explore the impact of community engagement on this population in response to public health emergencies that could challenge access to services.

Providers supporting access to care.

While this study found providers playing a more supportive role during the COVID-19 stay-at-home orders among Latinx SGM individuals, previous literature with the same population did not reflect this support. Earlier studies with Latinxs have reported that mistrust of the healthcare system, providers’ competency, and the quality of healthcare encounters lead to negative experiences with providers.^42,43 On the other hand, patient-centered experiences or encounters in which the patient and provider have a similar approach to care may lead to positive experiences for patients.⁴⁴ Our findings shed light on the potential of implementing nurturing conditions for positive healthcare encounters to reduce disparities in access to and retention in care.

While research investigating possible solutions to shortcomings in service delivery has identified several contributory factors, further investigation is needed for a clear understanding of the needs of key underserved populations. Addressing gaps in the curricula for healthcare providers (such as about HIV care and prevention methods, including PrEP), inadequate or a complete lack of culturally competent curricula, and poor representation of non-White providers—especially in non-White areas—only begin to address the needs of underserved people and the intersectionality of experiences (eg, the intersection of Latinas with HIV and Spanish speakers).^27,35 Similarly to studies focused on patients’ experiences, studies with a focus on providers also found language barriers, a lack of trust between patients and providers, and a need for better representation of Latinx and/or SGM providers to be the main barriers to connecting Latinx SGM individuals to healthcare services.^27,35

Our study had limitations. First, our findings were specific to the individuals included in this research project. Consistent with the goal of the study and the qualitative methodology used, the findings are not generalizable to any population. Nonetheless, the findings can inform future research to further explore and describe the themes identified in this analysis. Similarly, we did not conduct systematic comparisons among participants based on their HIV status, sexual orientation, gender identity, immigration status, or language. The selection of study participants was not designed to conduct these more in-depth analyses; these groups and comparisons should be analyzed separately because of the significant role these factors may have. We analyzed participants’ experiences in healthcare encounters, but, because of the breadth and depth of these findings, they are outside the scope of this manuscript and will be reported separately.

These limitations should be contextualized based on the strengths of this study. The strengths of the study include that participants represented Spanish- and English-speaking Latinxs, with all born outside the continental US. Additionally, we had a culturally congruent research team that could collect and analyze data in English and Spanish. Finally, this is a novel study integrating RQA to understand the impact of the response to the COVID-19 pandemic on providing healthcare to Latinx SGM individuals.

Conclusion

The early response to the COVID-19 pandemic was disruptive to all social systems. Healthcare services were particularly strained due to their role in responding to the public health emergency while sustaining preexisting services. During the stay-at-home orders early in the pandemic, Latinx SGM people were disproportionately affected by the direct effects of COVID-19, but findings from this study show that the impact that the pandemic had on the provision of care services increased the vulnerability of this population. The adverse health outcomes experienced by our research participants included problems with adherence to HIV medication, delays in care, and miscommunication with providers. During this period, Latinx SGM individuals also experienced challenges with transportation and with the use of technology. Fortunately, Latinx SGM people demonstrated their ability to engage in the response to this emergency as a community. They also valued the role of their providers and their efforts to facilitate access to and engagement in care. Future research should continue exploring the impact of public health emergencies on the health of populations historically made socially vulnerable, and innovative solutions should be developed and implemented to eliminate barriers to health equity.

This article is part of a special AJHP theme issue on healthcare considerations in sexual and gender minorities. Contributions to this issue were coordinated by Alex R. Mills, PharmD, BCACP, AAHIVP; Kevin N. Astle, PharmD, BCPS, BCACP, AAHIVP, CDCES; and Kyle Melín, PharmD, MSc, BCPS, AE-C.

Data availability

The date underlying this article cannot be shared publicly for the privacy of individuals who participated in the study.

Disclosures

This research was funded by a 2020 award from the District of Columbia Center for AIDS Research, an NIH-funded program (P30AI117970), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA, NIDDK, NIMHD, NIDCR, NINR, FIC, and OAR. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH.The authors have declared no potential conflicts of interest.