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 to103 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.

At the conclusion of 2005, ∼2.3 million children were living with HIV/AIDS. Globally, children accounted for 14% of all new HIV infections and 18% of all deaths from HIV/AIDS. The largest burden of disease in children ,5 years of age was in southern Africa, where HIV/AIDS accounted for more deaths than all other causes combined. 1 It was during this time that the Institute of Medicine recommended that the US federal government create and fund an umbrella organization called the US Global Health Service to mobilize US health care professionals to fight HIV/ AIDS. 2 In parallel with this call to action, the Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children' s Hospital announced the creation of a global health corps named the Pediatric AIDS Corps (PAC). This program was developed to address the critical shortage of physicians trained in the care of infants and children infected and affected with HIV/AIDS in Africa and other parts of the world. 3 The program was designed not only to expand existing health professional capacity for providing care and treatment in several hard-hit African countries, but also to institute training programs to supply local providers with the skills and confidence needed to take care of HIV-infected infants and children.
The PAC recruited board-eligible/ certified pediatricians, internists, and family medicine physicians for longterm assignments ($1 year) in Africa. Physicians were employed by Baylor College of Medicine (BCM) and were linked to BIPAI' s Clinical Centers of Excellence or other nongovernment organizations in African countries hard hit by HIV/AIDS. The recruitment, placement, and training of the PAC has been described in depth in previous publications. 4,5 Support for the first 5 years of this program was provided by the Bristol-Myers Squibb Foundation, Secure the Future Program, and BCM. The purpose of this report was to provide descriptive details and outputs for this unique program over the first 5 years of its existence.

METHODS
Basic demographic data were gathered from application files for all PAC physicians employed from July 2006 to June 2011. A 21-question survey was developed and used to query all PAC physicians about their experiences in the program. A link to this survey (SurveyMonkey at www.surveymonkey. com) was sent to each PAC physician on 4 occasions over a 2-month period. Data concerning clinical experiences were obtained through reviews of deidentified summary data from an electronic medical record. Local records were reviewed for educational endeavors. Incidence rates (IR) for depression and mental health evacuation were calculated using 239.94 PACyears. This was the number of years served by the physicians responding to the survey. Based on physicians coming into the program without a history of tuberculosis, 2664.5 PAC-months were used to calculate the IR of tuberculosis, which was defined as a new positive tuberculin skin test. The study was reviewed and approved by the institutional review board for human subject research for BCM and affiliated hospitals.
Approximately half continue to work with children and families living in resource-limited areas domestically or abroad. Seventy-three percent of responding physicians indicated that patient care was the most rewarding part of the PAC experience; program development was identified by 15%. The most difficult experiences identified were the number of deaths (27%), difficulty in accepting the limitations of the local health care system (24%), and managerial decisions made at the local clinics (21%). The most important accomplishments identified by PAC physicians were in the categories of infrastructure building (33%) and education (31%). The nonclinical endeavors the PAC physicians participated in are outlined in Table 4.
Forty-one percent of PAC physicians had problems transitioning home, and the most common areas identified were classified as personal issues (53%) and job-related difficulty (22%). The work (62%) and the relationships that were developed (36%) were identified as the best parts of being a member of PAC. Administrative issues, either locally (35%) or in Houston (19%), were the most common items mentioned as something that needed to change. Despite these issues, all physicians surveyed stated that they were happy to have been a member of PAC and 99% said that they would encourage others to participate in the program. The 1 physician who indicated that he or she would not recommend this program noted the fact that research experience was not the major focus of the program and those interested in a research career might find another venue that would be a better fit.
The health and safety of the PAC physicians also was evaluated (Table 5). Forty-two percent indicated that they had been a victim of robbery/theft/ violent crime or sexual assault while serving abroad. Sexual assaults involved groping. Malaria prophylaxis was required for PAC physicians working in malaria-endemic areas (Table 3). Of the 45 PAC physicians who commented on their malaria prophylaxis, 7 (16%) reported that they never took it, 26 (58%) reported that they took it intermittently or stopped it   prematurely, and only 12 (27%) stated that they took it regularly. Seven individuals had been treated for malaria at least once (Table 5).
Eighteen physicians required postexposure prophylaxis for occupational exposure to HIV (Table 3). These 18 physicians had 27 high-risk events, such as mucous membrane exposure with body fluids (14) or needle sticks (13). Five individuals reported 2 separate events, whereas 2 individuals reported 3 events. Completion of the prescribed course of antiretroviral prophylaxis was reported for 12 (44%) of the episodes. Gastrointestinal problems (nausea, vomiting, and distress) were the most common reason for discontinuation of prophylaxis. One physician sustained 2 different splash exposures near the eye and took prophylaxis with the first event but did not take it for the second. No PAC physician reported seroconversion to HIV after these events or after working with PAC.
Thirteen PAC physicians had a history of tuberculous disease before joining the program. All others were screened with a tuberculin test by using purified protein derivative before leaving for their assignments and yearly while abroad. Seven were subsequently diagnosed with latent tuberculosis infection while abroad or within 6 months after returning home. Each of the 7 had a positive tuberculin skin test with negative chest radiographs (Table 5; IR for latent and active tuberculous disease were 2.62 per 1000 PAC-months abroad and 0 per 1000 PAC-months abroad, respectively). Six were treated with isoniazid alone, and 1 received a course of pyrazinamide and ethambutol because of concern for multidrugresistant organisms.
Eleven percent of those surveyed identified depression as a problem while serving abroad (   Lesotho) were able to retain local physicians in numbers to be selfsufficient. The success of these 2 programs in building local capacity was in large part because of the work of the PAC physicians.
A total of 106 research studies either had been completed or were ongoing, with 34 publications at the conclusion of the 5 years. PAC physicians contributed substantially to the development of national treatment guidelines for HIV/ AIDS in a number of African countries as well as other relevant issues affecting maternal-child health (eg, guidelines for the prevention of mother-to-child transmission of HIV, care of the HIVexposed infant). In addition, PAC physicians worked as part of committees or writing groups at the invitation of Ministries of Health in preparing applications to the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

DISCUSSION
The 5-year history of PAC demonstrates that a global health corps can catalyze a rapid scale-up of clinical services and build local health professional capacity for pediatric health care in resourcelimited settings. Securing of the operational funds and recruitment of physicians in the later part of 2005 with a July to August 2006 training and deployment for the first PAC physicians was a logistical feat. This rapid scale-up and deployment allowed PAC physicians to become an integral part of each country' s antiretroviral therapy rollout for children, but was also most likely a reason behind the administrative challenges noted in the survey. Besides exceeding expectations in the areas of clinical service and education, a collateral benefit of this program was the involvement of PAC in numerous nonclinical care activities (eg, participation in guideline writing, project administration) that helped define health care delivery in each of the countries. The experience also helped shape the future career goals of the physicians as it relates to global health, as well as working with children living in resource-limited settings domestically. Despite the health and safety issues encountered, 100% of participants were happy with their decision to join this program.
The PAC program was established so that children with HIV/AIDS could receive quality health care and have access to antiretroviral therapy. The large number of physicians placed in countries allowed for the establishment of robust educational programs that achieved the goal of building local clinical capacity for the treatment of infants and children with HIV/AIDS and other serious or life-threatening medical conditions. In addition to the HIVfocused programs, the placement of pediatricians in Ethiopia helped address a poor student-to-teacher ratio that was jeopardizing the quality of education provided to medical students and interns in pediatrics. PAC physicians collaborated with Ethiopian pediatricians in re-designing the med-ical education program to meet student performance standards, instituting and shaping a pediatrics residency program. PAC also became active in other important nonclinical activities, such as national and global policy development, teen clubs, community health programs, and guideline writing that extended beyond HIV/AIDS.
Safety and health issues were identified as important components of the PAC experience. Robbery/theft and other violent crimes, in addition to motor vehicle accidents, are well recognized events leading to injury and death among international travelers and other humanitarian workers. [7][8][9][10][11] Issues relating to health and safety are addressed in the pretravel training that PAC physicians receive before leaving for their assignments abroad. 5 Despite a focus of the pretravel program on malaria prevention, it was concerning to note that there were physicians working in malaria-endemic regions that did not take chemoprophylaxis. Most of these physicians were concerned about the impact of long-term exposure to malaria prophylaxis on their health and chose to rely on bednetting and personal protection strategies. Those who chose not to take chemoprophylaxis were encouraged to have medications for self-treatment with them at all times.  16 Physicians who treat children in resourced countries are not exposed to the large-scale death encountered in resource-limited areas. This fact and the long work hours in a new country and unfamiliar culture no doubt contribute to the mental health issues encountered. The importance of mental health problems, including posttraumatic stress disorder, depression, and anxiety, are becoming recognized more commonly but are still underappreciated for individuals doing this type of work. 17 Beginning in July 2011, the name of our program changed from PAC to the Texas Children' s Global Health Corps. This name change not only reflects a change in funding, but also indicates that the program is expanding the clinical focus to include treatment of common childhood cancers, sickle cell disease, malnutrition, tuberculosis, and malaria. An additional 38 physicians have joined the program since July 2011. One was in the second group of PAC physicians and worked for 1 year in Lesotho and returned after hematology-oncology training to work in Botswana. Another physician was from Botswana, trained in pediatrics in the United States, and has returned to Botswana to work at the BIPAI Center of Excellence. These new global health corps physicians include not only the specialties of pediatrics, internal medicine, and family medicine, but also obstetrics/gynecology and general surgery. Physicians were assigned not only to Botswana, Ethiopia, Lesotho, Malawi, Swaziland, and Tanzania, but also to Equatorial Guinea, Angola, Liberia, Colombia, and Papua New Guinea.

CONCLUSIONS
PAC was envisioned and developed as a measure to aid and expand capacity in areas of the world that were combating the worst epidemic in human history. The positive evaluation of the program by the physician participants, and the documented scale-up of clinical and educational programs, provides evidence in support of the recent calls for the development of a national global health corps program. 18,19