Abstract
OBJECTIVES
To characterize factors associated with dual method use in a sample of adolescent women.
METHODS
We conducted a cross-sectional survey of sexually active African American females aged 14–19 years attending an urban Title X clinic in Georgia in 2012 (N=350). Participants completed a computerized survey assessing contraceptive and condom use at last two sexual encounters with their most recent partner. Dual method use was defined as use of a hormonal contraceptive or intrauterine device (IUD) plus condom. We applied multinomial logistic regression, using generalized estimating equations, to examine the adjusted association between dual method use (versus use of no methods or less effective methods alone, e.g. withdrawal) and select characteristics.
RESULTS
Dual methods were used by 20.6% of participants at last sexual intercourse and 23.6% at next to last sexual intercourse. Having a previous sexually transmitted disease (STD) (aOR 2.30, 95%CI 1.26–4.18), negative attitudes towards pregnancy (aOR 2.25, 95%CI 1.19–4.28) and a mother who gave birth as a teen (aOR 2.34, 95%CI 1.21–4.52) were associated with higher odds of dual method use. Having no health insurance (aOR 0.39, 95%CI 0.18–0.82), ≥ 4 lifetime sexual partners (aOR 0.42, 95%CI 0.22–0.78), sex at least weekly (aOR 0.54, 95%CI 0.29–0.99), and agreeing to monogamy with the most recent partner (aOR 0.40, 95%CI 0.16–0.96) were associated with decreased odds of dual method use.
CONCLUSIONS
Dual method use was uncommon in our sample. Efforts to increase use of dual methods should address individual and relationship factors.
INTRODUCTION
The adverse consequences of early and unintended pregnancy and sexually transmitted diseases (STDs) are substantial and well documented (1–6). Adolescents, particularly African American adolescents, carry a disproportionate risk for these outcomes (7–9). With varying levels of success, young people may employ a range of behaviors (e.g., condom use alone, condoms combined with other contraceptive use, STI testing, monogamy) to protect themselves from STDs and pregnancy. The strategies chosen are influenced by individual, relationship and social/structural factors (10–12). Dual method use (i.e., condoms with hormonal contraceptive or IUD use) and use of condoms alone are encouraged for adolescents who are sexually active because they may be effective at preventing STDs and pregnancy at the same time (13). This study examines contraceptive use, including use of dual methods, condoms alone, or hormonal methods/IUD alone among a sample of young African American women living in a Southeastern city with high rates of STDs and teen pregnancy (7). This analysis seeks to confirm role of known associated factors and identify potential additional factors which have not been addressed in this population (e.g. perceptions of STDs and pregnancy, agreeing to monogamy, mutual STD testing). Understanding factors that may influence contraceptive use is essential in conceptualizing programs to promote dual method use and thus better protect adolescent females from pregnancy and STDs.
MATERIALS AND METHODS
This study reports on a cross-sectional survey that was part of a mixed methods study assessing attitudes and practices surrounding the prevention of pregnancy and STDs among African American adolescents and young women. Survey participants were recruited between April and September 2012 from a single urban hospital-based teen clinic that receives Title X funding (i.e., federal funding for comprehensive family planning services, including hormonal contraceptives, implants, IUDs and condoms available to teens without out-of-pocket costs). Eligible participants were female, seeking clinical care on the day of recruitment, self-identified as US born African American, aged 14–19 years and had vaginal sex with a male partner in the past six months. This study received Institutional Review Board approval (including a waiver of parental consent to protect confidentiality of teens’ service use) from the Centers for Disease Control and Prevention and Emory University.
Teens were approached in the clinic waiting area and, if interested, discussed the study with a member of the study team in a private area. Interested and eligible teens completed informed consent or assent. Participants completed the survey using an Audio Computer-Assisted Self-Interviewing (ACASI) platform with individual tablet computers and headset. All participants received a $20 gift card for their participation.
Survey topics included demographics, family background, attitudes toward and outcome expectations for pregnancy and STDs, reproductive history (including sexual, pregnancy, and STD history and testing), characteristics of the relationship with their most recent male sexual partner (including relationship type, length, coital frequency and whether the participant and her partner had agreed to monogamy) and sexual behaviors. Participants were asked about condom and contraceptive use for their last two sexual encounters with their most recent male partner in the past six months.
Our outcome of interest was contraceptive method use, which we categorized into four groups: dual method (defined as use of a condom plus hormonal contraception or IUD), condom alone, hormonal contraception or IUD alone (defined as a combined hormonal contraceptive, injection, implant or IUD without use of a condom), or other/no method (use of withdrawal, “other”, or no method). To examine factors associated with contraceptive use, we constructed models in which each sexual episode inquired about (maximum of two) for each participant was included. We estimated unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for a 4-level multinomial outcome (dual method, condom alone, hormonal/IUD alone and other/no method [Referent]) using Generalized Estimating Equations (GEE). GEE was used to account for intra-subject correlation given some participants reported on contraceptive methods used at two sexual encounters with their most recent partner in the past six months. Backwards elimination was used to fit a multivariable model after all candidate variables were entered. Variables with p-values of <0.05 were retained in the model. SAS v.9.2 and R were used for analyses.
RESULTS
Characteristics of the study population
During the study period, we approached 698 young women attending an urban Title X clinic for participation; 173 declined to be screened for eligibility. Of the 525 women screened, 374 (71%) were eligible and 350 (93% of all eligible) enrolled. The most common reason for not being eligible was not having had sex with a male partner in the past six months (78%, 118/151).
Most participants were seventeen years of age or older (65.1%) (Table 1). Over 43% had a previous STD; over one quarter (26.3%) of participants reported a previous pregnancy, and 11% reported they were living with their child(ren). Over 80% indicated they did not want a pregnancy in the next 6 months. Participants had more negative attitudes toward STDs than pregnancy; 76.3% thought an STD would be “the worst thing that could happen” in the next six months, but only 31.4% thought the same thing about a pregnancy. The majority had agreed to monogamy with her partner (83.3%) and approximately one-third (39.0%) of participants and their partners had been tested for STDs while they were together (Table 1).
Table 1.
Characteristics of African American adolescent women (ages 14–19) seeking care in a reproductive health clinic
| n (%) N=350 |
|
|---|---|
| Age | |
| 14–16 years | 122 (34.9%) |
| 17–19 years | 228 (65.1%) |
| Insurance | |
| None | 86 (24.6%) |
| Private insurance | 28 (8.0%) |
| Public insurance | 188 (53.7%) |
| Don’t know | 48 (13.7%) |
| Participant’s mother completed High School or GED | 239 (68.3%) |
| Participant’s mother’s age at first birth <20 | 215 (61.4%) |
| Previous STD | 153 (43.7%) |
| Previous pregnancy | 92 (26.3%) |
| Participant has given birth to a child that lives with her | 40 (11.4%) |
| Desires pregnancy in next 6 months | |
| Definitely or probably “yes” | 32 (9.1%) |
| Definitely or probably “no” | 288 (82.3%) |
| Don’t know | 30 (8.6%) |
| Perception of diagnosis of pregnancy in next six months | |
| It would be the worst thing that could happen | 110 (31.4%) |
| It would be a problem, but I would deal with it | 196 (56.0%) |
| It would not be a problem | 30 (8.6%) |
| I’d be happy about it | 14 (4.0%) |
| Perception of diagnosis of STD in next six months | |
| It would be the worst thing that could happen | 267 (76.3%) |
| It would be a problem, but I would deal with it | 82 (23.4%) |
| It would not be a problem | 1 (0.3%) |
| Lifetime partners >3 | 161 (46.0%) |
| Relationship Length >6 months¶ | 193 (55.1%) |
| Considers partner¶: | |
| Serious boyfriend | 196 (56.0%) |
| On and off boyfriend | 69 (19.7%) |
| Friend | 53 (15.1%) |
| No one special/ex-boyfriend/other | 32 (9.1%) |
| Coital frequency at least once/week¶ | 170 (48.7%) |
| Agreed to monogamy¶ | 290 (83.3%) |
| Mutual STD testing* ¶ | 136 (39.0%) |
Refers to most recent partner
Participant and most recent partner each had STD testing while they were together
Use of dual methods at last and next to last sex
At last sex, 20.6% (n=72) of participants used dual methods, 20.6% (n=72) used a condom alone, 22.0% (n=77) used hormonal contraception/IUD alone, and 36.9% (n=129) used no method, withdrawal (n=5) or another method (n=1) of contraception.
We examined the most common reasons why condoms and contraception were not used at last sex. When asked for up to three of the most important reasons they didn’t use condoms at last sex (n=206), the most common reasons were that the participant and her partner trusted each other (60.7%), they did not think about condom use (51.0%), and they did not have a condom (37.9%). When asked for up to three of the most important reasons that contraception, other than condoms, was not used at last sex (n=155), the most common reasons were that she wasn’t planning on having sex (36.6%), she and her partner used condoms (31.4%), and she was concerned about side effects (27.3%).
The distribution of contraceptive method use reported at next to last sex was similar to the distribution at last sex. At next to last sex, 65 (23.9%) used dual methods, 69 (25.0%) used condoms alone, 47 (17.0%) used hormonal contraception/IUD alone, and 95 (34.4%) used no method or other methods. The majority of participants reporting on two episodes of sex (76%) were consistent in contraceptive method use at the last two sexual encounters.
Predictors of contraceptive behaviors and dual method use
Table 2 presents bivariate associations between selected participant characteristics and contraceptive use (dual method, condom alone and hormonal contraception/IUD alone compared to use of no method/other). Having no insurance was associated with decreased odds of use of dual methods (OR 0.41, 95% CI 0.21 – 0.82). Participants who had previously experienced reproductive health outcomes (such as prior STDs, prior pregnancy, giving birth to a child that now lives with her) had increased odds of hormonal/IUD use alone. Having a prior STD was associated with elevated odds of dual method use (OR 1.94, 95% CI 1.12 – 3.36). Participants who had negative attitudes toward pregnancy (thinking it would be the “worst thing that could happen”) had increased odds of dual method use (OR 2.51, 95% CI 1.40 – 4.52) and condom alone (OR 2.04, 95% CI 1.17 – 3.58). However, those who had negative attitudes toward STDs were not more likely than those without such attitudes to use any type of contraception. Having sex at least weekly was associated with a decreased odds of condom use (either alone or in dual methods, see Table 2). Mutual STD testing was associated with increased odds of dual method use (OR 1.78, 95% CI 1.03 – 3.10) and hormonal/IUD use alone (OR 1.90, 95% CI 1.09 – 3.32).
Table 2.
Associations between selected participant characteristics and use of dual methods, condom alone, or hormonal method or IUD alone; unadjusted odds ratios (OR) and 95% confidence intervals (CI)
| Dual Method OR1 (95% CI) |
Condom alone OR1 (95% CI) |
Hormonal/IUD alone OR1 (95% CI) |
|
|---|---|---|---|
| Age 14–16 years | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| 17–19 years | 1.11 (0.62 – 1.98) | 0.59 (0.35 – 0.99) | 1.23 (0.68 – 2.22) |
| Insurance | |||
| None | 0.41 (0.21 – 0.82) | 0.64 (0.35 – 1.14) | 0.54 (0.28 – 1.04) |
| Private, public or don’t know | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Participant’s mother completed High School or GED | |||
| Yes | 1.18 (0.65 – 2.13) | 1.58 (0.88 – 2.82) | 1.99 (1.05 – 3.76) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Participant’s mother’s age at first birth <20 | |||
| Yes | 1.88 (1.06 – 3.34) | 1.22 (0.73 – 2.06) | 1.40 (0.79 – 2.45) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Previous STD | |||
| Yes | 1.94 (1.12 – 3.36) | 0.87 (0.51 – 1.49) | 2.04 (1.17 – 3.56) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Previous pregnancy | |||
| Yes | 1.80 (0.99 – 3.27) | 0.82 (0.42 – 1.56) | 1.83 (1.01 – 3.31) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Participant has given birth to a child that lives with her | |||
| Yes | 2.01 (0.87 – 4.66) | 0.84 (0.30 – 2.41) | 3.41 (1.56 – 7.45) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Desires pregnancy in the next 6 months | |||
| Definitely or Probably Yes or Don’t Know | 0.52 (0.19 – 1.44) | 0.41 (0.15 – 1.09) | 1.25 (0.56 – 2.80) |
| Definitely or Probably No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Perception of diagnosis of pregnancy in next six months | |||
| It would be the worst thing that could happen | 2.51 (1.40 – 4.52) | 2.04 (1.17 – 3.58) | 1.25 (0.66 – 2.36) |
| Other | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Perception of diagnosis of STD in next six months | |||
| It would be the worst thing that could happen | 1.32 (0.68 – 2.56) | 0.99 (0.55 – 1.79) | 0.90 (0.49 – 1.67) |
| Other | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Lifetime partners | |||
| 1–3 | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| 4 or more | 0.65 (0.37 – 1.13) | 1.00 (0.60 – 1.68) | 1.03 (0.60 – 1.79) |
| Relationship length > 6 months | |||
| Yes | 0.86 (0.50 – 1.49) | 0.58 (0.34 – 0.97) | 1.15 (0.66 – 2.02) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Considers partner a serious boyfriend¶ | |||
| Yes | 0.64 (0.37 – 1.10) | 0.74 (0.44 – 1.25) | 1.34 (0.76 – 2.36) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Coital frequency ¶ | |||
| ≥ once per week | 0.51 (0.29 – 0.88) | 0.37 (0.22 – 0.63) | 0.98 (0.56 – 1.71) |
| < once per week | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Agreed to monogamy¶ | |||
| Yes | 0.50 (0.25 – 1.01) | 0.61 (0.31 – 1.21) | 1.83 (0.73 – 4.61) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Mutual STD testing* | |||
| Yes | 1.78 (1.03 – 3.10) | 0.78 (0.44 – 1.38) | 1.90 (1.09 – 3.32) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
Versus use of no method or other methods
Refers to most recent partner
Participant and most recent partner each had STD testing while they were together
Adjusted associations between participant characteristics and contraceptive use are presented in Table 3. Having no insurance (aOR 0.39, 95% CI 0.18–0.82), having four or more lifetime sexual partners (aOR 0.42, 95% CI 0.22 – 0.78), coital frequency at least weekly (aOR 0.54, 95% CI 0.29 – 0.99), and agreeing to monogamy with most recent partner (aOR 0.40, 95% CI 0.16 – 0.96) were significantly associated with decreased odds of dual method use compared to use of no/other method. Conversely, participants who reported having a mother who gave birth while she was a teen (aOR 2.34, 95% CI 1.21–4.52) those who reported a previous STD (aOR 2.30, 95% CI 1.26 – 4.18), and those having a negative attitude towards pregnancy (aOR 2.25, 95% CI 1.19 – 4.28) had more than twice the odds of reporting dual method use compared to no/other method.
Table 3.
Adjusted associations between selected participant characteristics and use of dual methods, condom alone, or hormonal method or IUD alone; adjusted odds ratios (aOR) and 95% confidence intervals (CI)*
| Dual Method aOR1 (95% CI) |
Condom alone aOR1 (95% CI) |
Hormonal/IUD alone aOR1 (95% CI) |
|
|---|---|---|---|
| Insurance | |||
| None | 0.39 (0.18 – 0.82) | 0.84 (0.45 – 1.57) | 0.57 (0.28 – 1.19) |
| Private, public or don’t know | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Participant’s mother completed High School or GED | |||
| Yes | 1.31 (0.68 – 2.51) | 1.71 (0.92 – 3.17) | 2.56 (1.35 – 4.87) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Participant’s mother’s age at first birth <20 | |||
| Yes | 2.34 (1.21 – 4.52) | 1.46 (0.83 – 2.60) | 1.54 (0.84 – 2.85) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Previous STD | |||
| Yes | 2.30 (1.26 – 4.18) | 0.98 (0.54 – 1.78) | 2.03 (1.12 – 3.69) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Participant has given birth to a child that lives with her | |||
| Yes | 2.13 (0.87 – 5.18) | 0.88 (0.28 – 2.83) | 3.86 (1.72 – 8.65) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Perception of diagnosis of pregnancy in next six months | |||
| It would be the worst thing that could happen | 2.25 (1.19 – 4.28) | 2.10 (1.15 – 3.82) | 1.18 (0.59 – 2.34) |
| Other | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Lifetime partners | |||
| 1–3 | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| 4 or more | 0.42 (0.22 – 0.78) | 1.02 (0.57 – 1.84) | 0.96 (0.52 – 1.74) |
| Coital frequency | |||
| ≥ once per week | 0.54 (0.29 – 0.99) | 0.34 (0.19 – 0.59) | 0.91 (0.51 – 1.63) |
| < once per week | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
| Agreed to monogamy with most recent partner | |||
| Yes | 0.40 (0.16 – 0.96) | 0.83 (0.38 – 1.83) | 2.04 (0.74 – 5.60) |
| No | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) |
Versus use of no method or other methods
All characteristics listed in Table 1 were entered into a full model. Generalized Estimating Equation was used to account for repeated measures in participants who reported more than one sexual encounter in the past six months with the same partner.
DISCUSSION
This study sought to characterize contraceptive use, including dual method use, and related factors in a sample of African American adolescents seeking care at a Title X urban family planning clinic. Dual method use at last sex (20.6%) was not common, but was higher than dual method use at last sex (14.8%) reported for 15–24 year old African American females who were sexually active in the past 3 months in an analysis of the National Survey of Family Growth (14). Our sample differs in that participants were younger and were recruited from a reproductive health clinic and so had ready access to methods requiring clinical care. The higher rate of dual method use in our sample, was tempered by the relatively high rate of other/no use of contraception. Over one-third of participants used other/no contraception at last sex compared to 17.5%–20.9% reported in nationally representative samples for young African American females(14, 15).
Some family and background factors were associated with dual method use. Not having insurance was associated with a significant reduction in reporting dual method use. Previous studies have reported cost as a barrier to adolescents accessing contraception and family planning services (14, 16). Efforts in health care to expand insurance to all young people may improve this. However, most, if not all, of the adolescents attending this clinic are given condoms at the end of each visit and would qualify for free methods through the Title X grant support received by the clinic. Increasing awareness among adolescents about programs (e.g., Title X, Medicaid, other state-based and local programs) that remove cost and linking young people to clinical care via schools, other community organizations or new media channels (e.g., web, app) may be important strategies to improve access (17).
Having a previous STD and having negative attitudes towards pregnancy were associated with dual method use; having a child who lives with her was strongly associated with contraceptive use. Focus group discussions from this population support these findings. Young women who were confronted with pregnancies, pregnancy scares and/or STD diagnoses reported that facing difficult conversations (e.g., telling parents), parenting stresses (e.g., less time to pursue own interests), and what they learned about STDs (e.g., may cause infertility) increased their motivation to avoid pregnancy and STDs in the future and improved their contraceptive and condom use (18). Previous quantitative investigations also reported similar increases in risk assessments and motivations to avoid pregnancy and STDS among those who experienced previous outcomes (14, 19, 20). Unique in our analysis, participants whose mothers gave birth as a teen were also more likely to report dual method use. Using role models and other ways to learn from peers or family members may shift individual perception of risk and motivate an increase in dual method use among those who have not experienced pregnancy and STDs.
Relationship factors that suggested a more serious relationship (i.e., having sex at least once per week and having agreed to monogamy) were strongly associated with decreased odds of dual method use. Other investigators have also reported that those in relationships that they expect to last and that those in relationships they deem “important” use dual methods less frequently (12, 21, 22)(18). Frequent sex was associated with a decrease in any condom use (dual method or condoms alone), which may be related to inertia for non-condom usage, adoption of non-coitally dependent contraception or other relationship influences. Those who agreed to monogamy were half as likely to report dual method use. Although monogamy may be associated with a lower the risk of STDs , the prevalence of concurrent or overlapping sexual encounters in adolescent relationships is high (23, 24). Warren and colleagues examined monogamy agreements in young adult couples, aged 18–25, and found high levels of discordance. Couples did not agree as to whether monogamy was discussed, agreed to or maintained (25). This raises concern for the high percentage (>80%) in this sample that reported agreeing to monogamy and the influence of this agreement on dual method use. We need a better understanding of the perceptions and processes of agreeing to monogamy, whether and how couples act out those agreements, and health outcomes in this population.
Taken together, our findings highlight issues that could be addressed in counseling and interventions to promote dual method use. First, efforts to encourage vicarious learning about STDs and pregnancy may help shift individual perception of risk and attitudes about protective behaviors. Those with strong negative perceptions of pregnancy were more likely to engage in protective behaviors, but those who had similar negative perceptions of STDs were not. Interestingly, those who had strong negative perceptions of pregnancy were more likely to use dual methods and condoms alone, but not hormonal contraception alone. Similarly, those who had had a previous STD were more likely to use dual methods, but were no more likely to report using a condom alone. While some young women may be able to apply dual method use after experiencing an STD or to avoid an unwanted pregnancy, many cannot. These inconsistencies also suggest knowledge gaps about transmission, risk and effective protection strategies from STDs and pregnancy (i.e., contraceptive and condom efficacy) as well as an urgent need to address the interplay between relationships and condom use. Our participants cited mutual trust most commonly as the reason a condom was not used at last sex. Trust is often a desirable trait in relationships, and some adolescents may perceive that not using protection demonstrates trust (18). However, this may lead to unfavorable health and emotional consequences for adolescents. In addition to providing information to improve knowledge gaps, future efforts need to concretely address relationships, acknowledging teens’ desire for more serious relationships while trying to help them perceive protective behaviors, especially dual method use, as ways to demonstrate caring for one another and supporting the sexual health of both partners in the relationship.
There are some limitations of this analysis. First, this is a cross-sectional study and, therefore, temporality and causation cannot be determined. Next, our data rely upon self-report, and though we have taken steps to ensure confidentiality and increase comfort in disclosure by using ACASI (26), this remains a limitation. Finally, we worked with a specific population, which may limit the generalizability of these results.
IMPLICATIONS.
In this analysis, dual method use among African American female adolescents was infrequent, and associated with several factors, including previous STD, perceptions about pregnancy and relationship characteristics. As a prevention strategy, dual method use may be effective in reducing STDs and unintended pregnancy. This study suggests efforts to increase dual method use in adolescents may benefit from leveraging the experiences of peers and family members to inform risk perception and attitudes toward pregnancy and STIs prevention. Further, it may be valuable to acknowledge adolescents’ desire for more serious relationships while framing dual method use as supporting the sexual health of both partners.
ACKNOWLEGDEMENTS
This study was funded by the CDC as a Special Interest Project #20 through the Emory Prevention Research Center (Co-operative agreement number U48DP001909-01 Revised) in collaboration with the CDC’s Division of Reproductive Health. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The authors would also like to acknowledge our study participants, the clinic staff at Grady Health System, and the entire study team that participated in this project.
Footnotes
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