Ethics approval and consent to participate
All methods and procedures in this study were carried out in accordance with all relevant guidelines and regulations in the Declaration of Helsinki as well as any additional ethical guidelines in Malawi and the USA. The University of Illinois at Chicago (Protocol #2015 − 0691) and the University of Malawi College of Medicine Research Committee (COMREC; Protocol P.10/15/1815) approved the protocol. Written signed informed consent prior to engaging in any research activities was obtained for every participant. For adolescents under age 18, the legal age of consent for research participation in Malawi, signed parental consent (permission) and youth assent were obtained. A waiver to obtain consent from only one parent or guardian was obtained. Because the youth participants in this study (ages 13–19) were old enough to understand the basics of what they were agreeing to do, the study was explained to the youth and parent or legal guardian together and questions from both parent and youth were answered. Then both parent and youth signed the consent form. To minimize any perceived parental coercion, youth assent was reconfirmed verbally prior to the first data collection when the parent was not present.