PEDIATRICS Vol. 123 No. 1 January 2009, pp. 134-136 (doi:10.1542/peds.2008-0402)
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SPECIAL ARTICLE |
The Pediatric AIDS Corps: Responding to the African HIV/AIDS Health Professional Resource Crisis
Baylor International Pediatric AIDS Initiative, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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ABSTRACT |
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 TOP ABSTRACT PROGRAM DESIGNDISCUSSIONREFERENCES |
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Health professional capacity for delivery of HIV/AIDS care and treatment is severely constrained across sub-Saharan Africa. African health professional expertise in pediatrics is in particularly short supply. Here we describe a Pediatric AIDS Corps program that was designed to place pediatricians and other physicians in Africa on a long-term basis to expand existing health professional capacity for pediatric and family HIV/AIDS care and treatment. In the first 2 years of this program, 76 physicians were placed in 5 African countries that have been hit hard by HIV/AIDS. Enrollment of HIV-infected children in care more than quadrupled over a 24-month period, to 26 590. We believe that this pilot program can serve as a model for larger-scale efforts to immediately expand access for African children and families to life-saving HIV/AIDS care and treatment.
Key Words: HIV infection • infant • child • international health
HIV and AIDS continue to exact a heavy toll on children globally, but especially in sub-Saharan Africa. Approximately 2.2 million (88%) of the 2.5 million children (<15 years of age) who were living with HIV/AIDS at the end of 2007 were African.1 Approximately 370 000 African children were newly infected with HIV in 2007 alone, and 290 000 died.
Health professional capacity for delivery of HIV/AIDS care and treatment is severely constrained across sub-Saharan Africa, where per-capita numbers of physicians and nurses are only 1% to 2% of those of the United States. A recent report of the Institute of Medicine recommended that the US federal government fund an umbrella organization to mobilize the nation's health professionals to help combat HIV/AIDS in hard-hit African, Caribbean, and Southeast Asian countries,2 but the principal US program addressing HIV/AIDS globally, the $15 billion President's Emergency Plan for AIDS Relief, has done little to send US physicians and nurses abroad.
African health professional expertise in pediatrics is in particularly short supply. In Malawi, Lesotho, Swaziland, and Botswana, for example, 4 countries particularly hard hit by HIV/AIDS, per-capita numbers of pediatricians range from 0.2 to 2.5 per 100 000 children (M.W.K., unpublished data), compared with a US figure of 
106 per 100 000 children.3 Relatively few African health professionals have training in the care and treatment of HIV-infected children or experience in the use of antiretroviral drugs in children. As a result, pediatric HIV/AIDS treatment often is viewed erroneously as prohibitively difficult or complex, and children are underrepresented among recipients of antiretroviral therapy in almost every setting.
Baylor College of Medicine and the Bristol-Myers Squibb Foundation announced in June 2005 the creation of a Pediatric AIDS Corps program that was designed to expand existing health professional capacity for pediatric and family HIV/AIDS care and treatment in several hard-hit African countries. We believe that this pilot program can serve as a model for larger-scale efforts to immediately expand access for African children and families to life-saving HIV/AIDS care and treatment.
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PROGRAM DESIGN |
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TOPABSTRACTPROGRAM DESIGNDISCUSSIONREFERENCES |
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The Pediatric AIDS Corps recruits graduates of residency training programs in pediatrics, family medicine, and internal medicine for long-term (
1 year) assignments in Africa. Participants train at Baylor College of Medicine in pediatric and family HIV/AIDS care and treatment and tropical and travel medicine before departing for Africa. Physicians are employed by Baylor and are linked to Baylor's Children's Clinical Centers of Excellence in Botswana, Lesotho, Swaziland, Malawi, and Burkina Faso for purposes of professional development and training, continuing education, and professional consultation. Participants provide primary and HIV/AIDS specialty care and treatment to children and families in care at the Children's Clinical Centers of Excellence, in satellite primary health centers, and on inpatient wards at associated public hospitals. Pediatric AIDS Corps members participate in training activities to build local capacity for pediatric and family primary and HIV/AIDS specialty care and treatment. Participants receive from the program a living stipend ($40 000/year) and full package of benefits, a housing allowance (maximum of $1200/month), and student loan debt relief (maximum of $40 000/year) for each year of service in Africa. Pediatric AIDS Corps physicians are placed and work under memoranda of agreement between Baylor and government ministries of health. They report administratively to the executive director of the locally registered Baylor College of Medicine Children's Foundation. A Baylor medical director and faculty provide supervision at each Children's Clinical Center of Excellence. A Baylor International Pediatric AIDS Initiative vice-president oversees the Pediatric AIDS Corps program as a whole.
Recruitment
An announcement regarding the Pediatric AIDS Corps was sent by e-mail in July 2005 to pediatric residency training program directors at 45 US medical schools. Information about the program also was posted with the American Academy of Pediatrics and the Pediatric Infectious Diseases Society and at www.medpedsjobs.com and www.bayloraids.org. The application process includes submission of curriculum vitae, a personal statement and list of professional references, and completion of a personal interview.
Training and Placement of Physicians
Before departing for Africa, all participants in the Pediatric AIDS Corps complete a course at Baylor College of Medicine in pediatric and family HIV/AIDS care and treatment and tropical and travel medicine.4 This course, given over a 4-week period and totaling 150 hours of classroom and laboratory instruction, is 1 of only 15 worldwide that have been approved by the American Society of Tropical Medicine and Hygiene as a diploma course in clinical tropical medicine and travelers’ health.
Allocation of physicians to host countries is need-based and determined in consultation with executive directors of the Children's Clinical Centers of Excellence and representatives of ministries of health. Participants in the Pediatric AIDS Corps are asked to rank-order possible country assignments. An informal matching process is used for making final assignments of physicians to the various participating countries.
Participating physicians receive additional training in HIV/AIDS and related conditions initially and on an ongoing basis at each of the Children's Clinical Centers of Excellence to which they are assigned. Locally relevant language training is provided also. Educational meetings of participants from across the entire Baylor Children's Clinical Centers of Excellence network are held twice annually.
Outcomes
A first-year recruitment target of 50 physicians was established. Ninety-seven physicians completed the application process. Fifty-three physicians were offered positions in the program in year 1, and 52 accepted the offer and were at assignment sites in Africa by August 2006. Thirty five (67%) of these physicians elected to continue in the Pediatric AIDS Corps for a second year. Most of those leaving the Pediatric AIDS Corps after 1 year did so to pursue other advanced training in a pediatric subspecialty or public health.
Twenty-four additional physicians were recruited to the Pediatric AIDS Corps in year 2 from a pool of 75 applicants, increasing the total number of Pediatric AIDS Corps physicians in Africa to 59 by August 2007. Characteristics of the 76 physicians who have participated in the program to date are shown in Table 1. These physicians are graduates of medical schools in the United States (45), Canada (2), Germany (2), Poland (1), Romania (1), and Nigeria (1).
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Enrollment of children in HIV/AIDS care by the Baylor Children's Clinical Centers of Excellence in Botswana, Lesotho, Swaziland, Malawi, and Burkina Faso more than quadrupled, from 6052 to 26 590, over the 24-month period between August 2006 and August 2008, an average rate of increase of 856 per month. Over the same period, enrollment of children on antiretroviral treatment increased from 2460 to 13 546 (average increase: 462/month).
Pediatric AIDS Corps physicians participate in the training of 1000 African health professionals each month. Much of this training is didactic in nature. African physicians, nurses, and other health professionals also participate in scheduled clinical rotations through the Baylor Children's Clinical Centers of Excellence. Pediatric AIDS Corps physicians participate on a monthly basis in attachments to outlying health centers where they serve in a mentoring role to local professionals.
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DISCUSSION |
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TOPABSTRACTPROGRAM DESIGNDISCUSSIONREFERENCES |
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A variety of strategies have been proposed for alleviating the critical shortage in sub-Saharan Africa of trained health workers, ranging from a US government–funded health service corps2 to task-shifting from more to less specialized health workers.5 None of these proposals have addressed specifically the needs of children for specialized pediatric care and the special role of pediatric professionals in expanding access of children to life-prolonging, health-restoring HIV/AIDS care and treatment.
Our approach to expanding access to pediatric and family HIV/AIDS care and treatment in our partner countries in Africa has centered on the development of so-called Children's Clinical Centers of Excellence. These centers provide primary care and HIV/AIDS specialty care and treatment services to children and families living in the urban communities in which they are located, but they also help to build capacity for HIV/AIDS care and treatment through training of local professionals and provide technical support to smaller satellite health centers across broad geographic areas. Early in the development of these centers, it became clear that they never would realize their full potential unless a plan was put in place to supplement the local availability of pediatric health professionals. As such, the Pediatric AIDS Corps was designed as an interim or emergency measure to scale up immediately the care and treatment of HIV-infected children and families as local capacity for HIV/AIDS care and treatment is established. Pediatric AIDS Corps physicians provide services directly to HIV-infected children and their families, but they also participate in the training of local health professionals to build health professional capacity that currently is lacking. By way of this 2-part mission, the Pediatric AIDS Corps helps to ensure its own obsolescence.
In part because pediatric HIV/AIDS care and treatment often are viewed as inherently complex or difficult, very few programs targeting this special population have been developed, and children continue to be underrepresented among recipients of such care and treatment across sub-Saharan Africa. We have demonstrated that the establishment of dedicated African pediatric Centers of Excellence, combined with the creation of a corps of pediatric health professionals designed to supplement and build local health professional capacity, can help to catalyze expanded access of children and families to HIV/AIDS care and treatment. With a minimum amount of advertising, and by addressing potential barriers to work in Africa (eg, heavy student loan debt and lack of training in HIV/AIDS and tropical medicine), we were able to recruit a well-qualified pool of physicians who were eager to work in Africa with HIV-infected children and families. We believe that the program we describe, which can be adapted easily to include other cadres of health professionals, provides a useful model for efforts to ensure that African children gain equal access to life-saving HIV/AIDS care and treatment.
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ACKNOWLEDGMENTS |
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The Baylor College of Medicine International Pediatric AIDS Initiative is supported by the Bristol-Myers Squibb Foundation (for the Pediatric AIDS Corps and Children's Clinical Centers of Excellence in Botswana, Lesotho, Swaziland, Uganda, and Burkina Faso), the Abbott Fund (for the Children's Clinical Centers of Excellence Network and individual centers in Romania and Malawi), the US Centers for Disease Control and Prevention (grant U62/CCU622420), the Fogarty International Center of the US National Institutes of Health (grant 5 D43 TW01036), and the National Institute of Allergy and Infectious Diseases (grant AI36211).
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FOOTNOTES |
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Accepted Apr 8, 2008.
Address correspondence to Mark W. Kline, MD, 6621 Fannin St, CC1210, Houston, TX 77030. E-mail: mkline{at}bcm.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPABSTRACTPROGRAM DESIGNDISCUSSIONREFERENCES |
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1. Joint United Nations Program on HIV/AIDS. AIDS Epidemic Update, 2007. Geneva, Switzerland: Joint United Nations Program on HIV/AIDS and World Health Organization; 2007:1–50. Available at: http://data.unaids.org/pub/epislides/2007/2007_epiupdate_en.pdf. Accessed September 22, 2008
2. Institute of Medicine, National Academy of Sciences. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: National Academies Press; 2005
3. Freed GL, Nahra TA, Wheeler JRC; Research Advisory Committee of the American Board of Pediatrics. Relation of per capita income and gross domestic product to the supply and distribution of pediatricians in the United States. J Pediatr. 2004;144 (6):723 –728[Web of Science][Medline]
4. Schutze GE, Ferris MG, Jones DC, et al. Education and preparation of physicians entering an international pediatric AIDS program: the Pediatric AIDS Corps. AIDS Patient Care STDS. 2008;22 (9):709 –714[CrossRef][Web of Science][Medline]
5. Samb B, Celletti F, Holloway J, Van Damme W, De Cock KM, Dybul M. Rapid expansion of the health workforce in response to the HIV epidemic.
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PEDIATRICS (ISSN 1098-4275). ©2009 by the American Academy of Pediatrics
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