In the Interest of Time: Assessing the Role of Resilience Across an Intergenerational Sample of People Living with HIV.

BACKGROUND: Biomedical advances have improved the quality of life of people living with HIV (PLWH); however, barriers to optimal well-being remain. A key feature in understanding the lived experiences of PLWH is resilience. The concept of resilience is quite complex in terms of its antecedents and expressions, suggesting the need for more nuanced understandings of how it could be harnessed to better support this population. METHOD: The concept of resilience was explored in a qualitative study involving 22 PLWH, selectively sampled by era of diagnosis. Through interviews focused on context and experiences of living with HIV, the sample highlighted resilience processes corresponding to Positive reappraisal of life events, Positive reappraisal of self, and Community as resilience. RESULTS: Participants who have lived with HIV longer more commonly described engaging in psychological processes of resilience, whereas those who were more recently diagnosed reported engaging in more social processes. However, these processes were not mutually exclusive and the ability to perform resilience through community seems to be key to optimizing outcomes, irrespective of era of diagnosis. CONCLUSION: PLWH are a heterogeneous population where engagement in distinct processes of resilience may have important implications for optimal social and health outcomes. Better understanding of the distinct and diverse pathways through which PLWH engage in resilience may inform interventions promoting optimal well-being.

Narratives of Disconnection: A Life Course Perspective of Methamphetamine Use Among Sexual Minority Men Living with HIV.

BACKGROUND: Sexual minority men (SMM) are exposed to societal and structural stressors that translate into poor health outcomes. One such outcome is substance use, which research has long documented as a prominent disparity among SMM. Methamphetamine is a particularly deleterious substance for SMM because its use is often framed as a coping response to social and structural stressors. METHOD: Guided by stress and coping theory and a life course perspective, the purpose of this qualitative study is to assess the development of coping strategies in the context of prominent social and structural determinants among SMM living with HIV who use methamphetamine. RESULTS: Data were collected from 2016 to 2018 via in-depth interviews with 24 SMM living with HIV who use methamphetamine in San Francisco, CA. Mean age of participants was 47 and over half self-identified as ethnoracial minorities. Narrative analysis surfaced a sequential pattern of disconnection at foundational, relational, and recovery levels. This analysis revealed that multi-level stressors were present across the life course that amplified engagement in methamphetamine use. CONCLUSION: Findings highlight the benefits of holistic, integrated, and trauma-informed approaches to address the function of methamphetamine use as a response to societal, cultural, and institutional processes of stigmatization and discrimination. Peer-based approaches may also be beneficial to reframe the ways in which SMM living with HIV who use methamphetamine form and sustain relationships.

HIV-related drivers of sexual compulsivity and sexuality in sexual minority men who use methamphetamine.

Although co-occurring methamphetamine (meth) use and HIV amplify the risk for neuropsychiatric comorbidities, the underlying neuroimmune mechanisms are not well characterized. We examined whether a detectable viral load and dysregulated metabolism of amino acid precursors for neurotransmitters predicted subsequent levels of sexual compulsivity and sexual sensation seeking. This 15-month longitudinal study enrolled 110 sexual minority men (SMM) living with HIV who had biologically confirmed meth use (i.e., reactive urine or hair toxicology results). Peripheral venous blood samples collected at baseline, 6 months, 12 months, and 15 months were used to measure a detectable viral load (> 40 copies/mL), the kynurenine/tryptophan (K/T) ratio, and the phenylalanine/tyrosine (P/T) ratio. The K/T and P/T ratios index dysregulated serotonin and catecholamine (e.g., dopamine) synthesis, respectively. In a cross-lagged panel model, a detectable viral load at 6 months predicted greater sexual compulsivity at 12 months after adjusting for prior levels of sexual compulsivity and recent stimulant use (ß = 0.26, p = 0.046). A greater P/T ratio at baseline predicted decreased sexual sensation seeking at 6 months (ß = - 0.25, p = 0.004) after adjusting for baseline sexual sensation seeking and recent stimulant use. Taken together, HIV replication and dysregulated catecholamine synthesis could potentiate sexual compulsivity while decreasing sexual pleasure in SMM who use meth.

PrEP uptake as a social movement among gay and bisexual men.

Despite PrEP's effectiveness as an HIV prevention intervention, uptake among gay and bisexual men remains low. Historical involvement in AIDS activism may reveal important ways of mobilising gay and bisexual men to increase PrEP uptake. Data come from a qualitative study to understand New York City gay and bisexual men's experiences with PrEP. Informed by a constructivist grounded theory approach, we assessed ways in which gay and bisexual men's relational experiences concerning PrEP were congruent with features of past AIDS activism. Participants' mean age was 32.5 years, half were men of colour, and over half had been taking PrEP for less than one year. Analysis revealed three primary themes related to AIDS activism strategies: (1) framing, which referenced how participants referred to PrEP as an empowering, liberatory and community-building intervention (2) reactions, which encompassed positive to negative expressions about PrEP and sex; and (3) innovation, which conveyed ways that participants engaged in processes of transferring lay knowledge about PrEP through leadership roles across social and digital encounters. Findings suggest that the ways in which gay and bisexual men communicate about PrEP with peers are consistent with features of AIDS activism. Deploying lay knowledge using framing strategies through peer-based intervention could expand PrEP uptake. However, elements of PrEP stigma must be addressed to engage with the wide-ranging HIV prevention needs of gay and bisexual men.

Finding Sunshine on a Cloudy Day: A Positive Affect Intervention for Co-Occurring Methamphetamine Use and HIV.

Among sexual minority men (i.e., gay, bisexual, and other men who have sex with men) living with HIV, those who use methamphetamine experience profound health disparities. Affect Regulation Treatment to Enhance Methamphetamine Intervention Success (ARTEMIS) is an evidence-based, 5-session, individually delivered positive affect intervention adapted for sexual minority men living with HIV who use methamphetamine. ARTEMIS was designed to amplify the benefits of evidence-based substance use interventions such as contingency management (CM) with this high-priority population. Delivering ARTEMIS during CM has been shown to assist participants in reducing stimulant use, increasing positive affect, and achieving durable reductions in HIV viral load. We describe the theoretical underpinnings of the ARTEMIS intervention, provide details of the training and session protocols with a case example, and discuss implications for future applications in research and clinical settings.

Factors influencing referrals for ultrasound-diagnosed complications during prenatal care in five low and middle income countries.

BACKGROUND: Ultrasound during antenatal care (ANC) is proposed as a strategy for increasing hospital deliveries for complicated pregnancies and improving maternal, fetal, and neonatal outcomes. The First Look study was a cluster-randomized trial conducted in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia to evaluate the impact of ANC-ultrasound on these outcomes. An additional survey was conducted to identify factors influencing women with complicated pregnancies to attend referrals for additional care. METHODS: Women who received referral due to ANC ultrasound findings participated in structured interviews to characterize their experiences. Cochran-Mantel-Haenszel statistics were used to examine differences between women who attended the referral and women who did not. Sonographers' exam findings were compared to referred women's recall. RESULTS: Among 700 referred women, 510 (71%) attended the referral. Among referred women, 97% received a referral card to present at the hospital, 91% were told where to go in the hospital, and 64% were told that the hospital was expecting them. The referred women who were told who to see at the hospital (88% vs 66%), where to go (94% vs 82%), or what should happen, were more likely to attend their referral (68% vs 56%). Barriers to attending referrals were cost, transportation, and distance. Barriers after reaching the hospital were substantial. These included not connecting with an appropriate provider, not knowing where to go, and being told to return later. These barriers at the hospital often led to an unsuccessful referral. CONCLUSIONS: Our study found that ultrasound screening at ANC alone does not adequately address barriers to referrals. Better communication between the sonographer and the patient increases the likelihood of a completed referral. These types of communication include describing the ultrasound findings, including the reason for the referral, to the mother and staff; providing a referral card; describing where to go in the hospital; and explaining the procedures at the hospital. Thus, there are three levels of communication that need to be addressed to increase completion of appropriate referrals-communication between the sonographer and the woman, the sonographer and the clinic staff, and the sonographer and the hospital. TRIAL REGISTRATION: NCT01990625 .

Navigating Barriers to Vocational Rehabilitation for HIV-Positive Persons.

This study documented the outcomes of 108 HIV-positive persons receiving vocational rehabilitation services. Over a 12-month follow-up, participants reported significantly decreased odds of any unstable housing [Adjusted Odds Ratio (AOR) = 0.21; 95 % CI 0.05-0.90; p < .05] and increased odds of being employed at least part-time (AOR = 10.19; 95 % CI 2.40-43.21; p < .01). However, reductions in perceived barriers to employment and increases in income were more pronounced among those not receiving disability benefits at baseline. This was consistent with findings from baseline qualitative interviews with 22 participants where those not on disability were subject to bureaucratic hurdles to rapidly accessing benefits and anticipated stigma of being on disability that propelled them to rejoin the workforce. Vocational rehabilitation could address key structural barriers to optimizing HIV treatment as prevention, and novel approaches are needed to improve outcomes among individuals receiving disability benefits.

A community-engaged randomized controlled trial of an integrative intervention with HIV-positive, methamphetamine-using men who have sex with men.

BACKGROUND: Contingency management (CM) is an evidence-based intervention providing tangible rewards as positive reinforcement for abstinence from stimulants such as methamphetamine. Integrative approaches targeting affect regulation could boost the effectiveness of CM in community-based settings and optimize HIV/AIDS prevention efforts. METHODS/DESIGN: This randomized controlled trial with HIV-positive, methamphetamine-using men who have sex with men (MSM) is examining the efficacy of a 5-session, individually delivered positive affect regulation intervention - Affect Regulation Treatment to Enhance Methamphetamine Intervention Success (ARTEMIS). ARTEMIS is designed to sensitize individuals to non-drug-related sources of reward as well as assist with managing depression and other symptoms of stimulant withdrawal during CM. HIV-positive, methamphetamine-using MSM who are enrolled in a community-based, 12-week CM program are randomized to receive ARTEMIS or an attention-matched control condition. Follow-up assessments are conducted at 3, 6, 12, and 15 months after enrollment in CM. Four peripheral venous blood samples are collected over the 15-month follow-up with specimen banking for planned biomarker sub-studies. The primary outcome is mean HIV viral load. Secondary outcomes include: sustained HIV viral suppression, T-helper cell count, psychological adjustment, stimulant use, and potentially amplified transmission risk behavior. DISCUSSION: Implementation of this randomized controlled trial highlights the importance of delineating boundaries between research activities and community-based service provision. It also provides insights into best practices for integrating the distinct agendas of academic and community partners in clinical research. This trial is currently enrolling and data collection is anticipated to be completed in September of 2018. TRIAL REGISTRATION: This trial was registered on clinicaltrials.gov ( NCT01926184 ) on August 16, 2013.

Pilot randomized controlled trial of an integrative intervention with methamphetamine-using men who have sex with men.

Contingency management (CM) is an evidence-based intervention that provides tangible rewards as positive reinforcement for biologically confirmed abstinence from substance use. Integrative approaches targeting positive affect regulation could boost the effectiveness of CM by sensitizing individuals to non-drug-related sources of reward and assisting them with effectively managing symptoms of withdrawal. This pilot randomized controlled trial with 21 methamphetamine-using men who have sex with men (MSM) examined the feasibility and acceptability of a 5-session, positive affect intervention delivered during CM-Affect Regulation Treatment to Enhance Methamphetamine Intervention Success (ARTEMIS). After completing 4 weeks of a 12-week CM program, participants were randomized to receive ARTEMIS+CM (n = 12) or CM-only (n = 9). Those randomized to receive the ARTEMIS positive affect intervention completed 98 % of sessions and reported marginally significant increases in positive affect over the five sessions. In exit interviews with ARTEMIS+CM participants, individuals noted that the positive affect regulation skills increased self-awareness and led to greater engagement in the recovery process. ARTEMIS+CM participants reported significant increases in positive affect and CM-only participants reported significant reductions in negative affect over a 2-month follow-up. These affective changes were not maintained, and no concurrent effects on stimulant use or sexual risk taking were observed over the 6-month follow-up. More definitive clinical research is necessary to examine the efficacy of ARTEMIS+CM with methamphetamine-using MSM.

Using stated preference methods to design cost-effective subsidy programs to induce technology adoption: an application to a stove program in southern Chile.

We study the design of an economic incentive based program - a subsidy - to induce adoption of more efficient technology in a pollution reduction program in southern Chile. Stated preferences methods, contingent valuation (CV), and choice experiment (CE) are used to estimate the probability of adoption and the willingness to share the cost of a new technology by a household. The cost-effectiveness property of different subsidy schemes is explored numerically for different regulatory objectives. Our results suggest that households are willing to participate in voluntary programs and to contribute by paying a share of the cost of adopting more efficient technologies. We find that attributes of the existing and the new technology, beyond the price, are relevant determinant factors of the participation decision and payment. Limited access to credit markets for low income families can be a major barrier for an effective implementation of these types of programs. Variations in the design of the subsidy and on the regulator's objective and constraints can have significant impact on the level and the cost of reduction of aggregate emissions achieved.

Provider Perspectives on Multi-level Barriers and Facilitators to PrEP Access Among Latinx Sexual and Gender Minorities.

Although pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention intervention, inequities in access remain among Latinx sexual and gender minorities (LSGM). There is also a gap in the PrEP literature regarding providers' perspective on access inequities. This qualitative case study sought to explore barriers and facilitators to PrEP engagement in a community-based integrated health center primarily serving Latinx populations in Northern California. We conducted in-depth, semi-structured interviews with providers (9/15) involved in PrEP services and engaged in a constructivist grounded theory analysis consisting of memoing, coding, and identifying salient themes. Three participants worked as medical providers, three as outreach staff, and one each in planning, education, and research. The analysis surfaced four themes: geopolitical differences, culture as barrier, clinic as context, and patient strengths and needs. Participants referenced a lack of resources to promote PrEP, as well as the difficulties of working within an institution that still struggles with cultural and organizational mores that deprioritize sexual health. Another barrier is related to sexual health being positioned outside of patients' immediate needs owing to structural barriers, including poverty, documentation status, and education. Participants, however, observed that peer-based models, which emboldened their decision-making processes, were conducive to better access to PrEP, as well as allowing them to build stronger community ties. These data underscore the need for interventions to help reduce sexual stigma, promote peer support, and ameliorate structural barriers to sexual healthcare among LSGM.

A Multi-Component Intervention to Improve Therapeutic Adherence in Uncontrolled Hypertensive Patients Within the Primary Care Level: A Before-and-After Study.

INTRODUCTION: Non-adherence to medication severely affects chronic disease control. AIM: To assess whether a multi-component intervention implemented at the public primary care level in Argentina improves adherence to antihypertensive medication and helps to reduce blood pressure (BP) levels in uncontrolled hypertensive patients. METHODS: A before-and-after study was conducted in five public primary care clinics located in the city of Almirante Brown, Argentina. One hundred and twenty-five uncontrolled hypertensive patients received a multi-component intervention based on the Chronic Care model and the 5As strategy (Ask, Advise, Agree, Assist, and Arrange). Medication possession ratio (MPR) and BP values were assessed before and after a 6-month period. RESULTS: The follow-up rate was 96.8%. Main baseline characteristics were as follows, male: 44.8%, mean age: 57.1 years (± 8.1), exclusive public healthcare coverage: 83.5%, primary school level or less: 68.8%, and mean systolic/diastolic BP: 157.4 (± 13.6)/97.7 (± 8.2) mmHg. After implementing the intervention, a significant increase in the proportion of adequate adherence (MPR ≥ 80%) was observed, from 16.8% at baseline to 47.2% (p < 0.001). A significant reduction of 16.4 mmHg (CI 95%: 19.6, 13.1) was observed for systolic blood pressure (SBP) and 12.0 mmHg (CI 95%: 14.2, 9.9) for diastolic blood pressure (DBP) (p < 0.001). At 6 months, 51.2% of the population achieved blood pressure control (SBP < 140 mmHg and DBP < 90 mmHg). CONCLUSIONS: The study intervention was associated with an increased adherence rate, achieving a significant reduction in BP values and reaching BP control in more than half of the population.

Assessing PrEP messaging and communication: A review of the qualitative literature.

Pre-exposure prophylaxis (PrEP) is a biomedical HIV prevention intervention approved by the FDA in 2012. Nevertheless, most sexual minority men (SMM) who could benefit from its use are not currently prescribed PrEP. The literature during the first decade of PrEP availability has suggested a diverse set of multi-level barriers and facilitators to PrEP uptake and adherence. Through a scoping review, 16 qualitative studies were surveyed to assess these barriers and facilitators, specifically regarding messaging and communication. Seven main themes were identified: information & misinformation, peer messaging, expansion of sexual experiences, relationships with providers, expectations & stigma, navigation support, and barriers to uptake & adherence. Data suggest that peer support, messaging around empowerment and agency, and PrEP's role in shifting sociosexual norms contributed to uptake and adherence. On the other hand, stigma, provider disconnection, and access issues hindered PrEP uptake and adherence. Findings could inform multi-level, strengths-based, and holistic approaches to designing effective interventions for PrEP engagement among SMM.

Development of an Implementation Facilitation Strategy to Link Mental Health Screening and eHealth Intervention for Clients in Ryan White-Funded Clinics in Chicago.

BACKGROUND: To reduce the impact of depression on people living with HIV, we are implementing a clinic-based behavioral health screener and referral to Optimizing Resilience and Coping with HIV through Internet Delivery, an evidenced-based intervention. We used the Consolidated Framework for Implementation Research to identify contextual barriers and facilitators in advance of implementation. SETTING: Sixteen Chicagoland area Ryan White Medical Case Management sites. METHODS: We conducted a sequential mixed-methods study with medical case managers and supervisors. Participants completed an online survey assessing Consolidated Framework for Implementation Research domains, scored on a 1 (strongly disagree) to 5 (strongly agree) scale. Survey results informed a purposive sampling frame and interview protocol. Interviews were analyzed by rapid qualitative analysis. RESULTS: On average, survey respondents (n = 58) slightly agreed with positive views of team culture, learning climate, and implementation readiness (mean = 3.80-3.87). Potential barriers included intervention complexity (mean = 3.47), needed human resources (mean = 2.71-3.33), and only slight agreement with relative advantage over existing screening/referral systems (mean = 3.09-3.71). Qualitative results (n = 15) identified low advantage for clinics with robust behavioral health systems but strong advantage in clinics without these services. Respondents identified system-wide training and monitoring strategies to facilitate implementation. CONCLUSIONS: Ryan White Medical Case Management sites are a generally favorable context for the implementation of the interventions. As illustrated in an implementation research logic model, barriers will be addressed through deploying strategies proposed to impact clinic- and individual-level outcomes, including electronic prompts (reduce complexity), training on Optimizing Resilience and Coping with HIV through Internet Delivery as a complement to other behavioral health services (increase relative advantage), and feedback during implementation (strengthen rewards/incentives).

The couple as context: Latino gay male couples and HIV.

HIV-prevention efforts with gay men in relationships frequently omit primary partners. When they are considered, examinations of race/ethnicity are often overlooked despite higher infection rates among gay men of colour. Acknowledging both the need to contextualise the behaviours that may affect HIV risk for gay men of colour and the disproportionate impact of HIV on Latino gay men, the present study utilised semi-structured, qualitative interviews to explore relationship dynamics, sexual agreements and behaviours, safer sex choices and HIV risk among nine Latino gay male couples. All participants were HIV-negative and in concordant negative relationships. Additionally, nearly all reported closed agreements. Analysis revealed participants engaging in four behaviours that may actively reduce their HIV risk: approaching sexual agreements from a practical standpoint, maintaining a high literacy around HIV, having exposure to social support groups for Latino gay men and finding support in their relationship with another Latino gay man. Additional issues are raised where long-term HIV prevention is concerned. Intimate relationships are an important context for understanding both HIV risk and prevention among Latino gay men. Likewise, race/ethnicity provides an indispensable perspective on all research with gay couples. Future prevention efforts with gay men must strive to include both.

Controlling urban air pollution caused by households: uncertainty, prices, and income.

We examine the control of air pollution caused by households burning wood for heating and cooking in the developing world. Since the problem is one of controlling emissions from nonpoint sources, regulations are likely to be directed at household choices of wood consumption and combustion technologies. Moreover, these choices are subtractions from, or contributions to, the pure public good of air quality. Consequently, the efficient policy design is not independent of the distribution of household income. Since it is unrealistic to assume that environmental authorities can make lump sum income transfers part of control policies, efficient control of air pollution caused by wood consumption entails a higher tax on wood consumption and a higher subsidy for more efficient combustion technologies for higher income households. Among other difficulties, implementing a policy to promote the adoption of cleaner combustion technologies must overcome the seemingly paradoxical result that efficient control calls for higher technology subsidies for higher income households.

Differential Effects of State Policy Environments on Substance Use by Sexual Identity: Findings From the 2000-2015 National Alcohol Surveys.

INTRODUCTION: This study explored whether structural stigma, defined by U.S. state policies related to sexual minority rights, moderated the relationship between sexual identity identity and heavy drinking, alcohol problems, and marijuana use among men and women. METHODS: Using combined data from the National Alcohol Survey (NAS) series (2000, 2005, 2010, and 2015), the sample included 11,115 men (421 sexual minority and 10,694 heterosexual) and 14,395 women (413 sexual minority and 13,982 heterosexual). State policy environment was assessed using a time-varying dichotomous indicator of comprehensive protections for sexual minorities (4-6 protections vs. limited or no protections). Gender-stratified logistic regression analyses examined the differential effect of the policy environment by sexual identity on three past-year substance use outcomes: high-intensity drinking (8+ drinks/day), any DSM-5 alcohol use disorder, and marijuana use. RESULTS: Among women, sexual minority status was associated with increased odds of all alcohol and marijuana use outcomes. Among men, sexual minority status was associated with decreased odds of high-intensity drinking but increased use of marijuana. Comprehensive policy protections were associated significantly decreased odds of high-intensity drinking among sexual minority men and marginally significant decreases among women. CONCLUSIONS: Comprehensive policy protections appear to be protective for high-intensity drinking among sexual minority men and women. Findings underscore the importance of supportive policies in reducing risk of alcohol-related problems among sexual minorities.

Including ultrasound scans in antenatal care in low-resource settings: Considering the complementarity of obstetric ultrasound screening and maternity waiting homes in strengthening referral systems in low-resource, rural settings.

Recent World Health Organization (WHO) antenatal care recommendations include an ultrasound scan as a part of routine antenatal care. The First Look Study, referenced in the WHO recommendation, subsequently shows that the routine use of ultrasound during antenatal care in rural, low-income settings did not improve maternal, fetal or neonatal mortality, nor did it increase women's use of antenatal care or the rate of hospital births. This article reviews the First Look Study, reconsidering the assumptions upon which it was built in light of these results, a supplemental descriptive study of interviews with patients and sonographers that participated in the First Look study intervention, and a review of the literature. Two themes surface from this review. The first is that focused emphasis on building the pregnancy risk screening skills of rural primary health care personnel may not lead to adaptations in referral hospital processes that could benefit the patient accordingly. The second is that agency to improve the quality of patient reception at referral hospitals may need to be manufactured for obstetric ultrasound screening, or remote pregnancy risk screening more generally, to have the desired impact. Stemming from the literature, this article goes on to examine the potential for complementarity between obstetric ultrasound screening and another approach encouraged by the WHO, the maternity waiting home. Each approach may address existing shortcomings in how the other is currently understood. This paper concludes by proposing a path toward developing and testing such a hybrid approach.

Evaluation of Focused Obstetric Ultrasound Examinations by Health Care Personnel in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan, and Zambia.

Prior studies have suggested that obstetrical (OB) ultrasound in low- and middle-income countries has aided in detection of high-risk conditions, which in turn could improve OB management. We are participating in a cluster-randomized clinical trial of OB ultrasound, which is designed to assess the effect of basic OB ultrasound on maternal mortality, fetal mortality, neonatal mortality, and maternal near-miss in 5 low-income countries. We designed a 2-week course in basic OB ultrasound, followed by 12 weeks of oversight, to train health care professionals with no prior ultrasound experience to perform basic OB ultrasound to screen for high-risk pregnancies. All patients with high-risk pregnancies identified by the trainees were referred to higher-level health facilities where fully trained sonographers confirmed the diagnoses before any actions were taken. Although there have been several published studies on basic OB ultrasound training courses for health care workers in low- and middle-income countries, quality control reporting has been limited. The purpose of this study is to report on quality control results of these trainees. Health care workers trained in similar courses could have an adjunctive role in ultrasound screening for high-risk OB conditions where access to care is limited. After completion of the ultrasound course, 41 trainees in 5 countries performed 3801 ultrasound examinations during a 12-week pilot period. Each examination was reviewed by ultrasound trainers for errors in scanning parameters and errors in diagnosis, using predetermined criteria. Of the 32,480 images comprising the 3801 examinations, 94.8% were rated as satisfactory by the reviewers. There was 99.4% concordance between trainee and reviewer ultrasound diagnosis. The results suggest that trained health care workers could play a role in ultrasound screening for high-risk OB conditions.