Abstract
Objective:
Heterosexual intercourse is the main mode of HIV transmission among heterosexual women in Puerto Rico and the third for men. We conducted an Internet-based study of heterosexual young adults in Puerto Rico to explore their sexual practices, beliefs and decision-making skills for HIV prevention. Data presented in this study will help to understand the factors that contribute to the sexual transmission of HIV among heterosexuals within the Puerto Rican context.
Method:
We administered an online-based survey to a sample of 618 young adult heterosexual men and women. Data were collected using Perseus Survey Solutions software.
Results:
Overall, most participants expressed they had the same sexual partner in the previous six months, never or almost never used male condoms with their main partner and did not perceive themselves at-risk of contracting HIV (have a low HIV risk perception). Men reported using male condoms more frequently than women (e.g. male condom on their male partner) during vaginal sex, in particular single and younger men. Women expressed more positive attitudes toward male condoms than men.
Conclusion:
Results confirm the need to implement interventions that increases the sense of vulnerability among heterosexuals, as well as skills and use of male condoms. This study contributes additional data on sexual practices and attitudes to encourage the identification of new or current changes in HIV protective or risk factors, specifically for an understudied population of Heterosexuals in Puerto Rico.
Keywords: Sexual practices, Condom use, Alcohol use, Internet, Heterosexuals
Resumen
Objetivo:
Las relaciones sexuales son el principal modo de transmisión del VIH entre mujeres heterosexuales en Puerto Rico y el tercero para los hombres. Se llevó a cabo un estudio a través del Internet con adultos jóvenes heterosexuales en Puerto Rico para explorar las prácticas sexuales, las creencias y las habilidades de toma de decisiones para la prevención del VIH. Los datos presentados en este estudio ayudarán a comprender los factores que contribuyen a la transmisión sexual del VIH en personas heterosexuales en el contexto puertorriqueño.
Método:
Se administró un cuestionario en línea a una muestra de 618 hombres y mujeres heterosexuales adultos jóvenes. Los datos fueron recopilados utilizando el software Perseus Survey Solutions. Resultados: La mayoría de los participantes expresaron tener la misma pareja sexual en los seis meses anteriores, y nunca o casi nunca haber usado condones masculinos con su pareja principal. La mayoría tampoco se percibía a riesgo de contraer el VIH. Los hombres informaron usar condones masculinos con más frecuencia que las mujeres durante el sexo vaginal. Las mujeres expresaron actitudes más positivas hacia los condones masculinos.
Conclusión:
Los resultados confirman la necesidad de implantar intervenciones que aumenten el sentido de vulnerabilidad, así como las destrezas y el uso de condones masculinos en esta población. Este estudio aporta datos adicionales sobre las prácticas y actitudes sexuales para fomentar la identificación de cambios nuevos o actuales en los factores de protección o de riesgo del VIH, específicamente para una población de Heterosexuales poco estudiada en Puerto Rico.
Puerto Rico has been disproportionately affected by the HIV/AIDS epidemic with 50,223 cases reported by July 31, 2020 (1). By 2018, the island had one of the highest HIV incidence rates (13.6 per 100,000 population) and was tenth in the diagnosis of HIV infection, when compared with any US state or territory (2). Heterosexual transmission is the main mode of HIV infection among women (68%) and the third mode of infection among men (16%). These data signal an urgent need to identify and alter the factors that make heterosexual women more vulnerable to infection.
Research shows that many heterosexuals are sexually active (3), but few use condoms (4). This includes the practice of unprotected anal sex (5). Excluding the desire for pregnancy, reasons for not using male condoms among heterosexuals are diverse. Some include low-risk perception (6–8); unequal power relationships (9,10); partner type which limit male condom use for casual partners (11,12); male circumcision (13); having multiple sex partners (14); intimate partner violence (15); alcohol use (16); and poverty (17).
A careful exploration of the individual and social contexts associated with HIV has been of extreme importance, particularly those that may explain heterosexual risk sexual behaviors and attitudes. This has led to the development and implementation of cutting-edge research. One example is the use of the Internet to recruit participants (18). In Puerto Rico, the Internet is a useful tool, given the youth and adult population’s widespread access to the web. In 2006, nearly 36% of Puerto Rico’s population had access to the Internet. By 2008 over 40% had access. In 2017, over 70.6% of the residents of Puerto Rico had Internet access, representing over 2.3 million people (19). Considering the usefulness of the Internet as a data collection source, and as a mean to attract the interest of a potential participants, we decided to use it as our main tool to conduct this study.
We administered a survey through to identify the demographic, motivational and behavioral factors that contribute to the sexual transmission of HIV among heterosexuals within the Puerto Rican context. Identifying these factors is crucial to develop multi-dimensional prevention approaches that help decrease the likelihood of HIV infection.
Materials and Methods
Study Design
This study was approved by the Institutional Review Board (IRB 00000944) of the University of Puerto Rico, Río Piedras Campus (Protocol # 9900–028). Participants’ demographics are presented in Table 1. A total of 618 Internet users met the inclusion criteria and completed the survey; 408 (66%) were women and 210 men (34%) with an average age of 29. Inclusion criteria included: 1) self-identifying as heterosexual; 2) having between 21–45 years of age; and 3) self-report being sexually active in the last three months. Visitors of the website of the major local newspaper on the island (El Nuevo Día Interactivo) were invited to complete the survey. A small banner link to the survey was placed on the website of the newspaper for 30 days inviting participants to complete a survey about sex. Participants who met the inclusion criteria were directed to a consent form that explained the survey, benefits, and risks. Once they agreed to participate and provided consent, they were granted access to the survey.
Table 1.
Demographics (N = 618)
| n | % | |
|---|---|---|
| Sex | ||
| Men | 210 | 34.0 |
| Women | 408 | 66.0 |
| Civil Status | ||
| Married or coexisting | 307 | 49.7 |
| Single, divorced or widow | 311 | 50.3 |
| Employment Status | ||
| Full-time job | 415 | 67.2 |
| Part-time job | 81 | 13.1 |
| Unemployed | 122 | 19.7 |
| Family Income (monthly) | ||
| $500 – $2,000 | 310 | 50.2 |
| $2,001 or more | 308 | 49.8 |
| Education | ||
| High school or less | 100 | 16.2 |
| More than high school | 518 | 83.8 |
| Religion | ||
| Catholic | 382 | 61.8 |
| Protestant | 149 | 24.1 |
| Other | 87 | 14.1 |
Measures
We administered a short version of a survey used in a previous study (20,21). In Table 2 we present the measures used with their interpretation and internal consistency index.
Table 2.
Measures used.
| Measure | Interpretation | Cronbach’s Alpha |
|---|---|---|
| “Knowledge about HIV” | 5-point Likert scale from 1 (Definitely true) to 5 (Definitely false). Higher scores indicate better knowledge about HIV. | .74 |
| “Sexual Decision-Making Skills” | 5-point Likert scale from 1 (Definitely true) to 5 (Definitely false). Higher scores indicate better sexual decision-making skills. | .64 |
| “Attitudes toward Male Condom Use”. | 5-point Likert scale from 1 (Totally agree) to 5 (Totally disagree). Higher scores indicate better attitudes toward male condom use. | .81 |
| “Male Sexual Beliefs” | 5-point Likert scale from 1 (Totally agree) to 5 (Totally disagree). Higher scores indicate better male sexual beliefs. | .67 |
| “Female Sexual Beliefs” | 5-point Likert scale from 1 (Totally agree) to 5 (Totally disagree). Higher scores indicate better female sexual beliefs. | .77 |
| “Social Support for Condom Use” | 5-point Likert scale from 1 (Never) to 5 (Always). Higher scores indicate a better social support for condom use. | .88 |
| “Sexual Negotiation” | 5-point Likert scale from 1 (Definitely no) to 5 (Definitely yes). Higher scores indicate a better sexual negotiation. | .86 |
Statistical Analysis
The data was collected during the months of April and May of 2003 using Perseus Survey Solutions software, version 6 (1997–2002). We established a control with the IP address to prevent the survey from being completed from the same computer or device more than once. The statistical analyses were conducted using R statistical software (22). We used Q-Q plots to examine whether the distribution of the knowledge about HIV, sexual decision-making skills, attitudes toward male condom use, male sexual beliefs, female sexual beliefs, social support for condom use, and sexual negotiation variables meet the parametric test assumptions. After visually inspecting the data with several Q-Q plots, we observed that none of the variables met the normality assumption. Therefore, we used non-parametric tests, as well as other robust methods to analyze the data such as Mann-Whitney and Kruskall Wallis tests as non-parametric alternatives to the T Test and One-way ANOVA. The Kendall rank correlation coefficient was used to examine the relationships between the variables of interest. The regression and simple mediation analyzes were corrected for normality using the bootstrap non-parametric resampling technique.
For continuous variables, we identified the median and the interquartile range. We performed cross-tabulations between the nominal variables using the Chi-Square test (χ2). Using the Mann-Whitney Wilcoxon test and the Chi-Square test, we conducted a comparison analysis with some variables to determine if relationship stability and gender are variables that contribute to HIV prevention. A Kruskall-Wallis test was conducted to compare the effect of alcohol use on the attitudes toward male condom use. We used the chi-squared test to examine the associations between the demographic and sexual practice variables with HIV risk perception and examined the Kendall rank correlation coefficients between the variables of interest and knowledge about HIV. Finally, we examined several regression models and a simple mediation model to establish the degree to which a causal variable, X, influences a criterion variable, Y, through a mediating variable (23).
Results
Sexual Practices
Most participants (n=476; 77%) expressed they had the same sexual partner in the previous six months. From those who had the same sexual partner, 15.7% (n=97) indicated they did not have sex with that person in the previous six months.
Male Condom Use
Most of the participants (n=369; 59.7%) reported they never or almost never used condoms with their main partner during the last three months. Only a fifth of the participants (n=136; 22%) expressed that they used condoms always or almost always. Of these, 65.4% (n=89) were single. Of those participants who had sex with other partners, 43.9% (n=73) reported they never or almost never used condoms and 48.8% (n=81) reported always or almost always using condoms. Men used condoms more frequently than women during vaginal sex with other women (X2 (2, N = 166) = 9.50, p < .01). Single men used male condoms more frequently during vaginal sex (X2 (2, N = 544) = 39.96, p <.001) and anal sex (X2 (2, N = 239) = 12.56, p < .01) than those who reported being married or cohabitating. We also found that those participants who had different sexual partners in the previous six months used male condoms more frequently for vaginal sex than those with a steady partner (X2 (2, N = 544) = 10.73, p <.01). When examining the relationship between male condom use and age, we found a significant relationship, X2 (2, N = 544) = 34.39, p <.001. Participants between 21–30 years of age used male condoms more often that those between 31–45.
Sexual Negotiation
There was a significant difference in the score for men (Mdn = 12.5, IQR =6) as compared to women (Mdn =15, IQR = 3), p < .001. Women perceived themselves more capable of negotiating safer sex. When comparing differences between those who were married or cohabitating and those single, we found a marginally significant difference in the score for those married (Mdn = 14, IQR = 4.5) and single (Mdn = 15, IQR = 3), p = .08. People who were single showed a trend toward perceiving themselves more capable of negotiating safer sex.
Attitudes toward Male Condom Use
Regarding gender, there was a significant difference in the score for men (Mdn = 18, IQR = 9) as compared to women (Mdn = 21, IQR = 8), p < .001. Women expressed more positive attitudes toward male condoms. Regarding religion, there was a significant difference in the score for those who believed that religion was not important (Mdn = 18.5, IQR = 9.8) and those who believed it was important (Mdn = 21, IQR = 9), p < .01. People who reported that religion was important had more positive attitudes toward male condoms.
HIV Risk Perception
Most of the participants (n=524; 84.8%) either did not perceived themselves at-risk or had a low HIV risk perception. Only 2.1% (n=13) expressed having a high-risk perception. We explored the association between risk perception and having sex with other partners and found that those participants reporting not having the same sexual partner in the previous six months had a higher risk perception than those reporting having the same sexual partner (X2 (3, N = 616) = 18.59, p <.001). We also found that those who had sex with other partners in the previous three months perceived themselves at higher risk of HIV infection (X2 (1, N = 616) = 24.35, p < .001). On the other hand, those that considered religion to be important (or very important) had a lower risk perception than those that considered it was not (X2 (3, N = 616) = 12.35, p < .01).
Alcohol Use
We found that 45% (n=278) of participants reported consuming alcohol several times a week or a month. A quarter of the sample (n=141; 22.8%) reported never consuming alcohol. We also found that men reported alcohol use more frequently than women (X2 (4, N = 618) = 26.74, p < .001). We compared alcohol use among those who work full-time, part-time and those who were unemployed and found that working full or part-time used alcohol more frequently than those unemployed (X2 (4, N = 618) = 15.40, p < .01). Results also showed that those who considered religion as important drank alcohol less often that those who considered it not important (X2 (4, N = 618) = 29.01, p <.001).
Single men reported using alcohol more frequently than those who were married or cohabitating (X2 (4, N = 618) = 21.33, p < .001). We also found that men and women reporting not having the same sexual partner in the previous six months consumed alcohol more often than those with a steady partner (X2 (4, N = 618) = 29.27, p < .001). More alcohol consumption was also reported among those with steady partners, but who had sex with other partners (X2 (4, N = 476) = 14.80, p < .01).
When comparing the effect of alcohol use on the attitudes toward male condom use we found that the effect of alcohol use on the attitudes toward male condoms was significant, H (2) = 14.6, p < .001. People who consumed alcohol more frequently had poorer attitudes toward male condoms, when compared with those that drank alcohol less frequently or never.
Associations Between the Demographic and Sexual Practice Variables with HIV Risk Perception
We found a significant association between having the same main partner for the past six months and HIV risk perception, χ² (3) = 18.59, p < .001. People who have been with another partner report higher HIV risk perception, when compared to those who had the same partner. We also found a significant association between the importance of religion and HIV risk perception, χ² (3) = 12.35, p < .01. Those who believe that religion is very important perceive more often that they are not at risk of contracting HIV, when compared to those who consider religion as not important.
There was a significant association between alcohol use and HIV risk perception, χ² (6) = 18.02, p < .01. Participants who never consumed alcohol showed a lower HIV risk perception, when compared to participants who drank alcohol frequently or very frequently.
There was a significant association between the frequency of male condom use during oral sex with the main partner and HIV risk perception, χ² (6) = 16.20, p < .05. People who always used a condom during oral sex with their main partner were more likely to report that they were not at risk of contracting HIV.
There was a significant association between the frequency of male condom use during vaginal sex with another partner and HIV risk perception, χ² (6) = 13.68, p < .05. Contrary to expectations, people who never used a condom during vaginal sex with another partner were more likely to report a low HIV risk perception, when compared to participants who used condoms sometimes or always. The associations between demographic and sexual practices variables with HIV risk perception are summarized in Table 3.
Table 3.
Chi-square values of the associations between demographic and sexual practices variables with HIV risk perception.
| Variable | Chi-square | DF* | p |
|---|---|---|---|
| Having the same sexual partner | 18.59 | 3 | < .001 |
| Importance of religion | 12.35 | 3 | < .01 |
| Frequency of alcohol use | 18.02 | 6 | < .01 |
| Condom use during oral sex with main partner | 16.20 | 6 | < .05 |
| Condom use during vaginal sex with another partner | 13.68 | 6 | < .05 |
Note. DF represents the degrees of freedom.
Kendall Rank Correlation Coefficients
The Kendall rank correlation coefficients between the variables of interest and knowledge about HIV are presented in Table 4.
Table 4.
Medians, interquartile ranges, and Kendall rank correlation coefficients.
| Variable | Mdn | IQR | 1 | 2 | 3 | 4 | 5 | 6 |
|---|---|---|---|---|---|---|---|---|
| 1. Knowledge about HIV | 21 | 7.00 | ||||||
| 2. Sexual decision-making skills | 21 | 7.00 | .14** | |||||
| 3. Attitudes toward male condom use | 20 | 8.75 | .04 | .20** | ||||
| 4. Male sexual beliefs | 25 | 7.00 | .14** | .20** | .23** | |||
| 5. Female sexual beliefs | 16 | 8.00 | .11** | .20** | .28** | .37** | ||
| 6. Social support for condom use | 21 | 9.00 | .00 | −.01 | −.09* | −.01 | .00 | |
| 7. Sexual negotiation | 15 | 4.00 | .09* | .22** | .32** | .20** | .24** | −.06 |
Note. Mdn and IQR are used to represent median and interquartile range, respectively.
indicates p < .05.
indicates p < .01.
Regression Models
After examining the Kendall rank correlation coefficients, four regression models were proposed (Table 5). Knowledge about HIV was predicted by sexual decision-making skills. Knowledge about HIV was predicted by sexual decision-making skills and female sexual beliefs. Knowledge about HIV was predicted by sexual decision-making skills, female sexual beliefs, and male sexual beliefs. Knowledge about HIV was predicted by sexual decision-making skills, female sexual beliefs, male sexual beliefs, and sexual negotiation. The confidence intervals of the estimates were corrected for normality using 10,000 non-parametric bootstrap samples.
Table 5.
Regression results using knowledge about HIV as the criterion.
| Predictor | b | b 95% CI [LL, UL] | beta | beta 95% CI [LL, UL] | sr2 | sr2 95% CI [LL, UL] | r | Fit | Difference |
|---|---|---|---|---|---|---|---|---|---|
| (Intercept) | 16.82** | [15.09, 18.50] | |||||||
| Sexual decision- making skills | 0.17** | [0.09, 0.25] | 0.16 | [0.08, 0.24] | .03 | [.01, .06] | .16** | ||
| R2 = .026** | |||||||||
| 95% CI[.01,.06] | |||||||||
| (Intercept) | 15.98** | [14.28, 17.76] | |||||||
| Sexual decision- making skills | 0.13** | [0.05, 0.21] | 0.13 | [0.05, 0.20] | .02 | [.00, .04] | .16** | ||
| Female sexual beliefs | 0.10** | [0.04, 0.16] | 0.13 | [0.05, 0.21] | .01 | [.00, .04] | .16** | ||
| R2 = .041** | ΔR2 = .015** | ||||||||
| 95% CI[.02,.08] | 95% CI[.00, .04] | ||||||||
| (Intercept) | 15.13** | [13.13, 17.11] | |||||||
| Sexual decision- making skills | 0.12** | [0.04, 0.20] | 0.12 | [0.04, 0.20] | .01 | [.00, .03] | .16** | ||
| Female sexual beliefs | 0.07* | [0.00, 0.14] | 0.09 | [0.00, 0.18] | .01 | [.00, .02] | .16** | ||
| Male sexual beliefs | 0.06 | [−0.01, 0.13] | 0.07 | [−0.01, 0.16] | .00 | [.00, .02] | .15** | ||
| R2 = .045** | ΔR2 = .004 | ||||||||
| 95% CI[.02,.09] | 95% CI[.00, .02] | ||||||||
| (Intercept) | 14.90** | [12.77, 16.99] | |||||||
| Sexual decision- making skills | 0.12** | [0.03, 0.20] | 0.11 | [0.03, 0.19] | .01 | [.00, .03] | .16** | ||
| Female sexual beliefs | 0.07 | [−0.01, 0.14] | 0.08 | [−0.01, 0.18] | .00 | [.00, .02] | .16** | ||
| Male sexual beliefs | 0.06 | [−0.01, 0.13] | 0.07 | [−0.01, 0.16] | .00 | [.00, .02] | .15** | ||
| Sexual negotiation | 0.04 | [−0.07, 0.15] | 0.03 | [−0.05, 0.12] | .00 | [.00, .01] | .11** | ||
| R2 = .046** | ΔR2 = .001 | ||||||||
| 95% CI[.02,.09] | 95% CI[.00, .01] |
Note. A significant b-weight indicates the beta-weight and semi-partial correlation are also significant. b represents unstandardized regression weights. beta indicates the standardized regression weights. sr2 represents the semi-partial correlation squared. r represents the zero-order correlation. LL and UL indicate the lower and upper limits of a confidence interval, respectively.
indicates p < .05.
indicates p < .01.
The simple linear regression model of HIV knowledge regressed on sexual decision-making skills was significant, b = 0.17, 95% CI [0.09, 0.25], R2 = .03. Equally important, the second model of HIV knowledge regressed on sexual decision-making skills (b = 0.13, 95% CI [0.05, 0.21]) and female sexual beliefs (b = 0.10, 95% CI [0.04, 0.16]) had an improved fit, compared to the first model, R2 = .04, ΔR2 = 0.02, p<.01. In contrast, the third and fourth models failed to significantly improve the fit of the model, both ΔR2 = .00, p>.05. Therefore, the second model clearly does the best job at predicting knowledge about HIV with a minimum number of predictor variables.
Simple Mediation Model
Based on the second regression model identified, a simple mediation model was tested to examine the mediating role of female sexual beliefs in the relationship between sexual decision-making skills and knowledge about HIV. The functions of the lavaan package (24) were used to examine the mediation model. The parameters of the regression coefficients were estimated using the maximum likelihood method (25). The results show that sexual decision-making skills exerts a significant indirect effect on knowledge about HIV, through female sexual beliefs, b = 0.04, BCa 95% [0.01, 0.07]. This effect has a small practical importance, based on the Kappa squared effect size, κ2 = .03. The model of sexual decision-making skills as predictor of knowledge about HIV, mediated by female sexual beliefs is illustrated in Figure 1.
Figure 1.
Model of sexual decision-making skills as predictor of knowledge about HIV, mediated by female sexual beliefs. The confidence interval for the indirect effect is a BCa 95% CI based on 10,000 samples. The standardized regression coefficients are reported in the diagram.
Discussion
This study contributes to the understanding of the risk factors associated with HIV infection in an understudied population of heterosexual young adults in Puerto Rico. While some results confirmed findings from other studies, others were much unexpected. It was not a surprise that male condoms are more frequently used by men and participants that are single, and with casual partners and casual sexual encounters. Similar findings have been reported in other studies (4,26). Furthermore, being in a steady relationship was directly related to a low perception of risk and affects adversely safer sex practices. Findings suggest that having sex with other partners increases the sense of vulnerability and may help explain why male condoms are more frequently used with secondary partners. Therefore, the fact that most participants do not perceive themselves at-risk of HIV infection could explain why they do not use male condoms.
It called our attention that women had more positive attitudes toward male condoms, but used condoms less frequently than men. Studies show that having positive attitudes toward male condoms increase the possibility of their use (27,28). Different authors have called our attention to the fact that women are immersed in unequal power dynamics that contribute to their vulnerability to HIV/STI infections and other risky behaviors such as intimate partner violence (29–31). This could explain why other prevention methods such as the female condom, microbicides, and cervical barriers have been or are currently being developed because they can be controlled by women (32,33), compared to male condoms.
Our data confirmed findings from other studies that suggest that marriage is a protective factor for many health conditions, including alcohol use (34,35). We consider that the key in this discussion is not whether the individual is legally married, but engaged in a relationship where partners take care of each other in a mutually supportive relationship. This helps explain why we found that those respondents who reported being married or cohabitating feel more capable of negotiating safer sex.
An unexpected finding was that those who reported believing that religion was important and having a low HIV risk perception also had more positive attitudes toward male condom use. We are certain that this result can be explained by the fact that there is a difference between believing religion is important and attending religious activities or being an active participant in a religion’s practice. It seems that for some people having religious beliefs serve as a protective factor, whether they practice these beliefs or not.
It was not a surprise to find that people who drink alcohol have poorer attitudes toward male condoms and reported using male condoms less often. This is consistent with studies that confirm this effect, not only in attitudes about male condoms, but toward male condom use (36,37). On the other hand, it was interesting to identify that those who reported drinking alcohol more frequently have a higher HIV risk perception even though they also reported using male condoms less often and showed poorer attitudes.
To the best of our knowledge, this is the first Internet-based study with heterosexual young adults in Puerto Rico that explores sexual practices and beliefs, and decision-making skills toward condom use. Results confirm the urgent need to design interventions that not only increase the sense of vulnerability to HIV/STI risk, but also increase intention to use, skills and actual use of condoms. Results also suggest the importance of continued epidemiological data collection, particularly for sexual practices, comparing rates, and identifying new or changes in protective factors for risk behaviors.
Acknowledgments
Special thanks to Ms. María del Carmen Cabrera-Aponte from the Puerto Rico Department of Health and Dr. José Martínez from the Albizu University for initial data analysis on an earlier version of this manuscript. We also thank the Scientific Writing Resources Unit of the Puerto Rico Clinical and Translational Research Consortium (PRCTRC) for their editing of this manuscript. Statement of funding sources: This research was funded by the Division of Mental Disorders, Behavioral Research & AIDS of the National Institute of Mental Health (R24 MH49368-10S1). This document was supported from the National Institute on Minority Health and Health Disparities and the National Institute of Allergy and Infectious Diseases of the National Institutes of Health (U54MD007587). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
The authors have no conflict of interest to disclose.
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