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BACKGROUND: The Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital created a global health corps named the Pediatric AIDS Corps (PAC) in June 2005. This report provides descriptive details and outputs for PAC over its first 5 years. METHODS: Demographic data were gathered about PAC physicians employed from July 2006 to June 2011. A 21-question survey was used to query PAC physicians about their experiences in the program. Data concerning clinical experiences and educational programs also were reviewed. RESULTS: A total of 128 physicians were employed with PAC. The median duration served was 22.7 months. Eighty-seven percent indicated that experience affected their future career choice, with half continuing to work with children and families living in resource-limited areas after they left PAC. Patient care was identified as the most rewarding part of their work (73%), whereas deaths (27%) were the most difficult. Baylor College of Medicine International Pediatric AIDS Initiative enrollment of HIV-infected children and adolescents into care and treatment increased from 6107 to103 731 with the addition of PAC physicians. Approximately 500 local health care professionals per quarter benefited from HIV clinical attachments that were not available before PAC arrival. PAC physicians visited outreach sites providing in-depth HIV mentoring of local health care professionals, leading to 37% of the sites becoming self-sufficient. CONCLUSIONS: The positive evaluation by the PAC and the scale-up of clinical and educational programs support the recent calls for the development of a national global health corps program.

Over 300,000 infants are born annually with sickle cell anemia (SCA) in sub-Saharan Africa, and >50% die young from infection or anemia, usually without diagnosis of SCA. Early identification by newborn screening (NBS), followed by simple interventions dramatically reduced the mortality of SCA in the United States, but this strategy is not yet established in Africa. We designed and implemented a proof-of-principle NBS and treatment program for SCA in Angola, with focus on capacity building and local ownership. Dried bloodspots from newborns were collected from five birthing centers. Hemoglobin identification was performed using isoelectric focusing; samples with abnormal hemoglobin patterns were analyzed by capillary electrophoresis. Infants with abnormal FS or FSC patterns were enrolled in a newborn clinic to initiate penicillin prophylaxis and receive education, pneumococcal immunization, and insecticide-treated bed nets. A total of 36,453 infants were screened with 77.31% FA, 21.03% FAS, 1.51% FS, and 0.019% FSC. A majority (54.3%) of affected infants were successfully contacted and brought to clinical care. Compliance in the newborn clinic was excellent (96.6%). Calculated first-year mortality rate for babies with SCA compares favorably to the national infant mortality rate (6.8 vs. 9.8%). The SCA burden is extremely high in Angola, but NBS is feasible. Capacity building and training provide local healthcare workers with skills needed for a functional screening program and clinic. Contact and retrieval of all affected SCA infants remains a challenge, but families are compliant with clinic appointments and treatment. Early mortality data suggest screening and early preventive care saves lives.

OBJECTIVES.The purpose of this work was to investigate the effect of institutionalization on death and CD4 decline in a cohort of 325 HIV-infected Romanian children. METHODS. A retrospective database analysis was conducted. Data from a nearly 3-year period were examined with Kaplan-Meier survival analysis and Cox regression analysis models. Subjects all received primary and HIV specialty care and treatment at the Romanian American Children's Center in Constanta, Romania. Children in one group resided with their biological families and the other children resided in “family home”–style institutions. RESULTS. There was no difference between groups for death during the follow-up period, although there was a trend for survival advantage for children in institutional care. There was no statistically significant difference between the study groups in terms of CD4 decline, although there was a trend toward greater decline among children who resided with their biological families. Children with their biological families were more likely to experience disease progression through either death or CD4 decline than were children in institutions. CONCLUSIONS. The family home–style institution may prove to be a replicable model for the safe and appropriate care of HIV-infected orphaned and abandoned children and teens.

Medical students and residents from resourced regions are increasingly seeking clinical rotations in resource-limited settings abroad. This interest has been matched by increased opportunities in many residency programs in the United States for residents to participate in global health electives (GHEs). Global health electives provide learners with opportunities to practice and learn within global health settings. This enhances their knowledge of local diseases and disease processes, leads to improved physical exam skills with decreased reliance on labs and other testing, and demonstrates the importance of communication across cultures and languages. In addition, studies have shown that short-term learners (STLs) who participate in GHEs are more likely to practice primary care medicine, obtain public health degrees, and practice medicine amongst underserved populations in their home countries.1 In 1999, the American Academy of Pediatrics (AAP) recommended that GHEs last a minimum of four weeks to allow learners to assimilate into the culture and maximize their time abroad.2 Currently, GHEs offered in pediatric residency programs range from three to eight weeks in length.3 To our knowledge there have been no discussions about the reasons for the recommended duration of four weeks for GHEs. We aimed to describe how clinical productivity of STLs varies by consecutive working days on a GHE. Evaluating global health rotation length The Baylor International Pediatric AIDS Initiative at Texas Children’s Hospital clinical network is the largest network of pediatric HIV clinics worldwide.4 Short-term learners from institutions in North America have been completing GHEs at the Baylor College of Medicine Bristol-Myers Squibb Children’s Clinical Centre of Excellence - Swaziland (Baylor-Swaziland) since 2006. In 2010, 26 STLs completed GHEs at Baylor-Swaziland, including medical residents, medical students, and non-clinical learners. Short-term learners spent two to four weeks with Baylor-Swaziland. The electronic medical records in Swaziland from 2010 were reviewed to assess the total number of patient encounters completed by both resident or fellow STLs and clinical preceptors per day. Based on the number of patient encounters per medical resident learner per day, there was a sequential increase in the number of patient encounters with more sequential workdays of the rotation. The number of patient encounters per day did not vary by level of STL training, with residents in their second, third, and fourth years of residency completing similar numbers of patient encounters per day. The number of patients seen by two different expatriate clinical preceptors during a one-month period was not affected by mentoring STLs. From our observations, STLs completed more patient encounters per day over time. This suggests that there is an inherent learning curve during a GHE. While the AAP currently recommends that GHEs last four weeks, longer rotations may offer STLs additional time to contribute to their site in meaningful ways. Studies assessing host preceptors’ perceptions of STLs have shown a preference for rotations lasting four to six weeks.5 Other studies have suggested an even longer elective length between two and three months,6 which may offer more opportunities to master a range of competencies in a global health setting. The learning curve we observed is likely due to a combination of operational, clinical, and cultural-linguistic factors. Operational factors include becoming familiar with the electronic medical record, clinic flow, and clinic processes. The concept of a learning curve in residency has been demonstrated in several fields.7 However, in a setting such as Swaziland, there are many clinical factors that STLs may not have encountered before. These include unfamiliarity with diseases that are less commonly encountered in the home setting, not being well versed in local or international clinical guidelines, not knowing the available medications, and inexperience working within resource limitations. Particularly in the Baylor-Swaziland clinic setting, management of pediatric HIV is unfamiliar to most STLs. Short-term learners are also likely to encounter some degree of cultural adjustment or emotional challenges in the new environment which may impact clinical productivity. In addition, language barriers and the need to use an interpreter during clinical encounters likely hinders productivity. Though our findings suggest that longer rotations may allow learners to get over the initial learning curve, there are many barriers to increasing rotation length for trainees. These include providing adequate call coverage at the home institution, funding of resident salaries when they are away, and restrictions by the Accreditation Council of Graduate Medical Education on time away.8 It would be ideal for programs to have the flexibility to have call- and continuity clinic-free months without jeopardizing accreditation or causing burdens on fellow residents. Furthermore, some residency programs require vacation to be taken during GHEs, further shortening actual time spent at host clinical sites. Between vacation, travel time, weekends, and possible public holidays, the actual clinical experience may be as short as ten working days or less. According to a recent survey of residents, 57% would not be willing to give up vacation time during international electives.9 Nevertheless, requiring residents to do so may have the favorable effect of selecting for those residents who are most dedicated to or interested in global health, which has been cited by international host preceptors as a desirable trait of STLs completing GHEs at their sites.10 Interestingly, the number of patient encounters per day did not vary by medical resident training level. This supports the argument that everyone, regardless of medical resident year of training, encounters an initial learning curve. Reassuringly, STLs in our study did not appear to hinder clinical preceptor productivity in terms of patient encounters per day. This is in contrast to other reports in which there was perceived efficiency burden on clinical preceptors of STLs.10 These differing findings may be explained by the measure of clinical efficiency (i.e. self-perceived versus directly measured). Additionally, STL mentoring tasks may detract from other non-clinical administrative roles that preceptors have in their clinics. Finally, the lack of hindrance on productivity could be because the host preceptors at Baylor-Swaziland were expatriate clinicians who may have had greater understanding of STLs’ capabilities and training background.

In the United States and in other developed countries, the number of children newly infected with human immunodeficiency virus (HIV) has decreased dramatically as a result of the availability of educational programs, counseling and testing services, and potent anti-HIV therapy. Children with HIV are living longer, healthier lives. However, the pediatric HIV pandemic continues virtually unabated across much of the developing world. The reasons for this difference are complicated and include lack of resources, lack of infrastructure, and lack of trained health professionals in many developing nations. The Baylor International Pediatric AIDS Initiative is addressing these issues by developing comprehensive programs for health professional education and HIV clinical research in parts of the world hardest hit by the HIV acquired immunodeficiency syndrome epidemic. Copyright © 2000 by W.B. Saunders Company

Health professional capacity for delivery of HIV/AIDS care and treatment is severely constrained across sub-Saharan Africa. African health professional expertise in pediatrics is in particularly short supply. Here we describe a Pediatric AIDS Corps program that was designed to place pediatricians and other physicians in Africa on a long-term basis to expand existing health professional capacity for pediatric and family HIV/AIDS care and treatment. In the first 2 years of this program, 76 physicians were placed in 5 African countries that have been hit hard by HIV/AIDS. Enrollment of HIV-infected children in care more than quadrupled over a 24-month period, to 26 590. We believe that this pilot program can serve as a model for larger-scale efforts to immediately expand access for African children and families to life-saving HIV/AIDS care and treatment.

The Pediatric AIDS Corps (PAC) are a group of physicians that were hired to provide clinical care and treatment to children and their families infected with HIV/AIDS and to help educate local health care professionals in the management of children with HIV/AIDS located in the high prevalence areas of sub-Saharan Africa. Prior to their departure the PAC were required to participate in a 4-week educational training program that included travel and tropical medicine and HIV infections in children, teaching skills, bioethics, and good clinical practice in human research training. Evaluation of the program was done using a 50-question pretest/posttest design, a standard postcourse evaluation, and a PAC focus group follow-up. Fifty-two physicians were hired who had been trained in the following specialties: pediatrics (77%), medicine/pediatrics (9%), family medicine (8%), and internal medicine (6%). Posttest scores improved by a mean of 10 points for all PAC physicians (p < 0.001) but those that had been in Africa for 5 months or more prior to the course continued to score higher than the other participants. Reviewing the results by category demonstrated significant improvement in all areas (p < or = 0.002) except for general pediatrics for the HIV/AIDS infected patients (p = 0.124) and psychosocial issues (p = 0.376). Changes for the next training were implemented based upon the information obtained from the PAC focus group. The foundation provided by this educational course was an important beginning for the PAC physicians. Other groups providing specialized care to patients in developing countries might consider a similar educational program.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that in 2004, there were 39.4 million people living with HIV/AIDS worldwide (UNAIDS/WHO Report on the global HIV/AIDS epidemic, 2004). Children less than 15 years of age comprise 2.2 million of these individuals. As more children globally gain access to highly active antiretroviral therapy (HAART), more children are growing to the age when disclosure of their HIV status is inevitable. This information may affect a child's disease trajectory, and in the context of HAART, may have wide-ranging impact in the management of paediatric HIV infection. This study is an investigation of the effect of disclosure of a child's own HIV infection status on death and CD4 decline in a cohort of 325 HIV-infected Romanian children receiving highly active antiretroviral therapy (HAART). A retrospective database analysis was conducted. Data from a nearly three-year period were examined. Children who were aware of their HIV diagnosis were compared with those who were not aware. We found significant associations between not knowing the HIV diagnosis and death, and not knowing the HIV diagnosis and disease progression defined as either death or CD4 decline. Our results imply that in the context of HAART, knowledge of one's own HIV infection status is associated with delayed HIV disease progression.

Abstract 2064 Background: Systematic newborn screening (NBS) for sickle cell anemia (SCA) is a practice limited almost entirely to developed countries, which include only a small fraction of annual global SCA births. There are several different laboratory methods used for NBS of hemoglobin disorders, including isoelectric focusing (IEF), capillary electrophoresis (CE), high-performance liquid chromatography (HPLC) and DNA-based testing. However, most NBS occurs in developed countries with standardized specimen collection and storage techniques, advanced laboratory technology and support, and adequate financial resources. For the newly instituted pilot newborn screening program in Angola, IEF and CE were initially selected as the laboratory methods of choice. After the first 12 months of the pilot program, we analyzed the costs of developing the NBS program and compared the reliability and consistency of newborn hemoglobin identification. Methods: After birth, two dried bloodspots (DBS) are collected by heelstick onto a Whatman screening card. Specimens are dried, placed in plastic bags for storage, and transported every 1–3 days to the central NBS laboratory at Hospital Pediátrico David Bernardino, where they are refrigerated until testing. All specimens are initially tested by IEF (RESOLVE neonatal hemoglobin system, PerkinElmer Inc.) within 3–5 days. Hemoglobin identification is performed using a fluorescent glow box and samples are scored according to the presence of HbF, HbA and HbS. The FAS pattern is consistent with sickle cell trait and FS is consistent with SCA. All IEF results with an FAS or FS pattern or an uncertain result are selected for repeat analysis by CE, performed using the CAPILLARYS 2 NEONAT FAST system (Sebia, Inc.). All newborns with an FS result by either method were contacted by telephone to obtain repeat sample for confirmatory testing and enrollment in the newborn sickle cell clinic. Results: Costs: Initial start-up costs included 20,000 DBS cards designed specifically for the Angolan program ($45,000 USD) and lab equipment ($40,330 for IEF, $118,155 for CE, total of $158,485 USD), sufficient for the entire first year of the program. Collection costs (including gloves, lancets and alcohol pads) were calculated at $0.46 USD per sample, while sample collection and transport was $0.09 per sample. Once the DBS samples were received at the central testing laboratory, the reagent costs for sample analysis were $1.06 for IEF and $3.52 for CE, while labor costs were $0.35 for each test. Laboratory Reliability: To date, 17,055 samples have been run by IEF and 100% of these samples have obtained an adequate IEF result regardless of quality of bloodspot. To date, 2,895 samples have been selected for CE analysis, but only 2,031 (70.2%) produced interpretable results by CE. The remaining 29.8% of samples (mostly within the first 6 months of CE training period) did not produce a result due to hemoglobin degradation, inadequate blood spotting technique, mechanical failure, or unclear technical issues. For specimens with a result by both IEF and CE, concordance was greater than 99%. Conclusions: The development of a newborn screening program for SCA in Angola required an initial financial investment to obtain appropriate laboratory testing equipment. After this upfront investment, the total cost of newborn screening for SCA, including costs of collection, processing and laboratory analysis was about $3 USD for each initial IEF screening test and $4–5 USD for each CE result. This per-cost test compares favorably in relation to the public health benefit of identifying and retrieving affected infants. The cost of initiating a program in other countries may be significantly less than in Angola, which has a very expensive economy and resulted in high prices for many of the reagent and equipment costs. Given the variable quality of dried blood spot collection and the unavailability of ideal specimen storage and transport conditions, isoelectric focusing appears to be a more reliable, robust and economical method of newborn screening than capillary electrophoresis for sickle cell anemia in sub-Saharan Africa. Disclosures: No relevant conflicts of interest to declare.

Abstract 480 Background: Sickle cell anemia (SCA) is a significant global health problem with >300,000 affected infants born each year in sub-Saharan Africa. Up to 80–90% of all children with SCA in Africa die before five years of age, due to infection or anemia, and usually without the proper diagnosis of SCA. Early identification by newborn screening (NBS), followed by interventions such as pneumococcal immunization and prophylactic penicillin, have dramatically reduced the mortality of children with SCA in the US, but this strategy not yet been established in Africa. A novel public-private partnership involving the Republic of Angola, Chevron Corporation, and Baylor College of Medicine/Texas Children's Hospital was created to develop a pilot NBS and treatment program for SCA, focusing on capacity building and local ownership. Methods: Two large maternity hospitals in the capital city of Luanda, Angola were initially selected for dried blood spot (DBS) collection and analysis, and a third local health center was soon added. Maternity nurses were taught DBS collection and laboratory technicians learned isoelectric focusing (IEF) and capillary electrophoresis (CE) techniques. Identifiers including cell phone numbers are collected onto the Whatman NBS card to facilitate retrieval of affected babies. After collection, DBS were transported to the central NBS laboratory at Hospital Pediátrico David Bernardino (HPDB) for hemoglobin identification by IEF and CE. Demographic data and test results were entered into a unique internet-based electronic data capture system designed with secure password-protection and servers located in Houston, Texas. Results: Since initiation of NBS in July 2011, 17,055 babies have DBS collection and laboratory results: 3,588 (21%) with FAS pattern (sickle cell trait), and 264 (1.55%) with FS (consistent with SCA). Twenty-one samples produced a result other than FA, FAS, or FS, including 10 FAC and 1 FSC. Families of infants with an FS screening result are notified by phone to initiate care and treatment, ideally by age 8 weeks. In the new infant SCA clinic at HPDB, infants receive penicillin prophylaxis and PCV-13 pneumococcal immunization, while parents receive sickle cell education and insecticide-treated bed nets for malaria protection. In the first 6 months, 67.8% of DBS cards had phone numbers documented, but with education and reinforcement, 81.4% of cards had phone numbers in the past 6 months. To date, 220 FS babies are age-eligible for contact and 110 (50%) families have been reached: 104 (47%) have come to the infant SCA clinic, 6 (2.7%) had already died within the first month of life, and 0 refused care. A total of 201 doses of PCV-13 have been provided as per routine vaccination scheduling. After initial visit, the return rate for second immunization is 94% with only 3 babies lost to follow-up including 2 deaths. The calculated first-year mortality rate for all contacted FS babies (6.9%) compares favorably to the national infant mortality rate (9.8%). Conclusions: This prospective pilot study documents that newborn screening for SCA is feasible in a developing country such as Angola. Capacity building and teaching provide local healthcare workers with skills necessary to have a functional NBS program and infant SCA clinic. The sickle cell burden is extremely high in Angola, and contact and retrieval of all affected FS infants remains an ongoing challenge, but families are compliant with clinic appointments and treatment. Early mortality data suggest comprehensive SCA care can save lives, suggesting that expansion of the pilot program is warranted with an eventual national strategy for the diagnosis, care, and treatment of children with SCA in Angola. Disclosures: No relevant conflicts of interest to declare.