Abstract
Purpose
Caribbean countries are among the most heavily burdened by both human immunodeficiency virus (HIV) and cancer, with prevalent stigmatization of both illnesses. This novel pilot study responds to the need to examine and understand both cancer- and HIV-related stigma among cancer survivors living with HIV (CSLWH).
Methods
Data were collected via quantitative surveys and administered in person in Trinidad and Tobago. The survey used in this pilot study included an HIV stigma scale and a cancer stigma scale. Descriptive analyses were conducted using IBM SPSS Statistics 29.0.0.
Results
For most stigma items, HIV stigma is higher than cancer stigma, especially for personal and relational self-stigma: 95% vs 28% of participants reported that they feel telling someone is risky for their HIV status and cancer status, respectively. HIV-related societal/community stigma is also higher than cancer-related stigma: 87% of participants reported that they feel most people believe a person who has HIV is dirty, vs 18% reported the same stigma for cancer. Most CSLWH believed HIV is more stigmatized than cancer by the community/society (90.6% vs 9.4%) and family/friends (93.8% vs 6.3%). However, cancer-related stigma exists in health outcome beliefs: 57% of CSLWH believed that once having cancer, a person will never be ‘normal’ again, while 45% of CSLWH felt the same for HIV.
Conclusions
Our preliminary findings suggest greater HIV-related personal and relational self-stigma and societal/community stigma compared to cancer-related stigma among CSLWH. However, more cancer-related health outcome beliefs are stigmatizing compared to HIV-related stigma among CSLWH.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12981-026-00902-4.
Keywords: Cancer survivors, HIV, Stigma, People living with HIV
Introduction
Globally, Caribbean countries are among the most heavily burdened by both HIV and cancer [1–6]. According to the Pan-American Health Organization (PAHO) [1] and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) [6], the Caribbean subregion has the highest HIV incidence rate in the Americas: with between 350,000 and 590,000 Caribbean people living with HIV (PWH), the region has an adult HIV prevalence rate between 1.9% and 3.1%. In addition, compared to the United States, the cancer morbidity and mortality in the Caribbean area are much higher, particularly for breast, cervical, and prostate cancers [4, 5]. The social and economic burden caused by cancer is expected to increase by 66% to 67% by 2040 in the Caribbean region, if no significant intervention is implemented [4, 5].
With highly successful advancements in HIV treatments, PWH are living longer and therefore are increasing among the population of cancer survivors. Since HIV leads to ongoing inflammation and damage to the immune system, PWH are more likely to develop certain types of cancer, especially those caused by viruses, such as cervical cancer [7]. In addition, PWH who are diagnosed with cancer are more likely to die from that cancer than people without HIV [7]. However, there is insufficient research focused on how cancer survivors living with HIV (CSLWH, patients who have been diagnosed with both cancer and HIV) perceive HIV and cancer stigmas.
Stigma is the negative attitude and behaviors of society, including those affected by different diseases [8–10]. It is influenced by income, ethnicity, gender norms, culture, and the type of disease, such as HIV and cancer [8–10]. For CSLWH, they are facing both HIV-stigma and cancer-stigma, which makes them even more vulnerable. Previous studies have indicated stigma can influence a person’s experience of illness(es), quality of care, and quality of life [11]. In addition, the external stigma may shape patients’ internalized perceptions since this discrimination, comprising fear, blame, and structure, is directly internalized by CSLWH, leading to self-stigma, shame, and damaged self-worth [12]. The internalization can cause severe health consequences such as mental health issues, delayed healthcare access, and reduced treatment adherence [13].
This study prioritized the Caribbean, which is a region of undue cancer and HIV burdens, as well as high HIV and cancer stigma prevalence [8–10, 14]. Further, this region suffers from tremendous income disparities and limited healthcare resources, especially for oncology care. Stigma has been studied in both illnesses independently. However, this novel pilot study responds to the need to examine and understand both cancer- and HIV-related stigma among persons living with a history of both HIV and cancer.
Methods
Study design and settings
This is a pilot study focusing on cancer- and HIV-related stigma and targeting CSLWH in Trinidad and Tobago. Data was obtained within the largest HIV clinic in Trinidad and Tobago and one of the largest HIV clinics in the Caribbean, and as of December 2025, there were 10,710 PWH registered. Authorized clinic healthcare professionals abstracted HIV and cancer diagnosis data from the health information system and conducted the interviews. The study was approved by the IRB of City of Hope Comprehensive Cancer Center and the IRB of the University of the West Indies. No personal identifiers were shared with the research team to protect the privacy of individuals and abide by Trinidad and Tobago’s data protection law.
Participants and data collection
CSLWH enrolled are people with HIV and diagnosed with at least one type of cancer (any type); no matter which illness was diagnosed first. For the study, 63 patients were approached and 3 were non-responders. Data was collected and administered by clinical medical professionals. No HIV viral load, viral suppression, or CD4 T-cell counts data were collected in this pilot study.
The quantitative questionnaire used in this study comprised demographic information along with a cancer stigma scale and an HIV stigma scale. Specifically, the HIV stigma scale was developed based on the 12-item short version of the HIV stigma scale [15] and the cancer stigma scale was developed based on a culturally trans-created Cancer Stigma Scale for the Caribbean context [8–10]. The stigma scales are 6-point Likert scales (Strongly Agree’, ‘Moderately Agree’, ‘Slightly Agree’, ‘Slightly Disagree’, ‘Moderately Disagree’, ‘Strongly Disagree’) and coded as 1 through 6 for strongly agree, moderately agree, slightly agree, slightly disagree, moderately disagree, and strongly disagree, respectively.
To compare the HIV and cancer stigma, we included stigma questions of 3 major categories in the questionnaire: 1) personal and relational self-stigma questions, including “People I care about stopped calling after learning I have…”, “I work hard to keep my … a secret”, “Telling someone I have … is risky”, “I am very careful who I tell that I have …”, “I feel guilty because I have …”, “I feel I’m not as good a person as others because I have …”, and “I have lost friends by telling them I have…”; 2) societal/community stigma questions, including “Some people avoid touching me once they know I have …”, “Most people believe a person who had … is dirty”, “People with … are treated like outcast”, “Most people are uncomfortable around someone with …”, and “People’s attitudes about … make feel worse about myself”; 3) health outcome beliefs questions, including “Once you’ve had … you can never be ‘normal’ again”, “Getting … means having to mentally prepare oneself for death”, “Having … usually ruins a person’s career”, “… usually ruins close personal relationships”, “A person with … is responsible for their condition”, and “It is acceptable for banks to refuse to give loans to people living with …”. We also have three overall comparison questions, including “Of the two illnesses (HIV/AIDS and Cancer), which do you believe society views more negatively?”, “Comparing cancer and HIV/AIDS, which do you believe is more stigmatized by society/the community?”, and “Comparing cancer and HIV/AIDS, which do you believe is more stigmatized by your family and friends?”.
Other related items are also included in the HIV stigma scale and cancer stigma scale, respectively, to obtain a better understanding of participants’ experiences and thoughts of stigma. Details can be found in the Results section.
Data analysis
All data were stored in the Research Electronic Data Capture system (REDCap), which is a secure, web-based application used for a wide variety of research studies. Categorical data were reported in frequency and percentage. Descriptive analyses were conducted using IBM SPSS Statistics 29.0.0.
Results
Demographic results
In total, 60 CSLWH were enrolled in this pilot study. Data collection took place in person from October 2024 to November 2025. Table 1 shows the demographic characteristics of all participants. For CSLWH, the majority (73.3%) were aged over 45 years old, and 63.3% were female. Notably, 88.3% of CSLWH reported as heterosexual/straight. Over half of CSLWH were single (53.3%); 48.3% had a full-time or part-time job. Most of them completed at least a secondary-level education (83.4%). No HIV viral load and viral suppression data was collected in this study.
Table 1.
Demographic characteristics of cancer survivors living with HIV, N = 60
| Demographic characteristics | Frequency, % |
|---|---|
| What is your age range? | |
| 18–25 | 1, 1.7% |
| 26–35 | 2, 3.3% |
| 36–45 | 13, 21.7% |
| 46–55 | 20, 33.3% |
| 56–65 | 12, 20.0% |
| 65+ | 12, 20.0% |
| Sex | |
| Male | 22, 36.7% |
| Female | 38, 63.3% |
| Sexual orientation | |
| Heterosexual/Straight | 53, 88.3% |
| Men who have sex with men (MSM) | 2, 3.3% |
| Bi-sexual | 2, 3.3% |
| Prefer not to answer | 3, 5.0% |
| What is your relationship status? | |
| Currently married/living with someone | 24, 40.0% |
| Divorced/Lived with someone in the past, but not now | 3, 5.0% |
| Single | 32, 53.3% |
| Prefer not to answer | 1, 1.7% |
| What is the highest level of education you completed? | |
| None | 2. 3.3% |
| Primary | 8, 13.3% |
| Secondary/High | 21, 35.0% |
| Trade or Technical School | 13, 21.7% |
| University | 16, 26.7% |
| What is your employment status? | |
| Full-time | 26, 43.3% |
| Part-time | 3, 5.0% |
| Retired | 15, 25.0% |
| Not employed | 16, 26.7% |
HIV stigma
CSLWH reported stigma in personal and relational self-stigma during their life like “I feel guilty because I have HIV (50.0%)”, “People I care about stopped calling after learning I have HIV (36.6%)”, “I feel I’m not as good a person as others because I have HIV (36.7%)”, and “I have lost friends by telling them I have HIV (35.0%)”. Additional personal and relational self-stigma exists too: most of the CSLWH stated “I work hard to keep my HIV a secret (86.6%)”, “Telling someone I have HIV is risky (95.0%)”, “I am very careful who I tell that I have HIV (96.7%)”.
For HIV-related health outcome beliefs, 68.4% of CSLWH believed HIV usually ruins close personal relationships; 63.3% believed “A person with HIV is responsible for their condition”; 53.4% of them believed getting HIV means having to mentally prepare oneself for death; 51.7% believed “Having HIV usually ruins a person’s career”; and 45.0% believed “Once you’ve had HIV you can never be ‘normal’ again”.
In the societal/community contexts, CSLWH believed that most people (86.6%) in society believe that a person who has HIV is dirty, people with HIV are treated like outcasts (86.7%), and most people are uncomfortable around someone with HIV (86.6%). Specifically, about 3 in 5 CSLWH felt “People’s attitudes about HIV make me feel worse about myself”. The frequency, percentages, and mean ± standard deviation for each HIV stigma item are provided in the supplementary document.
Cancer stigma
Overall, cancer stigma items exist among CSLWH. For cancer-related health outcome beliefs, over half of participants believed “Cancer devastates the lives of those it touches (69.9%)”, “Once you’ve had cancer you can never be ‘normal’ again (56.6%)”, “Getting cancer means having to mentally prepare oneself for death (53.3%)”, and “a person with cancer is accountable for their condition (45.0%)”. Societal/community stigma exists: 33.3% of CSLWH stated “most people are uncomfortable around someone with cancer” and 25.0% agreed that “People’s attitudes about cancer make feel worse about myself”. CSLWH also reported personal and relational self-stigma during their life: “I am very careful who I tell that I have cancer (61.6%)”, “Cancer usually ruins close personal relationships (43.3%)”, “I work hard to keep my cancer a secret (38.3%)”, “I feel guilty because I have cancer (20.1%)”. Most CSLWH argued that government, society, and community should provide more help to them to improve their quality of life: “We have a responsibility to provide the best possible care for people with cancer (96.7%)”, “More government funding should be spent on the care and treatment of those with cancer (95.0%)”, “The needs of people with cancer should be given top priority (95.0%)”. The frequency, percentages, and mean ± standard deviation for each HIV stigma item are provided in the supplementary document.
HIV stigma compared to cancer stigma
Table 2 shows the comparison of HIV stigma and cancer stigma among all CSLWH. Of the two illnesses (HIV/AIDS and Cancer), 87.5% of CSLWH believe society views HIV more negatively. Notably, most CSLWH agreed HIV is more stigmatized by society/the community (90.6%) and by their family and friends (93.8%).
Table 2.
Comparison of cancer stigma and HIV Stigma
| HIV stigma | Cancer stigma | |
|---|---|---|
| Overall Comparison | ||
| Of the two illnesses (HIV/AIDS and Cancer), which do you believe society views more negatively? | 87.5% | 12.5% |
| Comparing cancer and HIV/AIDS, which do you believe is more stigmatized by society/the community? | 90.6% | 9.4% |
| Comparing cancer and HIV/AIDS, which do you believe is more stigmatized by your family and friends? | 93.8% | 6.3% |
| Personal and relational self-stigma | ||
| People I care about stopped calling after learning I have… | 36.7% | 21.6% |
| I work hard to keep my … a secret | 86.6% | 38.3% |
| Telling someone I have … is risky | 95.0% | 28.4% |
| I am very careful who I tell that I have … | 96.7% | 61.6% |
| I feel guilty because I have … | 50.0% | 20.1% |
| I feel I’m not as good a person as others because I have … | 36.6% | 15.0% |
| I have lost friends by telling them I have… | 35.0% | 21.7% |
| Societal/community stigma | ||
| Some people avoid touching me once they know I have … | 48.8% | 15.0% |
| Most people believe a person who had … is dirty | 86.6% | 18.3% |
| People with … are treated like outcast | 86.7% | 23.4% |
| Most people are uncomfortable around someone with … | 86.6% | 33.3% |
| People’s attitudes about … make feel worse about myself | 56.7% | 25.0% |
| Health outcome beliefs | ||
| Once you’ve had … you can never be ‘normal’ again | 45.0% | 56.6% |
| Getting … means having to mentally prepare oneself for death | 53.4% | 53.3% |
| Having … usually ruins a person’s career | 51.7% | 31.7% |
| … usually ruins close personal relationships | 68.4% | 43.3% |
| A person with … is responsible for their condition | 63.3% | 41.7% |
| It is acceptable for banks to refuse to give loans to people living with … | 13.3% | 16.7% |
For most stigma items, HIV stigma is greater than cancer stigma, especially for personal and relational self-stigma, such as 86.6% vs. 38.3% of participants reported that they work hard to keep a secret of their HIV status and cancer status, respectively. Similarly, 95.0% vs. 28.4% of CSLWH reported that they feel telling someone is risky for their HIV diagnosis and cancer diagnosis, respectively. HIV-related societal/community stigma is also greater than cancer-related societal/community stigma, e.g., 86.6% agreed that they feel most people believe a person who has HIV is dirty, vs. 18.3% reported the same stigma for cancer. Additionally, 86.7% agreed that people with HIV are treated like outcasts, vs. 23.4% reported the same stigma for cancer and 86.6% agreed that most people are uncomfortable around someone with HIV, vs. 33.3% reported the same stigma for cancer. Also, 56.7% agreed that people’s attitudes about HIV make them feel worse about themselves, vs. 25.0% reported the same stigma for cancer.
However, cancer-related stigma exists in health outcome beliefs. 56.6% of CSLWH believed “once you’ve had cancer you can never be ‘normal’ again” while 45.0% believed so for HIV and 16.7% of CSLWH felt “It is acceptable for banks to refuse to give loans to people living with cancer” vs 13.3% for HIV.
Discussion
Caribbean countries are among the most heavily burdened by both HIV and cancer, with an urgent need to reduce the prevalence and incidence of both illnesses. Previous studies have addressed that stigma can influence a person’s experience of illness(es), quality of care, and quality of life, indicating the importance of reducing potential stigma for preventing HIV and cancer [11, 12]. However, most studies focused on HIV-related stigma or cancer-related stigma independently and there is a lack of research addressing both.
This pilot study is one of the first studies to understand and examine both HIV and cancer stigma, focusing on people living with both HIV and cancer (CSLWH). From our descriptive results, the co-occurrence of cancer and HIV can exacerbate HIV stigma. Possible reasons may be the perceived severity of both illnesses and societal beliefs that stigmatize cancer and heavily stigmatize HIV. Additionally, in this study, stigma was reported for some items like “I feel guilty because I have HIV” and “I am very careful who I tell that I have HIV”, which indicated HIV is still considered “shameful” and “non-curable” among CSLWH. Previous research stated that the health impact of intersectional stigma is complex within the fields of cancer and HIV: these overlapping, multilevel forms of stigma and discrimination bring more barriers to health and opportunities for coping among CSLWH [16, 17]. Policymakers should develop multidimensional, multilevel, multidirectional, and action-oriented interventions to reduce this intersectional stigma and eventually achieve the goals of eliminating HIV and cancer stigma.
Our results indicated that self-stigma plays an important role among CSLWH. Self-stigma related to HIV occurs when people living with HIV internalize negative stereotypes about HIV infection, leading to feelings of shame, worthlessness, and isolation. This internalized stigma negatively impacts mental health, access to treatment, treatment adherence, and overall quality of life [18, 19]. Self-stigma in cancer refers to a patient’s internalized feelings of shame, self-blame, and low self-worth due to their diagnosis, often leading to increased stress/depression and a worse quality of life. It may result from societal beliefs linking cancer to specific behaviors, cultural factors, or the association of cancer with death/disability. This internalized stigma can prevent individuals from seeking timely treatment and can negatively impact their quality of life, including their mental health [20, 21]. In this study, HIV-related personal and relational self-stigma are greater than cancer-related self-stigma, which indicates that HIV has more negative impacts on quality of life among CSLWH. Moreover, HIV has more negative societal/community stereotypes based on our findings that HIV-related societal/community stigma is greater.
In addition, over half of our participants were women, which indicates a higher prevalence of women living with HIV compared to patterns typically observed in the United States and Europe [22, 23]. In Trinidad and Tobago, gender and sociocultural roles may significantly influence stigma experiences due to their culture and social norms. Our findings align with previous research that women suffer more from additional stigma when diseases (such as cervical cancer and HIV) are linked to their reproductive system and traditional gender roles [8–10]. With the unique forms of social and internalized stigma that women encounter, many women living with HIV and cancers would avoid discussing their diseases and health, which is a barrier to their diagnosis, treatment, health outcomes, and quality of life. To reduce the stigma and secure the pathway to care among women living with HIV and cancer, women-tailored and culture-tailored health educational programs are necessary. A social media campaign can be a possible method to disseminate stigma-free educational materials as well as HIV/cancer- related health promotions throughout the whole country. One of our future studies will focus more on women living with HIV and cancer to understand their specific experiences, thoughts, and needs towards stigma.
Another noteworthy characteristic of our study population is that the majority of CSLWH completed at least a secondary level of education. Previous studies have stated that educational attainment and health literacy may influence perceptions of stigma [24]; however, the influence can be different: higher literacy may mitigate stigma through improved understanding of disease, or conversely, increase awareness of societal attitudes and thus heighten perceived stigma. In our study, a higher educational level may increase self-stigma since in their culture, people with a higher educational level should be “perfect” without any imperfection, including diseases like HIV and cancer. Relatedly, community-level literacy and public knowledge may also shape broader stigma dynamics and could be briefly addressed. We will continue to investigate the associations between educational attainment/health literacy and HIV/cancer-related stigma in the future.
Limitations
The present study has limitations that suggest directions for future research. First, this pilot study has a small sample size. Due to limited time and funding, we only enrolled 60 patients with both HIV and any type of cancer. Cancer-related stigma varies by cancer type, particularly for malignancies with visible manifestations or those historically associated with HIV, such as Kaposi sarcoma, as well as cancers requiring disfiguring treatments (e.g., mastectomy), which may influence both self-image and societal perceptions. However, this pilot study aims to obtain an initial and broad understanding of stigma experience among people with both HIV and cancer. The current inclusion criteria help us recruit as many eligible patients as possible to achieve our goal. We will recruit more eligible participants and analyze the associations between cancer type and stigma among CSLWH in the future. Similarly, data of clinical markers such as HIV viral load and CD4 T-cell counts were not collected in this pilot study, which limited the ability to assess relationships between stigma and clinical outcomes. One of our next studies will collect clinical outcome data and investigate whether stigma may impact adherence to antiretroviral therapy or engagement with cancer treatment and follow-up care. We will recruit more eligible participants and track their pathway to care to identify how stigma has affected their ability to seek and receive treatment, adhere to treatment plans, or continue long-term HIV or cancer care.
Second, since we used standardized stigma scales, the current questionnaire did not parallel all HIV and cancer stigma questions. In addition, the questionnaire used in this study focused only on cancer and HIV stigma; however, we acknowledged that CSLWH may experience other forms of stigma/discrimination not captured by this measurement as well, i.e., gender or sexual orientation discrimination. Also, this pilot study did not collect data on participants’ HIV viral suppression status, years living with HIV, etc., and these factors might be related to participants’ experiences of stigma, particularly for internalized stigma.
Third, data was from the HIV clinic in the north of Trinidad, the demographic would be more patients of African origin and mixed race and fewer of East Indian origin, compared to the general population. Most patients of East Indian origin live in central/south Trinidad. We will expand the study setting to include more clinics throughout the country and collect more data from patients to have a more comprehensive understanding in the future.
Future studies will continue to recruit more patients and develop a more comprehensive questionnaire. We will also examine stigma across different settings for either HIV or cancer, conduct studies on qualitative lived experiences of how stigma experiences intersect, and how intersecting stigmas affect HIV and Cancer care outcomes. We will recruit more eligible participants and also conduct analyses to identify potential factors that are associated with stigma (such as gender, age, educational level, etc.) among CSLWH.
Despite the limitations, this novel pilot study responds to the need to examine and understand both cancer- and HIV-related stigma among persons living with a history of both HIV and cancer. Our findings suggest the existence of HIV-related personal and relational self-stigma, HIV-related societal/community stigma, and cancer-related health outcome beliefs stigma. Therefore, more efforts are needed to improve awareness of both cancer and HIV in the Caribbean area to reduce stigma and its negative influence on people living with stigmatized illnesses and population health overall. In Trinidad and Tobago, culturally tailored educational interventions are needed; social media campaigns can be a possible method to disseminate stigma-free educational materials as well as HIV/cancer- related health promotions throughout the whole country. It is also important for their healthcare system to reduce the negative effects of stigma, which has affected CSLWH’s ability to seek and receive treatment, adhere to treatment plans, and continue long-term HIV or cancer care.
Conclusion
This novel pilot study responds to the need to understand cancer- and HIV-related stigma by prioritizing people living with both HIV and cancer (CSLWH), which is both urgent and compelling, as people living with HIV (PWH) are growing older and have an increased risk for cancer. Our findings show that both HIV and cancer stigma exist among CSLWH. HIV-related personal and relational self-stigma and HIV-related societal/community stigma are greater than those of cancer-related stigma. However, cancer-related health outcome beliefs stigma are greater than that of HIV stigma among CSLWH.
Supplementary Information
Acknowledgements
The funders had no role in the design and conduct of the study; Kindly check and confirm the placement of “Availability and requirements” section was appropriate. Otherwise advise us on how to proceed.collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
Study registration
This study was not formally registered.
Analytic plan pre-registration
The analysis plan was not formally pre-registered.
Use of artificial intelligence (AI)
Artificial intelligence was not used in the development of this manuscript.
Author contributions
Kimlin Ashing : Funding acquisition, Conceptualization, Methodology, Writing – review & editing, Supervision, Project administration, Resources. Gaole Song : Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. Sharon Soyer : Investigation, Data curation, Resources, Methodology, Writing – review & editing. Jonathan Edwards : Methodology, Writing – review & editing. Tessa Galindo : Investigation, Data curation, Resources, Methodology, Writing – review & editing. Selena Todd : Methodology, Writing – review & editing. Gregory Boyce : Methodology, Writing – review & editing. Virginia Savage : Methodology, Writing – review & editing. Jeffrey Edwards : Conceptualization, Methodology, Writing – review & editing, Supervision, Project administration, Resources.
Funding
This work was funded by the Cancer Center Stigma Grant P30CA03572, received by K. Ashing.
Data availability
The datasets generated and/or analyzed during the current study are not publicly available due to local government regulations; the data belong to the medical clinic contracted with the government to provide care. Thus, the IRB restricts data sharing. But data are available from the corresponding author on reasonable request.
Materials availability
Materials used to conduct the study are not publicly available.
Code availability
There is no analytic code associated with this study.
Declarations
Ethics approval and consent to participate
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was IRB-approved. Informed consent was obtained from all individual participants included in the study.
Consent for publication
The authors affirm that human research participants provided informed consent for publication of all contents.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Jeffrey Edwards, Email: jedwards@mrftt.org.
Kimlin Ashing, Email: KAshing@coh.org.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated and/or analyzed during the current study are not publicly available due to local government regulations; the data belong to the medical clinic contracted with the government to provide care. Thus, the IRB restricts data sharing. But data are available from the corresponding author on reasonable request.
Materials used to conduct the study are not publicly available.
There is no analytic code associated with this study.