A Methodological Approach for Evaluating the Enterprise Community Healthy Start Program in Rural Georgia: An Analysis Using Linked PRAMS, Birth Records and Program Data.

INTRODUCTION: Community Healthy Start program evaluations are often limited by a lack of robust data and rigorous study designs. This study describes an enhanced methodological approach using local program data linked with existing population-level datasets for external comparison to evaluate the Enterprise Community Healthy Start (ECHS) program in two rural Georgia counties and presents results from the evaluation. METHODS: ECHS program data were linked to birth records and the Pregnancy Risk Assessment Monitoring System (PRAMS) for 869 women who delivered a live birth in Burke and McDuffie counties from 2010 to 2011. Multivariate logistic regressions with and without propensity score methods modeled the association between ECHS participation and maternal health indicators and pregnancy outcomes. RESULTS: 107 ECHS participants and 726 non-participants responded to PRAMS and met eligibility criteria. Compared with non-participants, ECHS participants were younger, completed fewer years of education, and were more likely to be non-Hispanic Black, unmarried, insured with Medicaid, participating in WIC, and having an unintended pregnancy. Models with and without propensity score weighting derived similar results: there was a positive association between ECHS participation and receiving adequate or adequate plus prenatal care (p < 0.05); no statistically significant associations were observed between ECHS participation and any other health behaviors, health care access and utilization measures or pregnancy outcomes. DISCUSSION: Rigorous evaluation of a local Healthy Start program using linked PRAMS and birth records with a population-based external comparison group and propensity score methods is an enhanced and feasible approach that can be applied in other local and state jurisdictions.

Unnecessary workup of asymptomatic neonates in the era of group B streptococcus prophylaxis.

Asymptomatic term neonates born to mothers who are Group B Streptococcus (GBS) unknown or GBS positive but "inadequately" treated prior to delivery do not require invasive laboratory evaluation. We conducted a retrospective cohort study of mother/baby dyads born from January 1, 2005 until September 30, 2007 at the Medical College of Georgia. Their current protocol is to obtain a Complete Blood Count with Differential (CBC with D), Blood Culture (BC), and C-reactive protein (CRP) after birth. Mother/baby dyads (n = 242) that met inclusion criteria were reviewed. Of these 242 babies 25 (10%) were started on antibiotics after the initial lab values were known. None of the blood cultures were positive and the CRP's were normal. The 2002 GBS guidelines call for laboratory evaluation of "at-risk" neonates, but the workup of these babies is not only costly, it does not provide any advantage over old fashioned clinical observation for the evaluation and treatment of early onset GBS sepsis.

HIV-1 drug resistance surveillance using dried whole blood spots.

BACKGROUND: Field-friendly methods for HIV drug resistance (HIVDR) surveillance in resource-limited regions are urgently needed. Despite evidence that dried blood spots (DBS) are suitable for HIV serology, viral load and CD4+ T-cell enumeration, no study has evaluated DBS for HIVDR genotyping. We assessed the feasibility of genotyping HIV-1 from field-collected DBS stored under challenging environmental conditions. METHODS: We prospectively collected specimens from newly diagnosed, treatment-naive HIV-positive subjects in Mexico. Whole blood was spotted onto filter cards, air dried at ambient temperature and stored with desiccant at 37 degrees C and 85% humidity for 3 months. Genotypes obtained from DBS-extracted nucleic acids using an in-house nested reverse transcription-PCR method were compared to genotypes derived from matched plasma. RESULTS: Genotypes from 103 phylogenetically matched plasma and DBS were compared. In total, 90.1% of all DBS specimens could be amplified in either the region of HIV protease or the region of reverse transcriptase. Failure to amplify from DBS did not correlate with low plasma viral loads. Between paired specimens, the median nucleotide similarity was 99.95%. In the nine specimens with drug resistance mutations, all differences between pairs were partial discordances. Mutations identified in plasma were found in the majority of replicate DBS amplifications. CONCLUSION: The results suggest that genotypes obtained from DBS are equivalent to those from plasma. DBS are a promising public health tool for HIVDR surveillance of treatment-naive subjects, especially in regions where specimens might be exposed to severe environmental conditions and where logistical difficulties could prevent timely specimen processing. More studies are needed to validate DBS for patient monitoring.

The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings.

WHO has proposed a public-health approach to antiretroviral therapy (ART) to enable scaling-up access to treatment for HIV-positive people in developing countries, recognising that the western model of specialist physician management and advanced laboratory monitoring is not feasible in resource-poor settings. In this approach, standardised simplified treatment protocols and decentralised service delivery enable treatment to be delivered to large numbers of HIV-positive adults and children through the public and private sector. Simplified tools and approaches to clinical decision-making, centred on the "four Ss"--when to: start drug treatment; substitute for toxicity; switch after treatment failure; and stop--enable lower level health-care workers to deliver care. Simple limited formularies have driven large-scale production of fixed-dose combinations for first-line treatment for adults and lowered prices, but to ensure access to ART in the poorest countries, the care and drugs should be given free at point of service delivery. Population-based surveillance for acquired and transmitted resistance is needed to address concerns that switching regimens on the basis of clinical criteria for failure alone could lead to widespread emergence of drug-resistant virus strains. The integrated management of adult or childhood illness (IMAI/IMCI) facilitates decentralised implementation that is integrated within existing health systems. Simplified operational guidelines, tools, and training materials enable clinical teams in primary-care and second-level facilities to deliver HIV prevention, HIV care, and ART, and to use a standardised patient-tracking system.

How Uganda reversed its HIV epidemic.

Uganda is one of only two countries in the world that has successfully reversed the course of its HIV epidemic. There remains much controversy about how Uganda's HIV prevalence declined in the 1990s. This article describes the prevention programs and activities that were implemented in Uganda during critical years in its HIV epidemic, 1987 to 1994. Multiple resources were aggregated to fuel HV prevention campaigns at multiple levels to a far greater degree than in neighboring countries. We conclude that the reversed direction of the HIV epidemic in Uganda was the direct result of these interventions and that other countries in the developing world could similarly prevent or reverse the escalation of HIV epidemics with greater availability of HIV prevention resources, and well designed programs that take efforts to a critical breadth and depth of effort.