scholarly journals Rapid Antiretroviral Therapy (ART) Initiation at a Community-Based Clinic in Jackson, MS

2020 ◽  
Vol 17 (1) ◽  
Author(s):  
Courtney E. Sims Gomillia ◽  
Kandis V. Backus ◽  
James B. Brock ◽  
Sandra C. Melvin ◽  
Jason J. Parham ◽  
...  
Keyword(s):  
Viral Load ◽  
Antiretroviral Therapy ◽  
Median Time ◽  
Viral Suppression ◽  
Hiv Care ◽  
Virologic Suppression ◽  
Community Based ◽  
Art Initiation ◽  
Healthcare Center ◽  
The Impact

Abstract Background Rapid antiretroviral therapy (ART), ideally initiated within twenty-four hours of diagnosis, may be crucial in efforts to increase virologic suppression and reduce HIV transmission. Recent studies, including demonstration projects in large metropolitan areas such as Atlanta, Georgia; New Orleans, Louisiana; San Francisco, California; and Washington D.C., have demonstrated that rapid ART initiation is a novel tool for expediting viral suppression in clinical settings. Here we present an evaluation of the impact of a rapid ART initiation program in a community-based clinic in Jackson, MS. Methods We conducted a retrospective chart review of patients who were diagnosed with HIV at Open Arms Healthcare Center or were linked to the clinic for HIV care by the Mississippi State Department of Health Disease Intervention Specialists from January 1, 2016 to December 31, 2018. Initial viral load, CD4+ T cell count, issuance of an electronic prescription (e-script), subsequent viral loads until suppressed and patient demographics were collected for each individual seen in clinic during the review period. Viral suppression was defined as a viral load less than 200 copies/mL. Rapid ART initiation was defined as receiving an e-script for antiretrovirals within seven days of diagnosis. Results Between January 1, 2016 and December 31, 2018, 70 individuals were diagnosed with HIV and presented to Open Arms Healthcare Center, of which 63 (90%) completed an initial HIV counseling visit. Twenty-seven percent of patients were provided with an e-script for ART within 7 days of diagnosis. The median time to linkage to care for this sample was 12 days and 5.5 days for rapid ART starters (p < 0.001). Median time from diagnosis to viral suppression was 55 days for rapid ART starters (p = 0.03), a 22 day decrease from standard time to viral suppression. Conclusion Our results provide a similar level of evidence that rapid ART initiation is effective in decreasing time to viral suppression. Evidence from this evaluation supports the use of rapid ART initiation after an initial HIV diagnosis, including same-day treatment.

scholarly journals Comparison of Time to Viral Suppression Among Treatment-Naïve HIV-Infected Adults Initiating Combination Antiretroviral Therapy by Antiretroviral Regimen Class

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S432-S432
Author(s):  
Karen Jacobson ◽  
Onyema Ogbuagu
Keyword(s):  
Viral Load ◽  
Antiretroviral Therapy ◽  
Median Time ◽  
Viral Suppression ◽  
Limit Of Detection ◽  
Baseline Viral Load ◽  
Virologic Suppression ◽  
Hiv Patients ◽  
Art Initiation ◽  
Treatment Naïve

Abstract Background Antiretroviral therapy (ART) regimens for the treatment of HIV that incorporate the integrase strand inhibitor (INSTI) class of antiretroviral medications have high efficacy and tolerability, and may result in faster time to virologic suppression compared with regimens that contain protease inhibitors (PIs) or non-nucleoside reverse transcriptase inhibitors (NNRTIs). However, differences in viral suppression are not well-defined in routine clinical settings. Methods We performed a retrospective single-center chart review of treatment-naïve HIV patients initiating ART between 2013 and 2016. Among patients on different ART regimen types, we compared rates of achievement of viral suppression (defined as viral load less than limit of detection or &lt;20 copies/uL) over time and median time to viral suppression using chi-square and independent samples median testing. Patients who were prescribed nonstandard regimens, were nonadherent, or discontinued or changed ART within 6 months were excluded. Results One hundred and fifty-five patients—45 (29.0%) female and 110 (71%) male—met study inclusion criteria. Mean age at ART initiation was 41.3 years (SD 12.5), and mean baseline viral load was 293,974 copies/uL. Twelve (7.7%) patients had an opportunistic infection diagnosed at time of ART initiation. Seventy-one (45.8%) initiated an INSTI-based ART regimen, 58 (37.4%) initiated a NNRTI-based regimen, and 26 (16.8%) initiated a PI-based regimen. Eighty-one (52.3%) patients had documented viral suppression, with median time to viral suppression 105 days (IQR 49–159). Patients on INSTI regimens were more likely to achieve viral suppression by 6 months (93.2% compared with 69.7% on NNRTIs and 30.8% on PIs), and had lower median time to suppression (62.6 days vs. 140.5 days on NNRTI regimens and 154.5 days on PI regimens, P = 0.002). Conclusion In this cohort, patients on INSTI-based ART regimens experienced higher rates of viral suppression at 6 months and shorter time from ART initiation to viral suppression. In HIV patients on INSTI-based ART regimens, virologic failure should be suspected prior to the current recommendation of 6 months. Disclosures All authors: No reported disclosures.

Does Rapid Initiation of Antiretroviral Therapy At HIV Diagnosis Impact On Virological Response in a Real-Life Setting? A Single Centre Experience in Northern Italy

2021 ◽  
Author(s):  
Natalia Gregori ◽  
Stefano Renzetti ◽  
Ilaria Izzo ◽  
Giulio Faletti ◽  
Benedetta Fumarola ◽  
...  
Keyword(s):  
Antiretroviral Therapy ◽  
Median Time ◽  
Virological Response ◽  
Viral Suppression ◽  
Real Life ◽  
Hiv Care ◽  
Baseline Viral Load ◽  
Hiv Diagnosis ◽  
Art Initiation ◽  
Late Group

Abstract Background Rapid initiation of antiretroviral therapy (ART) has been largely proven efficacious and safe mostly through clinical trials. Further investigations are needed to better define feasibility and acceptability of rapid ART approach in real-life settings. Methods We conducted a retrospective, observational study on newly HIV-diagnosed patients referred to Infectious and Tropical Diseases department of ASST Spedali Civili Hospital of Brescia from September 1st, 2015, to July 31st, 2019. All patients’ baseline characteristics were anonymously extracted from medical records. According to the timing of ART initiation, we distinguished 3 groups of patients (rapid, intermediate and late group) and represented the trend of virological response during a 400 day-period. The hazard ratios of each predictor on viral suppression (HIV RNA < 50 copies/ml) were estimated through Cox proportional hazard model. Results Median time from HIV diagnosis to first medical referral was 15 days and median time from first HIV care access to therapy start was 24 days. Three groups of patients were differentiated depending on ART initiation: within 7 days (rapid group, 37.6%), between 8 and 30 days (intermediate group, 20.6%) and after 30 days (late group, 41.8%). Longer time to ART start and higher baseline viral load were associated with a reduced probability of viral suppression. After one year, all groups showed high viral suppression rate (99%). Conclusions In high-income setting as Italy, rapid ART approach seems to be useful to accelerate time to viral suppression. The latter tends to be great over time regardless the timing of ART initiation.

scholarly journals Longitudinal analysis of sociodemographic, clinical and therapeutic factors of HIV-infected individuals in Kinshasa at antiretroviral therapy initiation during 2006-2017

PLoS ONE ◽  
2021 ◽  
Vol 16 (11) ◽  
pp. e0259073
Author(s):  
Nadine Mayasi Ngongo ◽  
Gilles Darcis ◽  
Hippolyte Situakibanza Nanituna ◽  
Marcel Mbula Mambimbi ◽  
Nathalie Maes ◽  
...  
Keyword(s):  
Antiretroviral Therapy ◽  
Early Detection ◽  
Hiv Infection ◽  
Median Time ◽  
Clinical Stage ◽  
Hiv Care ◽  
Hiv Disease ◽  
Art Initiation ◽  
Time To Initiation ◽  
Advanced Hiv Disease

Background The benefits of antiretroviral therapy (ART) underpin the recommendations for the early detection of HIV infection and ART initiation. Late initiation (LI) of antiretroviral therapy compromises the benefits of ART both individually and in the community. Indeed, it promotes the transmission of infection and higher HIV-related morbidity and mortality with complicated and costly clinical management. This study aims to analyze the evolutionary trends in the median CD4 count, the median time to initiation of ART, the proportion of patients with advanced HIV disease at the initiation of ART between 2006 and 2017 and their factors. Methods and findings HIV-positive adults (≥ 16 years old) who initiated ART between January 1, 2006 and December 31, 2017 in 25 HIV care facilities in Kinshasa, the capital of DRC, were eligible. The data were processed anonymously. LI is defined as CD4≤350 cells/μl and/or WHO clinical stage III or IV and advanced HIV disease (AHD), as CD4≤200 cells/μl and/or stage WHO clinic IV. Factors associated with advanced HIV disease at ART initiation were analyzed, irrespective of year of enrollment in HIV care, using logistic regression models. A total of 7278 patients (55% admitted after 2013) with an average age of 40.9 years were included. The majority were composed of women (71%), highly educated women (68%) and married or widowed women (61%). The median CD4 was 213 cells/μl, 76.7% of patients had CD4≤350 cells/μl, 46.1% had CD4≤200 cells/μl, and 59% of patients were at WHO clinical stages 3 or 4. Men had a more advanced clinical stage (p <0.046) and immunosuppression (p<0.0007) than women. Overall, 70% of patients started ART late, and 25% had AHD. Between 2006 and 2017, the median CD4 count increased from 190 cells/μl to 331 cells/μl (p<0.0001), and the proportions of patients with LI and AHD decreased from 76% to 47% (p< 0.0001) and from 18.7% to 8.9% (p<0.0001), respectively. The median time to initiation of ART after screening for HIV infection decreased from 40 to zero months (p<0.0001), and the proportion of time to initiation of ART in the month increased from 39 to 93.3% (p<0.0001) in the same period. The probability of LI of ART was higher in married couples (OR: 1.7; 95% CI: 1.3–2.3) (p<0.0007) and lower in patients with higher education (OR: 0.74; 95% CI: 0.64–0.86) (p<0.0001). Conclusion Despite increasingly rapid treatment, the proportions of LI and AHD remain high. New approaches to early detection, the first condition for early ART and a key to ending the HIV epidemic, such as home and work HIV testing, HIV self-testing and screening at the point of service, must be implemented.

scholarly journals The HIV care cascade for adolescents initiated on antiretroviral therapy in a health district of South Africa: a retrospective cohort study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Roxanna Haghighat ◽  
Elona Toska ◽  
Nontuthuzelo Bungane ◽  
Lucie Cluver
Keyword(s):  
South Africa ◽  
Viral Load ◽  
Antiretroviral Therapy ◽  
Viral Suppression ◽  
Hiv Care ◽  
Loss To Follow Up ◽  
Hiv Care Cascade ◽  
Care Cascade ◽  
Clinical Records

Abstract Background Little evidence exists to comprehensively estimate adolescent viral suppression after initiation on antiretroviral therapy in sub-Saharan Africa. This study examines adolescent progression along the HIV care cascade to viral suppression for adolescents initiated on antiretroviral therapy in South Africa. Methods All adolescents ever initiated on antiretroviral therapy (n=1080) by 2015 in a health district of the Eastern Cape, South Africa, were interviewed in 2014–2015. Clinical records were extracted from 52 healthcare facilities through January 2018 (including records in multiple facilities). Mortality and loss to follow-up rates were corrected for transfers. Predictors of progression through the HIV care cascade were tested using sequential multivariable logistic regressions. Predicted probabilities for the effects of significant predictors were estimated by sex and mode of infection. Results Corrected mortality and loss to follow-up rates were 3.3 and 16.9%, respectively. Among adolescents with clinical records, 92.3% had ≥1 viral load, but only 51.1% of viral loads were from the past 12 months. Adolescents on ART for ≥2 years (AOR 3.42 [95%CI 2.14–5.47], p< 0.001) and who experienced decentralised care (AOR 1.39 [95%CI 1.06–1.83], p=0.018) were more likely to have a recent viral load. The average effect of decentralised care on recent viral load was greater for female (AOR 2.39 [95%CI 1.29–4.43], p=0.006) and sexually infected adolescents (AOR 3.48 [95%CI 1.04–11.65], p=0.043). Of the total cohort, 47.5% were recorded as fully virally suppressed at most recent test. Only 23.2% were recorded as fully virally suppressed within the past 12 months. Younger adolescents (AOR 1.39 [95%CI 1.06–1.82], p=0.017) and those on ART for ≥2 years (AOR 1.70 [95%CI 1.12–2.58], p=0.013) were more likely to be fully viral suppressed. Conclusions Viral load recording and viral suppression rates remain low for ART-initiated adolescents in South Africa. Improved outcomes for this population require stronger engagement in care and viral load monitoring.

scholarly journals All-Cause Mortality and Serious Non-AIDS Events in Adults With Low-level Human Immunodeficiency Virus Viremia During Combination Antiretroviral Therapy: Results From a Swedish Nationwide Observational Study

2020 ◽  
Author(s):  
Olof Elvstam ◽  
Gaetano Marrone ◽  
Patrik Medstrand ◽  
Carl Johan Treutiger ◽  
Anders Sönnerborg ◽  
...  
Keyword(s):  
Human Immunodeficiency Virus ◽  
Viral Load ◽  
Antiretroviral Therapy ◽  
Clinical Outcomes ◽  
Virologic Suppression ◽  
Combination Antiretroviral Therapy ◽  
Low Level ◽  
Immunodeficiency Virus ◽  
All Cause Mortality ◽  
The Impact

Abstract Background The impact of low levels of human immunodeficiency virus (HIV) RNA (low-level viremia [LLV]) during combination antiretroviral therapy (cART) on clinical outcomes is unclear. We explored the associations between LLV and all-cause mortality, AIDS, and serious non-AIDS events (SNAEs). Methods We grouped individuals starting cART 1996–2017 (identified from the Swedish InfCare HIV register) as virologic suppression (VS; &lt;50 copies/mL), LLV (repeated viral load, 50–999 copies/mL), and nonsuppressed viremia (NSV; ≥1000 copies/mL). Separately, LLV was subdivided into 50–199 and 200–999 copies/mL (reflecting different definitions of virologic failure). Proportional-hazard models (including sex, age, pre-ART CD4 count and viral load, country of birth, injection drug use, treatment experience and interruptions, and an interaction term between viremia and time) were fitted for the study outcomes. Results A total of 6956 participants were followed for a median of 5.7 years. At the end of follow-up, 60% were categorized as VS, 9% as LLV, and 31% as NSV. Compared with VS, LLV was associated with increased mortality (adjusted hazard ratio [aHR], 2.2; 95% confidence interval [CI], 1.3–3.6). This association was also observed for LLV 50–199 copies/mL (aHR, 2.2; 95% CI, 1.3–3.8), but was not statistically significant for LLV 200–999 copies/mL (aHR, 2.1; 95% CI, .96–4.7). LLV 50–999 copies/mL was not linked to increased risk of AIDS or SNAEs, but in subanalysis, LLV 200–999 copies/mL was associated with SNAEs (aHR, 2.0; 95% CI, 1.2–3.6). Conclusions In this population-based cohort, LLV during cART was associated with adverse clinical outcomes.

scholarly journals Clinic-Level Factors Associated With Time to Antiretroviral Initiation and Viral Suppression in a Large, Urban Cohort

2019 ◽  
Vol 71 (7) ◽  
pp. e151-e158 ◽  
Author(s):  
Anne K Monroe ◽  
Lindsey P Happ ◽  
Nabil Rayeed ◽  
Yan Ma ◽  
Maria J Jaurretche ◽  
...  
Keyword(s):  
Viral Suppression ◽  
Cox Regression ◽  
Care Delivery ◽  
Hiv Care ◽  
P Values ◽  
Factors Associated ◽  
Art Initiation ◽  
Retention In Hiv Care ◽  
The Impact ◽  
Medication Dispensing

Abstract Background Using the results of a site assessment survey performed at clinics throughout Washington, DC, we studied the impact of clinic-level factors on antiretroviral therapy (ART) initiation and viral suppression (VS) among people living with human immunodeficiency virus (HIV; PLWH). Methods This was a retrospective analysis from the District of Columbia (DC) Cohort, an observational, clinical cohort of PLWH from 2011–2018. We included data from PLWH not on ART and not virally suppressed at enrollment. Outcomes were ART initiation and VS (HIV RNA &lt; 200 copies/mL). A clinic survey captured information on care delivery (eg, clinical services, adherence services, patient monitoring services) and clinic characteristics (eg, types of providers, availability of evenings/weekends sessions). Multivariate marginal Cox regression models were generated to identify those factors associated with the time to ART initiation and VS. Results Multiple clinic-level factors were associated with ART initiation, including retention in care monitoring and medication dispensing reviews (adjusted hazard ratios [aHRs], 1.34 to 1.40; P values &lt; .05 for both). Furthermore, multiple factors were associated with VS, including retention in HIV care monitoring, medication dispensing reviews, and the presence of a peer interventionist (aHRs, 1.35 to 1.72; P values &lt; .05 for all). In multivariable models evaluating different combinations of clinic-level factors, enhanced adherence services (aHR, 1.37; 95% confidence interval [CI], 1.18–1.58), medication dispensing reviews (aHR, 1.22; 95% CI, 1.10–1.36), and the availability of opioid treatment (aHR, 1.26; 95% CI, 1.01–1.57) were all associated with the time to VS. Conclusions The observed association between clinic-level factors and ART initiation/VS suggests that the presence of specific clinic services may facilitate the achievement of HIV treatment goals.

scholarly journals Assessing the impact of HIV support groups on antiretroviral therapy adherence and viral suppression in the African cohort study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Prudence Mbah ◽  
Michael Iroezindu ◽  
Allahna L. Esber ◽  
Nicole Dear ◽  
Domonique Reed ◽  
...  
Keyword(s):  
Cohort Study ◽  
Antiretroviral Therapy ◽  
Support Groups ◽  
Support Group ◽  
Viral Suppression ◽  
Hiv Care ◽  
People Living With Hiv ◽  
Art Adherence ◽  
African Countries ◽  
The Impact

Abstract Background Support groups for people living with HIV (PLWH) may improve HIV care adherence and outcomes. We assessed the impact of support group attendance on antiretroviral therapy (ART) adherence and viral suppression in four African countries. Methods The ongoing African Cohort Study (AFRICOS) enrolls participants at 12 clinics in Kenya, Uganda, Tanzania, and Nigeria. Self-reported attendance of any support group meetings, self-reported ART adherence, and HIV RNA are assessed every 6 months. Logistic regression models with generalized estimating equations were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) for support group attendance and other factors potentially associated with ART adherence and viral suppression. Results From January 2013 to December 1, 2019, 1959 ART-experienced PLWH were enrolled and 320 (16.3%) reported any support group attendance prior to enrollment. Complete ART adherence, with no missed doses in the last 30 days, was reported by 87.8% while 92.4% had viral suppression <1000copies/mL across all available visits. There was no association between support group attendance and ART adherence in unadjusted (OR 1.01, 95% CI 0.99–1.03) or adjusted analyses (aOR 1.00, 95% CI 0.98–1.02). Compared to PLWH who did not report support group attendance, those who did had similar odds of viral suppression in unadjusted (OR 0.99, 95% CI 0.978–1.01) and adjusted analyses (aOR 0.99, 95% CI 0.97–1.01). Conclusion Support group attendance was not associated with significantly improved ART adherence or viral suppression, although low support group uptake may have limited our ability to detect a statistically significant impact.

scholarly journals Profile of patients undergoing third line anti-retroviral therapy

2020 ◽  
Vol 7 (9) ◽  
pp. 1394
Author(s):  
Dhileeban Maharajan P. ◽  
T. Jeetenkumar Singh ◽  
S. Bhagyabati Devi ◽  
H. Rebachandra Singh ◽  
Dipul Rudra Paul ◽  
...  
Keyword(s):  
Viral Load ◽  
Antiretroviral Therapy ◽  
Viral Suppression ◽  
Virologic Failure ◽  
Cd4 Count ◽  
Medical Sciences ◽  
Art Initiation ◽  
Number Of Patients ◽  
Third Line ◽  
One Year

Background: India has the third largest human HIV epidemic in the world. The advent of antiretroviral drug began a revolution in the management of HIV. Recent studies have shown that an increasing number of patients experiencing virologic failure on second line Antiretroviral therapy and require third line ART.Methods: This prospective cohort study was conducted in Regional Institute of Medical Sciences, Imphal for a period of two years, to study the clinical, immunological, and virological profile of patients undergoing third line Antiretroviral therapy and to study the early immuno-virological response to third line Antiretroviral therapy.Results: Mean CD4 count before third line ART initiation was 95.90±111.85 cells/μl with 60% of them had CD4 count <100 cells/μl. The mean CD4 count improved significantly (p<0.005) to 246.70±123.78 cells/μl after six months and 340.70±198.57 cells/μl after one year of the therapy. At the time of initiation of third line ART, none of the patients had viral load <150copies/ml while 60% of the population had viral load >100000 copies/ml. After one year of third line ART, 80 % of the patients showed viral suppression (VL<150copies/ml). At the end of one year, the improvement in CD4 count comparing to the Viral load was significant in those who showed viral suppression (VL<150 copies/ml).Conclusions: This study showed significant improvement in the CD4 count and viral suppression with third line medication without any major clinical adverse effect.

scholarly journals 880. Interim Analysis of Real-World Community-Based HIV Rapid Start Antiretroviral with BFTAF Versus Conventional HIV Antiretroviral Therapy Start – The RoCHaCHa Study, A Pilot Study

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S531-S532
Author(s):  
Ashley R Zuppelli ◽  
Jacob Scutaru ◽  
Alexandra Danforth ◽  
Robert Biernbaum ◽  
Roberto Corales ◽  
...  
Keyword(s):  
Antiretroviral Therapy ◽  
Interim Analysis ◽  
Viral Suppression ◽  
Standard Of Care ◽  
Retention In Care ◽  
Community Based ◽  
Art Initiation ◽  
Study Participants ◽  
Historical Controls ◽  
Research Grant

Abstract Background Trillium Health (TH) is a Federally Qualified Health Center look-alike and Ryan White C grantee in Rochester, NY providing primary and specialty care, including HIV prevention and treatment. Rapid Start Antiretroviral therapy (RSA) has been shown to decrease time to viral suppression while increasing linkage to and retention in care. However, data on a fixed-dose combination of BFTAF with these benefits are limited. We aim to show RSA with BFTAF time to viral suppression, adherence to medication, and retention in care is statistically significant in comparison to older treatment models. Additionally, we aim to demonstrate the feasibility and acceptability of RSA with BFTAF. Methods This is an interim analysis of participants who enrolled in the study and been in care at TH for at least 3 months as of May 2021. All participants complete a baseline assessment and start BFTAF. Follow up visits are conducted through 48 weeks. Primary and secondary endpoints are included in the attached table 2 Barriers to care and patient reported outcomes were evaluated through a standardized questionnaire at the final study visit. Study results were compared with non-RSA historical control data from patients who received standard of care universal ART initiation at TH. Results Thirty-four participants have been enrolled in the study for at least 12 weeks, 33 (97%) of whom have reached and maintained viral suppression. Twenty-one participants have completed all 48 weeks, with 20 (95%) reaching and maintaining viral suppression. In comparison to historical controls, the RSA study participants had a statistically significant shorter time to viral suppression, both from diagnosis and from ART initiation. The RSA patients had statistically significant higher retention at 12, 24, and 48 weeks in comparison to historical controls. Adherence was higher in the RSA patients, though not statistically significant. Enrollment Graphic for the Rochacha Study Baseline Demographics of Study Participants and Controls Clinical Outcomes of Study Participants compared to Controls Conclusion Our data show that RSA with BFTAF can be effective in a community based health center setting in participants facing barriers to care. The patients who were treated by RSA with BFTAF had a high viral suppression rate. To date, no BFTAF regimen had to be changed due to resistance or virologic failure in this study. These data support implementation of RSA with BFTAF as standard of care. Disclosures Ashley R. Zuppelli, PHARMD, BCACP, AAHIVP, Gilead Sciences (Research Grant or Support) Robert Biernbaum, DO, MS, FAAEM, AAHIVS, Gilead Sciences (Research Grant or Support) Roberto Corales, DO, AAHIVS, Gilead Sciences (Employee, Scientific Research Study Investigator) Shealynn Hilliard, MS, Gilead Sciences (Research Grant or Support) William M. Valenti, MD, FIDSA, Gilead Sciences (Research Grant or Support)

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