The Influence of a Wearable-Based Reward Program on Health Care Costs: Retrospective, Propensity Score-Matched Cohort Study.

BACKGROUND: Mobile health (mHealth) technology holds great promise as an easily accessible and effective solution to improve population health at scale. Despite the abundance of mHealth offerings, only a minority are grounded in evidence-based practice, whereas even fewer have line of sight into population-level health care spending, limiting the clinical utility of such tools. OBJECTIVE: This study aimed to explore the influence of a health plan-sponsored, wearable-based, and reward-driven digital health intervention (DHI) on health care spending over 1 year. The DHI was delivered through a smartphone-based mHealth app available only to members of a large commercial health plan and leveraged a combination of behavioral economics, user-generated sensor data from the connected wearable device, and claims history to create personalized, evidence-based recommendations for each user. METHODS: This study deployed a propensity score-matched, 2-group, and pre-post observational design. Adults (≥18 years of age) enrolled in a large, national commercial health plan and self-enlisted in the DHI for ≥7 months were allocated to the intervention group (n=56,816). Members who were eligible for the DHI but did not enlist were propensity score-matched to the comparison group (n=56,816). Average (and relative change from baseline) medical and pharmacy spending per user per month was computed for each member of the intervention and comparison groups during the pre- (ie, 12 months) and postenlistment (ie, 7-12 months) periods using claims data. RESULTS: Baseline characteristics and medical spending were similar between groups (P=.89). On average, the total included sample population (N=113,632) consisted of young to middle-age (mean age 38.81 years), mostly White (n=55,562, 48.90%), male (n=46,731, 41.12%) and female (n=66,482, 58.51%) participants. Compared to a propensity score-matched cohort, DHI users demonstrated approximately US $10 per user per month lower average medical spending (P=.02) with a concomitant increase in preventive care activities and decrease in nonemergent emergency department admissions. These savings translated to approximately US $6.8 million in avoidable health care costs over the course of 1 year. CONCLUSIONS: This employer-sponsored, digital health engagement program has a high likelihood for return on investment within 1 year owing to clinically meaningful changes in health-seeking behaviors and downstream medical cost savings. Future research should aim to elucidate health behavior-related mechanisms in support of these findings and continue to explore novel strategies to ensure equitable access of DHIs to underserved populations that stand to benefit the most.

Food insecurity, CD4 counts, and incomplete viral suppression among HIV+ patients from Texas Children's Hospital: a pilot study.

Determine the relationship between food insecurity and CD4 counts and viral suppression among pediatric HIV-positive patients. Food insecurity was assessed by validated survey. CD4 counts and viral load were abstracted from patients' charts. We used linear regression for the dependent variable of the natural log of CD4 counts and logistic regression for viral suppression, with backward deletion of covariates with p > 0.1. Food insecurity (ß = -0.23, 95 % CI [-0.40, -0.01]) was associated with lower CD4 counts and higher odds of incomplete viral suppression (OR = 4.07, 95 % CI [1.02, 13.92]). Food insecurity may adversely impact pediatric HIV outcomes.

Centralization of HIV services in HIV-positive African-American and Hispanic youth improves retention in care.

African-American and Hispanic HIV-infected youth are a high risk group for not remaining in HIV care. We examined differences in retention in care among 174 HIV-infected African-American and Hispanic youth between 13 and 23 years old who presented for HIV primary care between 1 January 2002 and 31 August 2008. Patients were included in three service eras, based on when they entered the clinic: when no youth-specific services were available (the decentralized era), after formation of a youth clinic staffed by adolescent providers and a case-manager (the centralized era), and after educational activities and support groups were added and the social services staff were trained in the use of motivational interviewing (the centralized with supportive services era). Patient and attendance data for the 12-months following entry into care were captured. Retention in HIV care was examined using two different measures: adequate visit constancy (at least three quarters with at least one visit in each quarter) and having a gap in care (two consecutive medical visits ≥180 days apart). Adequate visit constancy improved by service era from 31% in the decentralized era to 57% in the centralized era and 65% in the centralized with supportive services era (p=0.01). The percent of patients with no gap in care remained stable at about 80% in the decentralized and centralized eras, but then increased to 96% in the centralized with supportive services era (p=0.04). Results suggest that centralizing youth-specific care and expanding youth services can improve retention in HIV care. These system changes should be considered when resources allow.

Associations of cytokines, sleep patterns, and neurocognitive function in youth with HIV infection.

Youth infected with HIV at birth often have sleep disturbances, neurocognitive deficits, and abnormal psychosocial function which are associated with and possibly resulted from elevated blood cytokine levels that may lead to a decreased quality of life. To identify molecular pathways that might be associated with these disorders, we evaluated 38 HIV-infected and 35 uninfected subjects over 18-months for intracellular cytokine levels, sleep patterns and duration of sleep, and neurodevelopmental abilities. HIV infection was significantly associated with alterations of intracellular pro-inflammatory cytokines (TNF-α, IFN-γ, IL-12), sleep factors (total time asleep and daytime sleep patterns), and neurocognitive factors (parent and patient reported problems with socio-emotional, behavioral, and executive functions; working memory-mental fatigue; verbal memory; and sustained concentration and vigilance. By better defining the relationships between HIV infection, sleep disturbances, and poor psychosocial behavior and neurocognition, it may be possible to provide targeted pharmacologic and procedural interventions to improve these debilitating conditions.

Reverse transcriptase genotypes in pediatric patients failing initial antiretroviral therapy in Gaborone, Botswana.

BACKGROUND: Limited data are available on patterns of resistance mutations in pediatric patients in southern Africa, where HIV-1 subtype C (HIV-1C) predominates. METHODS: Retrospective chart review of pediatric patients. Nucleoside reverse transcriptase inhibitor (NRTI)- and nonnucleoside reverse transcriptase inhibitor (NNRTI)-associated resistance mutations quantified from population-based sequencing genotypic resistance assay results taken at time of first-line antiretroviral therapy (ART) failure (first-line ART = stavudine [d4T] or zidovudine [ZDV] + lamivudine [3TC] + nevirapine [NVP] or efavirenz [EFV]). RESULTS: Total number of patients with resistance assays analyzed is 45. Nucleoside reverse transcriptase inhibitor-associated mutation frequencies noted were M184V (n = 41; 91.1%); thymidine analogue mutations (TAMs; n = 20; 44.4%); >1 TAM (n = 9; 20%); TAM-2 pathway (n = 10; 22.2%); TAM-1 pathway (n = 7; 15.6%); TAM-1 and TAM-2 pathways (n = 3; 6.7%); K65R (n = 2; 4.4%); Q151M (n = 1; 2.2%); and L74V (n = 0; 0%). Nonnucleoside reverse transcriptase inhibitor-associated mutation frequencies noted were associated with notable resistance to either/both NVP and EFV (n = 40; 88.9%); K103N (n = 15; 33.3%); ≥1 mutations associated with etravirine (ETR) failure (K101E, Y181C, and G190A; n =20; 44.4%); and ≥2 notable NNRTI mutations (n = 12; 26.7%). CONCLUSIONS: In this cohort, low-genetic barrier mutations were common, as were TAMs, including more than 1 TAM. Mutations compromising nonthymidine analogue backbones were rare, suggesting that it is likely that children who fail first-line NRTI backbones containing d4T or ZDV/3TC would still respond to abacavir (ABC), didanosine (ddI), and, for adolescents, tenofovir (TDF). Our data support the empiric continuation of 3TC in second-line regimens.

Postexposure prophylaxis against human immunodeficiency virus.

Family physicians often encounter situations in which postexposure prophylaxis (PEP) with antiretroviral medications against human immunodeficiency virus (HIV) may be indicated. When the exposure source's HIV status is unknown and testing of the source is possible, use of a rapid HIV test kit may facilitate decision making at the point of care. When PEP is given, timing and duration are important, with data showing PEP to be most effective when initiated within 72 hours of exposure and continued for four weeks. Although two-drug PEP regimens are an option for some lower risk occupational exposures, three-drug regimens are advised for nonoccupational exposures. Sexual assault survivors should be given three-drug PEP regardless of assailant characteristics. In complicated situations, such as exposure of a pregnant woman or when a source is known to be infected with HIV, expert consultation is advised. In most cases, PEP is not indicated after an accidental needlestick in the community setting. Health care volunteers working abroad, particularly in areas of high HIV prevalence or where preferred PEP regimens may not be readily available, often choose to travel with personal supplies of PEP. Patients presenting for care after HIV exposure should have baseline testing for HIV antibodies, and follow-up HIV antibody testing at four to six weeks, three months, and six months after exposure.

Leprosy and international adoption: a case report and review of diagnostic and treatment dilemmas.

Hansen disease, commonly known as leprosy, is uncommon in the United States and poses difficult diagnostic and treatment challenges. A 10-year-old girl was adopted from Ethiopia with a history of "multibacillary leprosy" and "multidrug treatment" for 12 months. Three months after her arrival in the United States and 4 months after treatment was completed, she presented with new papules and plaques on her left nose and ear. Herein, we present her case and review current treatment options in leprosy in children and the management of immunologic reactions.

Risk factors of psychotropic polypharmacy in the treatment of children and adolescents with psychiatric disorders.

OBJECTIVE: To examine patient and provider characteristics associated with the use of pediatric psychotropic polypharmacy. METHODS: A retrospective study was conducted on children with psychiatric disorder diagnosis and treatment using the 2013-2015 claims data from a Pediatric Medicaid Managed Care Plan. Psychotropic polypharmacy was defined as the receipt of ≥2 psychotropic medications from different drug classes concurrently for ≥60 days. Stratified logistic regression analyses based on the number of prescribers involved in the treatment, i.e. single prescriber (SP) and multiple prescribers (MP) were conducted to determine the risk factors associated with multiclass psychotropic polypharmacy. The Fairlie decomposition method was used to test the difference in receipt of psychotropic polypharmacy between patients with and without a psychiatrist visit. RESULTS: A total of 24,147 children and adolescents met the inclusion criteria. The prevalence of psychotropic polypharmacy was 20.09%. In addition to patients' demographics, diagnoses, number of comorbid psychiatric disorders (MP only), and the number of prescribers involved in the treatment (MP only), patients with a psychiatrist involved in the treatment had 5.3 times and 3.6 times higher odds of receiving psychotropic polypharmacy in SP and MP groups respectively (SP: OR = 5.32; 95% CI 4.62-6.14 & MP: OR = 3.57; 95% CI 3.20-3.99). Only a quarter of the prescribing practice variation between psychiatrists and PCPs was explained by the observed need factors. CONCLUSIONS: Pediatric psychotropic polypharmacy may be necessary and justified as it is mainly prescribed by the best-trained providers.

Calculation of a Primary Immunodeficiency "Risk Vital Sign" via Population-Wide Analysis of Claims Data to Aid in Clinical Decision Support.

Background: Early diagnosis of primary immunodeficiency disease leads to reductions in illness and decreased healthcare costs. Analysis of electronic health record data may allow for identification of persons at risk of host-defense impairments from within the general population. Our hypothesis was that coded infection history would inform individual risk of disease and ultimately lead to diagnosis. Methods: In this study we assessed individual risk for primary immunodeficiency by analyzing diagnostic codes and pharmacy records from members (n = 185,892) of a large pediatric health network. Relevant infection-associated diagnostic codes were weighted and enumerated for individual members allowing for risk score calculations ("Risk Vital Sign"). At-risk individuals underwent further assessment by chart review and re-analysis of diagnostic codes 12 months later. Results: Of the original cohort, 2188 (1.2%) individuals were identified as medium-high-risk for having a primary immunodeficiency. This group included 41 subjects who were ultimately diagnosed with primary immunodeficiency. An additional 57 medium-high risk patients had coded diagnoses worthy of referral. Conclusions: Population-wide informatics approaches can facilitate disease detection and improve outcomes. Early identification of the 98 patients with confirmed or suspected primary immunodeficiency described here could represent an annual cost savings of up to $7.7 million US Dollars.

Behavioral health service utilization: Trends in utilization within a patient-centered medical home for low-income children and women.

BACKGROUND: Behavioral health (BH) problems frequently present in primary care settings. Despite high intervention needs, the majority of low-income, racially/ethnically diverse children and women do not receive necessary care. The current study examined utilization of BH care among low-income, racially/ethnically diverse pediatric and obstetric patients receiving services in an integrated patient-centered medical home (the Center) compared to patients receiving services in traditional settings. METHODS: A retrospective review was performed on all consecutive Texas Children's Health Plan (TCHP) patients who received outpatient BH services between 2015 and 2017. Children and woman who utilized BH services at the Center were compared against those who utilized BH services via a traditional sitting outside the Center. RESULTS: A total of 54,612 were identified. Of those, 3,559 (6.5%) patients were seen at the Center and 51,053 (93.5%) patients were seen in the traditional setting. A larger proportion of pregnant/postpartum women and African American and Hispanic/Latino children and women utilized BH services in the PCMH compared to the traditional setting. Results also indicated higher levels of BH service use for patients with behavior problems or anxiety disorders, and increased use of services provided by doctoral level psychologists in the PCMH. CONCLUSION: Findings support the benefit of integrated BH services in PCMH models for engaging traditionally marginalized populations in BH care.

Oral Dexamethasone to Control Wheezing in Children at an Outpatient Clinic.

Asthma, a chronic childhood disease, has resulted in increased emergency department (ED) visits with high costs. Many asthma ED visits are nonemergent and could be treated in outpatient clinics. Literature has concluded that a 2-day course of oral dexamethasone has comparable outcomes to a 5-day course of prednisone in the ED and hospital setting. A retrospective chart review was performed on children requiring in-house treatment with a corticosteroid (dexamethasone n = 23, prednisone n = 40) for acute asthma exacerbations at an ambulatory medical home. The rates of hospital admissions, ED visits, and symptom follow-up were similar between the 2 groups ( P > .05). The cost for a course of dexamethasone was US$1.28 versus US$16.20 for prednisolone. The average cost for an asthma exacerbation office visit was US$79.89 compared with US$3113.28 for an ED visit. A 2-day course of oral dexamethasone appears to be a promising clinical and cost-effective treatment for acute asthma exacerbations at the primary care level.

Physician Care Coordination and the Use of Psychotropic Polypharmacy in the Management of Pediatric Mental Disorders.

BACKGROUND: Psychotropic polypharmacy is a concern in the management of pediatric mental disorders due to the lack of pediatric data to support the practice. Although seeing multiple providers has been identified as an important predictor of polypharmacy, no study has yet assessed the effect of care coordination between providers on receipt of psychotropic polypharmacy. OBJECTIVE: To examine the association between the intensity of care coordination within a patient's care team and the likelihood of the patient receiving multiclass psychotropic polypharmacy. METHODS: A retrospective study was conducted using the 2013-2015 administrative claims data from a Medicaid managed care organization (Texas Children's Health Plan). Children and adolescents aged 18 years or younger with a diagnosis of a mental/behavioral disorder and receipt of psychotropic prescriptions from multiple prescribers were included in the study. Psychotropic polypharmacy was defined as the receipt of 2 or more psychotropic medications from different drug classes concurrently for 60 days or more. Care coordination was measured using social network analysis (SNA), a new technique included in the Agency for Healthcare Research and Quality Care Coordination Measures Atlas. Care density, an SNA surrogate for care coordination, was calculated as the ratio of the sum of patients shared by physician pairs within a patient's care team to the total number of physician pairs. The Andersen behavioral model was used to guide multivariate logistic regression analyses conducted to assess the association between care density and the likelihood of patients receiving psychotropic polypharmacy after controlling for predisposing and need factors. RESULTS: A total of 24,147 children and adolescents diagnosed with a mental/behavioral disorder were identified. About 34.0% (n = 8,092) of these individuals received psychotropic medications from multiple prescribers who were either primary care physicians (PCPs) or specialists. Logistic regression analysis showed a significant association between care density and the use of psychotropic polypharmacy. However, the direction of this relationship varied depending on the composition of the patient's care team. Among patients with only PCPs involved in their care team, patients in the higher care-density group were 28% less likely to receive psychotropic polypharmacy (OR = 0.72; 95% CI = 0.62-0.96) than those in the lower care-density group. In contrast, among patients who had both PCPs and specialists involved in their care team, those in the higher care-density group were 2 times more likely to experience psychotropic polypharmacy (OR = 2.01; 95% CI = 1.68-2.40). Care density was not significantly associated with the receipt of psychotropic polypharmacy in the specialist-only group. CONCLUSIONS: This study found significant associations between care density and prescription of psychotropic polypharmacy. This relationship varied depending on the patient's diagnosis, disease complexity, and composition of the patient's care team. DISCLOSURES: No outside funding supported this study. The authors do not have any financial relationships or potential conflicts of interest relevant to this article to disclose. The abstract for part of this study, titled "Association Between Physician Care Coordination and the Use of Psychotropic Polypharmacy in the Management of Pediatric Mental Disorders," was selected as a silver medal abstract and was presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2017; March 27-30, 2017; Denver, CO.

Illnesses among recently immigrated children.

The number of children immigrating to the United States has increased steadily during the last decade. American families are adopting a significant portion of these children, more than 20,000. Recently immigrated children face many different health risks when compared to children born in the United States. They are subject to many infectious diseases no longer seen commonly in the United States such as malaria, tuberculosis, and HIV. They are more likely to have inadequate immunity to vaccine-preventable illnesses. Recent immigrants have a higher likelihood of having malnutrition and developmental delay. Finally, many will have suffered psychological trauma in either institutions or refugee camps. These children require specialized testing, care, and treatment in the pediatric office.

Pharmacokinetics and pharmacodynamics of saquinavir in pediatric patients with human immunodeficiency virus infection.

OBJECTIVE: Our objective was to investigate the clinical pharmacologic characteristics of saquinavir given as a soft gelatin capsule, either alone or in combination with nelfinavir, to children and adolescents with human immunodeficiency virus infection. METHODS: The pharmacokinetics of 50 mg/kg saquinavir 3 times a day (tid) alone versus 33 mg/kg saquinavir tid plus 30 mg/kg nelfinavir tid was assessed after single-dose administration and after short- and long-term administration. The single-dose pharmacokinetics of fixed (1200 mg) versus unrestricted weight-adjusted dosing (50 mg/kg) was also investigated. RESULTS: Saquinavir as the sole protease inhibitor resulted in lower saquinavir exposure in children (steady-state geometric mean area under the concentration-time curve from time zero to 24 hours [AUC (0-24 h)], 5790 ng x h/ml; steady-state concentration 8 hours after drug administration [C(8h,SS)], 65 ng/ml) and adolescents [steady-state geometric mean AUC(0-24 h), 5914 ng x h/ml] than that reported in adults treated with 1200 mg tid [steady-state geometric mean AUC(0-24 h), 21,700 ng x h/ml; C(8h,SS), 223 ng/ml]. This finding appeared to be attributable to markedly higher apparent oral clearance, potentially as a result of increased systemic clearance and reduced oral bioavailability. Nelfinavir combined with saquinavir reduced apparent oral clearance, increasing saquinavir exposure in children [steady-state geometric mean AUC(0-24 h), 11,070 ng x h/ml; C(8h,SS), 380 ng/ml] to levels that approach those observed in adults. A significant correlation between average trough concentration and sustained viral load suppression was observed in children. The apparent threshold for maintaining viral load suppression was a mean trough saquinavir concentration above 200 ng/ml. CONCLUSIONS: The pharmacokinetics of saquinavir in children is different from that of adults, and administration of saquinavir alone will not give consistently efficacious plasma levels. The best way of improving saquinavir exposure in children is through combination therapy with other protease inhibitors that inhibit saquinavir metabolism.

False negative DNA polymerase chain reaction in an infant with subtype C human immunodeficiency virus 1 infection.

Diagnosis of HIV infection in early infancy generally relies on detection of HIV proviral DNA by PCR. However, many of the HIV DNA PCR assays currently in use are either not optimized or have not been validated for diagnosis of infection with non-subtype B HIV. We report the case of an HIV-infected African American immigrant infant with subtype C HIV infection who tested negative repeatedly by HIV DNA PCR. Clinicians should be aware of this particular limitation of HIV DNA PCR assays, because it is likely that an increasing proportion of the HIV-infected infants seen in US centers will be infected with non-subtype B HIV.

Disseminated Acanthamoeba infection in a human immunodeficiency virus-infected infant.

Infection with Acanthamoeba is difficult to diagnose and treat. We present the first case of disseminated Acanthamoeba infection in an HIV-infected infant. The infant survived 2 years with treatment with several agents having anti-Acanthamoeba activity in vitro.

Lipodystrophy syndrome in human immunodeficiency virus-infected children.

BACKGROUND: Lipodystrophy syndrome in HIV-infected adults is characterized by a variety of physical and/or metabolic abnormalities, including fat redistribution, hyperlipidemia (hypercholesterolemia and/or hypertriglyceridemia) and peripheral insulin resistance. Many studies suggest that antiretroviral therapy is the underlying cause of the condition. Few data exist for HIV-infected children. METHODS: This is a cross-sectional study evaluating HIV-infected children age 2 to 16 years. Fat redistribution was identified by physical examination and parental questionnaire. Fasting blood analysis included cholesterol, triglycerides, high density lipoprotein, low density lipoprotein, glucose, insulin and C-peptide. RESULTS: Forty HIV-infected children were recruited. Seven children (18%) exhibited physical signs of fat redistribution. Twenty-seven (68%), 11 (28%) and 3 (8%) children exhibited evidence for hypercholesterolemia, hypertriglyceridemia and insulin resistance, respectively. Eleven children (28%) had no physical signs or laboratory evidence of lipodystrophy. Statistical analysis did not reveal any significant association between the presence of lipodystrophic features and patient age, HIV-1 viral load, exposure to specific antiretroviral medications or duration of protease inhibitor or nucleoside reverse transcriptase inhibitor therapy. Drug dosing was significantly associated with the development of lipodystrophy features. Children receiving pediatric dosing regimens vs. adult dosing regimens were less likely to develop lipodystrophy (P = 0.003). CONCLUSIONS: Features associated with lipodystrophy syndrome arise in some HIV-infected children. Subjects receiving pediatric dosing regimens were less likely than those receiving adult regimens to develop lipodystrophy.

Comprehensive pediatric human immunodeficiency virus care and treatment in Constanta, Romania: implementation of a program of highly active antiretroviral therapy in a resource-poor setting.

BACKGROUND: Relatively few human immunodeficiency virus (HIV)-infected children worldwide have access to care and treatment. The Romanian-American Children's Center, a collaborative project of a U.S. health care institution and the Romanian government, has established a comprehensive program of highly active antiretroviral therapy for children in Constanta, Romania. OBJECTIVES: To describe the design and outcomes of a program of pediatric HIV/acquired immunodeficiency syndrome (AIDS) care and treatment in a resource-poor setting. SETTING: Outpatient center providing comprehensive primary and HIV/AIDS specialty care and treatment to all known HIV-infected children living in Constanta County, Romania. OUTCOMES: As of August 2003, a total of 452 children were receiving highly active antiretroviral therapy. Therapy has been well-tolerated, with approximately 90% of children continuing to receive treatment after a median duration of follow-up of 67 weeks. Normal weight and height growth velocities have been observed among treated children. Marked decreases have been observed in rates of hospitalization and mortality. The mean change in CD4+ lymphocyte count for 173 children who have both a baseline count and at least 1 follow-up count is +284 cells/microL (P < 0.0001). CONCLUSIONS: Highly active antiretroviral therapy can be administered safely and effectively to children in a resource-poor setting, with outcomes comparable with those observed in U.S. pediatric antiretroviral clinical trials.

Ethics and the AIDS pandemic in the developing world.

Traditional ethics provide insight, but often fall short of guiding the complex biomedical ethical concerns of research conducted in developing countries. The need to create research within a framework that is appropriate to the social, medical, and political context of developing countries is examined through the current AIDS pandemic in sub-Saharan Africa. A specific case study focuses on this issue. Over 70 percent of the 40 million people with HIV/AIDS live in sub-Saharan Africa. With at least one in five African adults infected with the disease, sub-Saharan Africa is now acknowledged as the epicenter of HIV/AIDS. The scale and scope of the disease in the environment of a developing economy presents unique issues that challenge the role and practices of traditional ethics in healthcare research programs. Medical research within developing countries, particularly for HIV/AIDS, requires a distinctive approach. For these populations, investigators must incorporate new thinking into traditional biomedical research ethics which will address the role of innovation; access to treatment; the impact of fear, stigma, and denial; concerns around autonomy for vulnerable populations; capacity building; and sustainable care to communities. Since May 1999, Secure the Future, a philanthropic program that focuses on care and support for women and children infected and affected by HIV/AIDS, has attempted to fulfill these ethical concepts in its processes. The program is a public and private sector partnership between governments, communities, practitioners, academia, and Bristol-Myers Squibb Company to respond to AIDS in five countries in sub-Saharan African countries: Botswana, Lesotho, Namibia, South Africa, and Swaziland. To ensure symmetry between ethical principles and local context, collaborative projects undergo a comprehensive review process. This includes review and approval by a national secretariat to ensure projects support objectives of national policies and local communities; approval by an ethics committee comprised of participating institutions; blinded peer review; and an examination by an external advisory board comprised of local and international medical experts, persons living with AIDS (PLWA), religious communities, governments, and nongovernmental organizations (NGOs). An independent monitor also oversees the approved programs. Cost-effective and practical interventions against HIV/AIDS must encompass ethical approaches appropriate to the contexts of the respective developing countries. Lessons learned to date are to focus on innovation; establish unassailable ethical standards that are sensitive to local contexts; ensure transparent communications among partners and the broader community; and build sustainable capacity.

The Pediatric AIDS Corps: a 5-year evaluation.

BACKGROUND: The Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children's Hospital created a global health corps named the Pediatric AIDS Corps (PAC) in June 2005. This report provides descriptive details and outputs for PAC over its first 5 years. METHODS: Demographic data were gathered about PAC physicians employed from July 2006 to June 2011. A 21-question survey was used to query PAC physicians about their experiences in the program. Data concerning clinical experiences and educational programs also were reviewed. RESULTS: A total of 128 physicians were employed with PAC. The median duration served was 22.7 months. Eighty-seven percent indicated that experience affected their future career choice, with half continuing to work with children and families living in resource-limited areas after they left PAC. Patient care was identified as the most rewarding part of their work (73%), whereas deaths (27%) were the most difficult. Baylor College of Medicine International Pediatric AIDS Initiative enrollment of HIV-infected children and adolescents into care and treatment increased from 6107 to 103 731 with the addition of PAC physicians. Approximately 500 local health care professionals per quarter benefited from HIV clinical attachments that were not available before PAC arrival. PAC physicians visited outreach sites providing in-depth HIV mentoring of local health care professionals, leading to 37% of the sites becoming self-sufficient. CONCLUSIONS: The positive evaluation by the PAC and the scale-up of clinical and educational programs support the recent calls for the development of a national global health corps program.