Development of Scholarship Core Competencies for Pediatric Hospital Medicine Fellowship Programs.

The Pediatric Hospital Medicine (PHM) Fellowship Directors, recent fellowship graduates, and senior leaders in PHM have long identified training in scholarly activities as a key educational priority for fellowship training programs. We led a 2-day conference funded by the Agency for Healthcare Research and Quality to develop scholarship core competencies for PHM fellows. Participants included fellowship directors, national experts in PHM research, and representatives from key stakeholder organizations. Through engagement in large group presentations and small group iterative feedback and editing, participants created and refined a set of scholarship core competencies. After the conference, goals and objectives were edited and harmonized by conference leaders incorporating feedback from conference participants. Core competency development included 7 domains: (1) study design and execution, (2) data management, (3) principles of analytics, (4) critical appraisal of the medical literature, (5) ethics and responsible conduct of research, (6) peer review, dissemination, and funding, and (7) professionalism and leadership. Specific objectives for each goal were further organized into 3 levels to indicate core skills for all fellowship trainees (level 1), specialized and specific skills determined by fellow scholarly focus (level 2), and advanced skills for fellows interested in a clinical investigator career path (level 3). These newly developed scholarship core competencies provide a foundation for curricular development and implementation to ensure that the field continues to expand academically, given the 2-year training period and variable infrastructure across programs.

Cost-effectiveness of a direct to beneficiary mobile communication programme in improving reproductive and child health outcomes in India.

INTRODUCTION: Kilkari is the largest maternal messaging programme of its kind globally. Between its initiation in 2012 in Bihar and its transition to the government in 2019, Kilkari was scaled to 13 states across India and reached over 10 million new and expectant mothers and their families. This study aims to determine the cost-effectiveness of exposure to Kilkari as compared with no exposure across 13 states in India. METHODS: The study was conducted from a programme perspective using an analytic time horizon aligned with national scale-up efforts from December 2014 to April 2019. Economic costs were derived from the financial records of implementing partners. Data on incremental changes in the practice of reproductive maternal newborn and child health (RMNCH) outcomes were drawn from an individually randomised controlled trial in Madhya Pradesh and inputted into the Lives Saved Tool to yield estimates of maternal and child lives saved. One-way and probabilistic sensitivity analyses were carried out to assess uncertainty. RESULTS: Inflation adjusted programme costs were US$8.4 million for the period of December 2014-April 2019, corresponding to an average cost of US$264 298 per year of implementation in each state. An estimated 13 842 lives were saved across 13 states, 96% among children and 4% among mothers. The cost per life saved ranged by year of implementation and with the addition of new states from US$392 ($385-$393) to US$953 ($889-$1092). Key drivers included call costs and incremental changes in coverage for key RMNCH practices. CONCLUSION: Kilkari is highly cost-effective using a threshold of India's national gross domestic product of US$1998. Study findings provide important evidence on the cost-effectiveness of a national maternal messaging programme in India. TRIAL REGISTRATION: NCT03576157.

Transitioning women to first-line preferred TLD regimen is lagging in Sub-Saharan Africa.

INTRODUCTION: In 2019, the World Health Organization (WHO) recommended tenofovir disoproxil fumarate-lamivudine-dolutegravir (TLD) as the preferred first line regimen for adults and adolescents regardless of childbearing status. Nevertheless, final eligibility is determined by local policies which may vary from WHO recommendations. We examined TLD transition by gender across five PEPFAR-supported HIV care programs in sub-Saharan Africa. METHODS: The African Cohort Study (AFRICOS) enrolls people living with HIV (PLWH) engaged in care in Uganda, Kenya (South Rift Valley and Kisumu West), Tanzania and Nigeria. PLWH with at least one study visit after the country introduced TLD were included. We generated Kaplan-Meier (KM) curves to compare TLD transition by gender from 1) time countries' introduction of TLD and 2) time of TLD eligibility according to local policies. RESULTS: Among 2.476 participants enrolled through September 2021 at 4 sites in sub-Saharan Africa and eligible to transition to TLD, fewer women (68%) compared to men (80%, p < 0.001) were taking TLD. Kaplan-Meier analysis showed time to transition varied by site, with women in Tanzania transitioning at the same rate as men. In Nigeria, women initially had a slower transition but caught up to men. After adjusting for local policies, women[1] in Kisumu West transitioned at the same rate as men. In South Rift Valley and Uganda, women were less likely to be transitioned. CONCLUSIONS: Despite TLD being the WHO's preferred regimen since 2019, transition of women to potentially lifesaving TLD has been slower than men at certain clinical sites even after accounting for local eligibility criteria.

Objective assessment of intra-oral suturing for certification of competency.

INTRODUCTION: Suturing is an essential skill for dental surgeons, yet there is limited evidence for objective measures of competence in this field, which can be applied to licensing or certification processes for dental surgeons to ensure patient safety. METHODS: In an objective structured clinical examination (OSCE), participants placed two simple interrupted sutures across a lower molar socket in different suturing environments: [A] commercial simulator, [B] suturing sponge mounted in a 3D printed model, [C] suturing sponge and [D] pig's jaw. Simulators [A] and [B] were mounted into phantom heads in dental chairs, and [C] and [D] were placed on bench tops. Performance indicators, overall task success, quality of sutures placed, length of suture remaining and time taken, were analysed against participants' characteristics such as previous suturing experience. RESULTS: Participants (n = 38) took significantly longer to successfully complete the sutures on models mounted in a phantom head. Time points at which each model differentiated between competent (n = 11) and novice (n = 27) participants were as follows: model A (3:26 min), B (2:41), C (2:05) and D (2:06). Model A showed a significant association between task completion and previous suturing experience (p = .006). CONCLUSION: Suturing simulators can be used to objectively differentiate between novice and competent dental surgeons. Model A demonstrated construct validity, as it reliably identified competence using time and task completion as objectively measurable parameters. Utilising model A, the candidate of unknown ability could be identified as appropriately skilled at intra-oral suturing. To ensure patient safety, further research is needed to identify other objective measures of competence in simulation environments.

National or population level interventions addressing the social determinants of mental health - an umbrella review.

BACKGROUND: Social circumstances in which people live and work impact the population's mental health. We aimed to synthesise evidence identifying effective interventions and policies that influence the social determinants of mental health at national or scaled population level. We searched five databases (Cochrane Library, Global Health, MEDLINE, EMBASE and PsycINFO) between Jan 1st 2000 and July 23rd 2019 to identify systematic reviews of population-level interventions or policies addressing a recognised social determinant of mental health and collected mental health outcomes. There were no restrictions on country, sub-population or age. A narrative overview of results is provided. Quality assessment was conducted using Assessment of Multiple Systematic Reviews (AMSTAR 2). This study was registered on PROSPERO (CRD42019140198). RESULTS: We identified 20 reviews for inclusion. Most reviews were of low or critically low quality. Primary studies were mostly observational and from higher income settings. Higher quality evidence indicates more generous welfare benefits may reduce socioeconomic inequalities in mental health outcomes. Lower quality evidence suggests unemployment insurance, warm housing interventions, neighbourhood renewal, paid parental leave, gender equality policies, community-based parenting programmes, and less restrictive migration policies are associated with improved mental health outcomes. Low quality evidence suggests restriction of access to lethal means and multi-component suicide prevention programmes are associated with reduced suicide risk. CONCLUSION: This umbrella review has identified a small and overall low-quality evidence base for population level interventions addressing the social determinants of mental health. There are significant gaps in the evidence base for key policy areas, which limit ability of national policymakers to understand how to effectively improve population mental health.

Examining the reach and exposure of a mobile phone-based training programme for frontline health workers (ASHAs) in 13 states across India.

Mobile phones are increasingly used to facilitate in-service training for frontline health workers (FLHWs). Mobile learning (mLearning) programmes have the potential to provide FLHWs with high quality, inexpensive, standardised learning at scale, and at the time and location of their choosing. However, further research is needed into FLHW engagement with mLearning content at scale, a factor which could influence knowledge and service delivery. Mobile Academy is an interactive voice response training course for FLHWs in India, which aims to improve interpersonal communication skills and refresh knowledge of preventative reproductive, maternal, neonatal and child health. FLHWs dial in to an audio course consisting of 11 chapters, each with a 4-question true/false quiz, resulting in a cumulative pass/fail score. In this paper, we analyse call data records from the national version of Mobile Academy to explore coverage, user engagement and completion. Over 158 596 Accredited Social Health Activists (ASHAs) initiated the national version, while 111 994 initiated the course on state-based platforms. Together, this represents 41% of the estimated total number of ASHAs registered in the government database across 13 states. Of those who initiated the national version, 81% completed it; and of those, over 99% passed. The initiation and completion rates varied by state, with Rajasthan having the highest initiation rate. Many ASHAs made multiple calls in the afternoons and evenings but called in for longer durations earlier in the day. Findings from this analysis provide important insights into the differential reach and uptake of the programme across states.

Can health information through mobile phones close the divide in health behaviours among the marginalised? An equity analysis of Kilkari in Madhya Pradesh, India.

Kilkari is one of the largest maternal mobile messaging programmes in the world. It makes weekly prerecorded calls to new and expectant mothers and their families from the fourth month of pregnancy until 1-year post partum. The programme delivers reproductive, maternal, neonatal and child health information directly to subscribers' phones. However, little is known about the reach of Kilkari among different subgroups in the population, or the differentiated benefits of the programme among these subgroups. In this analysis, we assess differentials in eligibility, enrolment, reach, exposure and impact across well-known proxies of socioeconomic position-that is, education, caste and wealth. Data are drawn from a randomised controlled trial (RCT) in Madhya Pradesh, India, including call data records from Kilkari subscribers in the RCT intervention arm, and the National Family Health Survey-4, 2015. The analysis identifies that disparities in household phone ownership and women's access to phones create inequities in the population eligible to receive Kilkari, and that among enrolled Kilkari subscribers, marginalised caste groups and those without education are under-represented. An analysis of who is left behind by such interventions and how to reach those groups through alternative communication channels and platforms should be undertaken at the intervention design phase to set reasonable expectations of impact. Results suggest that exposure to Kilkari has improved levels of some health behaviours across marginalised groups but has not completely closed pre-existing gaps in indicators such as wealth and education.

Prevalence of Food Insecurity Among Pregnant Women: A Canadian Study in a Large Urban Setting.

OBJECTIVE: Nutritional and financial needs increase during pregnancy, making pregnant women particularly vulnerable to food insecurity. Our objective was to document the prevalence of food insecurity among pregnant women receiving prenatal care in an urban centre in Canada and to identify factors associated with food insecurity. METHODS: This cross-sectional study recruited pregnant women receiving prenatal care at one of two Toronto hospitals: Site 1 and Site 2 (serving a more disadvantaged population) between October 1, 2018 and October 1, 2019. Demographic information was collected, and the U.S. Household Food Security Survey Module was used to assess food security. Comparisons were made using χ2 tests, two-tailed t tests, or Mann-Whitney tests for categorical and continuous variables, as appropriate. Binary logistic regression and multivariate analyses were performed to assess associations with food insecurity and differences between hospitals sites. RESULTS: We recruited 626 participants (316 at Site 1 and 310 at Site 2). Prevalence of food insecurity was 12.8% among all participants with Site 2 having nearly 5 times the prevalence of Site 1 (66/310 [21.3%] vs. 14/316 [4.4%]; P = 0.001). Several factors were associated with food insecurity, with non-White ethnicity (OR 2.04; 95% CI 0.98-4.25, P = 0.055] and lower household income (OR 37.53; 95% CI 14.04-100, P < 0.001 when less than CAD $23 000/y) being the most robust. CONCLUSION: This Canadian study documented the prevalence of and factors associated with food insecurity in pregnancy. Targeted interventions to help low-income women and programs geared towards non-White women may be beneficial in addressing food insecurity among pregnant women.

The evolution and utilization of telehealth in ambulatory nutrition practice.

The term telehealth is often used interchangeably with telemedicine. Telemedicine involves the electronic exchange of medical information between two remote sites for the optimization of patient care, whereas telehealth is the application of all electronic communication and delivery systems in the provision of healthcare. Telehealth gives patients an opportunity to communicate with their healthcare providers and, overall, access ambulatory care that otherwise is not available in their area of residence. Several telehealth delivery systems are available for electronic communication. Telehealth and other communications technologies used in the delivery of healthcare services are regulated at both the federal and state levels. Coverage and payment policies vary among the different insurers (e.g., Medicare, Medicaid, and private plans), and policies may further be defined by state telehealth parity laws. Telenutrition involves the use of digital technology to provide nutrition care to patients and caregivers and shows potential to optimize nutrition care and outcomes. The coronavirus disease 2019 pandemic has contributed to sweeping legislative and regulatory changes that allowed the temporary expansion of telehealth delivery and reimbursement to maintain continuity of care for patients who were not able to come in for an in-person office visit with their healthcare provider. The purpose of this review is to introduce key concepts of telehealth delivery systems including policy, legal, and regulatory considerations for ambulatory care as well as the role of telenutrition in nutrition care, and highlight the evolving role of telehealth in optimizing patient and nutrition care during a pandemic and beyond.

Does women's mobile phone ownership matter for health? Evidence from 15 countries.

Mobile phones have the potential to increase access to health information, improve patient-provider communication, and influence the content and quality of health services received. Evidence on the gender gap in ownership of mobile phones is limited, and efforts to link phone ownership among women to care-seeking and practices for reproductive maternal newborn and child health (RMNCH) have yet to be made. This analysis aims to assess household and women's access to phones and its effects on RMNCH health outcomes in 15 countries for which Demographic and Health Surveys data on phone ownership are available. Multilevel logistic regression models were used to explore factors associated with women's phone ownership, along with the association of phone ownership to a wide range of RMNCH indicators. Study findings suggest that (1) gender gaps in mobile phone ownership vary, but they can be substantial, with less than half of women owning mobile phones in several countries; (2) the gender gap in phone ownership is larger for rural and poorer women; (3) women's phone ownership is generally associated with better RMNCH indicators; (4) among women phone owners, utilisation of RMNCH care-seeking and practices differs based on their income status; and (5) more could be done to unleash the potential of mobile phones on women's health if data gaps and varied metrics are addressed. Findings reinforce the notion that without addressing the gender gap in phone ownership, digital health programmes may be at risk of worsening existing health inequities.

Are stage-based health information messages effective and good value for money in improving maternal newborn and child health outcomes in India? Protocol for an individually randomized controlled trial.

BACKGROUND: Evidence is limited on the effectiveness of mobile health programs which provide stage-based health information messages to pregnant and postpartum women. Kilkari is an outbound service that delivers weekly, stage-based audio messages about pregnancy, childbirth, and childcare directly to families in 13 states across India on their mobile phones. In this protocol we outline methods for measuring the effectiveness and cost-effectiveness of Kilkari. METHODS: The study is an individually randomized controlled trial (iRCT) with a parallel, partially concurrent, and unblinded design. Five thousand pregnant women will be enrolled from four districts of Madhya Pradesh and randomized to an intervention or control arm. The women in the intervention arm will receive Kilkari messages while the control group will not receive any Kilkari messages as part of the study. Women in both arms will be followed from enrollment in the second and early third trimesters of pregnancy until one year after delivery. Differences in primary outcomes across study arms including early and exclusive breastfeeding and the adoption of modern contraception at 1 year postpartum will be assessed using intention to treat methodology. Surveys will be administered at baseline and endline containing modules on phone ownership, geographical and demographic characteristics, knowledge, practices, respectful maternity care, and coverage for antenatal care, delivery, and postnatal care. In-depth interviews and focus group discussions will be carried out to understand user perceptions of Kilkari, and more broadly, experiences providing phone numbers and personal health information to health care providers. Costs and consequences will be estimated from a societal perspective for the 2018-2019 analytic time horizon. DISCUSSION: Kilkari is the largest maternal messaging program, in terms of absolute numbers, currently being implemented globally. Evaluations of similar initiatives elsewhere have been small in scale and focused on summative outcomes, presenting limited evidence on individual exposure to content. Drawing upon system-generated data, we explore linkages between successful receipt of calls, user engagement with calls, and reported outcomes. This is the first study of its kind in India and is anticipated to provide the most robust and comprehensive evidence to date on maternal messaging programs globally. TRIAL REGISTRATION: Clinicaltrials.gov, 90075552, NCT03576157 . Registered on 22 June 2018.

Effective Implementation of Peri-operative Local Guidelines for Metabolic Surgery in Patients with Diabetes Mellitus in a Tier 4 Setting Demonstrate Improved Work Efficiency and Resource Allocation.

BACKGROUND: Dynamic changes in glycaemia predominate peri-operatively in patients with type 2 diabetes mellitus (T2DM) undergoing metabolic surgery. There is a lack of consensus and clear guidance on effective glycaemic management of such patients. The aim of this study was to design, pilot, and implement a proforma to improve consistency of glycaemic management and clarity of communication with healthcare professionals following metabolic surgery in patients with T2DM, thereby reducing unnecessary diabetes specialist nurse (DSN) referrals. METHODS: A proforma was designed and piloted for 12 months to guide healthcare professionals on managing glycaemic therapies for T2DM patients undergoing metabolic surgery. Glycaemic control (HbA1c) and glycaemic therapies were reviewed 3 weeks pre-operatively and a proforma was completed accordingly. RESULTS: Of the patients with T2DM (n = 34) who underwent metabolic surgery prior to the new proforma being implemented, 71% (n = 24) had a DSN referral. Half of these referrals were deemed unnecessary by the DSNs. Of the patients with T2DM (n = 33) who underwent metabolic surgery following implementation of the proforma, 21% (n = 7) had a DSN referral. Only 10% of these were deemed unnecessary. Despite the reduced DSN input, no diabetes-related complications were reported. CONCLUSION: Implementation of our proforma effectively halved the proportion of patients with T2DM requiring a DSN referral. Additionally, there was a 40% absolute reduction in the proportion of unnecessary DSN referrals. The proforma improved clarity of communication and guidance for healthcare professionals in the glycaemic management of patients. This also facilitated improved work efficiency and resource allocation.

Development of a Curricular Framework for Pediatric Hospital Medicine Fellowships.

Pediatric Hospital Medicine (PHM) is an emerging field in pediatrics and one that has experienced immense growth and maturation in a short period of time. Evolution and rapid expansion of the field invigorated the goal of standardizing PHM fellowship curricula, which naturally aligned with the field's evolving pursuit of a defined identity and consideration of certification options. The national group of PHM fellowship program directors sought to establish curricular standards that would more accurately reflect the competencies needed to practice pediatric hospital medicine and meet future board certification needs. In this manuscript, we describe the method by which we reached consensus on a 2-year curricular framework for PHM fellowship programs, detail the current model for this framework, and provide examples of how this curricular framework may be applied to meet the needs of a variety of fellows and fellowship programs. The 2-year PHM fellowship curricular framework was developed over a number of years through an iterative process and with the input of PHM fellowship program directors (PDs), PHM fellowship graduates, PHM leaders, pediatric hospitalists practicing in a variety of clinical settings, and other educators outside the field. We have developed a curricular framework for PHM Fellowships that consists of 8 education units (defined as 4 weeks each) in 3 areas: clinical care, systems and scholarship, and individualized curriculum.

Current Roles and Perceived Needs of Pediatric Hospital Medicine Fellowship Graduates.

OBJECTIVES: Pediatric hospitalists report the need for additional training in clinical and nonclinical domains. Pediatric hospital medicine (PHM) fellowships seek to provide this training and produce leaders in the field. Our objective is to describe current roles and perceived training needs of PHM fellowship graduates. METHODS: In 2014, all PHM fellowship graduates were asked to complete a Web-based survey. Survey questions addressed demographics, past training, current roles, and training needs in clinical care, research, education, and administration. Associations between fellowship experiences and outcomes were examined. RESULTS: Fifty-one of 61 eligible individuals completed the survey. Average duration as a pediatric hospitalist was 5 years. Ninety percent completed pediatric categorical residency, whereas 10% completed an Internal Medicine-Pediatrics Residency. Most respondents completed a 1- (38%) or 2-year (46%) fellowship program. Ninety-six percent of respondents currently work in academic environments. The perceived need for additional clinical training was low, except procedures (44%). Nearly all teach medical students and pediatric residents, reporting adequate training in variety of teaching strategies. The majority of respondents conduct research, most commonly quality improvement (QI; 67%) and education (52%). Two-thirds are first authors on at least 1 peer-reviewed article. Research training needs include QI methodology (44%), biostatistics (43%), and obtaining funding (54%). A considerable number of respondents have academic leadership positions. CONCLUSIONS: PHM fellowship graduates are academic hospitalists with diverse responsibilities. Despite a short average career span, many have achieved leadership roles and been academically productive. Future curriculum development should focus on procedures, QI, and research training.

The current state of pediatric hospital medicine fellowships: A survey of program directors.

BACKGROUND: Pediatric hospital medicine (PHM) fellowship programs have grown rapidly over the last 20 years and have varied in duration and content. In an effort to standardize training in the absence of a single accrediting body, PHM fellowship directors now meet annually to discuss strategies for standardizing and enhancing training. OBJECTIVES: To explore similarities and differences in curricular structure among PHM fellowship programs in an effort to inform future curriculum standardization efforts. METHODS: An electronic survey was distributed by e-mail to all PHM fellowship directors in April 2014. The survey consisted of 30 multiple-choice and short-answer questions focused on various curricular aspects of training developed by the authors. RESULTS: Twenty-seven of 31 fellowship programs (87%) responded to the survey. Duration of most programs was 2 years (63%), with 6, 1-year programs (22%) and 4 (15%) 3-year programs making up the remainder. The average amount of clinical time among programs was 50% (range approximately 20%-65%). In addition to general inpatient pediatric service time, most programs require other clinical rotations. The majority of programs allow fellows to bill independently for their services. Most programs offer certificate courses, courses for credit or noncredit courses, with 11 programs offering masters' degrees. Twenty-one (81%) programs provide a scholarship oversight committee for their fellows. Current fellows' primary areas of research are varied. CONCLUSION: Though variability exists regarding program length, clinical composition, and nonclinical offerings, several common themes emerged that may help inform the development of a standard curriculum for use across all programs. This information provides a useful starting point if pediatric hospital medicine obtains formal subspecialty status. Journal of Hospital Medicine 2016;11:324-328. © 2016 Society of Hospital Medicine.

Correction: Cost Resulting from Anti-Tuberculosis Drug Shortages in the United States: A Hypothetical Cohort Study.

[This corrects the article DOI: 10.1371/journal.pone.0134597.].

Cost Resulting from Anti-Tuberculosis Drug Shortages in the United States: A Hypothetical Cohort Study.

BACKGROUND: From 2012 through 2014, the United States experienced acute shortages and price escalations of several first-line anti-tuberculosis (TB) medications. Because secondary TB drug regimens are longer and adverse events occur more frequently with them, we sought to conservatively estimate the cost, to patients and the health care system, of TB treatment and medication adverse events from alternative regimens during drug shortages. METHODS: We assessed the cost of treatment for TB disease in the absence of isoniazid (INH), rifampin (RIF), or pyrazinamide (PZA), or both INH and RIF. We simulated adverse events based on published probabilities using a monthly discrete-time stochastic model. For total costs, we summed costs of medications, routine testing, and treatment of adverse events using procedural terminology codes. We report average cost ratios of TB treatment during drug shortages to standard TB treatment. RESULTS: The cost ratio of TB treatment without INH, RIF, or PZA to standard treatment was 1.7 (Range: 1.2, 2.3), 4.9 (Range: 3.2, 7.3), and 1.1 (Range: 0.7, 1.7) times higher, respectively. Without both INH and RIF, the cost ratio was 18.6 (Range: 10.0, 39.0) times higher. When the prices for INH, RIF and PZA were increased, the cost for standard treatment increased by a factor of 2.7 (Range: 1.9, 3.0). The percentage of patients experiencing at least one adverse event while taking standard therapy was 3.9% (Range: 1.3%, 11.8%). This percentage increased to 51.5% (Range: 20.1%, 83.8%) when RIF was unavailable, and increased to 82.5% (Range: 41.2%, 98.5%) when both INH and RIF were unavailable. CONCLUSIONS: Our conservative model illustrates that an interruption in first-line anti-TB medications leads to appreciable additional costs and adverse events for patients. The availability of these drugs in the United States should be ensured. Models that incorporate the effectiveness of alternative regimens, delays in treatment initiation, and TB transmission can provide broader perspectives on the impact of drug shortages.

Bridging populations-sexual risk behaviors and HIV prevalence in clients and partners of female sex workers, Bangkok, Thailand 2007.

The aim of this study is to estimate HIV prevalence and assess sexual behaviors in a high-risk and difficult-to-reach population of clients of female sex workers (FSWs). A modified variation of respondent-driven sampling was conducted among FSWs in Bangkok, where FSWs recruited 3 FSW peers, 1 client, and 1 nonpaying partner. After informed consent was obtained, participants completed a questionnaire, were HIV-tested, and were asked to return for results. Analyses were weighted to control for the design of the survey. Among 540 FSWs, 188 (35%) recruited 1 client, and 88 (16%) recruited 1 nonpaying partner. Clients' median age was 38 years. HIV prevalence was 20% and was associated with younger age at first sexual experience [relative risk (RR) = 3.10, 95% confidence interval (CI) 1.16-8.24] and condom use during last sexual encounter with regular partner (RR = 3.97, 95% CI 1.09-14.61). Median age of nonpaying partners was 34 years, and HIV prevalence was 15.1%. There were 56 discordant FSW-client pairs and 14 discordant FSW-nonpaying partner pairs. Condom use was relatively high among discordant FSW-client pairs (90.1%) compared to discordant FSW-nonpaying partner pairs (18.7%). Results suggest that sexual partners of FSWs have a high HIV prevalence and can be a bridge for HIV transmission to other populations. Findings also highlight the importance of initiating surveillance and targeted programs for FSW partners, and demonstrate a recruitment method for hard-to-reach populations.