Group-Based Intervention to Improve Mental Health and Adherence Among Youth Living With HIV in Low Resource Settings
IMPAACT 2016 - Evaluating a Group-Based Intervention to Improve Mental Health and Antiretroviral Therapy (ART) Adherence Among Youth Living With HIV in Low Resource Settings
Study Overview
Status
Status
Conditions
Conditions
Intervention / Treatment
Intervention / Treatment
Detailed Description
IMPAACT 2016 was a multi-site, two-arm, individually randomized, controlled study to evaluate whether an Indigenous Leader Outreach Model (ILOM) of trauma-informed cognitive behavioral therapy (TI-CBT) delivered by Indigenous Youth Leaders (IYL) is associated with improved mental health outcomes and ART adherence among youth living with HIV in resource-limited settings. The trial was preceded by an adaption of the TI-CBT Intervention at each site using the "ADAPT-ITT" model, which included focus groups and pilot tests. Participant-level data was not collected during the focus group phase, and the pilot phase consent form specified that collected data would not be analyzed. Per protocol, only data from the randomized trial were analyzed. The study was closed early due to the funding constraints.
In the randomized study, youth were individually randomized to either the TI-CBT Intervention arm or the Discussion Control arm. Youth participants met as a group within their randomized arm and received multiple group sessions within an 8-week period. Each arm featured 15 groups with an average of 8.5 youth per group, or a total of 254 youth in the Randomized Trial. TI-CBT Intervention and Discussion Control groups could be mixed-gender, which required at least two participants of each gender. Caregivers (with consent and youth permission) were assigned to the same study arm as their youth. Caregiver participants met as a group within their arm for two caregiver-specific sessions on two separate weeks, separate from their youth's group sessions. Each arm featured 15 groups with an average of 7.7 caregivers per group, or a total of 230 caregivers in the Randomized Trial. Youth and caregivers completed a follow-up assessment immediately after their last group session and two additional follow-up assessments at 6 and 12 months. Youth and caregivers received 1 two-hour booster group session consistent with their assigned study arm immediately after the 6-month assessments. The booster sessions were intended to enhance treatment effects and increase sustainability.
Following completion of 6-month assessments (primary timepoint), data were analyzed to determine the short-term effects of the interventions. Additional analyses to assess long-term effects of the interventions, including the effects of the booster group session, will be performed after the completion of 12-month assessments.
Results are reported for youth participants in the randomized trial only, because limited sociodemographic characteristics and no primary or secondary outcome measures were collected for caregivers. As specified in the protocol and statistical analysis plan, primary outcomes were analyzed with groups as the analytic units due to the presence of intracluster correlation among participants in the same group.
Study Type
Study Type
Enrollment (Actual)
Enrollment
Phase
Phase
- Not Applicable
Contacts and Locations
Study Contact
Study Contact
- Name: Nicole Montañez, MSW
- Phone Number: 11844 919-544-7040
- Email: nmontanez@fhi360.org
Study Contact Backup
- Name: Jennifer Libous, MS
- Phone Number: 18131 202-884-8131
- Email: jlibous@fhi360.org
Study Locations
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Gaborone, Botswana
- Gaborone Prevention/Treatment Trials CRS 12701
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Molepolole, Botswana
- Molepolole Prevention/Treatment Trials CRS 12702
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Blantyre, Malawi
- College of Medicine CRS 30301
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Lilongwe, Malawi
- University of North Carolina Lilongwe CRS 12001
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Soweto, South Africa
- Soweto IMPAACT CRS 8052
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Chitungwiza, Zimbabwe
- St. Mary's CRS 30303
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Harare, Zimbabwe
- Harare Family Care CRS 31890
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Harare, Zimbabwe
- Seke North CRS 30306
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Participation Criteria
Eligibility Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Description
Inclusion Criteria - For Youth Participants:
- If of legal age to provide independent informed consent as determined by site Standard Operating Procedures (SOPs) and consistent with site IRB/EC policies and procedures: potential youth participant is willing and able to provide written informed consent for study participation.
- If not of legal age to provide independent informed consent: Parent or guardian is willing and able to provide written informed consent for study participation and potential youth participant is willing and able to provide written informed assent for study participation.
- Confirmed HIV-infection based on documented testing of two samples collected at different time points as documented in medical records or by confirmatory testing.
- Age limit 15-19 years
- At screening, aware of his or her HIV infection, as confirmed by Investigator of Record or designee.
- At screening, has been prescribed ART for a minimum of 24 weeks prior to screening based on medical record documentation.
At screening, meets at least one of the following indicators of moderate to severe mental health symptomology:
- Patient Health Questionnaire-9 (PHQ-9) score ≥ 10
- General Anxiety Disorder-7 (GAD-7) score ≥ 10
- UCLA Post-Traumatic Stress Disorder-Reaction Index (UCLA PTSD-RI) score >= 35
Inclusion Criteria - For Caregiver Participants:
- Caregiver, defined as a biological parent, legal guardian, or person who provides emotional, psychological and/or informational care to a youth taking part in the Randomized Trial, as identified by the youth, and for whom the youth has provided written permission to participate in the study.
- Of legal age to provide independent consent and willing and able to provide written informed consent for study participation.
Exclusion Criteria - For Youth Participants:
- At entry, participating in a study delivering a mental health or ART adherence intervention.
- Prior participation in an IMPAACT 2016 Focus Group or Pilot Test
- Any other condition, adverse social situation or cognitive impairment that, in the opinion of the site investigator, would preclude informed assent and informed consent, make study participation unsafe, complicate interpretation of study outcome data, or otherwise interfere with achieving the study objectives.
Exclusion Criteria - For Caregiver Participants:
Prior participation in an IMPAACT 2016 Focus Group or Pilot Test.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Supportive Care
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: None (Open Label)
Number of Arms
Arms and Interventions
Participant Group / ArmParticipant Group / Arm |
Intervention / TreatmentIntervention / Treatment |
|---|---|
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Experimental: Youth TI-CBT Intervention Arm
For youth, the TI-CBT intervention arm consisted of six 2-hour TI-CBT group sessions led by Indigenous Youth Leaders (IYL) during weeks 1 to 8 and one 2-hour booster group session at 6-months.
The TI-CBT Intervention was delivered in a group format.
The TI-CBT Intervention arm had 15 groups with an average of 8.5 youth per group (range 6-11).
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For youth, each TI-CBT group session was led by IYL.
TI-CBT teaches techniques and ways to manage distress through psychosocial health education, cognitive restructuring, and "mastery of trauma", which refers to the process by which survivors of psychological trauma work through the traumatic experience in a meaningful way, and are able to move on with life.
TI-CBT addresses both the trauma of learning one has HIV and the trauma associated with managing a chronic and stigmatized illness.
The intervention highlights links between HIV and traditional gender roles, gender inequities, and gender-based violence.
Finally, the relaxation training teaches youth strategies to relax and these are integrated at the beginning and end of each session.
TI-CBT Youth Intervention Manuals were distributed to sites for translation, backtranslation, and cultural adaptation in preparation for the Randomized Trial.
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Active Comparator: Youth Discussion Control Arm
For youth, the Discussion Control arm consisted of six 2-hour discussion group sessions led by IYL during weeks 1 to 8 and one 2-hour booster discussion group session at 6 months.
The Discussion Control was delivered in a group format.
The Discussion Control arm had 15 groups with an average of 8.4 youth per group (range 5-10).
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For youth, each discussion group session was led by IYL. Discussion topics were selected by youth in the group.
Discussion Control sessions took place at a separate time from TI-CBT Intervention sessions to minimize contamination.
Youth and caregiver group sessions were also held separately.
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Experimental: Caregiver TI-CBT Intervention Arm
For caregivers, the TI-CBT Intervention arm consisted of two 2-hour TI-CBT group sessions on two separate weeks within 8 weeks of their youth's first group session and one 2-hour booster group session at 6-months led by adult study staff.
The TI-CBT Intervention was delivered in group format.
The TI-CBT Intervention arm had 15 groups with an average of 7.7 caregivers per group (range 5-10).
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For caregivers, each TI-CBT group session was led by adult study staff.
TI-CBT teaches techniques and ways to manage distress through psychosocial health education, cognitive restructuring, and "mastery of trauma", which refers to the process by which survivors of psychological trauma work through the traumatic experience in a meaningful way, and are able to move on with life.
TI-CBT addresses both the trauma of learning one has HIV and the trauma associated with managing a chronic and stigmatized illness.
The intervention highlights links between HIV and traditional gender roles, gender inequities, and gender-based violence.
Finally, the relaxation training teaches strategies to relax and these are integrated at the beginning and end of each session.
TI-CBT Caregiver Intervention Manuals were distributed to sites for translation, backtranslation, and cultural adaptation in preparation for the Randomized Trial.
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Active Comparator: Caregivers Discussion Control Arm
For caregivers, the Discussion Control arm consisted of: two 2-hour discussion group sessions on two separate weeks within 8 weeks of their youth's first group session and one 2-hour booster discussion group session at 6 months led by adult study staff.
The Discussion Control intervention was delivered in a group format.
The Discussion Control arm had 15 groups with an average of 7.6 caregivers per group (range 3-10).
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For caregivers, each discussion group session was led by adult study staff.
Discussion topics were selected by caregivers in the group.
Discussion Control sessions took place at a separate time from TI-CBT Intervention sessions to minimize contamination.
Youth and caregiver group sessions were also held separately.
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What is the study measuring?
Primary Outcome Measures
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
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Group-level Mean General Anxiety Disorder-7 (GAD-7) at 6 Months
Time Frame: at 6 months
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Average (standard deviation) of the group-level mean General Anxiety Disorder-7 (GAD-7) score within arm.
The GAD-7 features 7 items assessing frequency of anxiety symptoms over the past 2 weeks on a scale from 0="Not at all" to 3="Nearly every day".
Responses to the 7 items are summed to obtain a GAD-7 score ranging from 0 (least) to 21 (most severe symptoms).
A score of 10 or more points indicates moderate to severe anxiety symptoms.
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at 6 months
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Group-level Mean UCLA Post-Traumatic Stress Disorder-Reaction Index (UCLA-PTSD-RI) at 6 Months
Time Frame: at 6 months
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Average (standard deviation) of the group-level mean UCLA Post Traumatic Stress Disorder-Reaction Index (PTSD-RI) score within arm.
The UCLA PTSD-RI assesses DSM-IV criteria for PTSD in youth.
If prior trauma is endorsed, assessment asks whether 31 PTSD symptoms have occurred within the past month on a scale from 0="None" to 4="Most of the time".
A scoring algorithm is applied to the 31 items to calculate a score ranging from 0 (least) to 80 (most severe symptoms).
A score of 35 or more indicates moderate to severe PTSD symptoms.
If no trauma is endorsed, no score is calculated.
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at 6 months
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Group-level Mean Composite Mental Health Measure at 6 Months
Time Frame: at 6 months
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Average (standard deviation) of the group-level mean Composite score within arm.
Composite scores are a study-specific measure of combined mental health symptoms.
A participant's PHQ-9, GAD-7, and UCLA PTSD-RI scores at the given timepoint are each standardized according to baseline to get Z scores.
The 3 Z scores are summed to obtain a Composite score.
Composite scores are not Z scores themselves and can range from -Inf to +Inf, with greater scores reflecting more severe symptoms overall.
Composite scores of 0 at baseline represent average symptom levels overall, but otherwise do not have a meaningful central value.
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at 6 months
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Group-level Mean Patient Health Questionnaire-9 (PHQ-9) at 6 Months
Time Frame: at 6 months
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Average (standard deviation) of the group-level mean Patient Health Questionnaire-9 (PHQ-9) score within arm.
The PHQ-9 features 9 items assessing the frequency of depression symptoms over the past 2 weeks on a scale from 0="Not at all" to 3="Nearly every day".
Responses to the 9 items are summed to obtain a PHQ-9 score ranging from 0 (least) to 27 (most severe symptoms).
A score of 10 or more points indicates moderate to severe depression symptoms.
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at 6 months
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Secondary Outcome Measures
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Group-level Mean General Anxiety Disorder-7 (GAD-7) at IPL (Immediately Post-Last Group Session)
Time Frame: After initial treatment completion (initial treatment lasted an average of 6 weeks)
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Average (standard deviation) of the group-level mean General Anxiety Disorder-7 (GAD-7) score within arm.
The GAD-7 features 7 items assessing frequency of anxiety symptoms over the past 2 weeks on a scale from 0="Not at all" to 3="Nearly every day".
Responses to the 7 items are summed to obtain a GAD-7 score ranging from 0 (least) to 21 (most severe symptoms).
A score of 10 or more points indicates moderate to severe anxiety symptoms.
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After initial treatment completion (initial treatment lasted an average of 6 weeks)
|
|
Group-level Mean Patient Health Questionnaire-9 (PHQ-9) at IPL (Immediately Post Last Group Session)
Time Frame: After initial treatment completion (initial treatment lasted an average of 6 weeks)
|
Average (standard deviation) of the group-level mean Patient Health Questionnaire-9 (PHQ-9) score within arm.
The PHQ-9 features 9 items assessing the frequency of depression symptoms over the past 2 weeks on a scale from 0="Not at all" to 3="Nearly every day".
Responses to the 9 items are summed to obtain a PHQ-9 score ranging from 0 (least) to 27 (most severe symptoms).
A score of 10 or more points indicates moderate to severe depression symptoms.
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After initial treatment completion (initial treatment lasted an average of 6 weeks)
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Group-level Mean UCLA Post-Traumatic Stress Disorder-Reaction Index (UCLA PTSD-RI) at IPL (Immediately Post-Last Group Session)
Time Frame: After initial treatment completion (initial treatment lasted an average of 6 weeks)
|
Average (standard deviation) of the group-level mean UCLA Post Traumatic Stress Disorder-Reaction Index (PTSD-RI) score within arm.
The UCLA PTSD-RI assesses DSM-IV criteria for PTSD in youth.
If prior trauma is endorsed, assessment asks whether 31 PTSD symptoms have occurred within the past month on a scale from 0="None" to 4="Most of the time".
A scoring algorithm is applied to the 31 items to calculate a score ranging from 0 (least) to 80 (most severe symptoms).
A score of 35 or more indicates moderate to severe PTSD symptoms.
If no trauma is endorsed, no score is calculated.
|
After initial treatment completion (initial treatment lasted an average of 6 weeks)
|
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Group-level Mean Composite Mental Health Measure at IPL (Immediately Post-Last Group Session)
Time Frame: After initial treatment completion (initial treatment lasted an average of 6 weeks)
|
Average (standard deviation) of the group-level mean Composite score within arm.
Composite scores are a study-specific measure of combined mental health symptoms.
A participant's PHQ-9, GAD-7, and UCLA PTSD-RI scores at the given timepoint are each standardized according to baseline to get Z scores.
The 3 Z scores are summed to obtain a Composite score.
Composite scores are not Z scores themselves and can range from -Inf to +Inf, with greater scores reflecting more severe symptoms overall.
Composite scores of 0 at baseline represent average symptom levels overall, but otherwise do not have a meaningful central value.
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After initial treatment completion (initial treatment lasted an average of 6 weeks)
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Group-level Mean ART Adherence at 6 Months
Time Frame: at 6 months
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Average (standard deviation) of the group-level mean antiretroviral therapy (ART) adherence score within arm.
The Wilson 3-Item Adherence Scale assessed self-reported ART adherence.
Within the past 30 days, the 3 items correspond to missed daily doses (0-30), adherence to medication instructions ("Very poor" to "Excellent"), and frequency of perfect use ("Never" to "Always").
Responses on the three items are transformed linearly to scores between 0 and 100 points and averaged to obtain a single score.
Scores range from 0 (worst) possible adherence to 100 (best possible adherence).
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at 6 months
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Viral Load at 6 Months
Time Frame: at 6 months
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HIV-1 RNA
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at 6 months
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Group-level Mean ART Adherence at IPL (Immediately Post-Last Group Session).
Time Frame: After initial treatment completion (initial treatment lasted an average of 6 weeks).
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Self-report - Wilson 3-item scale (range 0-100, higher=better)
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After initial treatment completion (initial treatment lasted an average of 6 weeks).
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Viral Load at IPL (Immediately Post-Last Group Session)
Time Frame: After initial treatment completion (initial treatment lasted an average of 6 weeks)
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HIV-1 RNA
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After initial treatment completion (initial treatment lasted an average of 6 weeks)
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Collaborators and Investigators
Sponsor
Sponsor
Collaborators
Collaborators
Investigators
Investigators
- Study Chair: Dorothy Dow, MD, MSc, Duke University
Publications and helpful links
General Publications
- Dow DE, Libous J, Ponatshego PL, Masheto G, Mvalo T, Payesa C, Buckley J, Stranix-Chibanda L, Nematadzira T, Vhembo T, Ace A, Warshaw M, Townley E, Lee S, Allison S, Donenberg G and the IMPAACT 2016 Team. High levels of mental distress among youth with HIV in Southern Africa: A description of enrollment into IMPAACT 2016, a randomized controlled trial of a peer-led, group-based mental health intervention. Presented at IAS, Kigali, Rwanda, 15 July 2025.
- Libous J, Jeffrey R, George K, Montañez N, Warshaw M, Shakes Raesi M, Ponatshego PL, Maliwichi L, Vhembo T, Mutasa T, Bere CT, Galvin L, Townley E, Varechtchouk O, Dow D, Donenberg G, and the IMPAACT 2016 Team. IMPAACT 2016: The ADAPT-ITT Framework Leveraging Youth and Supporter Voices in the Adaptation of a Trauma-Informed Cognitive Behavioral Therapy Group-Based Intervention for Youth Living with HIV and Mental Health Distress. Presented at Fast Track Cities, Paris, France, 13-15 October 2024.
- Vhemo T, Mhembere T, Mbengeranwa T, Bere TC, Mutasa T, Katsande R, Gumbo J, Mudzonga N, Nematadzira T, Maturure SJ, Mandima PF, Maonera S, Stranix-Chibanda L. High Prevalence of Common Mental Health Disorders Amongst Adolescents With HIV in Zimbabwe: IMPAACT 2016; Presented at International Workshop on Pediatrics & HIV, Munich, Germany, 19-20 July 2024.
- Libous JL, Montañez N, Donenberg G, Kapetanovic S, Dow D. IMPAACT 2016: Operationalizing the ADAPT-ITT Model to drive local adaptation of an intervention to improve mental health and medication adherence in youth living with HIV. Presented at Society for Clinical Research Associates 29th Annual Conference, Virtual, 23-26 September 2020.
- Warshaw M, Dow D, Kapetanovic S, Libous J, Reding C, Montañez , Donenberg G. IMPAACT 2016: Interdisciplinary Collaboration at Multiple Levels. Society for Clinical Trials 41st Annual Meeting, Baltimore, MD (Virtual), 2020.
- Libous JL, Montanez NA, Dow DE, Kapetanovic S, Buckley J, Kakhu TJ, Kamthunzi P, Maliwichi LA, Vhembo T, Chawana TD, Nematadzira T, Donenberg GR. IMPAACT 2016: Operationalizing HIV Intervention Adaptations to Inform the Science and Outcomes of Implementation. Front Reprod Health. 2021 May 28;3:662912. doi: 10.3389/frph.2021.662912. eCollection 2021.
Study record dates
Study Major Dates
Study Start (Actual)
Study Start
Primary Completion (Actual)
Primary Completion
Study Completion (Actual)
Study Completion
Study Registration Dates
First Submitted
First Submitted
First Submitted That Met QC Criteria
First Submitted That Met QC Criteria
First Posted (Actual)
First Posted
Study Record Updates
Last Update Posted (Actual)
Last Update Posted
Last Update Submitted That Met QC Criteria
Last Update Submitted That Met QC Criteria
Last Verified
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
Other Study ID Numbers
- IMPAACT 2016
- DAIDS ID #38506 (Other Identifier: DAIDS/NIAID/NIH)
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
IPD Sharing Time Frame
IPD Sharing Access Criteria
Data will be shared with researchers who provide a methodologically sound proposal for use of the data that is approved by the IMPAACT Network.
Types of Analyses: Specifically for the types of analyses needed to achieve aims in the proposal approved by the IMPAACT Network.
Mechanism: Researchers may submit a request for access to data using the IMPAACT "Data Request" form at: https://www.impaactnetwork.org/studies/submit-research-proposal. Researchers of approved proposals will need to sign an IMPAACT Data Use Agreement before receiving the data.
IPD Sharing Supporting Information Type
- STUDY_PROTOCOL
- SAP
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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