Abstract
Partner notification and treatment are essential components of sexually transmitted infection (STI) management, but little is known about such practices among adolescents and young adults. Using data from a prospective cohort study (AYAZAZI) of youth aged 16–24 years in Durban, South Africa, we assessed the STI care cascade across participant diagnosis, STI treatment, partner notification, and partner treatment; index recurrent STI and associated factors; and reasons for not notifying partner of STI. Participants completed laboratory-based STI screening (Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Trichomonas vaginalis) at enrollment and at 12 months. Of the 37/216 participants with STI (17%), 27/37 (73%) were women and 10/37 (27%) were men. Median age was 19 years (IQR: 18–20). Of the participants with STI, 23/37 (62%) completed a Treatment and Partner Tracing Survey within 6 months of diagnosis. All survey participants reported completing STI treatment (100%), 17/23 (74%) notified a partner, and 6/23 (35%) reported partner treatment. Overall, 4/23 (11%) participants had 12-month recurrent C. trachomatis infection, with no association with partner notification or treatment. Stigma and lack of STI knowledge were reasons for not notifying partner of STI. STI partner notification and treatment is a challenge among youth. Novel strategies are needed to overcome barriers along the STI care cascade.
Introduction
Globally in 2016, 376 million people were infected with one of four, curable sexually transmitted infections (STIs), specifically Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Treponema pallidum.1 Sub-Saharan Africa (SSA) carries a large burden of this incidence.1 Untreated STIs cause morbidity, potential mortality for neonates, and increase HIV transmission and acquisition risks.2–5
Adolescents and young adults in SSA have a higher STI prevalence compared to older cohorts.6,7 This is due to a combination of factors, including young people’s lack of previous STI exposure and immunity,8,9 less sexual health knowledge,10 lower STI/HIV-acquisition risk-perception,11 higher sexual partner exchange, and low condom-use.10,12 These patient characteristics are compounded by poor access to healthcare facilities that adequately serve the sexual and reproductive health needs of youth.13,14,15
As laboratory-based STI testing is not widely available in many countries, the World Health Organization (WHO) advocates use of the syndromic management approach. In this approach, patients with symptoms and signs associated with STIs are categorized into WHO-classified syndromes associated with specific pathogens and treatments.16,17 Given that syndromic management was designed as a tool to improve the case management of patients with symptomatic STIs, asymptomatic STIs, which are particularly prevalent among youth, are missed and remain untreated.11
Effective STI cure and control requires individual treatment alongside partner notification and treatment. Partner notification is the process of notifying sexual partners of STI exposure as well as potential education and treatment.18 Models for partner notification include provider-based, patient-based, and contract referral which entails a patient-based notification deadline, which if not met allows the provider to notify the partner.18,19 WHO syndromic management guidelines recommend partner notification18 as a part of STI care but do not provide specific implementation recommendations, and consequently, partner notification often is not practiced.20 Barriers to partner notification include health system barriers related to dissemination of correct STI information, socioeconomic barriers consisting of geospatial separation of sexual partners, as well as interpersonal barriers including stigma, fearing accusations of infidelity, and the threat of violence.21
While the optimal method for partner notification is unknown in South Africa and similar settings, the latest South Africa National Strategic Plan for HIV, TB, and STIs outlines the need to assess ideal partner notification methods and focus on key populations including adolescent girls and young women.22 This issue is of great importance for young people, who are less likely to notify their partners of STIs compared with older adults,23–26 likely contributing to STI recurrence rates of up to 60% among South African youth.27
The limits of syndromic STI management among youth,11,27–31 alongside the current lack but ongoing development of cost-effective, point-of-care diagnostics,32 support the argument for lower-resourced settings to consider laboratory-based STI screening, and thus appropriate medications for individuals and their sexual partners for the first time. This focus on STI diagnostics and targeted treatment requires a better understanding of each step along the STI care cascade from participant diagnosis to partner notification and treatment.
Among adolescents and young adults in South Africa, our team recently demonstrated a 19% STI prevalence.11 Our team’s longitudinal follow-up of participants’ post-STI diagnoses presented an opportunity to assess partner notification and treatment outcomes. Within a prospective, community-based, cohort study of South African youth (aged 16–24 years) diagnosed with an STI, we assessed (1) the prevalence of partner notification practices and treatment uptake within six-months after STI diagnosis; (2) the STI care cascade across participant diagnosis, STI treatment, partner notification, and partner treatment; (3) partner notification outcomes and correlates of participants’ 12-month STI incidence; and (4) reasons for not undertaking partner notification.
Methods
AYAZAZI study overview
AYAZAZI (meaning “knowing themselves” in isiZulu) was a prospective cohort study assessing socio-behavioral, clinical, and biomedical HIV risk factors among South African youth in Durban and Soweto.11
The Durban cohort was based at the Maternal, Adolescent, and Child Health (MatCH) Research Unit in the Central Business District (2015–2017) and the Soweto cohort was based at the Perinatal HIV Research Unit (PHRU) located at Chris Hani Baragwanath Hospital (2014–2017).
Inclusion criteria for enrollment in AYAZAZI included being 16–24 years, negative or unknown HIV-serostatus, and able and willing to provide voluntary informed consent (≥18 years old) or parental consent and participant assent (16–17 years old) for study procedures. Exclusion criteria consisted of current participation in another HIV prevention study. This analysis is restricted to AYAZAZI participants in Durban who were diagnosed with an enrollment, laboratory-screened STI and who completed additional follow-up procedures.
All AYAZAZI participants completed behavioral questionnaires at enrollment, 3, 6, and 12 months and laboratory-based STI screening at enrollment and 12 months. Youth peer-interviewers administered questionnaires to study participants focused on demographic and socio-economic information, reproductive history, sexual/relationship health and behavior, HIV risk, and STI history.11,33 Questionnaires were conducted in English or isiZulu per participant preference. Survey data were captured electronically using DataFAX™ software produced by DF/Net Research.
To screen for STIs, participants completed a medical history form and nurse-performed STI symptom screen and physical examination in accordance with the South African National Department of Health (DoH) STI management guidelines to determine syndromic management diagnoses, treatments, and counseling.16 Participants also completed STI laboratory-screening at enrollment and 12-months which included Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium via the Roche LightCycler polymerase chain reaction and Trichomonas vaginalis testing via the GeneXpert nucleic acid amplification testing with samples taken from urine (males) and nurse-collected vaginal swabs (women). STI testing was performed in batches at the Global Clinical and Viral Laboratory in Durban. Pregnant women were not offered enrollment laboratory-based STI screening and instead were referred to antenatal clinics for comprehensive prenatal care. Among currently menstruating women, STI testing was deferred to a later date due to concerns about blood products interfering with testing procedures. Study participants with newly diagnosed HIV underwent sero-conversion counseling and were referred to a DoH clinic for antiretroviral therapy initiation. While the counseling urged HIV-diagnosis disclosure to sexual partners, new HIV diagnoses were not part of the STI partner notification procedures. Additional details about AYAZAZI are published elsewhere.11
STI treatment and partner notification procedures
AYAZAZI Durban participants diagnosed with an STI through symptom-reporting received same-day STI risk reduction counseling and treatment. STI antimicrobial treatment was in accordance with South African National DoH STI management guidelines.16 Participants diagnosed with an STI through laboratory-screening were called once the results returned after several days and advised to return to a DoH clinic or the study-site to receive their results, risk reduction counseling, and pathogen-specific treatment. Participants diagnosed with an STI between September 2015-March 2016 were given a referral letter to receive treatment and follow-up care at a local DoH clinic where DoH nurses completed an AYAZAZI treatment form. Beginning April 2016, STI treatment was offered at the Durban study site. Participants with a positive STI symptom screen but negative laboratory tests, received standard, same-day, STI treatment and counseling but were not administered the six-month Treatment and Partner Tracing Survey. If these participants also had a laboratory-diagnosed STI, they were called back for further counseling about partner notification and treatment and given partner notification cards.
Partner notification cards stated the possibility of STI exposure and encouraged the recipient to seek medical attention. Partners could present the card at the study-site or a DoH clinic for STI syndromic management. Participants were encouraged but not required to take partner notification cards.
A Treatment and Partner Tracing Survey was approved by the ethical review boards as an amendment to the Durban study site in April, 2016. All Durban participants with enrollment STI, who attended their six-month study visit after April 2016 were asked to complete this nurse-administered Treatment and Partner Tracing Survey, which captured data regarding whether the participant completed his/her STI treatment, notified his/her partner about their STI diagnosis, believed the partner had sought medical evaluation/treatment for STI exposure, and explored reasons why participants may not have discussed STI results with partner.
Inclusion criteria
This analysis of partner notification and treatment outcomes was restricted to the 37 participants with laboratory-diagnosed STI in Durban. AYAZAZI participants in Soweto were not administered the six-month Treatment and Partner Tracing Survey due to the Soweto site’s early recruitment schedule compared to the Durban site and regulatory delays.
Measures
Among participants with an enrollment, laboratory-diagnosed STI and who completed the six-month Treatment and Partner Tracing Survey, the primary outcome was the proportion of participants who reported partner notification (Yes vs No) and partner treatment (Yes vs No vs Don’t Know). The secondary outcome was STI recurrence of the previous laboratory-confirmed STI at the 12-month follow-up visit.
Data analysis
We used descriptive statistics to summarize participant characteristics, participant STI prevalence and treatment, and partner notification and treatment outcomes, stratified by sex. We used Fisher’s exact test (categorical variables) and Wilcoxon rank sum test (continuous variables) to compare differences in the distribution of enrollment characteristics between men and women with STI and to compare differences in partner notification outcomes among those with and without 12-month recurrent STIs. P-value <0.05 was considered statistically significant. Data were analyzed with STATA version 13.
Ethics
All participants, age 18–24 years, provided voluntary, written, informed consent at enrollment. For participants aged 16–17 years, parents/legal guardians provided voluntary, written, informed consent, and participants provided voluntary, written, informed assent. Ethical approval was provided by the research ethics boards of Simon Fraser University Office of Research Ethics (2014s0413), the University of the Witwatersrand Health Research Ethics Committee (HREC) (140707), and the University of KwaZulu-Natal Biomedical Research Ethics Committee granted reciprocity to the University of Witwatersrand HREC. Additional approval was granted by the KwaZulu-Natal DoH. Participants were reimbursed 150 ZAR (~$12 USD) at each visit for transportation and time.
Results
Enrollment characteristics
Of 216 youth enrolled in the Durban AYAZAZI cohort and screened for STIs, 37/216 (17%) had at least one laboratory-diagnosed STI, including 22/216 (10%) with Chlamydia trachomatis, 7/216 (3%) with Neisseria gonorrhoeae, 10/216 (5%) with Mycoplasma genitalium, 4/216 (2%) with Trichomonas vaginalis, and 6/216 (3%) had ≥2 STI co-infections. STI prevalence stratified by sex is shown in Figure 1.
Figure 1:
Sex-stratified prevalence of laboratory-diagnosed STI among Durban adolescents and young adults (aged 16–24) enrolled in the AYAZAZI study (n=216)1
1Four (3%) women and two (2%) men had ≥2 STI co-infection
Overall, 27/37 (73%) with STI were women and 10/37 (27%) participants were men, with a median age of 19 (IQR 18–21) years. Most 15/27 (56%) women and all 10/10 (100%) men reported having ≥2 partners in the past six months (p<0.05), with 9/24 (38%) women and 4/9 (44%) men reporting condom-use at last sexual encounter (p=1.00). Overall, 3/27 (11%) women and 1/10 (10%) men reported receiving STI treatment within six months pre-enrollment (p=1.00). (Table 1)
Table 1:
Enrollment characteristics of AYAZAZI Durban adolescents and young adults (aged 16–24 years) with a laboratory-diagnosed STI, overall and by sex (n=37)
| Total participants (n=37) | Women (n=27) n (%) |
Men (n=10) n (%) |
Overall (n=37) n (%) |
p-value |
|---|---|---|---|---|
| Age, median (IQR) | 19 (18–21) | 20 (18–21) | 19 (18–21) | 0.280 |
| Monthly Income (ZAR)1 | 0.041 | |||
| ≤ 400 | 8 (29.6) | 5 (50.0) | 13 (35.1) | |
| 401–1600 | 17 (63.0) | 2 (20.0) | 19 (51.4) | |
| ≥ 1601 | 2 (7.4) | 3 (30.0) | 5 (13.5) | |
| Formal Housing | 19 (70.4) | 10 (100.0) | 29 (78.4) | 0.079 |
| Food Insecurity2 | 9 (33.3) | 2 (20.0) | 11 (29.7) | 0.688 |
| Current Student | 17 (63.0) | 8 (80.0) | 25 (67.6) | 0.445 |
| Sexual orientation: LGBTQ3 | 2 (7.4) | 0 (0.0) | 2 (5.4) | 1.00 |
| Relationship status | 0.597 | |||
| No current partner | 3 (11.1) | 2 (20.0) | 5 (13.5) | |
| Sexual partner, not living together | 24 (88.9) | 8 (80.0) | 32 (86.5) | |
| Sexual partner, living together | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Number of lifetime sexual partners | 0.033 | |||
| 0 | 2 (7.4) | 0 (0.0) | 2 (5.4) | |
| 1 partner | 10 (37.0) | 0 (0.0) | 10 (27.0) | |
| ≥2 partners | 15 (55.6) | 10 (100.0) | 25 (67.6) | |
| Condom use at last sex4 | 9 (37.5) | 4 (44.4) | 13 (39.4) | 1.00 |
| Ever experienced intimate partner violence (IPV) | 3 (33.3) | 1 (10.0) | 4 (10.8) | 1.00 |
| Ever perpetrated IPV | 2 (7.4) | 4 (40.0) | 6 (16.22) | 0.035 |
| Ever experienced any sexual violence | 4 (14.8) | 0 (0.0) | 4 (10.8) | 0.557 |
| Any STI treatment in the 6 months prior to study enrollment | 3 (11.1) | 1 (10.0) | 4 (10.8) | 1.00 |
Notes:
$1 USD equals approximately 13 South African ZAR
Food insecurity was defined as not having food in the house to eat due to a lack of money in the past month
Lesbian/gay/bisexual/trans gender/queer
Out of n=33. Among those who reported sexual activity in the prior six months.
Completion of six-month STI Treatment and Partner Tracing Survey
Overall, 23/37 (62%) participants with at least one laboratory-diagnosed STI completed the six-month Treatment and Partner Tracing Survey, including 15/27 (56%) women and 8/10 (80%) men. Fourteen participants did not complete the survey due to the survey being introduced after participant enrollment, participant missed visits, and lost-to-follow-up. Comparing participants who completed the six-month Treatment and Partner Tracing Survey with those who did not, there were no statistically significant socio-demographic differences. (Supplemental Table 1)
STI care cascade - participant treatment and partner notification and treatment outcomes
Among participants who completed the six-month Treatment and Partner Tracing Survey (n=23), all reported receiving (100%) and completing (100%) STI treatment per the study protocol. With respect to partner notification, 17/23 (74%) participants, including 13/15 (86.7%) women and 4/8 (50%) men, notified their sexual partner about STI exposure. Of these participants, 6/17 (35%) participants, including 5/13 (38%) women and ¼ (25%) men reported partner STI treatment. Additionally, 4/13 (31%) women and 2/4 (50%) men reported no partner treatment, and 4/13 (31%) women and ¼ (25%) men reported unknown partner treatment. (Table 2) Along the STI care cascade, attrition was greatest at the step between partner notification and reported partner treatment. (Figure 2)
Table 2:
Self-reported STI treatment and partner notification outcomes six months after STI diagnosis among AYAZAZI Durban adolescents and young adults (aged 16–24 years), overall and by sex
| Total Participants Completing 6-month Treatment and Partner Tracing Survey (n=23) | Women (n=15) n (%) |
Men (n=8) n (%) |
Overall (n=23) n (%) |
|---|---|---|---|
| Treatment given for STI | |||
| Yes | 15 (100) | 8 (100) | 23 (100) |
| No | 0 (0) | 0 (0) | 0 (0) |
| Completed STI treatment | |||
| Yes | 15 (100) | 8 (100) | 23 (100) |
| No | 0 (0) | 0 (0) | 0 (0) |
| Completed partner notification | |||
| Yes | 13 (86.7) | 4 (50.0) | 17 (73.9) |
| No | 2 (13.3) | 4 (50.0) | 6 (26.1) |
| Partner went to clinic for STI treatment (per participant report)1 | |||
| Yes | 5 (38.5) | 1 (25.0) | 6 (35.3) |
| No | 4 (30.8) | 2 (50.0) | 6 (35.3) |
| Don’t Know/Missing | 4 (30.8) | 1 (25.0) | 5 (29.4) |
Notes:
Out of n=17. Among those who reported partner notification.
Figure 2:
STI care cascade among AYAZAZI Durban adolescents and young adults (aged 16–24 years) with an enrollment, laboratory-diagnosed STI and who completed the 6M Treatment and Partner Tracing Survey (n=23)
Reasons for not notifying partner
Of the 6/23 (26%) participants who reported not notifying their partner of STI exposure, reasons included being embarrassed (n=2), afraid of partner judgement (n=1), unaware their infection was an STI and required partner notification (n=1), and the dissolution of the partnership (n=2).
STI partner notification and recurrence
Among participants with enrollment STI who returned for the 12-month follow-up visit and were screened for STI (n=32), 4/32 (13%) had 12-month STI recurrence with Chlamydia trachomatis, and 28/32 (88%) participants did not have recurrent STI with the enrollment pathogen. Five participants with enrollment STI did not undergo STI testing at 12-months, including one due to pregnancy, one due to menstruation, and three for unknown reasons. Partner notification and partner treatment were not significantly associated with Chlamydia trachomatis recurrence (Fisher’s exact test p=0.644 and p=1.00, respectively). (Table 3)
Table 3:
Twelve-month recurrence with the same enrollment STI among AYAZAZI Durban adolescents and young adults (aged 16–24 years), by partner notification and treatment practices
| Diagnosed with same STI at 12M (n=32)1 | |||
|---|---|---|---|
| Yes, same STI (n=4) N (%) |
No (n=28) N (%) |
p-value | |
| Notified partner of enrollment STI | |||
| Yes | 2 (50%) | 14 (50.0%) | 0.644 |
| No | 0 (0%) | 6 (21.4%) | |
| Unknown | 2 (50%) | 8 (28.6%) | |
| Reported partner treated at enrollment2 | |||
| Yes | 1 (50%) | 5 (35.7%) | 1.000 |
| No | 1 (50%) | 5 (35.7%) | |
| Don’t know | 0 | 4 (28.6%) | |
Notes:
Five of 37 participants diagnosed with an STI at enrollment did not undergo STI testing at 12-months and were excluded from this analysis.
Among those who notified their partner.
Discussion
This study reported partner notification and treatment outcomes and laboratory-screened STI recurrence among adolescents and young adults diagnosed with enrollment STI in the AYAZAZI Durban study. These data highlighted a high STI prevalence among youth, particularly among women compared to men. Moreover, although all participants reported STI treatment, a smaller proportion of youth reported notifying partners of their STI results or partner STI treatment uptake. Participants reported stigma, dissolution of the relationship, and patient confusion regarding the need for partner notification as challenges to partner notification. While 13% had 12-month STI recurrence, there was no association between recurrence and previous partner notification and treatment outcomes. Understanding barriers along each step of the STI care cascade from index patient testing to partner treatment, and developing interventions to overcome such barriers is crucial to curbing STI spread.
Consistent with global findings revealing gender differentials,25,34 we found a higher proportion of young women reported partner notification compared with men. A South African survey assessing perceived barriers to partner notification found that women were more likely than men to plan to notify their partner(s) of STIs. Of those not planning partner notification, both men and women primarily feared physical violence and partner abandonment.35 These findings echo our study participants’ concerns of stigma, though they did not report fear of violence as a reason for not notifying a partner of an STI. Groups with lower likelihood of STI partner notification may require increased attention and counseling to engage in STI partner notification. A Zambian randomized controlled trial (RCT) assessing the role of counseling on the dissemination of partner notification slips found the intervention had a significant impact on male partner notification but did not affect partner notification among women.36 More research is needed on how best to support young men and women to disclose STIs to their partner(s), especially in the context of partner concurrency and/or serial monogamy.37
Our STI care cascade demonstrated significant attrition between the steps of partner notification and partner treatment. These findings are consistent with the sparse STI partner notification literature across sub-Saharan Africa. A Rwandan analysis found that only 58% of study participants accepted partner notification coupons, and of these, 45% successfully referred their partners for STI treatment.25 Qualitative work among women with STI in Botswana found that despite partner notification, male partners did not seek STI treatment due to busy work schedules, confusion over what to request if without an STI contact slip, and overall healthcare engagement reluctance.38 While this gap in the STI care cascade likely reflects true attrition, nearly all studies measure STI partner notification and treatment by index patient report, which likely underestimates partner treatment. There is a need to measure partner treatment directly to understand the true STI care cascade.
Understanding how index patients communicate STI diagnoses and partners’ reactions is necessary to designing and implementing STI partner notification interventions among youth. Targeted interventions such as intensive counseling,21 the use of internet/texting notification,39,40 and patient-delivered partner medications (PDPM) (whereby a patient delivers a single-dose STI medication to their partner(s), saving the partner(s) a clinical assessment) are all potential areas of future research. A Ugandan RCT randomizing 383 male and female adults to PDPM vs. patient-based partner referral (PBPR) found that 74% vs. 34% (p<0.001) of participants reported partner treatment in the PDPM vs. PBPR groups respectively.41 These methods all have the potential to overcome the STI partner notification to treatment gap among youth.
Our 12-month STI recurrence was low and was not associated with partner notification or partner treatment. Our findings would have been strengthened with a test of cure among those with enrollment STI to better determine whether the 12-month STI represented unresolved or new infection. Prevalent STI is a known risk factor for subsequent infection with the same pathogen.42,43 A New Zealand retrospective review of primary care electronic health records found that among participants with prevalent STIs who were re-screened between six weeks and six months, 15/79 (19%) re-tested positive.44 As the purpose of STI partner notification and treatment is to prevent recurrence among sexual partners, more research is needed on the relationship between partner treatment and index recurrence.
Limitations
This is a small but unique prospective cohort study of young adults diagnosed with an STI in an HIV-endemic setting. Self-reporting on partner notification and partner treatment six-months after the initial STI diagnosis and treatment is subject to social desirability and recall bias. Additionally, partner treatment was reported by the participant, and since participants may not know their partners’ medical and sexual history, this endpoint was likely under-reported. Finally, we were unable to understand the effect of multiple sexual partners on STI recurrence given the limitations of our Treatment and Partner Tracing Survey. Despite these limitations, our study team increased survey response quality by implementing training on good questionnaire administration practice. The team regularly built trust with participants by using anti-stigmatizing language and cultivating a youth-centered, sex-positive, research environment resulting in high study retention.
Conclusion
We found that nearly three-quarters of Durban adolescents and young adults with STI conducted partner notification procedures, which is consistent with much of the adult literature. Fewer participants’ partners received STI treatment, and understanding these barriers is crucial to improving STI care. Young women were more likely than young men to notify their partners of STI, and further research and policy interventions are needed regarding improving STI partner notification and partner treatment outcomes, particularly among young men. Understanding how to ideally implement STI partner notification programs for adolescents and young adults is especially important as we progress towards point-of-care based STI diagnostics.
Supplementary Material
Acknowledgments
The AYAZAZI Research Team would like to thank our youth participants for their contributions to this study. We also thank our international team of co-investigators, collaborators, and youth representatives, and acknowledge the Adolescent Community Advisory Boards and our partnering organizations for supporting the study.
We would also like to thank our youth-engaged team members: In Durban, Nonhlonipho Bhengu, Sphamandla Gumbo, and Thandeka Sithole were youth interviewers, and led participant recruitment and retention efforts. Thulile Mathenjwa was the AYAZAZI Durban project coordinator. Thakasile Ndolovu was the study social worker and HIV counselor, Savannah Sheri was the project assistant and HIV counselor, and Simangele Bengu was the study nurse. In Soweto, Leonard Letsoara and Nomathemba Madise were youth interviewers, and led participant recruitment and retention efforts. Stefanie Hornschuh was the AYAZAZI Soweto project coordinator.
Funding Sources: AYAZAZI is funded through the Canadian HIV Vaccine Initiative (CHVI) and the Canadian Institutes of Health Research (CIHR), with support from the South African Medical Research Council. PC received funding from the National Institute of Allergy and Infectious Diseases under award number T32 AI007433, and from the Fogarty International Center and National Institute of Mental Health under award number D43 TW010543 all under the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. AK and MB received salary support awards from the Canada Research Chair program. TN is supported by the South Africa Research Chairs Initiative and the Sub-Saharan African Network for TB/HIV Research Excellence (SANTHE), a DELTAS Africa Initiative [grant # DEL-15–006]. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust [grant # 107752/Z/15/Z] and the UK government. The views expressed in this publication are those of the author(s) and not necessarily those of AAS, NEPAD Agency, Wellcome Trust, or the UK government.
Footnotes
Availability of data and materials: For researchers and trainees who meet criteria for accessing confidential study data, requests can be sent to the corresponding author, Dr. Angela Kaida, at kangela@sfu.ca. The criteria for accessing confidential data includes1) being added as an AYAZAZI researcher or trainee to the SFU research ethics board application and 2) signing the AYAZAZI Data Sharing and Collaboration Agreement. Co-authorship is a requirement for data access. The de-identified dataset cannot be publicly shared as we do not have community or REB approval to do so. Similarly, please contact the corresponding author, Dr. Angela Kaida, to request access to the questionnaires used in the AYAZAZI study.
Competing Interests
The authors declare no conflicts of interest.
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