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G6PD deficiency is the most common human enzymopathy, particularly in individuals of African descent. Its epidemiology has not been studied in the Dominican Republic, where many individuals have African ancestry. HIV-infected patients are at risk for adverse effects from G6PD deficiency due to receiving prophylaxis with oxidative drugs, which can induce hemolysis in G6PD-deficient patients. We determined the prevalence of G6PD deficiency, as well as the spectrum of variants, in HIV-infected patients at the Clínica de Familia La Romana, a free HIV clinic in the Dominican Republic. A medical history, chart review, and G6PD testing were performed for 238 consenting HIV-positive adults. A qualitative assay (Trinity Biotech), performed at the clinic, was assessed for color change at 30 and 60 minutes. All blood samples were also shipped to our home institution for quantifying enzyme activity (Trinity Biotech) and molecular testing by Sanger sequencing. The threshold for G6PD deficiency was 5.42 U/g hemoglobin (Hb; i.e. The overall prevalence of G6PD deficiency was 8.8% and was similar in males (9.3% [9/97]) and females (8.5% [12/141]), but higher in Haitians (18% [9/50]) as compared to Dominicans (6.4% [12/187]; p=0.01), determined by maternal country of birth. All G6PD-deficient subjects carried the “African” variant (G6PD A-). ∼60% of patients had received and ∼15% were currently on trimethoprim-sulfamethoxazole (TMP-SMX), regardless of G6PD status. Two G6PD-normal patients received Dapsone after TMP-SMX was stopped for allergy or anemia. Univariate analysis identified variables associated with G6PD deficiency in this cohort. A multivariable logistic regression model identified three variables that predicted G6PD status (p Screening for G6PD deficiency in the developing world is further complicated by lack of access to confirmatory testing. Detecting heterozygous females with intermediate, or even normal, G6PD activity is a diagnostic challenge for enzyme assays. To diagnose heterozygotes definitively, all G6PD exons were sequenced for all subjects with G6PD activity near or below the threshold, with discordant qualitative and quantitative Results, and for selected controls. Of 55 subjects sequenced, 29 had at least one G6PD A- allele. The G6PD A+ allele, also associated with African ancestry, was the only other variant detected. Overall, the 3 Methods agreed well when subjects had low or high G6PD activity, with uncertainty near the quantitative threshold for G6PD deficiency. The sequencing assay detected the G6PD A- allele in all subjects found to be G6PD-deficient by the quantitative assay, but also identified 8 heterozygous females with normal enzyme activity. The qualitative assay, whose sensitivity was increased by assessing color change at 30 minutes, was able to detect the majority (12/19) of heterozygous females, but 6 were heterozygotes with normal enzyme activity. Nonetheless, because genotype does not directly correlate with clinical severity, low activity remains the gold standard for diagnosing G6PD deficiency. Therefore, optimizing qualitative enzyme assays to detect biochemically deficient patients in conjunction with using clinical screening to increase pretest probability may together improve the diagnosis of clinically relevant G6PD deficiency in resource-limited settings. Disclosures: No relevant conflicts of interest to declare.

OBJECTIVES: To assess the safety acceptability and preliminary efficacy of a culturally-adapted disclosure intervention for perinatally HIV-infected combined antiretroviral therapy patients in Haiti and the Dominican Republic. DESIGN: A quasi-experimental trial was conducted comparing caregiver-youth pairs who completed the intervention [adapted Blasini disclosure model (aBDM)] to pairs who discontinued aBDM participation before disclosure. aBDM consists of five components: structured healthcare worker training; one-on one pre-disclosure intervention/education sessions for youth (describing pediatric chronic diseases including cancer diabetes and HIV) and for caregivers (strengthening capacity for disclosure); a scheduled supportive disclosure session; and one-on-one postdisclosure support for caregivers and youth. METHODS: Caregivers of nondisclosed combined antiretroviral therapy patients aged 10.0-17.8 years were invited to participate. Data were collected by separate one-on-one face-to-face interviews of caregivers and youth by study staff and medical record review by pediatricians at enrollment and 3 months after disclosure or after intervention discontinuation. RESULTS: To date 65 Dominican Republic and 27 Haiti caregiver-youth pairs have enrolled. At enrollment only 46.4% of youth had viral suppression and 43.4% of caregivers had clinically significant depressive symptomatology. To date two serious study-related adverse events have occurred. Seven of the 92 (7.6% 6 in the Dominican Republic) enrolled pairs discontinued participation before disclosure and 39 had completed postdisclosure participation. Median plasma HIV-RNA concentration was lower in youth who completed aBDM than in youth who discontinued participation before aBDM disclosure (

The Caribbean has the highest adult HIV prevalence in the world after sub-Saharan Africa (2011). One sub-population in the Dominican Republic is the migratory Batey community primarily comprised of Haitian immigrants with limited access to healthcare and HIV prevalence rates of between 3.0% and 9.0%, compared to 0.7% nationally. This retrospective cohort study describes the cumulative retention from diagnosis to virological suppression for newly-diagnosed HIV-infected adults presenting to the Clínica de Familia and its Batey programme in La Romana, during 2011. Of the patients diagnosed with HIV, 65% entered into care, 59% completed immunologic testing, 53% were eligible for antiretroviral therapy (ART) initiation, 36% initiated ART within three months of eligibility and 27% were retained in care. Seventeen per cent of those retained on ART with a 12-month viral load measure had undetectable viral load. Attrition primarily occurred before ART initiation. The Batey programme had a first step lost-to-follow-up of 88% compared to 20% at the clinic ( p

Innovative empirical frameworks to evaluate progress in efforts addressing HIV treatment and prevention barriers in resource-limited areas are sorely needed to achieve the UNAIDS 90-90-90 goal (90% diagnosed, 90% on treatment, and 90% virally suppressed). A triadic implementation framework (TIF) is a comprehensive conceptual tool for (1) monitoring attrition, (2) evaluating operational programs, and (3) measuring the impact of specific implementation goals within the care continuum. TIF will assess the effects of enhanced programs on adherence and virologic suppression within the HIV care continuum at a regional clinic in the Dominican Republic (Clínica de Familia La Romana [CFLR]) and its program serving high-risk, migratory batey (sugarcane cultivation) communities. A retrospective cohort study completed during 2015 collected deidentified data from a CFLR chart review of adult HIV patients diagnosed in 2013. The results were quantitatively analyzed and compared to 2011 cohort data. In 2013, 310 patients were diagnosed HIV positive. The results demonstrated 73% enrolling in care, 28% adhering to care, and 16% achieving viral load suppression. Engagement increased across all steps of the care continuum compared to a 2011 cohort, culminating in a significant increase in undetectable viral load from 4% to 16% (p 0.001). The batey program showed significant increases in patient enrollment compared to the 2011 cohort (p 0.001). Meeting the UNAIDS 90-90-90 goal requires enhanced services in high-burden, resource-limited regions. CFLR employs TIF to assess progress and programmatic areas in need of strengthening. Data suggest enhanced CFLR services improve outcomes. Given improvements, maintenance and expansion of similar programs are warranted to achieve the 90-90-90 goal.

36 www.thelancet.com/lancetgh Published Online April 8, 2016 Columbia University Medical Center, New York, NY, USA (A Gomes BA, C Nicholas BA, S Amesty MD, R Perez-Figueroa MD, S Nicholas MD, B Taylor MD); Instituto Dermatologico y Cirugia de Piel “Dr. Humberto Bogaert Diaz”, Santo Domingo, Dominican Republic (Y Donastorg MD, M Perez MS); University of Texas Health Science Center San Antonio, San Antonio, TX, USA (B Taylor MD) Correspondence to Angelina Gomes amg2272@cumc.columbia.edu Barriers and opportunities for sexual health services for key populations in the Dominican Republic: provider, government, and community-leader perspectives Angelina Gomes, Catherine Nicholas, Yeycy Donastorg, Martha Perez, Silvia Amesty, Rafael Perez-Figueroa, Stephen W Nicholas, Barbara S Taylor Abstract Background Sexually transmitted infections (STIs) are an important health issue in developing countries. Key populations, including people living with HIV, men who have sex with men, trans women, transactional sex workers, pregnant adolescents, and migrants, are at high risk of STIs and have barriers to sexual health services. In this study, we aim to understand capacities and barriers to access for key populations in the Dominican Republic, and to identify opportunities to improve services.Background Sexually transmitted infections (STIs) are an important health issue in developing countries. Key populations, including people living with HIV, men who have sex with men, trans women, transactional sex workers, pregnant adolescents, and migrants, are at high risk of STIs and have barriers to sexual health services. In this study, we aim to understand capacities and barriers to access for key populations in the Dominican Republic, and to identify opportunities to improve services. Methods We used purposive sampling to solicit views from stakeholders in Santo Domingo, Dominican Republic, including health-care agencies, community-based organisations, and government entities that guide STI screening policy. We conducted 19 semi-structured interviews between February, 2015, and May, 2015, with: nine health providers, seven community leaders, and three government authorities, asking questions about STI services for key populations, gaps in services, and barriers to access. Comprehensive notes and audio recordings were iteratively reviewed by two investigators to defi ne barriers and opportunities for STI screening. Findings Respondents identifi ed barriers to access at individual, community, organisational, and policy levels. Individual barriers include poor risk perception and health knowledge, drug use in transactional sex workers and trans women, inability to negotiate condom use in sex worker and adolescent groups, and poverty. Community barriers include: discrimination against sex workers, trans women, people living with HIV, men who have sex with men, and migrants; and a culture of self-medicating in all populations. Organisational barriers include a lack of centres off ering STI testing, unavailability of medications in centres accessed by key population, and poor knowledge of available resources in the community. Policy barriers include poor access to insurance in populations; low resource allocation to STIs, other than HIV; and inconsistent supply of materials and funds. Despite these barriers, local organisations that work with key populations expressed interest in increasing capacity to screen and treat STIs. Interpretation There are many barriers to STI services for key populations in the Dominican Republic. Communitybased organisations working with such populations could leverage their expertise to increase STI awareness, screening, and treatment. Our fi ndings can help generate sustainable interventions to reduce the burden of STIs in these key populations. Funding NIAID (K23AI081538 to B Taylor); Columbia University IFAP Global Health. Copyright © Gomes et al. Open Access article distributed under the terms of CC BY. Declaration of interests We declare no competing interests.

Objective To investigate whether costs of multidose antiretroviral regimens (MD-ARVs), including highly active antiretroviral therapy (HAART), for prevention of mother-to-child transmission (PMTCT) of HIV might be offset by savings gained from treating fewer perinatally acquired infections. Methods Rates of MTCT reported in the Dominican Republic among mother-infant pairs treated with single-dose nevirapine (SD-NVP; n = 39) and MD-ARVs (n = 91) for PMTCT were compared. Annual births to women infected with HIV were estimated from seroprevalence studies. Antiretroviral costs for both PMTCT and for HAART during the first 2 years of life (in cases of perinatal infection) were based on 2008 low-income country price estimates. Results Rates of MTCT were 3.3% and 15.4% for the MD-ARV and SD-NVP groups, respectively (P = 0.02). Assuming that 5775 of 231 000 annual births (2.5%) were to HIV-positive women, it was estimated that 191 perinatally acquired infections would occur using MD-ARVs and 889 using SD-NVP. High costs of maternal MD-ARVs (HAART, US$914,760 versus SD-NVP, $1155) would be offset by lower 2-year HAART costs ($250,344 versus $1,168,272 for infants in the SD-NVP group) for the lower number of children with prenatally acquired infection (191 versus 889) associated with the use of MD-ARVs for PMTCT (net national saving $3168). Conclusion Despite the high costs, use of MD-ARVs, such as HAART, for PMTCT offer societal savings because fewer perinatally acquired infections are anticipated to require treatment.

A mixed-methods study was conducted to determine the proportion of HIV-infected children who knew their status, identify characteristics associated with children’s knowledge of their status, and describe caregivers’ and adolescents’ experiences relevant to disclosure in the Dominican Republic (DR). Of 327 patients aged 6–18 years treated in the principal DR pediatric HIV facilities, 74 (22.6 %) knew their status. Patients aged 13 years or older and/or who had participated in non-clinical activities for HIV-infected children were more likely to know their status. Caregivers who had disclosed cited healthcare providers’ advice, children’s desire to know and concerns that children might initiate sexual activity before knowing or discover their status by accidental or malicious disclosure. Non-disclosing caregivers worried that children would be traumatized by disclosure and/or stigmatized if they revealed it to others. Adolescents supported disclosure by 10–12 years of age, considered withholding of children’s HIV diagnosis ill-advised, and recommended a disclosure process focused initially on promoting non-stigmatizing attitudes about HIV.

To examine the association between body mass index (BMI) percentile and asthma in children 2–11 years of age, we performed a cross-sectional analysis of 853 Black and Hispanic children from a community-based sample of 2- to 11-year olds with measured heights and weights screened for asthma by the Harlem Children’s Zone Asthma Initiative. Current asthma was defined as parent/guardian-reported diagnosis of asthma and asthma-related symptoms or emergency care in the previous 12 months. Among girls, asthma prevalence increased approximately linearly with increasing body mass index (BMI) percentile, from a low of 12.0% among underweight girls (BMI ≤5th percentile) to a high of 33.3% among girls at risk for overweight (BMI 85th–94th percentile). Among boys, asthma prevalence was associated in a U-shaped curve with the extremes of BMI percentile, that is, 36.4% among underweight boys, 19.1% among normal weight boys (BMI 6th–84th percentile), and 34.8% among overweight boys (>95th percentile). After adjusting for age, race/ethnicity, and household smoking, among girls, having asthma was associated with being at risk for overweight (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.4–5.0) and being overweight (OR, 2.1; 95% CI, 1.2–3.8) compared to normal weight; among boys, having asthma was associated both with overweight (OR, 2.4; 95% CI, 1.4–4.3) and with underweight (OR, 2.9; 95% CI, 1.1–7.7). Large, prospective studies that include very young children are needed to further explore the observed association between underweight and asthma among boys. Early interventions that concomitantly address asthma and weight gain are needed among pre-school and school-aged children.

Health disparities that affect whole communities may involve factors like housing quality that lie at least partly within planners' realm of policy influence. This article demonstrates a link between housing and childhood asthma. The magnitude of the childhood asthma epidemic in Harlem in New York City and the commitment of engaged community partners led to an interdisciplinary, participatory, and multifaceted approach to the planning, implementation, and evaluation of the Harlem Children's Zone Asthma Initiative. Here we present the first year's data on environmental triggers in the homes of program participants, showing that intensive, community-based programs can reduce both home environmental triggers and adverse childhood asthma outcomes. This provides an example of a community-wide public health intervention that informs public policy and planning, and may provide a sustainable model for reducing childhood asthma in impoverished communities.

This letter is written in response to Dr. Wayne C. Turner's request in Energy Engineering Vol. 101, No. 5, “How about you writing to me and sharing some of your ideas for immediate results?” The immediate results would be based on successful energy management programs that would save significant money with few or no negative consequences. The projects should also help and not hinder maintenance as well. The ideas should also work well in most areas to make it simple and easy to implement by others.

Objectives. We determined the prevalence of asthma and estimated baseline asthma symptoms and asthma management strategies among children aged 0–12 years in Central Harlem. Methods. The Harlem Children’s Zone Asthma Initiative is a longitudinal, community-based intervention designed for poor children with asthma. Children aged 0–12 years who live or go to school in the Harlem Children’s Zone Project or who participate in any Harlem Children’s Zone, Inc, program were screened for asthma. Children with asthma or asthma-like symptoms were invited to participate in an intensive intervention. Results. Of the 1982 children currently screened, 28.5% have been told by a doctor or nurse that they have asthma, and 30.3% have asthma or asthma-like symptoms. To date, 229 children are enrolled in the Harlem Children’s Zone Asthma Initiative; at baseline, 24.0% had missed school in the last 14 days because of asthma. Conclusion. The high prevalence of asthma among children in the Harlem Children’s Zone Project is consistent with reports from other poor urban communities. Intensive efforts are under way to reduce children’s asthma symptoms and improve their asthma management strategies.

Increasing numbers of perinatally HIV-infected children are surviving into their teens and beyond. Research and clinical reports suggest that many HIV-infected children, particularly those younger than 13 years, do not know they are HIV infected owing to parental concerns about the impact on their mental health. This study examines patterns of HIV status disclosure to 77 perinatally HIV-infected ethnic minority children (aged 3–13 years), and explores the association between knowledge of HIV status and emotional and behavioral outcomes. The majority of children in this study (70%) did not know their HIV status. On average, children who knew their HIV status were older and tended to have lower CD4%. Child knowledge of HIV status was not associated with gender, ethnicity, caregiver education, parent–child relationship factors, type of placement (biological vs adoptive), or other health status indicators. As hypothesized, HIV status disclosure to infected children did not result in increased mental health problems. There was a statistical trend for children who knew their HIV status to be less depressed than children who did not know. Also, greater social disclosure (e.g. communication of child’s status to family and friends) was found when the child had an AIDS diagnosis or lower CD4%, as well as when the caregiver was HIV negative, African American and not the child’s biological parent. In conclusion, pediatric HIV infection remains a highly stigmatized issue that is difficult to discuss with the infected child and others. Yet, contrary to the beliefs of many caregivers, disclosure did not result in increased mental health problems.

A pilot study is underway to assess safety and acceptability of an intervention to disclose their HIV infection status to status-naive pediatric antiretroviral therapy patients in Hispaniola [the island shared by Haiti and the Dominican Republic (DR)]. Of 22 Haiti and 47 DR caregivers recruited to date 68.2% Haiti and 34.0% DR caregivers had clinically significant depressive symptomatology at the time of enrollment (p = 0.008). Depressive symptom prevalence was higher in Haiti caregivers who were female (81.3% vs. 0 in males; p = 0.02) and in DR caregivers who were patients mothers (50.0%) or grandmothers (66.7%; 56.0% combined) than others (9.1%) (p < 0.001). Internalized stigma was more commonly reported by Haiti (85.7%) than DR (53.2%; p = 0.01) caregivers; 56.4% of Haiti and DR caregivers reporting internalized stigma vs. 26.1% of caregivers denying it had depressive symptoms (p = 0.02). Depression is common in Hispaniola caregivers possibly affecting disclosure timing. Study participation presents opportunities for addressing caregiver depression. (c) The Author [2014]. Published by Oxford University Press. All rights reserved. For Permissions please email: journals.permissions@oup.com.

Orphans and vulnerable youth who live in group homes are at risk of poor mental health and sexual and drug-using behaviors that increase the risk of HIV transmission. This study explores factors related to this risk among youth living in group homes (“children’s homes”) for orphans and vulnerable children in South Africa, a country afflicted by high levels of parental loss due to HIV. The study explores 1) knowledge and attitudes about HIV, 2) social support, 3) communication with group home caregivers, and 4) the relevance of an existing evidence-based HIV prevention and mental health promotion program to situations where sexual and drug risk behaviors can occur. In-depth qualitative individual interviews were conducted with 20 youth (age 10 to 16 years) residing in two children’s homes in Durban, South Africa. Content analysis focused on critical themes related to coping and prevention of risk activities. Respondents exhibited inconsistent and incomplete knowledge of HIV transmission and prevention. They displayed positive attitudes toward people living with HIV, but reported experiencing or witnessing HIV-related stigma. Participants witnessed substance use and romantic/sexual relationships among their peers; few admitted to their own involvement. While relationships with childcare workers were central to their lives, youth reported communication barriers related to substance use, sex, HIV, and personal history (including parental loss, abuse, and other trauma). In conclusion, these qualitative data suggest that evidence-based HIV prevention programs that bring caregivers and youth together to improve communication, HIV knowledge, social support, youth self-esteem, and health care, reduce sexual and drug risk behaviors, and strengthen skills related to negotiating situations of sexual and substance use possibility could benefit youth and childcare workers in children’s homes.

In 1999, prevention of mother-to-child transmission (pMTCT) using antiretrovirals was introduced in the Dominican Republic (DR). Highly active antiretroviral therapy (HAART) was introduced for immunosuppressed persons in 2004 and for pMTCT in 2008. To assess progress towards MTCT elimination, data from requisitions for HIV nucleic acid amplification tests for diagnosis of HIV infection in perinatally exposed infants born in the DR from 1999 to 2011 were analyzed. The MTCT rate was 142/1,274 (11.1%) in 1999–2008 and 12/302 (4.0%) in 2009–2011 (P<.001), with a rate of 154/1,576 (9.8%) for both periods combined. This decline was associated with significant increases in the proportions of women who received prenatal HAART (from 12.3% to 67.9%) and infants who received exclusive formula feeding (from 76.3% to 86.1%) and declines in proportions of women who received no prenatal antiretrovirals (from 31.9% to 12.2%) or received only single-dose nevirapine (from 39.5% to 19.5%). In 2007, over 95% of DR pregnant women received prenatal care, HIV testing, and professionally attended delivery. However, only 58% of women in underserved sugarcane plantation communities (2007) and 76% in HIV sentinel surveillance hospitals (2003–2005) received their HIV test results. HIV-MTCT elimination is feasible but persistent lack of access to critical pMTCT measures must be addressed.

The HIV-infected child with fever presents a diagnostic and therapeutic challenge to the clinician. Although fever may be the harbinger of a life-threatening infection, many episodes of fever ultimately prove to be unexplainable or trivial events. The optimal management of the febrile HIV-positive child is unknown, but multiple factors should be considered. Good clinical judgment and familiarity with the patient's past history and current problems are essential. Evaluation ideally should be performed by the patient's regular primary care provider; when this is not feasible, consultation by telephone with the primary care giver is recommended. Several concepts are relevant to managing fever in an HIV-positive child. The clinician should be aware that HIV-infected children may develop a humoral immunodeficiency 1-3 that not only can cause impaired antibody responses to immunization 4 but also may result in life-threatening and sometimes recurrent bacterial infections, such as sepsis, meningitis, pneumonia, and abscesses of internal organs, as well as recurrent urinary tract infections. In addition to the typical bacterial pathogens of childhood, such as Haemophilus influenzae type b and Streptococcus pneumonia, some HIV-infected children are predisposed to infection with gram-negative enteric bacteria, such as Salmonella, Escherichia coli, and Enterobacter. 6, 7 Children infected with HIV may, less commonly, have marked cellular immunodeficiency that predisposes them to opportunistic infections. 8"1~ Infections in HIV-infected adults, such as cryptococcosis and toxoplasmosis, are believed to be due usually to activation of a latent infection acquired asymptomatieally early in life. 11 Cryptococcosis and toxoplasmosis occasionally have been reported in HIVinfected children but, when present, may represent primary de novo infections.ll A high percentage of HIV-infected intravenous drug-using adults have tuberculosis, 12 and rates of tuberculosis are on the rise in inner-city populations, 13 but surprisingly few children with HIV and tuberculosis have been reported. The explanation for this is unknown, but may be related to underdiagnosis. Children infected with HIV do get normal childhood infections, and often tolerate them without difficulty. Further, some HIV-infected children have fever frequently (daily O r several times per week) without an obvious underlying infection other than HIV. It is important to be aware that multiple infections may coexist concurrently in the HIV-infected child. Overall, constant vigilance is required to diagnose new and potentially treatable infections, particularly in chronically ill HIV-infected children.

OBJECTIVES: To strengthen prevention of mother-to-child HIV transmission (pMTCT) program implementation in La Romana (LR) province, by estimating HIV prevalence and identifying characteristics associated with HIV infection in parturients. METHODS: Umbilical cord blood samples were collected at seven obstetrical sites where over 95 percent of LR's deliveries occur during four phases (pilot, expanded pilot, full study, and pMTCT program monitoring) from 2 August 2002 to 30 September 2006. Results were linked to data abstracted from delivery records. RESULTS: HIV seroprevalence was 2.6 percent (263/10 040 overall; 114/4 452, full-study phase (95 percent confidence interval = 2.1 percent-3.1 percent)). Most HIV-infected parturients were Dominican (68.9 percent) and urban (64.0 percent). However, prevalence was higher among Haitians (3.7 percent) than Dominicans (2.3 percent (p 0.001)), especially those aged 21-25 years (5.2 percent vs. 2.3 percent (p 0.001)), and among rural, batey, and peri-urban (vs. urban) parturients (3.4 percent vs. 2.3 percent, (p = 0.003)). HIV prevalence was associated with commercial sex work (reported by only 0.4 percent), and prior pregnancy. In logistic regression analysis, commercial sex work, Haitian nationality, and prior pregnancy were independently associated with HIV infection. Caesarean deliveries were more frequent, and rose in the last years of the study, among HIV seropositives; however, most deliveries among seropositives (57.5 percent) were vaginal. CONCLUSIONS: HIV prevalence among LR parturients was higher than the estimated prevalence in the Dominican Republic (0.8 percent-1.0 percent) and, in contrast to past studies, predominantly affected urban Dominicans. HIV prevalence among LR Haitian parturients was higher than among Dominican counterparts and prenatal clinic attendees in Haiti (who had a rate of 3.1 percent). Consistently implemented, targeted pMTCT interventions are needed.(AU)

In 1991 Dr. Kenneth Olden became the first AfricanAmerican director of an institute in the National Institutes of Health (NIH) when he assumed the leadership of the National Institute of Environmental Health Sciences (NIEHS) (Brown 2004). That same year, the NIEHS—with Dr. Olden in prominent attendance—hosted the Interagency Symposium on Health Research Needs to Ensure Environmental Justice, which was held 11 February 1994 in Arlington, Virginia (Shepard et al. 2002). Throughout his tenure at the helm of NIEHS, Dr. Olden has listened to the needs, both small and large, of communities that have experienced severe disparities in both environmental exposures and health outcomes. This E s s a y o n Community-Based Participatory Research

To determine the maternal risk factors and infant outcome for unattended out-of-hospital deliveries brought to an inner-city public hospital.We compared 59 infants born alive out of hospital during 1989 with 151 randomly selected in-hospital live births, all with birth weight greater than 500 g.History of cocaine use during pregnancy (odds ratio [OR], 4.20; 95% confidence interval [CI], 1.68 to 10.5) and lack of Medicaid or other health insurance (OR, 2.15; 95% CI, 1.04 to 4.45) were independently associated with out-of-hospital delivery. Out-of-hospital delivery was associated with hypothermia (defined as admission axillary temperature35 degrees C; OR, 20.8; 95% CI, 4.81 to 89.9) and with hypoglycemia (defined as admission glucose reagent strip reading2.2 mmol/L [40 mg/dL]; OR, 4.41; 95% CI, 1.29 to 15.1) in separate analyses controlling for birth weight and other risk factors. Polycythemia (venous or arterial hematocrit0.65 at ageor = 6 hours) occurred in 14% (eight of 59) of out-of-hospital births. The increased neonatal mortality rate for infants born out of hospital (20.3 vs 7.3 per 1000 live births; OR, 2.82; 95% CI, 1.23 to 6.47) was due to an excess of infants weighing 500 to 999 g.Unattended out-of-hospital births result in increased neonatal morbidity that may be partly preventable by simple interventions used routinely at inhospital deliveries.

Dr. Mary E. Northridge is the deputy director o f the Harlem Health Promotion Center at Columbia University in New York City. Dr. Betina Jean-Louis, director o f evaluation, and Ms. Katherine Shoemaker, director o f special projects for the president, are with Harlem Children's Zone, Inc. Dr. Stephen Nicholas is the director o f Pediatrics at Harlem Hospital Center and the principal investigator o f the asthma initiative

This study evaluates genetic influence on susceptibility to perinatal HIV-1 infection among 106 Black infants from New York and San Francisco born to mothers infected with HIV-1. Genes tested by molecular techniques are HLA class II loci DRB1, DPB1 and DQA1; HLA class III loci complement C4A and C4B; alpha and beta interferons; and the constant region of the T-cell receptor beta chain. Of the 106 infants analysed, 54 are infected with HIV and 52 remain uninfected at age 15 months and older. Genotypes in the HLA region appear to influence risk of HIV infection. Specifically, infants with the amino acid sequence -asp-glu-ala-val- at DPB1 positions #84-87 are more likely to be infected (P = 0.001) and infants with the allele DQA1*0102 are less likely to be infected (P = 0.031). Combinations of these two risk factors show a strong dose response (P = 0.0005). HLA DPB1 and DQA1 may play a direct role in immune response associated with HIV-1 infection, or the critical region may be located between these two genes. Characterisation of other class II HLA genes in these infants will allow more precise determination of the role of HLA loci in susceptibility to HIV-1 infection.

Pediatric HIV disease often leads to marked failure to thrive and multiple nutritional deficiencies, particularly protein calorie malnutrition. Nutrition management may be difficult when children develop recurrent fevers, respiratory distress, diarrhea and malabsorption, vomiting, developmental delays, neurologic impairment, or other conditions that alter caloric needs, interfere with food intake, or reduce nutrient absorption. Malnutrition itself may produce an acquired irnmunodeficiency similar to that caused by HIVfl 2 Cellular immunity defects (including lymphopenia, anergy, and reversed T4 to T8 lymphocyte ratios), abnormal macrophage function, wasting, recurrent fevers, gastrointestinal dysfunction. and increased susceptibility to opportunistic infections all have been described in patients with protein calorie malnutrition and other nutritional deficiencies. Thus, although malnutrition may ultimately be the inescapable result of progressive HIV disease, early nutritional intervention may reduce susceptibility to or severity of infections, provide some protection to the immune system, and lead to a better quality of life for HIV-infected children. Few studies have addressed the nutritional needs of HIV-infected adults or children. 3"5 These guidelines therefore combine what little is known with pragmatic approaches to common nutritional problems encountered in the management of HIV-infected children.

Objective: To determine the prevalence of human immunodeficiency virus type 1 (HIV-1) infection and its association with illicit drug use for mothers being delivered of infants at an inner-city municipal hospital. Methods: We anonymously tested the umbilical cord blood for HIV-1 antibody of 98.1% (2971/3028) of singleton infants with birth weight greater than 500 g born during 1989 and linked the results to a maternal-infant database from which all identifying information had been removed. Results: Overall, HIV-1 seroprevalence was 3.3% (99/2971). Among HIV-1–seropositive mothers, 79% (78/99) gave no history of ever using injected drugs. Seropositivity for HIV-1 was independently associated with history of maternal cocaine use during pregnancy (odds ratio, 3.55; 95% confidence interval, 2.18, 5.78), history of ever using injected drugs (odds ratio, 6.02; 95% confidence interval, 3.14,11.6), positive serologic test result for syphilis during pregnancy (odds ratio, 3.37; 95% confidence interval, 1.94, 5.88), and increasing maternal age per year (odds ratio, 1.04; 95% confidence interval, 1.00,1.09). Voluntary testing programs failed to identify 71% (70/99) of all HIV-1–infected women. Infants placed into foster care were eight times more likely to be HIV-1 seropositive than those discharged to their mothers. Conclusions: Most HIV-1–infected mothers seem to have acquired the infection via heterosexual transmission rather than via injected drug use. Associations of maternal HIV-1 infection with cocaine use, syphilis, and increasing age probably operate through behaviors that increase maternal risk of exposure to an HIV-1–infected sexual partner or, in the case of syphilis, also through biologic factors that may predispose to HIV-1 transmission. The failure of voluntary testing to identify most HIV-1–infected mothers provides a strong rationale for routine HIV-1 testing during pregnancy and in the newborn period. (Arch Pediatr Adolesc Med. 1994;148:813-819)

During the first half of this decade, much new information about the acquired immunodeficiency syndrome (AIDS) became available, including landmark reports of the syndrome in children from Oleske et al, Rubinstein et al, and Scott et al; descriptions of AIDS in pregnancy by Wetli et al, Rawlinson et al, and Minkoff et al; and discovery of the agent that causes AIDS, the human immunodeficiency virus (HIV, formerly called HTLV-III/LAV). The first sets of health guidelines pertaining to HIV-infected children and adolescents in school, day-care and foster care settings were published by the American Academy of Pediatrics' Committee on Infectious Diseases in March 1986 and 1987. In 1987, the Surgeon General's Workshop on Children With HIV Infection and Their Families provided the first comprehensive set of recommendations relevant to the provision of pediatric and obstetrical care to infected mothers, infants, children, and adolescents. Most recently, during February 1988, the Secretary of Health and Human Services formed the Secretary's Work Group on Pediatric HIV Infection and Disease that consisted of members from each of the health and human services agencies, including the Social Security Administration and the Health Care Financing Administration. The broad mandate of this group was to make recommendations to facilitate the removal of barriers to care, treatment, and financial burdens of children and adolescents with HIV infection and their families. In contrast, HIV infection has not received sufficiently widespread attention from the obstetric, pediatric, or adolescent research communities. The uneven geographic distribution of the disease; its associated social, legal, and ethical complexities; and the lack of sufficient research monies all have contributed to this problem.

To estimate the cost of hospital care for children infected with the human immunodeficiency virus (n = 37) at Harlem Hospital Center, New York, a cost-based inventory of medical resource consumption was developed. Six thousand thirty-five inpatient days were audited by retrospective chart review. The total cost of care between 1981 and 1986 was $3 362 597. Average lifetime costs were $90 347 per child. One third of the total inpatient days and over 20% of the cost resulted from social rather than medical factors. Per diem costs were highest for children with opportunistic infections ($705) and lowest for homeless "boarder babies" ($466). Boarder babies had a mean length of stay nearly four times longer than those with homes (339 days vs 89 days). The primary predictors of length of stay were maternal intravenous drug use and boarder baby status, regardless of medical need. The unique needs of human immunodeficiency virus—infected children require innovative medical, social, and financial solutions. (JAMA1988;260:1901-1905)

The preliminary data from the California survey of heelstick samples from newborns indicate a lower rate of HIV seroprevalence in childbearing women than was reported for Massachusetts and New York. It is also interesting that the rate for California female military recruits matches that of childbearing women. The lower HIV seroprevalence rates in California women compared with East Coast states raises important questions about differing patterns of HIV transmission to women in the two areas. Regional stratification of the statewide rates, especially for inner-city neighborhoods, should provide relevant data for understanding these patterns.