JAIDS Journal of Acquired Immune Deficiency Syndromes:
Epidemiology and Social Science
Burden of Depression Among Impoverished HIV-Positive Women in Peru
Wu, Diana Ying MD, MSc*; Munoz, Maribel RN†; Espiritu, Betty RN†; Zeladita, Jhon RN†; Sanchez, Eduardo MD†; Callacna, Miriam RN†; Rojas, Christian MD†; Arevalo, Jorge MD†; Caldas, Adolfo MSW‡; Shin, Sonya MD, MPH‡
From the *Stanford University Hospital; †Socios en Salud, Lima, Peru; ‡Brigham and Women's Hospital, Partners in Health, Harvard Medical School.
Received for publication November 4, 2007; accepted April 24, 2008.
Correspondence to: Sonya Shin, MD, MPH, Harvard School of Public Health, 651 Huntington Avenue, 7th Floor, Boston, MA, 02115.
Objectives: In resource-poor settings, the mental health burden among HIV-positive women is exacerbated by poverty. We sought to describe the extent, risk factors, and experience of depression among impoverished HIV-positive women living in Lima, Peru.
Methods: This is a case series of 78 HIV-positive women in Lima, Peru. We measured depression, stigma, and social support and performed a multivariable analysis to identify factors associated with depression.
Results: Among 78 HIV-positive patients, 68% were depressed. Depression and suicidal ideation were rarely diagnosed by providers. In multivariable analysis, HIV-related stigma and food scarcity were associated with depression.
Conclusions: In our cohort of HIV-positive women in Lima, Peru, poverty and socioeconomic vulnerability contributed to depression. Findings highlight the heavy burden of depression in this cohort of poor women and the need to incorporate mental health services as an integral component of HIV care.
Depression impacts HIV outcomes both through nonadherence to antiretroviral therapy1-6 and direct physiological effects on the immune system.7-10 The end result is the association of depression with increased HIV progression and a 2-fold mortality risk among persons living with HIV/AIDS (PLHA).8,11-13 In resource-poor settings, the burden of depression among PLHA is indisputable.14 Although reports vary due to sociocultural and sampling/measurement differences, the prevalence of depression among PLHA living in resource-poor settings ranges from 21% to 57%.2,15-22 The vicious cycle of depression and HIV is worsened by poverty-related factors, such as social isolation, lack of material resources, and gender inequality.2,21,23,24 In many settings, women living in poverty disproportionately bear the burden of these 2 diseases.25-28 Yet, few have described the frequency and characteristics of depression specifically among women living with HIV/AIDS (WLHA) in such settings.28 To contribute to our limited knowledge of depression among women in resource-limited settings, we describe the prevalence of and factors associated with depression among Peruvian WLHA.
STUDY SETTING AND METHODS
In Peru, an estimated 93,000 individuals (0.6%) live with HIV.29 Published reports on HIV transmission in Peru cite primary risk factors for HIV of early sexual activity and number of past partners among women.30 Among the most impoverished strata of patients in Lima, heterosexual sex is an increasingly prevalent mode of transmission. Supported by the Global Fund, the Peruvian National HIV Program began to offer free highly active antiretroviral therapy (HAART) in 2004. Since 2005, the Peruvian National HIV Program has collaborated with a nongovernmental organization, Socios En Salud, to implement a community-based accompaniment program, consisting of home-based directly observed HAART, psychosocial support, and socioeconomic assistance with the goal of improving adherence among Peruvian patients initiating HAART for the first time. Although all impoverished patients starting HAART were eligible, referring physicians gave priority to women and tuberculosis coinfected patients.31 Between November 2005 and August 2007, we enrolled 159 adults-of these 78 women-recently starting or about to start HAART based on World Health Organization guidelines.32 Our study took place in 2 hospitals (Hospital Hipolito Unanue and Hospital Dos de Mayo). Patients provided informed consent, which was verbally read to all patients.
Data Collection and Analysis
Baseline socioeconomic and clinical data were collected using standardized forms, based on patient interview and chart review. Psychosocial data were obtained in a series of one-on-one verbal interviews, conducted privately in a site specified by the patient. To assess depression, we used the Hopkins Symptom Checklist-15.33,34 This 15-item questionnaire has demonstrated adequate performance in assessing depression in HIV-positive individuals and in multicultural populations,18,35-37 including Latino college students in the United States,38 and Spanish-speaking populations in El Salvador and Guatemala.39-41 Questions are scored on a severity scale from 1 (para nada) to 4 (mucho), with a higher score indicating more depressive symptoms. Although not calibrated in our cohort, we used the conventional cutoff score of 1.75.42-44 We assessed stigma and social support using the Berger Stigma Instrument45 and Duke University of North Carolina Social Support Scale.46 A review of these instruments and our validation procedures is described elsewhere.47 For all instruments, the Cronbach's alpha was >0.80 in this cohort. Data were entered into an ACCESS database (Microsoft, Seattle, WA). We summarized demographic, clinical, and psychosocial characteristics of patients and performed a univariate analysis to assess for characteristics associated with depression, using χ2 test or Fisher exact test for categorical variables and the t test or Wilcoxon test for continuous variables. All variables with a level of significance of <0.05 were included in a multivariable analysis using a stepwise logistic regression model to retain only those variables with a P value of <0.05. For this model, we created binary psychosocial variables assigning a poor status for those scoring worse than the cohort median. We did not include colinear variables (defined as a Pearson correlation coefficient >0.6) in the model. Analyses were conducted using SAS Version 9.1 (SAS Institute, Inc, Cary, NC).
The study was approved by the Partners Human Subjects Committee at the Brigham and Women's Hospital, the Institutional Review Board of the Peruvian National Institute of Health, and the ethics committees of both participating hospitals. Given the high rates of depression and other psychosocial stressors in our cohort, we developed a brief checklist of psychiatric symptoms. Health promoters administer this interview monthly to identify and refer cases with severe psychiatric and psychosocial problems.
Of 275 women identified to start HAART in the study hospitals during the study period, 91 women were referred to and enrolled into our study. We excluded 13 from analysis who died before completing baseline interviews. Of the remaining 78 women, 53 (68.0%) met criteria for depression. Of these, providers identified depression in only 11 (24.5%). Fourteen women had contemplated suicide in the past 30 days, but only 2 had communicated this to their provider. As shown in Table 1, the majority of women were unemployed and had difficulty accessing health services. Almost half reported food scarcity, defined as having gone at least a day in the past 3 months without eating, due to economic hardship.
On univariate analysis, food scarcity, having missed an appointment in the past 30 days, high stigma, and low emotional social support were associated with depression. None of these variables were colinear. Stepwise regression retained food scarcity and stigma greater than cohort mean, with adjusted odds ratios (95% confidence interval) of 3.95 (1.23, 12.69) and 4.81 (1.34, 17.30), respectively.
Based on Hopkins Symptom Checklist criteria, we encountered a high prevalence of depression (68%). This rate is much higher than the prevalence of depression among women in Lima, Peru (13.5% lifetime).48 This high burden of depression may be partially attributable to the nature of our cohort, WLHA who were specifically targeted for psychosocial support due to their impoverished and marginalized status. The rate of suicidal ideation among these women (18.0%) was lower than that found in a US study of HIV-positive men and women (26%)49 but higher than that found in a Brazilian study of depression in women with HIV (15.8%).22 Both depression and suicidal ideation were underdiagnosed by providers. These findings highlight the need to train HIV providers to diagnose and manage depression and suicidal ideation in their patients.
Stigma was significantly associated with depression in our cohort, consistent with other reports.17,50-52 Stigma and disclosure concerns stress women's relationships with partners and extended family, limiting their ability to tap into social supports and fulfill their roles as caregivers.53-55 Women also worry that their diagnosis may stigmatize their children.53
Lower socioeconomic status-reflected in missed appointments in the past 3 months due to economic hardship and low educational level-was associated with depression. Among socioeconomic indicators, food scarcity was most strongly associated with depression. This association has been described among other vulnerable women, although not among WLHA.56-59 This relationship reflects the pervasive stress associated with obtaining food day after day for oneself and one's family.60 This struggle for sheer survival characterizes the lives of many impoverished WLHA and limits their ability to adopt healthy behaviors, such as HAART adherence, avoiding breast-feeding, and practicing safe sex.61 The implications of food scarcity on health outcomes go beyond its impact on depression because malnutrition and micronutrient deficiencies accelerate HIV progression and increase mortality among HIV-positive individuals.62-67
Although not significant on multivariable analysis, we found a trend of association between lack of emotional social support and depression in our cohort. This finding corroborates other reports.68-71 The intense synergy between depression, low social support, poverty, and stigma among PLHA is remarkably consistent across cultures.17,50,54,72,73
Our findings did not support the association between depression and time since HIV diagnosis16 or substance use,17,74,75 nor did we find a significant association between depression and CD4 cell count, similar to some studies76-78 and contrary to others.21 The small cohort size limits the null findings of our study. Further, our cohort comprises women who were specifically referred for psychosocial support and may reflect referral bias of the most vulnerable women. Therefore, our findings may not be generalizable to the overall female HIV population in this region or elsewhere but at least highlight the formidable barriers faced by the most vulnerable WLHA. Another limitation is the lack of validation of the Hopkins Symptom Checklist cutoff score in our population. If this score overestimates the rate of depression, then the high rate of depression and the discordance between Hopkins Symptom Checklist defined and physician-documented depression could reflect poor calibration. However, our preliminary data demonstrate a decrease in depression based on this cutoff from 57% at baseline to 4% at 12 months,31 suggesting that this cutoff score may be appropriate in this population. Finally, we could not quantify or rule out the contribution of other factors (eg, cognitive disorders, central nervous system pathology, substance use, and medication toxicity) and modifying factors (eg, use of antidepressant therapy) on depressive symptoms.
Our findings provide insight into the complex interplay of poverty, stigma, and depression among HIV-positive women. Depression and suicidal ideation were largely not communicated to providers and went unaddressed, highlighting the need to integrate the wide array of evidence-based treatment of depression into HIV care.79-85 Although funding for global health has increased, there remains insufficient allocation for mental health services, which are crucial components of effective health interventions for all types of diseases.86 Community-based services could be one cost-effective approach to expand availability of mental health interventions.87
1. Penzak SR, Reddy YS, Grimsley SR. Depression in patients with HIV infection. Am J Health Syst Pharm
. 2000;57:376-386; quiz 378-379.
2. Nogueira Campos L, De Fatima Bonolo P, Crosland Guimaraes MD. Anxiety and depression assessment prior to initiating antiretroviral treatment in Brazil. AIDS Care
3. Ammassari A, Antinori A, Aloisi MS, et al. Depressive symptoms, neurocognitive impairment, and adherence to highly active antiretroviral therapy among HIV-infected persons. Psychosomatics
4. Molassiotis A, Callaghan P, Twinn SF, et al. A pilot study of the effects of cognitive-behavioral group therapy and peer support/counseling in decreasing psychologic distress and improving quality of life in Chinese patients with symptomatic HIV disease. AIDS Patient Care STDS
5. van Servellen G, Chang B, Garcia L, et al. Individual and system level factors associated with treatment nonadherence in human immunodeficiency virus-infected men and women. AIDS Patient Care STDS
6. Tucker JS, Kanouse DE, Miu A, et al. HIV risk behaviors and their correlates among HIV-positive adults with serious mental illness. AIDS Behav
7. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. JAMA
8. Ironson G, O'Cleirigh C, Fletcher MA, et al. Psychosocial factors predict CD4 and viral load change in men and women with human immunodeficiency virus in the era of highly active antiretroviral treatment. Psychosom Med
9. Valente SM. Depression and HIV disease. J Assoc Nurses AIDS Care
10. Yirmiya R, Pollak Y, Morag M, et al. Illness, cytokines, and depression. Ann N Y Acad Sci
11. Antelman G, Smith Fawzi MC, Kaaya S, et al. Predictors of HIV-1 serostatus disclosure: a prospective study among HIV-infected pregnant women in Dar es Salaam, Tanzania. AIDS
12. Ickovics JR, Hamburger ME, Vlahov D, et al. Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: longitudinal analysis from the HIV Epidemiology Research Study. JAMA
13. Antelman G, Kaaya S, Wei R, et al. Depressive symptoms increase risk of HIV disease progression and mortality among women in Tanzania. J Acquir Immune Defic Syndr
14. Collins PY, Holman AR, Freeman MC, et al. What is the relevance of mental health to HIV/AIDS care and treatment programs in developing countries? A systematic review. AIDS
15. Shisana O, Rehle T, Simbayi LC. South African National HIV Prevalence, Incidence, Behaviour and Communication Survey
. Cape Town, South Africa: Human Sciences Research Council Press; 2005.
16. Olley BO, Seedat S, Stein DJ. Persistence of psychiatric disorders in a cohort of HIV/AIDS patients in South Africa: a 6-month follow-up study. J Psychosom Res
17. Simbayi LC, Kalichman S, Strebel A, et al. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Soc Sci Med
18. Kaaya SF, Fawzi MC, Mbwambo JK, et al. Validity of the Hopkins Symptom Checklist-25 amongst HIV-positive pregnant women in Tanzania. Acta Psychiatr Scand
19. Molassiotis A, Nahas-Lopez V, Chung WY, et al. Factors associated with adherence to antiretroviral medication in HIV-infected patients. Int J STD AIDS
20. Jin H, Hampton Atkinson J, Yu X, et al. Depression and suicidality in HIV/AIDS in China. J Affect Disord
21. Kaharuza FM, Bunnell R, Moss S, et al. Depression and CD4 cell count among persons with HIV infection in Uganda. AIDS Behav
22. Mello VA, Malbergier A. Depression in women infected with HIV. Rev Bras Psiquiatr
23. Patel V, Kleinman A. Poverty and common mental disorders in developing countries. Bull World Health Organ
24. Weiser SD, Riley ED, Ragland K, et al. Brief report: factors associated with depression among homeless and marginally housed HIV-infected men in San Francisco. J Gen Intern Med
25. Catz SL, Gore-Felton C, McClure JB. Psychological distress among minority and low-income women living with HIV. Behav Med
26. Grigoriadis S, Robinson GE. Gender issues in depression. Ann Clin Psychiatry
27. Piot P, Greener R, Russell S. Squaring the circle: AIDS, poverty, and human development. PLoS Med
28. Morrison MF, Petitto JM, Ten Have T, et al. Depressive and anxiety disorders in women with HIV infection. Am J Psychiatry
29. Cohen J. HIV/AIDS: Latin America & Caribbean. South America. Science
30. Alarcon JO, Johnson KM, Courtois B, et al. Determinants and prevalence of HIV infection in pregnant Peruvian women. AIDS
31. Sebastián J, Muñoz L, Mestanza L, et al. Atencion Integral en la comunidad a personas pobres con VIH/SIDA- TB en LIMA ESTE-Peru. IV Foro Latinoamericano y del Caribe en VIH/SIDA e ITS. Argentina, South America: 2007.
33. Derogatis LR, Lipman RS, Rickels K, et al. The Hopkins Symptom Checklist (HSCL). A measure of primary symptom dimensions. Mod Probl Pharmacopsychiatry
34. Derogatis LR, Lipman RS, Rickels K, et al. The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behav Sci
35. Joseph JG, Caumartin SM, Tal M, et al. Psychological functioning in a cohort of gay men at risk for AIDS. A three-year descriptive study. J Nerv Ment Dis
36. Lackner JB, Joseph JG, Ostrow DG, et al. The effects of social support on Hopkins Symptom Checklist-assessed depression and distress in a cohort of human immunodeficiency virus-positive and -negative gay men. A longitudinal study at six time points. J Nerv Ment Dis
37. Weiss JJ, Mulder CL, Antoni MH, et al. Effects of a supportive-expressive group intervention on long-term psychosocial adjustment in HIV-infected gay men. Psychother Psychosom
38. Cepeda-Benito A, Gleaves DH. Cross-ethnic equivalence of the Hopkins Symptom Checklist-21 in European American, African American, and Latino college students. Cultur Divers Ethnic Minor Psychol
39. Barthauer LM, Leventhal JM. Prevalence and effects of child sexual abuse in a poor, rural community in El Salvador: a retrospective study of women after 12 years of civil war. Child Abuse Negl
40. Sabin M, Lopes Cardozo B, Nackerud L, et al. Factors associated with poor mental health among Guatemalan refugees living in Mexico 20 years after civil conflict. JAMA
41. Sabin M, Sabin K, Kim HY, et al. The mental health status of Mayan refugees after repatriation to Guatemala. Rev Panam Salud Publica
42. Mollica RF, Wyshak G, de Marneffe D, et al. Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry
43. Sandanger I, Moum T, Ingebrigtsen G, et al. Concordance between symptom screening and diagnostic procedure: the Hopkins Symptom Checklist-25 and the Composite International Diagnostic Interview I. Soc Psychiatry Psychiatr Epidemiol
44. Tsutsumi A, Izutsu T, Poudyal AK, et al. Mental health of female survivors of human trafficking in Nepal. Soc Sci Med
45. Berger BE, Ferrans CE, Lashley FR. Measuring stigma in people with HIV: psychometric assessment of the HIV stigma scale. Res Nurs Health
46. Broadhead WE, Gehlbach SH, de Gruy FV, et al. The Duke-UNC Functional Social Support Questionnaire. Measurement of social support in family medicine patients. Med Care
47. Shin S, Munoz M, Espiritu B, et al. Psychosocial impact of poverty on antiretroviral nonadherence among HIV-TB coinfected patients in Lima, Peru. J Int Assoc Physicians AIDS Care (Chic Ill)
48. Kohn R, Levav I, de Almeida JM, et al. Mental disorders in Latin America and the Caribbean: a public health priority. Rev Panam Salud Publica
49. Kalichman SC, Heckman T, Kochman A, et al. Depression and thoughts of suicide among middle-aged and older persons living with HIV-AIDS. Psychiatr Serv
50. Lichtenstein B, Laska MK, Clair JM. Chronic sorrow in the HIV-positive patient: issues of race, gender, and social support. AIDS Patient Care STDS
51. Wingood GM, Diclemente RJ, Mikhail I, et al. HIV discrimination and the health of women living with HIV. Women Health
52. Vanable PA, Carey MP, Blair DC, et al. Impact of HIV-related stigma on health behaviors and psychological adjustment among HIV-positive men and women. AIDS Behav
53. Hackl KL, Somlai AM, Kelly JA, et al. Women living with HIV/AIDS: the dual challenge of being a patient and caregiver. Health Soc Work
54. Sandelowski M, Lambe C, Barroso J. Stigma in HIV-positive women. J Nurs Scholarsh
55. Sandelowski M, Barroso J. Motherhood in the context of maternal HIV infection. Res Nurs Health
56. Hadley C, Patil CL. Food insecurity in rural Tanzania is associated with maternal anxiety and depression. Am J Hum Biol
57. Whitaker RC, Phillips SM, Orzol SM. Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children. Pediatrics
58. Weigel MM, Armijos RX, Hall YP, et al. The household food insecurity and health outcomes of U.S.-Mexico border migrant and seasonal farmworkers. J Immigr Minor Health
59. Casey P, Goolsby S, Berkowitz C, et al. Maternal depression, changing public assistance, food security, and child health status. Pediatrics
60. Harpham T, Huttly S, De Silva MJ, et al. Maternal mental health and child nutritional status in four developing countries. J Epidemiol Community Health
61. Amuyunzu-Nyamongo M, Okeng'o L, Wagura A, et al. Putting on a brave face: the experiences of women living with HIV and AIDS in informal settlements of Nairobi, Kenya. AIDS Care
. 2007;19 (Suppl 1):S25-S34.
62. Anabwani G, Navario P. Nutrition and HIV/AIDS in sub-Saharan Africa: an overview. Nutrition
63. Fawzi W, Msamanga G, Spiegelman D, et al. Studies of vitamins and minerals and HIV transmission and disease progression. J Nutr
64. Fawzi WW, Msamanga GI, Hunter D, et al. Randomized trial of vitamin supplements in relation to transmission of HIV-1 through breastfeeding and early child mortality. AIDS
65. Scrimshaw NS, SanGiovanni JP. Synergism of nutrition, infection, and immunity: an overview. Am J Clin Nutr
66. Semba RD, Caiaffa WT, Graham NM, et al. Vitamin A deficiency and wasting as predictors of mortality in human immunodeficiency virus-infected injection drug users. J Infect Dis
67. Skurnick JH, Bogden JD, Baker H, et al. Micronutrient profiles in HIV-1-infected heterosexual adults. J Acquir Immune Defic Syndr Hum Retrovirol
68. Solomon P, Wilkins S. Participation among women living with HIV: a rehabilitation perspective. AIDS Care
69. Miles MS, Holditch-Davis D, Pedersen C, et al. Emotional distress in African American women with HIV. J Prev Interv Community
70. Remien RH, Exner T, Kertzner RM, et al. Depressive symptomatology among HIV-positive women in the era of HAART: a stress and coping model. Am J Community Psychol
71. Simoni JM, Montoya HD, Huang B, et al. Social support and depressive symptomatology among HIV-positive women: the mediating role of self-esteem and mastery. Women Health
72. Trzynka SL, Erlen JA. HIV disease susceptibility in women and the barriers to adherence. Medsurg Nurs
73. Prachakul W, Grant JS, Keltner NL. Relationships among functional social support, HIV-related stigma, social problem solving, and depressive symptoms in people living with HIV: a pilot study. J Assoc Nurses AIDS Care
74. Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry
75. Arnsten JH, Li X, Mizuno Y, et al. Factors associated with antiretroviral therapy adherence and medication errors among HIV-infected injection drug users. J Acquir Immune Defic Syndr
. 2007;46 (Suppl 2):S64-S71.
76. Olley BO, Seedat S, Nei DG, et al. Predictors of major depression in recently diagnosed patients with HIV/AIDS in South Africa. AIDS Patient Care STDS
77. Rabkin JG, Williams JB, Remien RH, et al. Depression, distress, lymphocyte subsets, and human immunodeficiency virus symptoms on two occasions in HIV-positive homosexual men. Arch Gen Psychiatry
78. Huang TL, Leu HS, Liu JW. Lymphocyte subsets and viral load in male AIDS patients with major depression: naturalistic study. Psychiatry Clin Neurosci
79. Caballero J, Nahata MC. Use of selective serotonin-reuptake inhibitors in the treatment of depression in adults with HIV. Ann Pharmacother
80. Crepaz N, Passin WF, Herbst JH, et al. Meta-analysis of cognitive-behavioral interventions on HIV-positive persons' mental health and immune functioning. Health Psychol
81. Ferrando SJ, Freyberg Z. Treatment of depression in HIV positive individuals: a critical review. Int Rev Psychiatry
82. Himelhoch S, Medoff DR. Efficacy of antidepressant medication among HIV-positive individuals with depression: a systematic review and meta-analysis. AIDS Patient Care STDS
83. Himelhoch S, Medoff DR, Oyeniyi G. Efficacy of group psychotherapy to reduce depressive symptoms among HIV-infected individuals: a systematic review and meta-analysis. AIDS Patient Care STDS
84. Rabkin JG, Wagner GJ, McElhiney MC, et al. Testosterone versus fluoxetine for depression and fatigue in HIV/AIDS: a placebo-controlled trial. J Clin Psychopharmacol
85. Wagner GJ, Rabkin R. Effects of dextroamphetamine on depression and fatigue in men with HIV: a double-blind, placebo-controlled trial. J Clin Psychiatry
86. Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet
87. Chisholm D, Flisher AJ, Lund C, et al. Scale up services for mental disorders: a call for action. Lancet
This article has been cited 1 time(s).
HIV; poverty; psychosocial; social support; depression; women; stigma; Peru; resource-poor settings
© 2008 Lippincott Williams & Wilkins, Inc.
What does "Remember me" mean?
By checking this box, you'll stay logged in until you logout. You'll get easier access to your articles, collections,
media, and all your other content, even if you close your browser or shut down your
To protect your most sensitive data and activities (like changing your password),
we'll ask you to re-enter your password when you access these services.
What if I'm on a computer that I share with others?
If you're using a public computer or you share this computer with others, we recommend
that you uncheck the "Remember me" box.
Highlight selected keywords in the article text.
Data is temporarily unavailable. Please try again soon.