The Pediatric AIDS Corps: A 5-Year Evaluation

Results

A total of 128 physicians were employed with PAC between July 2006 and June 2011 (Table 1). One physician worked in Malawi in 2006–2007, left the program and completed a pediatric hematology-oncology fellowship, and returned to Malawi for 2010–2011. The median duration of service in PAC was 22.7 months (range: 8.8–59.5 months). The 12 countries where the PAC physicians worked are listed in Table 2. There were 107 doctors who worked in 1 country each, whereas 16 worked in 2 countries, 4 worked in 3 countries, and 1 worked in 4 countries. Most PAC physicians worked at BIPAI’s Clinical Centers of Excellence and/or outreach clinics in Botswana, Burkina Faso, Lesotho, Malawi, Swaziland, and Tanzania. These centers focused on the care and treatment of children and their families with HIV/AIDS. A small number of physicians were linked with other nongovernment organizations working with pediatric HIV/AIDS in Tanzania and Mozambique (Elizabeth Glaser Pediatric AIDS Foundation) and South Africa (Harvard University). In Ethiopia, physicians worked at the Gondar University Hospital in the Department of Pediatrics to teach medical students and train interns in general pediatrics. This program was in conjunction with the American Joint Jewish Distribution Committee and funded by the Mary L. and William J. Osher Foundation. One PAC physician worked for BIPAI as a consultant in India for 6 months under an agreement with UNICEF to evaluate all of the pediatric HIV/AIDS clinical centers in that country.

The Bristol-Myers Squibb Foundation’s Secure the Future Program provided $22.5 million to support the program’s administration and physicians’ salary, training, living, and travel expenses. Eighty-seven (68%) of the PAC physicians came into the program with educational debt. The total amount of debt owed by this cohort was $10 262 426 (mean: $117 958 per person; range: $31 326–$228 007). At the conclusion of the 5-year program, BCM had provided $6 057 518 in loan repayments and 26 (30%) became debt-free through their participation in the PAC program.

A total of 126 PAC physicians (2 were deceased) were contacted with a survey link and 111 (88%) completed the survey. Sixteen percent of the physicians were currently working for BIPAI under a revision of the program referred to as the Texas Children’s Global Health Corps, 22% had left PAC <1 year before, 37% had been out from 1 to 3 years, and 25% had been out for >3 years. The experience of the PAC physicians was noted to have affected further career choices in 87% (Table 3). Of those who had their career choice affected, 71% indicated that global health would remain a focus of their career, whereas half of those who pursued additional training included training in public health alone (eg, master’s or doctorate degrees, Epidemic Intelligence Service) or in addition to subspecialty training. Subspecialty training pursued included infectious diseases (9), emergency medicine (4), hematology-oncology (3), cardiology (2), pulmonology (2), academic pediatrics (2), unspecified (2), neonatology, critical care, integrative medicine, preventive medicine, and combined hematology-oncology-infectious disease. 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 multidrug-resistant organisms.

Eleven percent of those surveyed identified depression as a problem while serving abroad (Table 5; IR: 50 per 1000 PAC-years abroad). Two physicians required evacuation from their assigned country to South Africa for stabilization of psychiatric illness (IR: 8.3 per 1000 PAC-years abroad) before returning home. For the 12% who responded that there were other significant events that affected their health or safety or a family member’s, most were medical illnesses in a family member (eg, diarrheal disease, malaria).

Before the deployment of PAC in July 2006, BIPAI had enrolled 6107 patients into HIV/AIDS care. By June 2011, BIPAI had enrolled 103 731 children and adolescents into care and treatment.⁶ Parents of children (10 771) also were brought for care at specially created family care clinics. Approximately 42% were treated at the BIPAI Centers of Excellence, whereas the remainder were cared for at BIPAI satellite sites or in outreach locations visited by PAC doctors. At 4 of the centers (Botswana, Lesotho, Malawi, and Swaziland) where the PAC provided most of the care, >92 000 patients were enrolled with ∼48% of HIV-infected patients receiving antiretroviral therapy (Table 6).

As a result of training activities carried out by PAC doctors by June 2011, ∼500 local health care professionals per quarter were benefiting from clinical attachments of at least 1 week at the Centers of Excellence, whereas >700 health care professionals per month were attending didactic training sessions on HIV/AIDS, either at the centers or at outreach sites.⁶ In addition, PAC doctors were visiting outreach sites between 1 and 4 times per month, providing in-depth mentoring of local health care professionals. Clinical progress at these outreach sites was monitored, and when a set of established criteria for standards of care were met, sites were graduated. By June 2011, 52 (37%) of 142 sites had graduated across the network. Of the 4 major sites with physician shortages that required the use of PAC physicians to scale up the clinical work in 2006 (Botswana, Lesotho, Malawi, and Swaziland), by June 2011, 2 (Botswana, Lesotho) were able to retain local physicians in numbers to be self-sufficient. 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 HIV-exposed 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.