Self-Reported Side Effects and Adherence to Antiretroviral Therapy in HIV-Infected Pregnant Women under Option B+: A Prospective Study
Identifieur interne : 000494 ( Pmc/Checkpoint ); précédent : 000493; suivant : 000495Self-Reported Side Effects and Adherence to Antiretroviral Therapy in HIV-Infected Pregnant Women under Option B+: A Prospective Study
Auteurs : Tamsin Phillips [Afrique du Sud] ; Annibale Cois [Afrique du Sud] ; Robert H. Remien [États-Unis] ; Claude A. Mellins [États-Unis] ; James A. Mcintyre [Afrique du Sud] ; Greg Petro [Afrique du Sud] ; Elaine J. Abrams [États-Unis] ; Landon Myer [Afrique du Sud]Source :
- PLoS ONE [ 1932-6203 ] ; 2016.
Abstract
Antiretroviral therapy (ART) regimens containing efavirenz (EFV) are recommended as part of universal ART for pregnant and breastfeeding women. EFV may have appreciable side effects (SE), and ART adherence in pregnancy is a major concern, but little is known about ART SE and associations with adherence in pregnancy.
We investigated the distribution of patient-reported SE (based on Division of AIDS categories) and the association of SE with missed ART doses in a cohort of 517 women starting EFV+3TC/FTC+TDF during pregnancy. In analysis, SE were considered in terms of their overall frequency, by systems category, and by latent classes.
Overall 97% of women reported experiencing at least one SE after ART initiation, with 48% experiencing more than five SE. Gastrointestinal, central nervous system, systemic and skin SE were reported by 81%, 85%, 79% and 31% of women, respectively, with considerable overlap across groups. At least one missed dose was reported by 32% of women. In multivariable models, ART non-adherence was associated with systemic SE compared to other systems categories, and measures of the overall burden of SE experienced were most strongly associated with missed ART doses.
These data demonstrate very high levels of SE in pregnant women initiating EFV-based ART and a strong association between SE burden and ART adherence. ART regimens with reduced SE profiles may enhance adherence, and as countries expand universal ART for all adult patients, counseling must include preparation for ART SE.
Url:
DOI: 10.1371/journal.pone.0163079
PubMed: 27760126
PubMed Central: 5070813
Affiliations:
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<front><div type="abstract" xml:lang="en"><sec id="sec001"><title>Background</title>
<p>Antiretroviral therapy (ART) regimens containing efavirenz (EFV) are recommended as part of universal ART for pregnant and breastfeeding women. EFV may have appreciable side effects (SE), and ART adherence in pregnancy is a major concern, but little is known about ART SE and associations with adherence in pregnancy.</p>
</sec>
<sec id="sec002"><title>Methods</title>
<p>We investigated the distribution of patient-reported SE (based on Division of AIDS categories) and the association of SE with missed ART doses in a cohort of 517 women starting EFV+3TC/FTC+TDF during pregnancy. In analysis, SE were considered in terms of their overall frequency, by systems category, and by latent classes.</p>
</sec>
<sec id="sec003"><title>Results</title>
<p>Overall 97% of women reported experiencing at least one SE after ART initiation, with 48% experiencing more than five SE. Gastrointestinal, central nervous system, systemic and skin SE were reported by 81%, 85%, 79% and 31% of women, respectively, with considerable overlap across groups. At least one missed dose was reported by 32% of women. In multivariable models, ART non-adherence was associated with systemic SE compared to other systems categories, and measures of the overall burden of SE experienced were most strongly associated with missed ART doses.</p>
</sec>
<sec id="sec004"><title>Conclusion</title>
<p>These data demonstrate very high levels of SE in pregnant women initiating EFV-based ART and a strong association between SE burden and ART adherence. ART regimens with reduced SE profiles may enhance adherence, and as countries expand universal ART for all adult patients, counseling must include preparation for ART SE.</p>
</sec>
</div>
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<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS One</journal-id>
<journal-id journal-id-type="iso-abbrev">PLoS ONE</journal-id>
<journal-id journal-id-type="publisher-id">plos</journal-id>
<journal-id journal-id-type="pmc">plosone</journal-id>
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<issn pub-type="epub">1932-6203</issn>
<publisher><publisher-name>Public Library of Science</publisher-name>
<publisher-loc>San Francisco, CA USA</publisher-loc>
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<article-meta><article-id pub-id-type="pmid">27760126</article-id>
<article-id pub-id-type="pmc">5070813</article-id>
<article-id pub-id-type="doi">10.1371/journal.pone.0163079</article-id>
<article-id pub-id-type="publisher-id">PONE-D-16-13067</article-id>
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<subj-group><subject>Immunology</subject>
<subj-group><subject>Vaccination and Immunization</subject>
<subj-group><subject>Antiviral Therapy</subject>
<subj-group><subject>Antiretroviral Therapy</subject>
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<subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject>
<subj-group><subject>Immunology</subject>
<subj-group><subject>Vaccination and Immunization</subject>
<subj-group><subject>Antiviral Therapy</subject>
<subj-group><subject>Antiretroviral Therapy</subject>
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<subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject>
<subj-group><subject>Public and Occupational Health</subject>
<subj-group><subject>Preventive Medicine</subject>
<subj-group><subject>Vaccination and Immunization</subject>
<subj-group><subject>Antiviral Therapy</subject>
<subj-group><subject>Antiretroviral Therapy</subject>
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<subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject>
<subj-group><subject>Women's Health</subject>
<subj-group><subject>Maternal Health</subject>
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<subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject>
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<subj-group><subject>Obstetrics and Gynecology</subject>
<subj-group><subject>Pregnancy</subject>
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<subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject>
<subj-group><subject>Anatomy</subject>
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<subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject>
<subj-group><subject>Anatomy</subject>
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<subj-group><subject>Central Nervous System</subject>
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</subj-group>
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<subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject>
<subj-group><subject>Women's Health</subject>
<subj-group><subject>Maternal Health</subject>
<subj-group><subject>Antenatal Care</subject>
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<subj-group subj-group-type="Discipline-v3"><subject>People and Places</subject>
<subj-group><subject>Population Groupings</subject>
<subj-group><subject>Age Groups</subject>
<subj-group><subject>Adults</subject>
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</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject>
<subj-group><subject>Otorhinolaryngology</subject>
<subj-group><subject>Otology</subject>
<subj-group><subject>Vertigo</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject>
<subj-group><subject>Microbiology</subject>
<subj-group><subject>Medical Microbiology</subject>
<subj-group><subject>Microbial Pathogens</subject>
<subj-group><subject>Viral Pathogens</subject>
<subj-group><subject>Immunodeficiency Viruses</subject>
<subj-group><subject>HIV</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject>
<subj-group><subject>Pathology and Laboratory Medicine</subject>
<subj-group><subject>Pathogens</subject>
<subj-group><subject>Microbial Pathogens</subject>
<subj-group><subject>Viral Pathogens</subject>
<subj-group><subject>Immunodeficiency Viruses</subject>
<subj-group><subject>HIV</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject>
<subj-group><subject>Organisms</subject>
<subj-group><subject>Viruses</subject>
<subj-group><subject>Viral Pathogens</subject>
<subj-group><subject>Immunodeficiency Viruses</subject>
<subj-group><subject>HIV</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject>
<subj-group><subject>Organisms</subject>
<subj-group><subject>Viruses</subject>
<subj-group><subject>Immunodeficiency Viruses</subject>
<subj-group><subject>HIV</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3"><subject>Biology and life sciences</subject>
<subj-group><subject>Organisms</subject>
<subj-group><subject>Viruses</subject>
<subj-group><subject>RNA viruses</subject>
<subj-group><subject>Retroviruses</subject>
<subj-group><subject>Lentivirus</subject>
<subj-group><subject>HIV</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject>
<subj-group><subject>Microbiology</subject>
<subj-group><subject>Medical Microbiology</subject>
<subj-group><subject>Microbial Pathogens</subject>
<subj-group><subject>Viral Pathogens</subject>
<subj-group><subject>Retroviruses</subject>
<subj-group><subject>Lentivirus</subject>
<subj-group><subject>HIV</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject>
<subj-group><subject>Pathology and Laboratory Medicine</subject>
<subj-group><subject>Pathogens</subject>
<subj-group><subject>Microbial Pathogens</subject>
<subj-group><subject>Viral Pathogens</subject>
<subj-group><subject>Retroviruses</subject>
<subj-group><subject>Lentivirus</subject>
<subj-group><subject>HIV</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject>
<subj-group><subject>Organisms</subject>
<subj-group><subject>Viruses</subject>
<subj-group><subject>Viral Pathogens</subject>
<subj-group><subject>Retroviruses</subject>
<subj-group><subject>Lentivirus</subject>
<subj-group><subject>HIV</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject>
<subj-group><subject>Pharmaceutics</subject>
<subj-group><subject>Dose Prediction Methods</subject>
</subj-group>
</subj-group>
</subj-group>
</article-categories>
<title-group><article-title>Self-Reported Side Effects and Adherence to Antiretroviral Therapy in HIV-Infected Pregnant Women under Option B+: A Prospective Study</article-title>
<alt-title alt-title-type="running-head">Maternal ART Side effects and Adherence</alt-title>
</title-group>
<contrib-group><contrib contrib-type="author"><contrib-id authenticated="true" contrib-id-type="orcid">http://orcid.org/0000-0003-4554-2922</contrib-id>
<name><surname>Phillips</surname>
<given-names>Tamsin</given-names>
</name>
<xref ref-type="aff" rid="aff001"><sup>1</sup>
</xref>
<xref ref-type="aff" rid="aff002"><sup>2</sup>
</xref>
<xref ref-type="corresp" rid="cor001">*</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Cois</surname>
<given-names>Annibale</given-names>
</name>
<xref ref-type="aff" rid="aff001"><sup>1</sup>
</xref>
<xref ref-type="aff" rid="aff002"><sup>2</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Remien</surname>
<given-names>Robert H.</given-names>
</name>
<xref ref-type="aff" rid="aff003"><sup>3</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Mellins</surname>
<given-names>Claude A.</given-names>
</name>
<xref ref-type="aff" rid="aff003"><sup>3</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>McIntyre</surname>
<given-names>James A.</given-names>
</name>
<xref ref-type="aff" rid="aff001"><sup>1</sup>
</xref>
<xref ref-type="aff" rid="aff004"><sup>4</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Petro</surname>
<given-names>Greg</given-names>
</name>
<xref ref-type="aff" rid="aff005"><sup>5</sup>
</xref>
<xref ref-type="aff" rid="aff006"><sup>6</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Abrams</surname>
<given-names>Elaine J.</given-names>
</name>
<xref ref-type="aff" rid="aff007"><sup>7</sup>
</xref>
<xref ref-type="aff" rid="aff008"><sup>8</sup>
</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Myer</surname>
<given-names>Landon</given-names>
</name>
<xref ref-type="aff" rid="aff001"><sup>1</sup>
</xref>
<xref ref-type="aff" rid="aff002"><sup>2</sup>
</xref>
</contrib>
</contrib-group>
<aff id="aff001"><label>1</label>
<addr-line>Division of Epidemiology & Biostatistics, University of Cape Town, Cape Town, South Africa</addr-line>
</aff>
<aff id="aff002"><label>2</label>
<addr-line>Centre for Infectious Diseases Epidemiology & Research, University of Cape Town, Cape Town, South Africa</addr-line>
</aff>
<aff id="aff003"><label>3</label>
<addr-line>HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, United States of America</addr-line>
</aff>
<aff id="aff004"><label>4</label>
<addr-line>Anova Health Institute, Johannesburg, South Africa</addr-line>
</aff>
<aff id="aff005"><label>5</label>
<addr-line>Department of Obstetrics & Gynaecology, University of Cape Town, Cape Town, South Africa</addr-line>
</aff>
<aff id="aff006"><label>6</label>
<addr-line>New Somerset Hospital, Cape Town, South Africa</addr-line>
</aff>
<aff id="aff007"><label>7</label>
<addr-line>ICAP, Columbia University, Mailman School of Public Health, New York, NY, United States of America</addr-line>
</aff>
<aff id="aff008"><label>8</label>
<addr-line>College of Physicians & Surgeons, Columbia University, New York, NY, United States of America</addr-line>
</aff>
<contrib-group><contrib contrib-type="editor"><name><surname>Abimiku</surname>
<given-names>Alash'le G.</given-names>
</name>
<role>Editor</role>
<xref ref-type="aff" rid="edit1"></xref>
</contrib>
</contrib-group>
<aff id="edit1"><addr-line>University of Maryland School of Medicine, UNITED STATES</addr-line>
</aff>
<author-notes><fn fn-type="COI-statement" id="coi001"><p><bold>Competing Interests: </bold>
The authors have declared that no competing interests exist.</p>
</fn>
<fn fn-type="con"><p><list list-type="simple"><list-item><p><bold>Conceptualization:</bold>
TP LM EJA AC JAM.</p>
</list-item>
<list-item><p><bold>Formal analysis:</bold>
TP AC LM.</p>
</list-item>
<list-item><p><bold>Methodology:</bold>
AC.</p>
</list-item>
<list-item><p><bold>Resources:</bold>
CAM RHR.</p>
</list-item>
<list-item><p><bold>Supervision:</bold>
LM EJA.</p>
</list-item>
<list-item><p><bold>Visualization:</bold>
TP AC LM.</p>
</list-item>
<list-item><p><bold>Writing – original draft:</bold>
TP AC.</p>
</list-item>
<list-item><p><bold>Writing – review & editing:</bold>
LM EJA RHR CAM JAM GP.</p>
</list-item>
</list>
</p>
</fn>
<corresp id="cor001">* E-mail: <email>tk.phillips@uct.ac.za</email>
</corresp>
</author-notes>
<pub-date pub-type="epub"><day>19</day>
<month>10</month>
<year>2016</year>
</pub-date>
<pub-date pub-type="collection"><year>2016</year>
</pub-date>
<volume>11</volume>
<issue>10</issue>
<elocation-id>e0163079</elocation-id>
<history><date date-type="received"><day>31</day>
<month>3</month>
<year>2016</year>
</date>
<date date-type="accepted"><day>2</day>
<month>9</month>
<year>2016</year>
</date>
</history>
<permissions><copyright-statement>© 2016 Phillips et al</copyright-statement>
<copyright-year>2016</copyright-year>
<copyright-holder>Phillips et al</copyright-holder>
<license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>
, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p>
</license>
</permissions>
<self-uri content-type="pdf" xlink:href="pone.0163079.pdf"></self-uri>
<abstract><sec id="sec001"><title>Background</title>
<p>Antiretroviral therapy (ART) regimens containing efavirenz (EFV) are recommended as part of universal ART for pregnant and breastfeeding women. EFV may have appreciable side effects (SE), and ART adherence in pregnancy is a major concern, but little is known about ART SE and associations with adherence in pregnancy.</p>
</sec>
<sec id="sec002"><title>Methods</title>
<p>We investigated the distribution of patient-reported SE (based on Division of AIDS categories) and the association of SE with missed ART doses in a cohort of 517 women starting EFV+3TC/FTC+TDF during pregnancy. In analysis, SE were considered in terms of their overall frequency, by systems category, and by latent classes.</p>
</sec>
<sec id="sec003"><title>Results</title>
<p>Overall 97% of women reported experiencing at least one SE after ART initiation, with 48% experiencing more than five SE. Gastrointestinal, central nervous system, systemic and skin SE were reported by 81%, 85%, 79% and 31% of women, respectively, with considerable overlap across groups. At least one missed dose was reported by 32% of women. In multivariable models, ART non-adherence was associated with systemic SE compared to other systems categories, and measures of the overall burden of SE experienced were most strongly associated with missed ART doses.</p>
</sec>
<sec id="sec004"><title>Conclusion</title>
<p>These data demonstrate very high levels of SE in pregnant women initiating EFV-based ART and a strong association between SE burden and ART adherence. ART regimens with reduced SE profiles may enhance adherence, and as countries expand universal ART for all adult patients, counseling must include preparation for ART SE.</p>
</sec>
</abstract>
<funding-group><award-group id="award001"><funding-source><institution-wrap><institution-id institution-id-type="funder-id">http://dx.doi.org/10.13039/100000071</institution-id>
<institution>National Institute of Child Health and Human Development</institution>
</institution-wrap>
</funding-source>
<award-id>1R01HD074558</award-id>
<principal-award-recipient><name><surname>Abrams</surname>
<given-names>Elaine J.</given-names>
</name>
</principal-award-recipient>
</award-group>
<award-group id="award002"><funding-source><institution>HIV Center for Clinical and Behavioral Studies</institution>
</funding-source>
<award-id>P30-MH43520</award-id>
<principal-award-recipient><name><surname>Remien</surname>
<given-names>Robert H.</given-names>
</name>
</principal-award-recipient>
</award-group>
<award-group id="award003"><funding-source><institution-wrap><institution-id institution-id-type="funder-id">http://dx.doi.org/10.13039/501100004513</institution-id>
<institution>Harry Crossley Foundation</institution>
</institution-wrap>
</funding-source>
<award-id>Harry Crossley Senior Clinical Fellowship 2015-2016</award-id>
<principal-award-recipient><name><surname>Cois</surname>
<given-names>Annibale</given-names>
</name>
</principal-award-recipient>
</award-group>
<funding-statement>This research was funded by the President's Emergency Plan for AIDS Relief (PEPFAR) through the National Institute of Child Health and Human Development (NICHD), grant number 1R01HD074558(<ext-link ext-link-type="uri" xlink:href="https://www.nichd.nih.gov/grants-funding/Pages/default.aspx">https://www.nichd.nih.gov/grants-funding/Pages/default.aspx</ext-link>
). Drs. Mellins and Remien were also supported by the HIV Center for Clinical and Behavioral Studies (P30-MH43520 (<ext-link ext-link-type="uri" xlink:href="http://www.cumc.columbia.edu/publications/press_releases/hiv_center.html">http://www.cumc.columbia.edu/publications/press_releases/hiv_center.html</ext-link>
) and Annibale Cois was supported by the Harry Crossley Foundation (Harry Crossley Senior Clinical Fellowship 2015-2016). Tamsin Phillips is supported by a bursary from the South African Centre for Epidemiological Modelling and Analysis. Additional funding comes from the Elizabeth Glaser Pediatric AIDS Foundation (<ext-link ext-link-type="uri" xlink:href="http://www.pedaids.org">http://www.pedaids.org</ext-link>
). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</funding-statement>
</funding-group>
<counts><fig-count count="3"></fig-count>
<table-count count="2"></table-count>
<page-count count="15"></page-count>
</counts>
<custom-meta-group><custom-meta id="data-availability"><meta-name>Data Availability</meta-name>
<meta-value>The variables and observations included in this report are provided as supporting information. However, because data collection for the parent study (<ext-link ext-link-type="uri" xlink:href="https://clinicaltrials.gov/ct2/show/NCT01933477">https://clinicaltrials.gov/ct2/show/NCT01933477</ext-link>
) is ongoing, the full study dataset will not be available until mid-2017 approximately. At that time, the data will be housed in a standard data repository linked to the Centre for Infectious Diseases Epidemiology & Research at the University of Cape Town, South Africa. The Supporting Information file contains the minimal data set underlying the findings of this specific study.</meta-value>
</custom-meta>
</custom-meta-group>
</article-meta>
<notes><title>Data Availability</title>
<p>The variables and observations included in this report are provided as supporting information. However, because data collection for the parent study (<ext-link ext-link-type="uri" xlink:href="https://clinicaltrials.gov/ct2/show/NCT01933477">https://clinicaltrials.gov/ct2/show/NCT01933477</ext-link>
) is ongoing, the full study dataset will not be available until mid-2017 approximately. At that time, the data will be housed in a standard data repository linked to the Centre for Infectious Diseases Epidemiology & Research at the University of Cape Town, South Africa. The Supporting Information file contains the minimal data set underlying the findings of this specific study.</p>
</notes>
</front>
</pmc>
<affiliations><list><country><li>Afrique du Sud</li>
<li>États-Unis</li>
</country>
<region><li>État de New York</li>
</region>
<settlement><li>New York</li>
</settlement>
<orgName><li>Université Columbia</li>
</orgName>
</list>
<tree><country name="Afrique du Sud"><noRegion><name sortKey="Phillips, Tamsin" sort="Phillips, Tamsin" uniqKey="Phillips T" first="Tamsin" last="Phillips">Tamsin Phillips</name>
</noRegion>
<name sortKey="Cois, Annibale" sort="Cois, Annibale" uniqKey="Cois A" first="Annibale" last="Cois">Annibale Cois</name>
<name sortKey="Cois, Annibale" sort="Cois, Annibale" uniqKey="Cois A" first="Annibale" last="Cois">Annibale Cois</name>
<name sortKey="Mcintyre, James A" sort="Mcintyre, James A" uniqKey="Mcintyre J" first="James A." last="Mcintyre">James A. Mcintyre</name>
<name sortKey="Mcintyre, James A" sort="Mcintyre, James A" uniqKey="Mcintyre J" first="James A." last="Mcintyre">James A. Mcintyre</name>
<name sortKey="Myer, Landon" sort="Myer, Landon" uniqKey="Myer L" first="Landon" last="Myer">Landon Myer</name>
<name sortKey="Myer, Landon" sort="Myer, Landon" uniqKey="Myer L" first="Landon" last="Myer">Landon Myer</name>
<name sortKey="Petro, Greg" sort="Petro, Greg" uniqKey="Petro G" first="Greg" last="Petro">Greg Petro</name>
<name sortKey="Petro, Greg" sort="Petro, Greg" uniqKey="Petro G" first="Greg" last="Petro">Greg Petro</name>
<name sortKey="Phillips, Tamsin" sort="Phillips, Tamsin" uniqKey="Phillips T" first="Tamsin" last="Phillips">Tamsin Phillips</name>
</country>
<country name="États-Unis"><region name="État de New York"><name sortKey="Remien, Robert H" sort="Remien, Robert H" uniqKey="Remien R" first="Robert H." last="Remien">Robert H. Remien</name>
</region>
<name sortKey="Abrams, Elaine J" sort="Abrams, Elaine J" uniqKey="Abrams E" first="Elaine J." last="Abrams">Elaine J. Abrams</name>
<name sortKey="Abrams, Elaine J" sort="Abrams, Elaine J" uniqKey="Abrams E" first="Elaine J." last="Abrams">Elaine J. Abrams</name>
<name sortKey="Mellins, Claude A" sort="Mellins, Claude A" uniqKey="Mellins C" first="Claude A." last="Mellins">Claude A. Mellins</name>
</country>
</tree>
</affiliations>
</record>
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