Church-Based HIV Screening in Racial/Ethnic Minority Communities of California,2011-2012

Abstract

Community-based human immunodeficiency virus (HIV) testing at religious congregations has been proposed as a potentially effective way to increase screening among disproportionately affected populations, such as those self-identifying as African American and Latino. Although congregations may provide reach into these communities, the extent to which church-based HIV testing alleviates access barriers, identifies new cases, and reaches people at increased risk for HIV is not well documented. We examined the results of an HIV testing program that was conducted as part of a larger intervention aimed at reducing HIV stigma at five churches in Los Angeles County, California, in 2011-2012. HIV screening identified one positive result in 323 tests but reached a substantial proportion of people who had not been tested before, including many who lacked health insurance. Although this approach may not be an efficient way to identify cases of previously unknown HIV infection, it could help achieve universal testing goals.

Keywords

HIV testing religious congregations access to care

Human immunodeficiency virus (HIV) testing and early treatment of those who are tested are important ways to stem the HIV epidemic and ensure that infected patients gain access to timely HIV services.^1

–6 When people learn that they are HIV positive, they engage in fewer transmission behaviors,^7

–11 and their risk of HIV-related morbidity and mortality^12
–14 is reduced as a result of early diagnosis and treatment.^3,15

To maximize the benefits of screening, the Centers for Disease Control and Prevention (CDC) recommends that HIV testing be offered in medical settings to all people aged 13-64 years.¹⁶ However, as of 2010, only about 44% of adults had been tested.¹⁷ An estimated 21% of the 1.1 million people with HIV infection in the United States do not know they are infected.⁸ HIV testing of racial/ethnic minority groups is of particular concern because these groups have an increased risk of being infected. For example, unrecognized HIV infection is highest among African Americans,¹⁸ and one recent study of men who have sex with men (MSM) found that 48% of Latino MSM who tested positive for HIV infection were unaware of their infection.¹⁹

Barriers to testing include a lack of knowledge about where testing is conducted,²⁰ fears about HIV disease, and concerns about disclosure and HIV stigma.^20,21 Access barriers, such as longer travel distances to providers²² and lack of health insurance,²³ are also important. Studies have found consistently that uninsured people are less likely than insured people to report having had an HIV test.^24,25 Because of these barriers, it is important to diversify HIV screening strategies, in particular beyond clinical settings, to reach previously untested populations.^23,26,27

An effective way to expand HIV screening is to offer testing in community settings.^28

–31 Community-based testing can expand access to screening for high-risk and hard-to-reach populations,^{22,28,31

–34} including racial/ethnic minority groups^29,35

–38 and those without health insurance. Expanded screening also has the potential to normalize HIV testing behaviors in the community.³⁹

Offering community-based testing at church sites has been proposed as a potentially effective way to expand testing opportunities.^40,41 Religious congregations in underserved neighborhoods are often credible, stable entities that have substantial reach within the community, as well as a history of providing and supporting social services, including health promotion and care. Racial/ethnic minority congregations in particular are often viewed as trusted resources by their members^42
–44 and can help provide access to culturally appropriate programs to improve health. Furthermore, because African American and Latino populations are more likely than the general population to self-identify as religious,^45,46 churches are an especially important point of access to these populations.

The reach of HIV testing at African American churches is growing, but studies are lacking. Two church-based programs that included HIV testing as part of an intervention reported only the number of testing events⁴⁷ or the number of people tested,⁴¹ without reporting information on the characteristics of testing participants. A report on the correlates of lifetime HIV testing of a church-based sample found positive associations with health insurance and inconsistent condom use; however, about 77% of the sample’s subjects were tested in a health-care setting, and whether any of the other subjects were tested at a religious site is unclear.⁴⁸ Another study of a church-affiliated testing program found 72 newly identified cases of HIV infection among 1,947 participants. In this program, six African American churches in areas of Atlanta, Georgia, with a high prevalence of drug use participated. Outreach workers were trained to engage substance users and motivate them to get tested. Those agreeing to be tested were offered a financial incentive, linkage to HIV care for those who tested positive, and recovery support services.⁴⁹

It remains uncertain whether church-based HIV testing consistently uncovers cases of previously undiagnosed HIV in the community or reaches key populations, particularly disproportionately affected groups (e.g., African American, Latino). For example, will church-based testing events reach populations that have previously never been tested, are uninsured, otherwise have limited access to testing services, or are considered high risk because of current or past sexual or drug use behaviors? Given the additional resources needed for coordination, planning, and logistics of church-based testing, identifying the benefits of expanding community-based testing to religious settings is important. In African American and Latino communities, these benefits could include reaching people who are not likely to be tested in other venues, reaching those who are at higher-than-average risk of HIV infection, and reducing the stigma of HIV testing by gaining the support of church leaders in the community. To examine the distinctive characteristics of the people tested at church-based testing events, a comparison of their demographic characteristics and self-reported behaviors with those of population-based samples drawn from the same community is useful.

In this case study, we addressed the current gaps in knowledge on church-based HIV testing by examining testing conducted at five churches (three Latino and two African American churches) in areas of Los Angeles County, California, with a high prevalence of HIV infection. We focused on the number of cases of previously undetected HIV infection and assessed whether or not these church-based testing events reached high-risk populations (e.g., people who had not previously been tested for HIV, people with low levels of access to health-care services because of health insurance status, people with high-risk behaviors).

Methods

Context for Church-Based Testing

The testing events occurred as part of a larger intervention, the Facilitating Awareness to Increase Testing for HIV (FAITH) project, which focused on reducing HIV stigma and promoting HIV testing in collaboration with African American and Latino churches. Stigma-reduction activities involved educating congregations about HIV in their communities and engendering empathy for people with HIV through testimonials, role-plays, sermons, and simulated interactions.⁵⁰ Church-based testing was incorporated into the intervention for two reasons: (a) to increase access to screening in communities with high HIV prevalence and (b) to test our hypothesis that church-based testing would reduce stigma by normalizing HIV testing as a public health strategy. We included as a key partner the local health department to promote long-term sustainability of the church-based testing events. This study was approved by RAND's Human Subjects Protection Committee.

Setting

Testing was conducted at churches in and around Long Beach, California, which has a cumulative incidence rate of 1,347 cases of acquired immunodeficiency syndrome per 100,000 residents, a rate that is more than twice that for Los Angeles County and California overall.⁵¹ African American (14% of the population) and Latino (41% of the population) people compose more than half of the population in Long Beach,⁵² and 31.8% of Long Beach residents are uninsured.⁵³

Study Churches

We identified 61 African American and Latino churches in Long Beach and adjacent areas through local faith-based and telephone directories and conducted a brief telephone screening survey (response rate, 54%). Eleven churches met eligibility criteria (i.e., >70% African American or Latino congregants, typical Sunday attendance of at least 100 people, and the church had conducted few HIV-related activities previously). We selected 6 of the 11 churches to represent a range of congregations in racial/ethnic composition, denominational type, and size, and we successfully recruited five churches for our intervention pilot (two medium-sized African American Baptist churches, one large Latino Roman Catholic church, and two small Latino Pentecostal churches).

Testing Event Protocol

Church-based testing events, held in 2011 and 2012, included rapid oral fluid testing and counseling by health department staff members with additional logistic support from research team members. Health department staff members operated out of a mobile testing van that had private testing and counseling rooms. Counselors began with a pretest interview, completed intake paperwork, and administered the client assessment questionnaire required by the state of California to be completed before receiving an HIV test (Table 1). The testing and counseling procedure was modified slightly from that typically used in City of Long Beach Department of Health and Human Services mobile testing activities to increase throughput at each event from 6 people to 20 people tested per hour. Modifications included increasing the number of staff members at each event, using church space to conduct the intake paperwork and survey, and using the van to conduct the swab and provide results and posttest counseling to participants.

Table 1.

Information collected in a client assessment questionnaire during HIV testing at 5 churches, Los Angeles County, California, 2011-2012^a

Domain and variable	Variable type	Additional variable details
HIV testing and risk behaviors
Ever tested for HIV	Dichotomous	Yes or no
HIV status	Categorical	Seven category responses: negative, positive, preliminary positive, other, don’t know, no test result received, or no response
Risk behaviors and sexual risk history
Number of sex partners in past 12 months	Categorical	Three category responses: 0, 1, or ≥2 partners
Had sex without a condom in past 12 months	Dichotomous	Yes or no
Receipt of drugs, money, or other items for sex in past 12 months	Dichotomous	Yes or no
Had sex with injection drug user in past 12 months	Dichotomous	Yes or no
Had sex with a person who was HIV positive in past 12 months	Dichotomous	Yes or no
Had sex with men who have had sex with other men in past 12 months	Dichotomous	Yes or no; asked only of females
Had sex with a man in past 12 months	Dichotomous	Yes or no; asked of everyone
Type of sex with a man	Categorical	Four category responses: vaginal, anal insertive, anal receptive, and oral (respondent could check all that apply)
Had sex with a woman in past 12 months	Dichotomous	Yes or no; asked of everyone
Type of sex with a woman	Categorical	Three category responses: vaginal, anal, and oral (respondent could check all that apply)
Had sex with a transgender person in past 12 months	Dichotomous	Yes or no
Type of sex with transgender person	Categorical	Four category responses: vaginal, anal insertive, anal receptive, and oral (respondent could check all that apply)
Use of drugs in past 12 months	Categorical	Five category responses: speed, powder cocaine, crack, poppers, and no use (respondent could check all that apply)
Used injection drugs in past 12 months	Dichotomous	Yes or no
Shared needles to inject drugs in past 12 months	Dichotomous	Asked only of those who indicated having used injection drugs
Type of drug injected	Categorical	Five category responses: speed, powder cocaine, crack, heroin, and other drug (specify) (respondent could check all that apply)
Ever diagnosed with hepatitis C	Dichotomous	Yes or no
Diagnosis of a sexually transmitted infection in past 12 months	Categorical	Four category responses: chlamydia, gonorrhea, syphilis, and no diagnosis (respondent could check all that apply)
Existence of other factors that put the testing participant at risk	Dichotomous	Yes or no
Sociodemographic characteristics
Race/ethnicity	Categorical	Seven category responses: African American, Hispanic/Latino, white, Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, and no response (respondent could check all that apply)
Sex	Categorical	Three categories of biological sex: male, female, and intersex
Sexual identity	Categorical	Four category responses: male, female, transgender, or other
Sexual orientation	Categorical	Five category responses: heterosexual/straight; bisexual; gay, lesbian, queer, or same-gender loving; other orientation (specify); or don’t know
Age	Continuous	Birth year (used to calculate age at time of survey)
Homeless or not	Dichotomous	Yes or no
Current health insurance status	Categorical	Seven category responses: no insurance; private; Medi-Cal, Medicare, military, and Indian Health Service, which were combined into one category (public); or other
ZIP code	Categorical	Open-ended response

Abbreviation: HIV, human immunodeficiency virus. ^aThe client assessment questionnaire is required by the State of California to be completed before receiving an HIV test.

We took several steps to increase participation. First, the churches promoted the testing events through announcements and bulletins distributed during services leading up to the event. Second, testing events were scheduled around the church’s calendar, with priority given to regularly scheduled worship services to increase visibility. Participants were allowed to leave and reenter services or other fellowship activities during testing and while they waited for results. In a few instances, testing took place at special testing events rather than around church services or activities. Finally, church pastors and lay leaders were asked to take part in the screening program. At several events, the congregational leaders were among the first people tested. At one church, the pastor shared from the pulpit that he had recently been tested during an insurance examination.⁵⁰

Data and Measures

To compare church-based testing participants with a more general sample of community residents, we used data from four additional sources: the 2005, 2007, and 2011 waves of the Los Angeles County Health Survey and the 2007 California Health Interview Survey.^54

–57 Data were drawn from different years because survey items do not appear in every wave. Thus, we drew items from the wave closest in time to the testing events. The Los Angeles County Health Survey collects data on the current health status of Los Angeles County residents, using a population-based telephone survey conducted by the Los Angeles County Department of Public Health. The California Health Interview Survey, a biannual probability survey of about 40,000-50,000 California adults conducted by telephone, collects information on health, access to care, health-care utilization, social support, housing, and neighborhood environments. Combined, these sources provide a detailed picture of the health and health-care utilization of county residents, including data by race/ethnicity at the level of service planning areas (SPAs), which are the smaller units into which the Los Angeles County Department of Public Health has divided the county for planning and service delivery. SPA 8 encompasses Long Beach and the surrounding communities in which the study churches reside. These data sources allowed us to compare the characteristics and reported behaviors of the testing participants with county residents.

We analyzed data for both the county total and SPA 8 to allow us to study data as close as possible geographically to the community surrounding Long Beach. Because nearly all of the church-based testing participants were either African American or Latino, we limited the samples in both the testing participants and community data to those groups and examined all results by race/ethnicity.

We used the measures that were common between the church-based data and the county sources: sex, age, ever tested for HIV, number of sexual partners in the past 12 months, condom use in the past 12 months, use of injection drugs, sexual orientation, and health insurance status. Then, to compare those tested at church-based testing events with a general sample of African American and Latino residents of SPA 8 and the county, we calculated means and proportions for the sociodemographic characteristics, prior testing history, and risk behaviors and compared them across the datasets. Church-based testing participants ranged in age from 13 to 81 years. To make it comparable to the population-based samples, we limited our analyses to the entire sample of adults ≥18 years of age, by race/ethnicity.

Outcomes

Eleven testing events were conducted at the five churches (range: 1-5 testing events per church) with a total of 323 people tested (range: 11-61 people per testing event). One of 323 tests (0.3%) was reported as preliminary positive and later confirmed as HIV positive.

Overall, our sample of church-based HIV testing participants differed from the county and SPA residents on several key measures. The church-based testing participants included a higher percentage of uninsured people (48.7%) and lower percentage of privately insured people (32.8%) than SPA 8 residents (26.5% and 49.5% of uninsured and privately insured people, respectively). The percentage of people who had ever been tested for HIV was lower among the church-based testing participants (45.7%) than among SPA 8 residents (56.5%). We also found differences in risk behaviors. Compared with SPA 8 residents, church-based testing participants had a higher percentage of people with two or more sexual partners (17.9% vs. 9.0%). Compared with SPA 8 residents, church-based testing participants had about the same percentage of people reporting that they were heterosexual, fewer people 18-24 years of age, and more women (Table 2).

Table 2.

Characteristics of community residents and people tested for HIV at 5 churches, by race/ethnicity, Los Angeles County, California, 2005-2012

	All Latino and African American participants		Latino participants		African American participants
Characteristics	Church-based Percent	SPA 8^a Percent (95% CI)^b	Church-based Percent	SPA 8^a Percent (95% CI)^b	Church-based Percent	SPA 8^a Percent (95% CI)^b
Sex^c
Female	58.6	50.3 (43.9-56.7)	55.0	51.3 (43.3-59.4)	65.4	48.0 (37.9-58.1)
Male	41.4	49.7 (43.3-56.1)	45.0	48.7 (40.6-56.7)	34.6	52.0 (41.9-62.1)
Age, in years^d
18-24	12.2	18.3 (13.1-23.5)	12.3	19.2 (13.0-25.3)	12.0	16.4 (6.6-26.1)
25-29	4.6	14.8 (9.5-19.9)	5.8	17.3 (10.7-23.9)	2.4	8.6 (1.3-15.8)
30-39	24.4	23.1 (18.4-27.8)	25.2	24.0 (18.6-29.4)	22.9	21.1 (11.6-30.6)
40-49	24.8	20.5 (16.5-24.6)	27.7	22.2 (17.1-27.3)	19.3	16.6 (10.4-22.7)
50-59	18.1	12.1 (9.2-15.0)	15.5	8.8 (5.9-11.7)	22.9	20.0 (13.0-27.0)
60-64	7.1	4.8 (2.8-6.8)	7.1	4.4 (1.8-6.9)	7.2	5.9 (3.1-8.6)
≥65	8.8	6.4 (4.4-8.4)	6.5	4.2 (2.5-5.9)	13.3	11.5 (6.2-16.9)
Sexual orientation^e
Bisexual	0.5	NA^f	0.7	NA^f	0.0	NA^f
Don’t know	1.8	1.5 (0.2-2.8)	2.2	1.8 (0.1-3.6)	1.3	NA^f
Gay/lesbian	0.9	NA^f	1.5	NA^f	0.0	NA^f
Heterosexual	96.8	96.8 (94.5-99.1)	95.6	96.5 (93.5-99.5)	98.8	97.4 (94.3-100.0)
Health insurance status^e
None	48.7	26.5 (21.3-31.7)	63.1	33.9 (27.2-40.6)	22.9	19.0 (9.9-28.2)
Public (Medicaid, Medicare)^g	15.5	23.9 (17.8-30.1)	18.8	24.7 (18.5-30.8)	9.6	9.7 (3.6-15.9)
Private	32.8	49.5 (43.5-55.6)	14.8	41.0 (34.1-47.8)	65.1	68.9 (58.3-79.6)
Other	3.0	NR	3.4	NR	2.4	NR
Ever tested for HIV^c	45.7	56.5 (49.9-63.2)	40.5	52.9 (44.6-61.2)	55.7	65.0 (55.0-75.0)
Number of sexual partners in past 12 months^e
0	22.5	31.7 (26.2-37.2)	21.4	31.2 (24.8-37.6)	24.7	32.9 (22.5-43.3)
1	59.6	58.7 (52.9-64.6)	65.5	60.4 (53.5-67.3)	47.9	54.6 (43.6-65.5)
≥2	17.9	9.6 (6.0-13.2)	13.1	8.4 (4.4-12.4)	27.4	12.5 (4.9-20.1)
Had sex without a condom^d	77.1	79.4 (73.0-85.8)	74.8	79.4 (72.2-86.7)	81.8	79.2 (66.3-92.2)
Ever used injection drugs^h	0.4	1.0 (0.3-1.8)	0.7	NA^f	0.0	NA^f
Total numberⁱ	238		155		83

Abbreviations: CI, confidence interval; HIV, human immunodeficiency virus; NA, not available; NR, not reported; SPA, service planning area. ^aSPAs are the smaller units into which the Los Angeles County Department of Public Health divides the county for planning and service delivery. SPA 8 encompasses Long Beach and the surrounding communities in which the study churches are located.

^bPercentages may not total to 100 because of rounding; 95% CIs are provided only for estimates calculated from county-based surveys because the church-based percentages are calculated directly from data collected on HIV testing event participants.

^cSPA 8 data drawn from the 2007 California Health Interview Survey. UCLA Center for Health Policy Research. ASKCHIS 2007 [cited 2016 Jun 29]. Available from: http://ask.chis.ucla.edu

^dSPA 8 data drawn from the 2011 Los Angeles County Health Survey. County of Los Angeles Public Health, Office of Health Assessment and Epidemiology. LA HealthDataNow! 2011 [cited 2014 Aug 15]. Available from: https://dqs.publichealth.lacounty.gov/query.aspx?d=2

^eSPA 8 data drawn from the 2007 Los Angeles County Health Survey. County of Los Angeles Public Health, Office of Health Assessment and Epidemiology. LA HealthDataNow! 2007 [cited 2014 Aug 15]. Available from: https://dqs.publichealth.lacounty.gov/query.aspx?d=2

^fFor purposes of confidentiality, the county did not provide estimates for sexual orientation categories when the raw data had cell sizes <5.

^gPublic insurance includes estimates of those with Medicare and Medicaid. The Los Angeles County Health Survey for 2007 reported that the Medicare estimate for the African American population in SPA 8 was too small to estimate, so only Medicaid recipients are counted in that cell. As a result, percentages for this variable do not total to 100 because the estimate for Medicare is missing from the African American estimate.

^hSPA 8 data drawn from the 2005 Los Angeles County Health Survey. County of Los Angeles Public Health, Office of Health Assessment and Epidemiology. LA HealthDataNow! 2005 [cited 2014 Aug 15]. Available from: https://dqs.publichealth.lacounty.gov/query.aspx?d=2

ⁱThe total number of survey participants is not provided for the community sample because there is no single total; these numbers differ for each survey that was used to produce the estimates.

We found similar patterns when we compared characteristics of the African American and Latino testing participants independently. The percentage of people who had ever been tested for HIV was lower than the corresponding percentage in the population-based sample of SPA 8 residents for Latinos (40.5% vs. 52.9%) and for African Americans (55.7% vs. 65.0%). Similarly, the percentage of uninsured people was higher among testing participants than among the population-based sample of Latino (63.1% vs. 33.9%) and African American (22.9% vs. 19.0%). Additionally, compared with the population-based sample, a higher percentage in both groups of testing participants indicated having two or more sexual partners (13.1% vs. 8.4% for Latino and 27.4% vs. 12.5% for African American people, respectively) (Table 2).

Lessons Learned

The lessons learned from this study address whether or not testing at church-based venues uncovers previously undiagnosed HIV infections and whether or not high-risk populations (e.g., those who have never been tested, those with poor access otherwise, and those with high-risk behaviors) receive HIV testing. Although we found a low rate of newly identified infections (only one positive test result of 323 tests), the church-based testing events reached a substantial proportion of people (both in absolute terms and relative to their peers in the broader community) that had not been tested before, and many of those reached were people who lacked health insurance. These observations suggest that offering church-based testing can contribute to the goal of screening all people aged 13–64 years and could fill an important gap in existing community-based testing services by reaching populations that have never been tested and for whom health insurance status has been a barrier to testing. We also found higher percentages of people reporting sex with two or more people in the past 12 months among the church-based testing participants compared with SPA 8 residents, indicating some degree of risk behaviors in the church sample. This finding may be particularly important, because 80% of the individuals tested reported having sex without using a condom.

These data do not provide a way to directly measure whether or not the testing events helped to create supportive social norms that promote HIV screening; however, the success of these initial events in the number of people tested and that the vans were often close to or at capacity at many events suggest that HIV testing was an accepted activity in these settings.

Limitations

This case study had several limitations. First, our testing was conducted in five selected churches in a single urban area, and responses to HIV testing might differ in other churches or communities. For example, congregations that have more negative attitudes and beliefs about HIV might be less willing than congregations that have less negative attitudes and beliefs about HIV to engage in testing, or members of congregations that have more negative attitudes and beliefs about HIV may be less willing to be tested at the church than members of congregations that have less negative attitudes and beliefs about HIV. Some evidence also suggests that more theologically conservative congregations are less likely than other congregations to engage in any type of social service program.^58
–60 Although the churches in this case study represented a range of faith traditions and theologies, the small number limited its generalizability.

Second, these data are cross-sectional and drawn from a sample of people who received HIV testing rather than from a sample that included congregation members who may have participated in other church-based activities but not in testing. This exploratory study was designed to provide new information on who participates in HIV testing in church-based settings. Thus, we did not aim to identify causes, and we did not calculate inferential statistics. For these reasons, we could not determine how those who were tested differed from other members of the congregation or the extent to which characteristics (e.g., lack of prior testing, lack of health insurance, high-risk behaviors) influenced those tested to seek screening.

Third, community-based data are drawn from surveys conducted in different years. If the behavior of these populations changed over time, our comparisons may not represent the actual differences in behaviors between community residents and testing participants. Finally, although we found higher rates of multiple sex partners in our church-based sample than for SPA 8 as a whole, we found a lower percentage of participants reporting sexually transmitted diseases, prior drug use, and other risk factors. Thus, this sample may have been relatively low risk compared with other members of the community. Moreover, the age profile for those tested at churches was older than for adults in the community as a whole, which may also have mitigated risk.

Further study is needed to assess the efficacy of such church-based testing events to reach high-risk community members. For example, Whiters and colleagues⁹ demonstrated that a church-based approach that targeted community members rather than church members identified more previously undiagnosed cases of HIV infection than we did. However, this activity was resource intensive and relied on trained outreach workers to recruit and incentivize substance users to get tested.

Conclusion

Church-based testing events can fill an important gap in the reach of both health-care settings and community-based HIV testing programs; compared with a population-based sample, a higher percentage of people who had never been previously tested for HIV and were uninsured were tested at these events. Church-based testing can be an important strategy for reaching the goal of testing those aged 13-64 years for HIV, regardless of their risk profile.

Footnotes

Authors' Note

The authors thank Kerry Brown, Carlos Campa, Patricia Montes, and all other staff members of the Long Beach Department of Health and Human Services for their efforts during the HIV testing events; Roy M. Pitkin for his expert editorial review; and Marcela Gaither for her assistance in preparing the manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Grant 1 R01 HD050150 (to K.P.D.) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of NICHD.

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