Ayesha Mirza

Background: Preterm birth (PTB) and small-for-gestational age (SGA) often occur in infants born to women with HIV and may influence growth among children perinatally HIV- exposed but uninfected (CHEU). Setting: U.S. cohort at 22 sites Methods: CHEU were enrolled at birth into the SMARTT Dynamic cohort of the Pediatric HIV/AIDS Cohort Study network and followed through age 17 years. We calculated Z scores for singleton CHEU through age 7 years for weight (WAZ), length or height (LAZ/HAZ), and weight-for-length/body mass index (WFL/BMI)]; excessive catch-up growth was defined as WAZ increase >0.67 SD from birth to age 2 years. Birth weight-for-gestational age (GA) was categorized as small- (SGA), appropriate- (AGA), and large-for-GA (LGA). Piecewise linear regression models with slope changes were used to assess growth trajectories by SGA and PTB. Results: Among 2,765 CHEU born 2007-2022, 9.2% were SGA, 14.4% preterm, and 47% had excessive catch-up growth. Among term infants, those born SGA had the highest percent (65%) with excessive catch-up growth. Those born SGA had lower mean WAZ and WLZ/BMIZ than AGA through age 7 years. Infants with PTB had higher mean WAZ, LAZ/HAZ, and WLZ/BMIZ at birth than term infants, but were similar by age 7 years. Conclusions: A high proportion of CHEU had excessive catch-up growth and obesity at age 5 years. While SGA infants had persistently lower Z-scores than AGA, obesity rates at age 5 years were comparable. These findings represent a paradigm shift from undernutrition to overnutrition, particularly in countries where obesity prevalence is high.

Background: The efficacy of integrase strand transfer inhibitors (INSTIs) among adults with HIV is well-established, though adverse effects, particularly weight gain, are common. Comparable data for treatment-experienced adolescents and young adults with perinatally-acquired HIV (AYAPHIV) are limited. Methods: AYAPHIV in the US-based Pediatric HIV/AIDS Cohort Study who switched to bictegravir (BIC), dolutegravir (DTG), elvitegravir (EVG), or raltegravir (RAL) from any prior regimen were eligible. Using mixed-effects models, viral load, CD4 count, weight, and body mass index were described through 2 years after switch for each INSTI. Results: Among 556 AYAPHIV, there were 167 switches to BIC, 282 to DTG, 189 to EVG, and 151 to RAL. Viral suppression (<200 copies/mL) at 1 and 2 years after switch was 74% and 69% for BIC, 62% and 60% for DTG, 76% and 68% for EVG, and 58% and 52% for RAL. Mean CD4 counts were above 500 cells/mm3 after switch through 2 years for all INSTIs. Average weight gain in the first year after switch to BIC, DTG, EVG, and RAL was 0.2, 2.5, 3.8, and −0.2 kilograms for females and 2.3, 4.8, 2.9, and 2.6 kilograms for males. Among previously underweight/healthy individuals, 13%, 18%, 36%, and 12% of females and 6%, 8%, 12%, and 11% of males switching to BIC, DTG, EVG, and RAL were overweight/obese by 2 years after switch. Conclusions: Individual INSTI-based regimens among treatment-experienced AYAPHIV had moderate effectiveness with respect to viral suppression. Continued average weight gain across INSTIs raises concerns about long-term cardiometabolic sequalae.

Integrating global health (GH) training in medical education has become prevalent in the United States over the last two decades. Many medical school graduates participate in some type of international learning experience during their undergraduate/graduate training, with plans to make this a part of their life-long learning experiences. Recognizing this trend, many pediatric national organizations, such as the American Academy of Pediatrics, the Association of Pediatric Program Directors, and the American Board of Pediatrics, have developed initiatives integrating GH education into existing curricula. We report our experience with using virtual learning on a cloud-based platform to remain connected with our GH training partners, and utilize this opportunity to further strengthen our existing relationships during the ongoing COVID-19 pandemic. Overall, our experience thus far shows that this is an effective way to maintain communication even when international travel is not possible. It allows for the ongoing exchange of ideas and the development of long-term sustainable relationships. There are many important lessons our trainees can learn from such partnerships.

Health care quality and patient safety remain one of the core areas of focus for the Accreditation Council for Graduate Medical Education. In addition to using the traditional approach to teaching patient safety, disclosure of a safety event and introduction to the concepts of just culture and safely doing less add a unique perspective to our module. This 4-hour learning activity was conducted using a formal PowerPoint presentation, simulation, and interactive discussion/debriefing. The presentation reviewed safety concepts and introduced learners to the concepts of just culture and safely doing less. The first case was a standard scenario in which participants assessed a sick but stable child and evaluated the use of premature closure bias that might preclude them from making the correct diagnosis. The second case represented disclosure of a medical error. Participants were evaluated on their communication/professionalism skills and challenged to discover overuse as one of the root causes of medication error. Pre- and posttest surveys were used for learner evaluation. Participants showed significant improvement on content-based questions, increasing from 51.7% to 69.3% correct (p < .001). After Bonferroni correction, only the question on overdiagnosis showed significant improvement (p = .001). Participants reported significantly increased confidence in all areas evaluated (p < .001). Participants placed high value on the workshop. The question on overdiagnosis showed significant improvement on the posttest. The concepts of patient safety, just culture, and safely doing less can be introduced to learners at a formative stage in their career through simulation.