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Early infant diagnosis (EID) of HIV-1 infection confers substantial benefits to HIV-infected and HIV-uninfected infants, to their families, and to programs providing prevention of mother-to-child transmission (PMTCT) services, but has been challenging to implement in resource-limited settings. In order to correctly inform parents/caregivers of infant infection status and link HIV-infected infants to care and treatment, a 'cascade' of events must successfully occur. A frequently cited barrier to expansion of EID programs is the cost of the required laboratory assays. However, substantial implementation barriers, as well as personnel and infrastructure requirements, exist at each step in the cascade. In this update, we review challenges to uptake at each step in the EID cascade, highlighting that even with the highest reported levels of uptake, nearly half of HIV-infected infants may not complete the cascade successfully. We next synthesize the available literature about the costs and cost effectiveness of EID programs; identify areas for future research; and place these findings within the context of the benefits and challenges to EID implementation in resource-limited settings.
Mother-to-child transmission (MTCT) of HIV-1 results in approximately 370,000 infant infections worldwide each year [1]. HIV-1 early infant diagnosis (EID) programs seek to inform the caregivers of HIV-exposed infants of infant HIV infection status, and to link HIV-infected infants to care and treatment. EID of HIV confers substantial benefits to infants and families, both for HIV-infected and uninfected infants, as well as to programs providing prevention of mother-to-child transmission (PMTCT) services. The World Health Organization (WHO) estimates that only 6% to 15% of HIV-exposed infants under 1 year of age accessed EID programs in 2008-2009 [2], highlighting that the implementation of effective EID programs has been challenging in resource-limited settings and demands careful attention.
A frequently cited barrier to expansion of EID programs is the availability and cost of the required laboratory assays, which are usually PCR based and therefore more expensive than the antibody-based testing used for older children and adults [3,4]. However, cost is not the only barrier to implementing EID programs. Opportunities to optimize infant outcomes may be lost at each step in a 'cascade' of EID and pediatric HIV care (Figure 1), conceptually similar to the recently described 'cascade' of care required for effective PMTCT services [5]. The EID cascade includes the offer and acceptance of EID testing among HIV-exposed infants, including those for whom HIV exposure was unknown; accurate specimen collection, transport, and laboratory processing; relay of results to both healthcare providers and infants' families/caregivers; and linkage to care, cotrimoxazole prophylaxis, and antiretroviral therapy (ART) for infants identified as HIV infected. In this review, we outline the ways in which interventions targeting each step in this EID cascade may impact clinical outcomes, costs, and cost effectiveness of EID programs.
Figure 1. Early infant diagnosis (EID) cascade: where could interventions be most effective and cost effective? The cascade of care required for optimally effective EID programs, with two primary goals: (1) correctly informing caregivers of infant infection status and (2) linking all HIV-infected infants to care and antiretroviral therapy (ART). BF = breastfeeding; CTX = cotrimoxazole; PMTCT = prevention of mother-to-child HIV transmission.
Currently available assays for early infant diagnosis
In adults and older children, chronic HIV-1 infection can be diagnosed accurately by detection of serum antibodies against HIV-1 [6]. However, in infants born to HIV-infected women, maternal anti-HIV antibodies cross the placenta and persist in infant blood for up to 18 months (Figure 2). When detected in young infants, these antibodies usually represent exposure to maternal HIV rather than true infant HIV infection [7,8]. Antibody-based tests can therefore be accurately used only to exclude infant infection after 12 months of age, or to confirm infant infection after 15-18 months of age [6,9].
Figure 2. HIV RNA levels and anti-HIV antibody responses among HIV-exposed infants with and without HIV infection. Schematic depiction of the timing of positive HIV-1 antibody testing and RNA levels among HIV-exposed infants. The horizontal axis shows infant age in months. The left vertical axis shows mean HIV-1 RNA level on a logarithmic scale, and corresponds to the green lines on each graph. The right vertical axis shows the proportion of infants for whom an HIV antibody test would likely return positive, and corresponds to the red lines on each graph. The proportion of infants with a positive antibody test in all panels is approximate, based on a wide range of reported ages at which transmitted maternal HIV antibody fades from detection in the sera of uninfected infants [7,105]. Similarly, the mean RNA level is also approximate, based on several studies of infected infants with and without receipt of antiretroviral drugs for prevention of mother-to-child HIV transmission (PMTCT) [106-109]. (a) Results for an HIV-exposed infant who is born without HIV infection and remains uninfected throughout breastfeeding. In this case, HIV-RNA level remains zero, and maternal HIV antibody fades with time. (b) Results for infants infected before birth, either during the intrauterine period (IU; resulting in a high RNA level immediately after birth) or during the intrapartum period (IP; resulting in a 1-2 week delay before viremia is detectable). Maternal HIV antibody is present at birth; although maternal antibody fades with time, endogenous infant antibody production begins in response to infant infection. (c) Results for an HIV-exposed infant who is uninfected at birth, but becomes infected at approximately 6 months of age through breastfeeding. HIV RNA is undetectable while the infant is uninfected, but rises rapidly within the first few weeks after infection. Maternal antibody is present at birth and begins to fade with time, but infant antibody production begins after infant infection occurs.
Accurate EID before 12-18 months of age therefore requires detection of viral components in infant blood ('virological testing'), including cell-free RNA, DNA integrated into host cells, or the viral capsid p24 antigen. Both RNA and DNA can be detected by PCR-based assays. DNA PCR assays, which provide a qualitative result, have traditionally been preferred for EID over quantitative RNA PCR assays, which are more often used for viral load monitoring after established diagnosis. This preference for DNA PCR assays developed for two primary reasons: (1) DNA assays require whole blood, which is easier to obtain than the plasma required for RNA assays, and (2) early-generation DNA assays demonstrated greater sensitivity than RNA assays if mothers or infants received antiretroviral drugs for PMTCT [10-14]. Multiple RNA and DNA PCR assays are now used for EID in resource-limited settings; the sensitivity, specificity, and limitations of these assays have been well summarized [11,12,15-19]. In addition to PCR assays, ultrasensitive (immune complex-dissociated) p24 antigen assays may soon represent an accurate, low-cost method for EID [8,11,15,20-27]. Furthermore, the use of dried blood spots (DBS; whole blood obtained via heel stick or finger prick and dried on filter paper) has obviated phlebotomy requirements for all three assay types. Because DBS specimens are heat stable, non-infectious, and can be shipped via mail or courier, DBS sampling has also reduced the cost of specimen transport to laboratories with PCR or p24 processing capacity [8,20,21,28-32].
Assays for early HIV diagnosis among breastfed infants
Breastfed infants are at ongoing risk of postnatal HIV acquisition [6]. A positive virological test result in a breastfed infant indicates infant HIV infection; however, virological tests may be falsely negative immediately after postnatal infection has occurred (Figure 2). HIV care and treatment guidelines therefore recommend that HIV infection in an HIV-exposed infant cannot be definitively excluded until at least 6 weeks after cessation of breastfeeding [10]. Additionally, breastfeeding in many settings may continue through the first 2-3 years of life, suggesting an important role for repeat testing, both during the breastfeeding period, to detect incident infant infections, and at least 6 weeks after weaning, to confirm HIV-negative diagnoses.
Benefits of early infant diagnosis
The Children with HIV Early ART (CHER) trial in South Africa recently demonstrated a 76% reduction in morbidity, a 75% reduction in mortality, and notable short-term cost reductions when HIV-infected infants initiated ART before 3 months of age and before clinical signs and symptoms of HIV developed [33,34]. Based on this trial and a growing body of observational data [35-37], WHO pediatric treatment guidelines now recommend ART initiation for all HIV-infected infants under 24 months of age [6,32]. In order to facilitate ART initiation as soon as possible after infection, WHO recommends HIV diagnostic testing for all HIV-exposed infants (infants born to HIV-infected mothers) at 4-6 weeks of age [32].
EID confers many potential benefits in addition to early ART initiation. As PMTCT programs are expanded, the majority of HIV-exposed infants will be uninfected and negative virological tests in infancy will provide reassurance to families [11]. In addition, when HIV-exposed infants are raised by extended families due to maternal disability or death, caregivers may bond more readily to infants known to be HIV negative [38]. Documented infant HIV status also permits assessment of PMTCT program effectiveness, and the recognition that a large proportion of HIV-exposed infants are uninfected has improved morale among PMTCT program staff [11].
Accurate EID also informs infant feeding decisions in settings where breastfeeding is recommended for improved infant health. For example, if infants are found to be HIV infected, WHO recommends breastfeeding for 2 years or longer, to avoid the increased incidence of diarrhea, pneumonia, and death observed with replacement feeding [39,40]. A diagnosis of HIV infection also permits discontinuation of postnatal antiretroviral prophylaxis, reducing the risk of drug-resistant virus associated with these medications [41,42]. If infants are found to be uninfected, decisions to avoid early mixed feeding and to shorten the duration of breastfeeding to 12 months can preserve many of the benefits of breastfeeding, while reducing the risk of HIV infection [11,43-45].
The EID 'cascade' in resource-limited settings
Access to virological tests for EID has been limited in many resource-constrained settings, and pediatric providers have often relied on infant diagnosis algorithms that combine clinical symptoms with infant antibody testing [10,46-48]. As described above, these algorithms are neither sensitive nor specific in young infants [49], and HIV diagnosis and ART initiation often occur well after infancy [50,51]. Since 2005, PMTCT and pediatrics programs report rapidly expanding access to EID and infant ART [52]. Published and presented reports emphasize that DBS RNA [53,54] and DNA [1,3,28,31,55-71] PCR assays are feasible and acceptable for EID in resource-limited settings. However, these reports highlight that many infants are lost from care at each step in the EID cascade (Figure 1), including: infant presentation to care, test offer by healthcare professionals and test acceptance by parents/caregivers, specimen processing, result return to healthcare facilities and parents/caregivers, and linkage to care. Reported experiences of EID programs in resource-limited settings are summarized in Table 1. Many of these reports suggest high losses to follow-up at each step in the EID cascade, which likely have important impacts on the clinical outcomes, costs, and cost effectiveness of EID programs.
Table 1. Recent reports of early infant diagnostic testing programs in resource-limited settings: loss to follow-up at key steps in the 'cascade' of care
Proportion of HIV-exposed infants undergoing EID testing
A large proportion of HIV-exposed infants never enter the EID pathway. To undergo EID testing, an infant must be brought by a caregiver to a healthcare facility, and healthcare providers must offer EID testing to the infant/caregiver pair. Most EID programs target infants for whom maternal HIV infection is already known (Table 1). Focusing testing efforts only on these known HIV-exposed infants may result in missed testing opportunities for more than half of all truly HIV-exposed infants [4,71-73].
Even when HIV-infected mothers are aware of their own HIV infection, this information may not be shared with pediatric providers, for example if the importance of disclosure is not emphasized, if mothers are reluctant to disclose their HIV infections, or if infants are brought to care by non-maternal caregivers [68,71,73]. Strategies to improve linkage between PMTCT and pediatric records are under investigation, and include child health cards indicating maternal HIV status [74] and integrated maternal and child health programs [75,76].
Such efforts may miss the large number of infants whose mothers are unaware of their own HIV infections. This may occur for many HIV-infected women, as a result of lack of HIV testing in pregnancy or false-negative HIV antibody tests during acute maternal infection [1]. Importantly, children of women with undiagnosed HIV infection are at substantial risk for HIV infection due to missed opportunities for PMTCT interventions [73,77], and those unknowingly infected in the peripartum or postpartum periods likely have the highest risk of MTCT [77,78]. When HIV diagnosis is unknown, healthcare providers may not consider EID testing necessary, or may feel uncomfortable offering an infant test that will reveal maternal HIV status [68].
To improve testing rates among both known and unknown HIV-exposed infants, several EID programs have broadened their target population to include sick infants presenting to care in inpatient or outpatient settings [3,55,79-81]. However, such programs offer testing when infants develop symptoms suggestive of HIV/AIDS, obviating the benefits of ART initiation before symptoms develop [33]. An innovative strategy of 'universal testing' of healthy infants at vaccination clinics (regardless of information about maternal HIV status) was found to be feasible and acceptable in South Africa, a high-HIV prevalence setting [68,82]. Importantly, parental acceptance of routine infant HIV testing at well child and vaccination visits may be substantially lower in lower-prevalence settings [81].
Specimen collection and processing
There are also major challenges in EID specimen collection and processing (Table 1). Reported rates of unevaluable specimens vary widely, from 0.03% to 16% [61,64]. Reasons for unevaluable specimens include errors in specimen collection, labeling, packaging and data entry, as well as damage or loss of specimens and assay failures in the laboratory [3,28,61,63,66].
Return of results to clinics and patients/caregivers
After EID assays are performed in the laboratory, results must next be returned to healthcare providers and then to families/caregivers. Rates of result return (37% to 90%) and time to result return (9 days to 21 weeks) range widely [3,62,70]. The time required for processing in the laboratory can be variable (1-51 days in a report from Tanzania) [28]. However, equally important events leading to lack of result return (Table 1) and delays in result return (Table 1) occur during the transmission of results from laboratory to healthcare providers and from providers to patients and families.
Currently, many central laboratories send paper-based EID results via commercial couriers, which may result in slow delivery [61,83]. Telephone-based and facsimile-based result return are limited by resource and internet availability, as well as laws regarding electronic transmission of health information [83,84]. Furthermore, health centers may lack systematic processes for following up test results. Because EID programs lie at the interface of PMTCT and pediatric programs [70] (in some cases, with separate health ministries overseeing each), there may be no clearly identified single agency responsible for ensuring that caregivers receive infant test results. Anecdotes describe single healthcare workers assuming this role; when these workers are absent, results may go unretrieved and unreturned [85,86]. In addition, since laboratory reports may be lost or delayed, EID results may not be available when caregivers return to receive them. The variability in result availability at patient return visits may be a more important reason for lack of patient result receipt than is failure of patients to keep follow-up appointments [76,83].
There is a clear need for improved medical informatics for laboratories and health centers [84]. Simple, inexpensive, and portable point-of-care DNA PCR and p24 antigen assays are also in development, but may be years from widespread use in remote settings [23,27,87]. In the interim, novel testing algorithms seek to minimize the need for return visits to receive results. For example, results of an antibody-based rapid HIV test (RHT) can be returned at an initial testing visit [66,68,70,79]. From 9-12 months of age, a negative RHT result can be reassuring with regard to both maternal and infant status, while a reactive result may motivate caregivers to return for the results of a PCR assay, which can be then performed on the same DBS sample used for the rapid test [55].
Linkage to HIV care and treatment
Finally, delays and losses to follow-up between receipt of positive HIV test results and the initiation of HIV care and ART are additional missed opportunities to improve pediatric health. Pre-ART losses to program have been less well described in children than in adults [88]. Where available, program reports have demonstrated that up to 35% of infants diagnosed through EID programs may fail to link to HIV treatment clinics (Table 1) [3]. A large proportion of children enrolling in HIV care may also experience delays in ART initiation (in some cases leading to pre-ART mortality) [59], or lack of appropriate ART initiation [3,62,65,69,89]. These studies must be interpreted in view of changing ART initiation guidelines during the study periods; because ART was only recently recommended for all HIV-infected infants, programs operating before 2008 would not have sought to place 100% of HIV-infected infants on ART [6,10,32].
Overall participation
An 'index of participation' can be calculated to reflect successful completion of the EID cascade (Table 2). The index of participation is derived by multiplying the proportions of infants with successful uptake at each step in the cascade, prior to and including any given step of interest. For example, using the highest reported values of uptake at each step from Table 1, an estimated 87.9% of HIV-exposed infants would be expected to undergoing EID testing and receive test results. Using the lowest published values, this proportion would be 1.9%. When extended to include linkage to HIV care and initiation of ART, the estimated rates of successful completion of the entire cascade range from 0.5% to 52.8%, highlighting that even under the best reported conditions, nearly half of HIV-infected infants may not link successfully to care and ART.
Table 2. Index of participation through each step in the early infant diagnosis (EID) cascade
Economic analyses of EID testing algorithms
Cost is often described as the principal barrier to the expansion of early infant diagnosis and ART [11], and a growing body of literature examines the current costs of EID programs. Here, we review published economic analyses of EID programs, focusing on three primary approaches: (1) costs to healthcare providers and HIV care programs, (2) costs to patients, and (3) cost effectiveness. The first approach, program-perspective or provider-perspective cost estimates, are valuable in planning short-term budgets for EID programs. However, these estimates omit important direct or indirect costs incurred by the families and caregivers of patients, which are included in the second approach. The third approach is the formal evaluation of cost effectiveness, which estimates the health and economic benefits obtained in return for investment in EID programs.
Provider-perspective or program-perspective costs
When EID costs are reported, most authors describe the cost, per patient tested, to healthcare providers or health programs [3,11,23,61]. Although purchase prices of DNA PCR test kits may be variably negotiated between governments and producers, published per-patient test kit prices range from $8.00 in Botswana [3] to $50.00 in South Africa (years of currency not reported) [90]. In addition to test kits, a Kenyan pilot program highlights other important costs (2007 US$): insurance, freight, and taxes ($4 per specimen); filter papers ($2 per specimen); other reagents ($4 per specimen); courier services ($0.50 per specimen); and personnel time ($1 per specimen); combined with test kits costing $10.67 per patient, these costs led to a total per-test cost of $22.17 [61]. In Uganda, EID costs including personnel, supplies, and equipment totaled $23.90 to $24.01 (2007 US$), with test kits comprising 55% of total costs [66]; in Botswana, incorporation of the costs of test kits, laboratory products, technician time, and machine maintenance led to an estimated total cost of $19.60 per patient tested [3].
While these reports from Botswana, Kenya, and Uganda explicitly include many key costs [3,61,66], five key components of EID programs are difficult to cost accurately and are omitted from many other EID program reports:
Transport costs
The costs of specimen transport from testing sites to processing laboratories, as well as the transport of results (electronically or on paper) back to providers, are infrequently described [28,61].
Laboratory costs
Current assays for EID require substantial laboratory infrastructure, including not only PCR machines, laboratory space, and stable electricity, but also detailed and accurate systems for recording and delivering results. Reported assay costs usually include costs of disposable elements and reagents [61,66], but less often incorporate amortized costs of PCR machines or ongoing machine maintenance costs [3,23].
Training costs
Training costs are rarely reported, including training of phlebotomists, laboratory technicians and counselors, for whom previous training may not have addressed ways to discuss results that reveal not only infant, but also maternal, HIV status [63,64,68].
Quality control/quality assurance costs
Available cost estimates exclude the cost of ongoing quality control and quality assurance programs. Such programs are likely to be both time and labor intensive when conducted thoroughly, for example via shipment and processing of standardized 'control' specimens [91], but are clearly needed to prevent rejection of up to 16% of specimens due to poor specimen quality (Table 1) [64].
Healthcare delivery systems
The economic impacts of variation in healthcare delivery systems are also rarely described, including anticipated reductions in per-test costs as greater numbers of infants are tested, reflecting economies of scale, and variations in cost between primary, district, and tertiary health centers. In addition, EID programs may be integrated into other maternal, neonatal, and child health programs. For example, return visits to receive EID test results are often scheduled alongside routine immunization visits [4]. An important consideration in EID cost analyses is the degree to which many of the costs described above are already included in existing maternal-child health program budgets.
Patient or societal perspective costs
The second approach to estimating EID costs incorporates not only costs to healthcare providers and programs, but also costs to patients, family members, and society. This 'societal perspective' includes both direct costs (money spent by health programs or patients) and indirect costs, such as wages lost when patients miss work to attend clinic appointments or when illness limits economic productivity. While societal-perspective cost estimates are more difficult to calculate and may be less directly useful to program directors planning short-term budgets than program-perspective or provider-perspective estimates, they permit a more comprehensive evaluation of the economic impact of EID programs.
Sherman and colleagues in Johannesburg reported a cost analysis of an 'early diagnosis protocol', consisting of DBS PCR at 6 weeks of age, with a planned return visit to receive results at 3 months of age [4]. The early diagnosis protocol was compared to the standard diagnosis protocol at that time: HIV ELISA testing at 12 and 15-18 months. The early diagnosis protocol was estimated to identify 39% of all HIV-infected infants in the PMTCT program, compared to 15% identified by the standard protocol. In a provider-perspective cost analysis, the standard protocol cost $62.38 per patient (2003 US$) and the early diagnosis protocol cost $63.81 per patient. In a societal-perspective analysis, direct patient expenditures (travel fare, refreshments) and indirect costs, such as forfeited wages, were included. In this analysis, due to a large number of clinic visits averted, the early diagnosis protocol was cost saving compared to the standard protocol ($80.69 vs. $107.51 per patient). Extrapolating to all HIV-exposed infants in South Africa, the authors note that implementing the early diagnosis protocol would cost the health system over $400,000 per year, but would lead to societal savings of $7.5 million for those infants [4].
Cost-effectiveness analysis
Because the costs associated with EID in Africa are high relative to antibody-based strategies for HIV diagnosis ($1 to $2 per test [11]), program planners and policy makers must evaluate whether the benefits of EID programs are 'worth' their greater costs. Cost-effectiveness analysis is a formal methodology used to address this question, incorporating not only costs, but also clinical outcomes, of alternative health interventions. By convention, both current and future costs and savings are included. Similarly, both short-term and long-term clinical benefits are quantified, most often in either years of life saved (YLS) or quality-adjusted years of life saved (QALY, which value each year lived in imperfect health less than each year in perfect health) [92].
Using the cost and effectiveness outcomes for two alternative healthcare strategies, one can calculate an incremental cost-effectiveness ratio (ICER). The difference in costs between the competing strategies is the numerator, and the difference in effectiveness, or the incremental health benefit, comprises the denominator. ICERs are conventionally reported in $/YLS or $/QALY. Because these units are not specific to any single health condition, they can help inform decisions among a variety of health interventions for a given population. In addition, ICERs in $/QALY can be compared to international standards of cost effectiveness, such as the WHO-supported Commission on Macroeconomics and Health recommendation that an intervention with an ICER less than the per capita GDP of a country be considered 'very cost effective' in that setting [93]. It is important to note that cost-effectiveness results are not intended to be the sole factor in health-related decision-making; issues of fairness, feasibility, and affordability may be of equal or greater importance.
The calculation of health benefits in YLS requires detailed information regarding both short-term and long-term survival associated with key possible health outcomes from the program under evaluation. For example, in an EID program, one would need estimates of the life expectancy of: (1) an HIV-infected child diagnosed and linked to HIV care through an EID program, (2) an HIV-infected child diagnosed and linked to care through a comparator program (for example, antibody testing at 15-18 months of age), (3) an HIV-exposed uninfected child, and (4) an HIV-unexposed child. Such life expectancy estimates, which may require long-term clinical studies or detailed computer simulation models to determine, are rarely available for resource-limited settings [94,95]. As a result, many cost-effectiveness analyses related to pediatric HIV prevention [96-99] or diagnosis [66,100,101] have used a cost-effectiveness outcome of 'cost/case of pediatric HIV prevented' or 'cost/case of pediatric HIV diagnosed'. Although there are no international cost-effectiveness standards denominated in these units, if several cost-effectiveness analyses use the same outcome measure, the 'cost/case diagnosed' of a newly examined testing strategy can be compared to the 'cost/case diagnosed' of strategies previously described or currently in use.
Only one published study has examined the cost effectiveness of EID programs in resource-limited settings: a population of known HIV-exposed children in Uganda [66]. Using both a computer model and program data, the authors examined DBS-based strategies of DNA PCR for all infants ('PCR') and RHT followed by DNA PCR if RHT results were reactive ('RHT→PCR'). In all scenarios, RHT→PCR was less expensive; it was also less effective in most. Among known HIV-exposed infants in a 'poor compliance' scenario (with a 43% index of participation that is similar to many programs, Table 1[4,59,68,71]), the ICER of the PCR algorithm compared to RHT→PCR was $539 per 'infant correctly diagnosed and informed of result'. If RHT→PCR were the current practice, adopting the PCR algorithm would be economically efficient if policymakers were willing to pay $539 to correctly diagnose one infant and inform him/her of test results. Because ICERs in such units are not directly comparable to other published cost-effectiveness outcomes, it remains challenging to answer the question, is the PCR algorithm cost effective in Uganda compared to the RHT→PCR algorithm? However, this detailed analysis demonstrates that the RHT→PCR algorithm may lead to nearly equivalent clinical outcomes and lower costs, and may become economically preferred in specific settings, for example where retention in care is high, breastfeeding is common, or HIV prevalence is low.
Impact of the EID cascade on costs and cost effectiveness
Current EID cost and cost-effectiveness analyses, combined with recent programmatic reports (Table 1), highlight the key factors that may effect both feasibility and cost effectiveness of EID programs in resource-limited settings. These factors reflect key steps along the 'cascade' of events required for effective EID and delineate high-priority areas of future research that will be needed to comprehensively assess the cost effectiveness of EID programs.
Proportion of HIV-exposed infants undergoing EID testing
The numbers of infants who present for initial testing will dramatically impact the total costs and total benefits of an EID program. However, an increase in the number of infants tested may not impact the cost effectiveness of an EID program compared to deferred clinical or antibody-based diagnosis, since greater costs and greater benefits will accrue in both programs, and the incremental differences may be small. An important exception may occur if the prevalence of HIV exposure or HIV infection differs among the additional infants presenting for EID, as compared to deferred diagnosis. To best assess the cost effectiveness of sick-infant or 'universal testing' strategies, a formal evaluation of the demographics and HIV prevalence even of those not undergoing HIV testing (perhaps via anonymous seroprevalence studies) would be useful.
Improvements in result receipt and linkage to HIV care
The proportion of children and families who receive their EID test results and link to pediatric HIV care and ART will likely have a greater impact on the cost effectiveness than will the proportion of truly HIV-exposed infants who seek EID testing. This occurs because children who undergo an EID test and are then lost to follow-up incur the cost of testing without receiving any benefit from early HIV care. As described previously, several innovative approaches to improve result return have been investigated, including screening via rapid HIV tests, followed by confirmatory PCR assays.
HIV prevalence and populations targeted by EID programs
The cost effectiveness of any screening program depends on the prevalence of disease in the screened population [102]. Menzies and colleagues found that the RHT→PCR algorithm, while cost saving, was slightly less effective than a strategy of PCR testing, in a population comprised entirely of HIV-exposed infants [66]. However, known HIV-exposed infants may not be the population in which an RHT→PCR algorithm would be most effective or cost effective. Among very young HIV-exposed infants, negative RHTs are by definition false negatives with regard to maternal status and are therefore more likely to be false negatives with regard to infant infection status. False negativity may result from inherent test insensitivity, processing errors, or the 'window period' between postnatal infection and infant antibody production [6,10]. Among known HIV-exposed infants, then, routine PCR testing is more effective, and may also be cost effective. Rollins and colleagues investigated the RHT→PCR algorithm in a population in which it may be more cost effective: 'universal testing' at vaccination clinics [68,82].
As proof of concept [66,82] and feasibility and acceptability studies [68], both Menzies et al. and Rollins et al. processed DBS specimens for RHT [66] or ELISA [68,82] and PCR off site, and were therefore unable to return antibody results to caregivers at the same visit on which samples were obtained. Additional evaluations of the RHT/PCR algorithm are needed in populations of infants without known HIV exposure, with specific focus on the proportions of infants/caregivers receiving immediate RHT results, receiving delayed PCR results, and linking to HIV care.
Long-term clinical and economic impacts of early infant diagnosis and care
To comprehensively assess the cost effectiveness of EID compared to traditional deferred diagnostic strategies, it will be critical to understand the clinical events and costs associated with early and late diagnosis and therapy. These factors may have greater impact on EID cost effectiveness than the comprehensive costs of laboratory assays including transport, equipment, training, and quality assurance. The immediate costs for PCR-based EID are higher than for deferred antibody-based testing [11]. Medication costs associated with early diagnosis will increase further if infants link to HIV services and early ART. Considering short-term benefits, such as the number of infants diagnosed, does not capture the larger clinical benefits of early diagnosis and therapy [33,103]. In addition, EID and early ART initiation will likely avert a large number of opportunistic infections and deaths [33,103], for which care is expensive; in the short term, this may offset a proportion of the upfront costs of EID programs [104]. For example, substantial cost savings were observed over a 10-month period in South Africa when ART was initiated immediately after EID, compared to ART deferred until the development of signs or symptoms of AIDS [34]. Data to inform clinical outcomes for HIV-exposed and HIV-infected children in various resource-limited settings are needed. As such data become available, health policy models [66,95] can integrate data from multiple sources, highlight future research priorities by identifying the most influential data parameters, and assist in informing HIV testing and treatment guidelines.
Access to early infant diagnosis of HIV infection is improving in resource-limited settings, but key barriers exist to testing, result receipt, and linkage to care. Infants of mothers who are unaware of their own HIV infections or who did not access PMTCT services may be the most difficult population to capture, but may also be the population with the greatest need for EID. The benefits of successful EID are substantial, not only for HIV-infected infants, in whom morbidity and mortality can be reduced with early ART initiation, but also for HIV-negative infants, their caregivers, and PMTCT and pediatric providers. Costs are a frequently cited barrier to EID expansion. However, more detailed cost-effectiveness analyses will be important to assess the degree to which the benefits of EID programs render them 'worth' their costs, and long-term data and model-based projections can further inform future clinical and economic benefits. Innovative approaches to improve rates of testing, result receipt, and linkage to care will have lasting impacts on the health of HIV-exposed infants and the value of EID programs in resource-limited settings.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
ALC conceived the study, conducted literature review, data extraction, and interpretation of results, and drafted the manuscript. JP conducted literature review and data extraction. JP, LRA, KAF, RPW, and VL participated in the design of the study and interpretation of study results. All authors critically reviewed the manuscript and contributed to manuscript drafting, and all authors read and approved the final submitted manuscript.
The authors gratefully acknowledge Asinath Rusibamayila and Sarah Bancroft Lorenzana for assistance in manuscript and figure preparation. Funding for this work was provided by the National Institute of Allergy and Infectious Disease (K01 AI078754 (ALC), R01 AI058736 (KAF, RPW, JP), the National Institute of Child Health and Human Development (T32HD 055148-02 (LR)), the Elizabeth Glaser Pediatric AIDS Foundation (ALC, JP, KF, RPW), and the French National Institute of Health and Medical Research (VL). The funders had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication.
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International AIDS Society, Geneva, Switzerland
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International AIDS Society, Geneva, Switzerland
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Rely K, Bertozzi SM, Avila-Figueroa C, Guijarro MT: Cost-effectiveness of strategies to reduce mother-to-child HIV transmission in Mexico, a low-prevalence setting.
Health Policy Plan 2003, 18:290-298. PubMed Abstract | Publisher Full Text
Chen KT, Sell RL, Tuomala RE: Cost-effectiveness of elective cesarean delivery in human immunodeficiency virus-infected women(1).
Obstet Gynecol 2001, 97:161-168. PubMed Abstract | Publisher Full Text
Stringer JS, Rouse DJ: Rapid testing and zidovudine treatment to prevent vertical transmission of human immunodeficiency virus in unregistered parturients: a cost-effectiveness analysis.
Obstet Gynecol 1999, 94:34-40. PubMed Abstract | Publisher Full Text
Mrus JM, Yi MS, Eckman MH, Tsevat J: The impact of expected HIV transmission rates on the effectiveness and cost of ruling out HIV infection in infants.
Med Decis Making 2002, 22:S38-44. PubMed Abstract | Publisher Full Text
Doyle NM, Levison JE, Gardner MO: Rapid HIV versus enzyme-linked immunosorbent assay screening in a low-risk Mexican American population presenting in labor: a cost-effectiveness analysis.
Am J Obstet Gynecol 2005, 193:1280-1285. PubMed Abstract | Publisher Full Text
Agency for Healthcare Research and Quality: Screening for human immunodeficiency birus: focused update of a 2005 systematic evidence review for the U.S. Preventive Services Task Force. [http://www.uspreventiveservicestaskforce.org/uspstf07/hiv/hivrevup.pdf] webcite
Prendergast A, Mphatswe W, Tudor-Williams G, Rakgotho M, Pillay V, Thobakgale C, McCarthy N, Morris L, Walker BD, Goulder P: Early virological suppression with three-class antiretroviral therapy in HIV-infected African infants.
AIDS 2008, 22:1333-1343. PubMed Abstract | Publisher Full Text
Cleary SM, McIntyre D, Boulle AM: The cost-effectiveness of antiretroviral treatment in Khayelitsha, South Africa - a primary data analysis.
Cost Eff Resour Alloc 2006, 4:20. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text
Sohn AH, Thanh TC, Thinh le Q, Khanh TH, Thu HK, Giang le T, Lien TX: Failure of human immunodeficiency virus enzyme immunoassay to rule out infection among polymerase chain reaction-negative Vietnamese infants at 12 months of age.
Pediatr Infect Dis J 2009, 28:273-276. PubMed Abstract | Publisher Full Text | PubMed Central Full Text
Dabis F, Bequet L, Ekouevi DK, Viho I, Rouet F, Horo A, Sakarovitch C, Becquet R, Fassinou P, Dequae-Merchadou L, Welffens-Ekra C, Rouzioux C, Leroy V, ANRS 1201/1202 DITRAME PLUS Study Group: Field efficacy of zidovudine, lamivudine and single-dose nevirapine to prevent peripartum HIV transmission.
AIDS 2005, 19:309-318. PubMed Abstract | Publisher Full Text | PubMed Central Full Text
Mphatswe W, Blanckenberg N, Tudor-Williams G, Prendergast A, Thobakgale C, Mkhwanazi N, McCarthy N, Walker BD, Kiepiela P, Goulder P: High frequency of rapid immunological progression in African infants infected in the era of perinatal HIV prophylaxis.
AIDS 2007, 21:1253-1261. PubMed Abstract | Publisher Full Text
Mofenson LM, Korelitz J, Meyer WA, Bethel J, Rich K, Pahwa S, Moye J Jr, Nugent R, Read J: The relationship between serum human immunodeficiency virus type 1 (HIV-1) RNA level, CD4 lymphocyte percent, and long-term mortality risk in HIV-1-infected children. National Institute of Child Health and Human Development Intravenous Immunoglobulin Clinical Trial Study Group.
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Shearer WT, Quinn TC, LaRussa P, Lew JF, Mofenson L, Almy S, Rich K, Handelsman E, Diaz C, Pagano M, Smeriglio V, Kalish LA: Viral load and disease progression in infants infected with human immunodeficiency virus type 1. Women and Infants Transmission Study Group.
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Braun M, Kabue MM, McCollum ED, Ahmed S, Kim M, Aertker L, Chirwa M, Eliya M, Mofolo I, Hoffman I, Kazembe PN, van der Horst C, Kline MW, Hosseinipour MC: Inadequate coordination of maternal and infant HIV services detrimentally affects early infant diagnosis outcomes in Lilongwe, Malawi.
Pre-publication history
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We Heart Art Penthouse Evening with Live Jazz
- Music
- 420 Park Ave South, New York, NY, 10020
Power of the Purse 2013!
Women's Fund of New Jersey
Thursday, March 7, 2013 from 6:00 PM to 9:00 PM (EST)
About The Women's Fund of New Jersey: Founded in 1995, the Women's Fund of New Jersey is the only foundation in our state dedicated to investing in women and girls. Our mission is to invest in the power of women and girls through advocacy, grant-making, and strategic programming. WFNJ created a Women's Policy Institute in 2008 to train grass-roots women leaders in the art of advocacy and help bring positive social change and improve the overall health and well-being of women and their families. And during the summer 2012, the organization started "Tweet2Eat" a social-media experiment in which inner-city girls tweeted their legislators about the importance of having access to fresh and healthy food.

subset: commoncrawl


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D.L. & Co.
Pisces Horoscope Candle
Please select an available size.
Please select a size.
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Description: Pisces Horoscope Candle:
- Fragrance Notes: Prickly Pear and Anjou Pear
- Comes in a glass vessel
- Packaged in a gift box
- Each 3 ounce candle measures 2 inches in diameter by 2½ inches in height with a 20 hour burn time
- Wipe vessel with a damp cloth
Material: Wax and glass
Brand: D.L. & Co.
Origin: Imported


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"The eBay Movie" Trailer - The Auction Site
You don't get to 500 million auctions without selling a few crappy items.
This post was created by a user and has not been vetted or endorsed by BuzzFeed's editorial staff. BuzzFeed Community is a place where anyone can post awesome lists and creations. Learn more or post your buzz!
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text: On Mon, Sep 28, 2009 at 09:03:37PM -0500, Charles Duffy wrote: > Charles Duffy wrote: > >What I'm tempted to do is add a command which sends a sigil to stderr to > >the end of the exec: migration lines specified by libvirt, and wait for > >either that sigil or an error to show up in the log for that domain > >before issuing the cont; if my memory is at all correct, libvirt should > >have some helper functions useful for that purpose already available. > > Ugh, bad idea -- I was thinking only of the migrate-from-file case, and > not of migration from any alternate source; any non-exec source doesn't > allow for this hack. > > Anthony suggested dropping -S from the command line on incoming > migrations, and using "info status" to poll for when the guest resumes > itself; however, this doesn't work for cases when the VM was saved or > migrated in a paused state and the end-user expectation is for it to > remain paused. We can't drop -S, because we need to be able to run 'info cpus' and then do sched_setaffinity on each vCPU, before it ever starts executing, otherwise memory will end u pinned to the wrong NUMA nodes > I'm tempted to add additional output to "info migrate" indicating > whether an inbound migration is ongoing; however, this wouldn't help > versions of qemu without the patch applied. Yeah, I've been thinking much the same this morning. I think we should consider what the optimal setup is for our needs long term and try and do whatever we can for that in QEMU now. I think it'd definitely be worthwhile to have an 'info migrate' impl for incoming migration, and even to make '-incoming' optional, and add a 'migrate-incoming' command to the monitor, which like 'migrate' could be run in either blocking or non-blocking mode. For existing QEMU, it might be sufficient to just put an arbitrary 'sleep(5)' before issuing 'cont', which would at least give it a reasonable chance of avoiding the race condition. Regards, Daniel -- |: Red Hat, Engineering, London -o- http://people.redhat.com/berrange/ :| |: http://libvirt.org -o- http://virt-manager.org -o- http://ovirt.org :| |: http://autobuild.org -o- http://search.cpan.org/~danberr/ :| |: GnuPG: 7D3B9505 -o- F3C9 553F A1DA 4AC2 5648 23C1 B3DF F742 7D3B 9505 :|


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About Schools in Nellysford, VA
Contact a Coldwell Banker® real estate agent to learn more about the schools and school districts in Nellysford, VA.FIND AN AGENT
Nellysford, Virginia is located in Nelson County. Nearby cities and towns include Wintergreen, Sherando, Lyndhurst, Lovingston, Waynesboro, Stuarts Draft, Schuyler, Shipman, Dooms, Fishersville, Crozet, Greenville, Arrington, Esmont, Jolivue, Crimora, Ivy, New Hope, Staunton, Yogaville, Verona, Middlebrook, Harriston, University of Virginia, Scottsville, Charlottesville, Free Union, Mount Sidney, Amherst, and Grottoes. Nellysford is a rural community with a population of 1,076. The median household income is $73,461. In Nellysford, 70% of residents are married, and families with children reside in 10% of the households. Half the population of Nellysford commutes 29 minutes or less to work, with 74% of residents holding white collar jobs and 26% residents holding blue collar jobs. The median age of homes in Nellysford, VA is 15 years, with 66% of those homes owned, 10% rented, and 25% not occupied. In the previous year, 15 Nellysford properties were sold. The median sale price of a home in Nellysford in the previous year was $316,945.
Contact a Coldwell Banker® real estate agent to learn more about the schools and school districts in Nellysford, VA.FIND AN AGENT
See if your personality and goals are right for real estate.SEE ALL REAL ESTATE CAREERS
Community information and market data Powered by Onboard Informatics. Copyright ©2015 Onboard Informatics. Information is deemed reliable but not guaranteed.
This information is provided for general informational purposes only and should not be relied on in making any home-buying decisions. School information does not guarantee enrollment. Contact a local real estate professional or the school district(s) for current information on schools. This information is not intended for use in determining a person's eligibility to attend a school or to use or benefit from other city, town or local services.


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Gem Cards Available at Retailers
Looking to snag some gems? You will be able to purchase from real retailer this week with the new Gem Cards.
[ANET]You can purchase gems in-game from the Black Lion Trading Company, but starting this week you can also purchase Guild Wars 2 gems in real life at select retailers. These cards, which make a great gift, contain a serial code that can be redeemed in Guild Wars 2 for gems.
If gem cards aren't in stock at your favorite retailer yet, be sure to ask if and when they'll be arriving.[/ANET]
Related Stories


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6 Books You Must Read
Emotional Equations by Chip Conley
Mathematical equations can provide insights into your feelings and emotions.
Don't think it's possible? Surely you've thought, "Once I looked at that differently I felt a lot better," right? Conley's equations provide a mental framework that can help center you when you're wallowing in despair... or help you contain your euphoria when your expectations are out of control.
Balance is everything; knowing the equations, and acting accordingly, can help you achieve that balance.


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Space News Archive - November 04, 2011
The reddest galaxies with the largest central bulb show the largest bars -gigantic central columns of stars and dark matter-, according to a scientific study that used Google Maps to observe the sky.
A lunar sample from a rock that once sat on the surface of the moon will be on public display at Arizona State University (ASU) in Tempe, AZ beginning November 5, 2011.
Reporters are invited to NASA's John C. Stennis Space Center in Mississippi on Wednesday, Nov. 9 to view a test firing of the J-2X rocket engine, a key component of NASA's Space Launch System, which will carry the Orion spacecraft, its crew, cargo, equipment and science experiments beyond Earth orbit.
In a new paper, researchers from Harvard-Smithsonian Center for Astrophysics and Princeton suggest a new technique for finding aliens: look for their city lights.
NASA's Mars Science Laboratory Curiosity Rover was moved from NASA Kennedy Space Center to Space Launch Complex 41 at Cape Canaveral Air Force Station on Thursday morning in preparation for lift-off
After 520-days of a simulated mission to Mars, the Mars500 crew finally "returned to Earth" on Friday after stepping out of their "spacecraft."
A team of scientists has used the NASA/ESA Hubble Space Telescope to observe a quasar accretion disc — a brightly glowing disc of matter that is slowly being sucked into its galaxy's central black hole.
Part of human fascination with space is the chance to look back at our own planet from afar. The unique vantage from the International Space Station affords a vista both breathtaking and scientifically illuminating.
NASA's Solar Dynamics Observatory (SDO) spotted one of the largest new sunspots to have appeared on the surface of the sun in years.
- An uxorious, effeminate, or spiritless man.
- A timorous, cowardly fellow.


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NIT-K, Surathkal, is getting more incentives for research and quality improvement
The National Institute of Technology-Karnataka (NIT-K) at Surathkal in Mangalore, in its golden jubilee year, has many reasons to cheer.
The government has sanctioned for the institute 67 new faculty positions which will help it to strengthen the academic and research programmes. In addition, the government is likely to choose it as the nodal agency for selecting and admitting foreign students for all National Institutes of Technology (NITs) and some other engineering institutes for the academic year 2010-11.
Sandeep Sancheti, Director, NIT-K, said that the Ministry of Human Resource Development has given preliminary clearance for the institute to this effect. It is under a programme called DASA (Direct Admission of Students from Abroad). "The final clearance is awaited,'' he said. Once it comes through the process of selecting and admitting foreign students will begin from next year.
The NIT Council, in its October meeting, selected NIT-K as one among a three-member committee of NITs in the country for updating curriculum and improvement. In addition, the NIT-K has been chosen as one among a five-member committee of NITs to study and reform admission aspects to NITs. Admission is based on the All-India Engineering Entrance Examination (AIEEE). There are 20 NITs in the country.
Prof. Sancheti said that the Union Government has recognised the institute as a full-fledged centre for its quality improvement programme. Government teachers serving in engineering colleges and polytechnics all over India can pursue M. Tech. and Ph.D. courses at the institute on full-time basis. It is the second NIT in the country to be recognised under the programme after Rourkela NIT.
New course
The NIT-K has proposed to start a post-graduate course in Information Technology from the next academic year. The institute will have a student exchange programme with Dublin City University from next year. The Union Government and the Government of Ireland will support it. The ambassadors of both the countries have taken keen interest in this regard. In addition, it will have student exchange programmes with the University of Applied Sciences, Western Switzerland.
Prof. Sancheti said that NIT-K will sign a memorandum of understanding with Bosch Limited this month to set up a mechatronics laboratory at the institute. The company will sponsor the laboratory. In addition, it will fund the institute to set up a professorial chair and support joint research activities. NIT-K will open two more inter-disciplinary centres of excellence. They will be in the domains of sensor networks and graphical system design. Presently it has inter-disciplinary centres of excellence in materials research and engineering, disaster management and sustainable technologies.
The institute is also planning to set up a centre to support innovators.
The director said that now the institute offers B.Tech courses in nine disciplines and M.Tech courses in 16 disciplines with 23 specialisations. In addition it is offering MBA and MCA courses and M.Sc. in two disciplines.
The B.Tech and M.Tech courses which have completed five years of existence have been accredited by the National Board of Accreditation, most of them with the highest rating.
Science Congress
The NIT-K will host the 24th Indian Engineering Congress from December 10 to 13 in association with the Institution of Engineers (India). The theme will be "national growth and security technological challenges." The meet is being held in Karnataka after a gap of nine years. It had been held in Bangalore nine years ago.
He said that 80 technical papers will be presented in 12 sessions from December 11 to 13. Of these 20 are invited papers on five major topics. They are nuclear energy, ecology and environment, Geographic Information System and applications, ports and shipping, and oil and gas sector.
Keywords: National Institute of Technology-Karnataka, NIT-K, Surathkal, Mangalore, golden jubilee, Sandeep Sancheti, Director, DASA, Direct Admission of Students from Abroad, NIT Council, All-India Engineering Entrance Examination, AIEEE, Indian Engineering Congress


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- Shopping Bag ( 0 items )
From the Publisher'This handbook is a comprehensive guide to the most popular and useful of these devices, including about 370 circuits with diagrams.'
Elektor Electronics
'The book provides, in an easily-readable style, a thorough grounding in theoretical information relating to various aspects of modern audio systems and to various dedicated types of audio IC's.'
Sound and Communication Systems International


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Not that kind of toad (he's got a girlfriend nowadays), a big ass dogtooth tuna! According to Healey's Twitter account, the famed big wave charger and all around waterman was "happy as a bearded clam" after shooting this tuna in Fiji. And he should be, apparently it's a Fijian record! Well done Healey!
CATEGORIZED: News
TAGS: fiji, Mark Healey, Riffe, Spearfishing
TAGS: fiji, Mark Healey, Riffe, Spearfishing


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The John Murray Show
A lively mix of entertainment, human interest and lifestyle features with Kathryn Thomas
A lively mix of entertainment, human interest and lifestyle features with Kathryn Thomas
Kathryn's first guest this morning has in one year gone from being a self-published author to having a publishing deal with Harper Collins. On the line is Carmel Harrington, who self-published her ebook a year ago titled 'Beyond Graces Rainbow' . Carmel tells us all about her dream coming true!
Lead guitarist with The Pogues & founding member of The Radiators from Space, had been given the all clear after five years battling cancer but it has returned & it is inoperable. Friends & collaborators have come together for a musical testimonial. In the great tradition of football testimonials, the event takes place this Saturday night August 24th at the Olympia Theatre in Dublin.
Joining Kathryn in studio are Radiators from Space members Steve Averill & Pete Holidai & from a London studio Cait O'Riordan, exPogue & exRadiator member.
Rumours, gossip, big name shake-ups, the clock is ticking on the Premier League transfer window which closes in 12 days time. In studio with Kathryn this morning is Richard Sadlier, who has been player, agent, director of Millwall Youth Academy to reveal a little of the wheeling & dealing & sums of money that flows through the premier league.
1. Talent must be emerging rather than established. Open to those who have not received considerable air-play and/or exposure. Entrants must also normally be resident in the 32 counties.
2. It is open to all musical genres like punk, pop, rock 'n' roll, folk, country, electronic, compositional etc.
3. A backline and sound engineer will be provided by the Saturday Night Show on the night of the winning performance, May 30, but the winning act will provide their own instruments and drum kit. The winning act will look after their own expenses on the night of the Saturday Night Show performance.
4. The act must be available to perform on the John Murray Show on Friday, May 29th and on the Saturday Night Show on Saturday, May 30th.
5. How do I enter?
All entries are by email only and should be sent to firstname.lastname@example.com
6. What should my entry include?
Your email should include a short description (maximum 100 words) of the musician or band, a contact mobile phone number and ONE audio file attachment. The audio filename should contain the band/musician name and composition title. The entry should also include a photo of act of approximately 1Mb.
Only original work will be considered – no covers or samples. Due to a high volume of entries we cannot give individual feedback on music received.
7. Which type audio files should I send?
Audio files must be sent in high-quality audio, preferably stereo and of as high a production standard as possible as this track is what will be played on the John Murray Show on RTE Radio One. MP3 (192kbps or higher) files only will be accepted. No other file types should be entered as they will not be accepted. Tracks should be no longer than 3'30" in duration.
8. Can I enter more than once?
No. One entry is sufficient.
9. Deadline for submission?
Get your music in ASAP. Deadline for submissions is 12 noon, Friday, May 8th.
If you require a CD copy of this programme please e-mail firstname.lastname@example.com or click here for RTÉ Archives sales form. Transfer fees and terms and conditions apply.
Presenter: John Murray
Tip: You can drag and scroll the programme grid with your mouse


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FAIRMONT — There were plenty of questions heading into this season for Fairmont's boys basketball team.
Who would replace county player of the year Kwinton Hinson's scoring production in the frontcourt? How would the loss of Charlton Townsend affect post play?
The playoffs start next week and most of those answers have already surfaced.
The Golden Tornadoes wrapped up their fourth consecutive Three Rivers Conference regular-season championship Wednesday night against South Columbus, smothering the Stallions, 103-50, for their 17th win this season.
"We wanted to make a statement after (Red Springs thought we would stumble) and we certainly came out ready to play," said Fairmont coach Michael Baker. "We did a lot of stuff right. We ran it and pushed the basketball throughout."
Fairmont had extra motivation as the school celebrated the 20th anniversary of the 1994 state championship.
Baker was coach then, too.
"All of the postponements kind of made it difficult to schedule this ceremony, but our starting five and our sixth man were able to show up" he said. "We had good representation of that memorable team. The guys seemed really appreciative."
The Golden Tornadoes (17-5, 12-1) used a 12-0 run midway through the first quarter to take a double-digit lead into the second and never looked back. Senior guard Kashawn Leonard, coming off a season-high 25 points in Monday's victory at East Columbus, was one of six players in double figures with 17 points.
He's helped shoulder some of the scoring burden down the stretch in Hinson's absence and sophomore Alshaquan Williams has proven to be an ideal replacement for Townsend down low.
Williams poured in 20 against the Stallions Wednesday night.
"We knew we would be okay after losing those guys, but I didn't think we'd be where we are right now with 17 wins," Baker said. "I didn't see us hitting 100 (points) as many times as we have. Our ball movement has made the difference."
With the league's top playoff seed secured, Fairmont's locked in home playoff contests the first and second round. Despite clinching at least a share of a conference title, Baker says his team won't take South Robeson — losers of 12 of their last 13 games — lightly Friday in Rowland.
"We're going to get after it," Baker said. "We don't want to share anything."
In the girls contest, Fairmont struggled to score in the final three minutes and fell to the Stallions, 43-32.
South Columbus' previous lone win in the conference came before the new year and Wednesday's victory snapped a 10-game skid. Freshman guard Carrington Mitchell led the Lady Golden Tornadoes with 12 points.
Lumberton girls clinch playoff spot
LAURINBURG — Mariah Locklear was understandably a little nervous when she got an open 3-point look in the closing moments of Wednesday's 47-44, but that didn't stop her from seizing the chance.
"I got open and I knew I had to hit it. I feel most comfortable when the ball is in my hands," Locklear said.
The shot fell, giving the Pirates (14-8, 5-4) in the final points of the night with 8.5 seconds left. It was Scotland's (11-8 and 9-1) only conference loss of the year.
It was the first game winner that Locklear said she can remember making, and it was followed by a desperation shot at the buzzer by ShanQaylia Stanton.
The overtime capped a fourth-quarter comeback by the Pirates. The game had been close all night, with Scotland staying ahead by just a handful of points. The Scots led by two at halftime and four at the start of the fourth quarter. The lead got as high as five points with 2:40 left before Lumberton's Katlyn Singletary hit two key shots to send it to overtime tied at 42.
"I thought our kids played real hard and played with much resiliency tonight. We really challenged them on the way over here, on the court and during halftime to step up and really play well," said Lumberton coach Danny Graham, who earned his 399th career win. "Our key to the game was to try and cut off Scotland's best talent, which is inside and we did a good job, not a great job, but our kids did what we asked them to do and they gave us a great effort."
The extra period was a defensive struggle, with neither team scoring until the final minute. Alexis Andrews scored first for Lumberton before Scotland tied it with 38 seconds left. Lumberton called a timeout, and got the ball to Locklear for the final points.
Singletary and Randi Bullard led the Pirates with 10 points each and Locklear had nine. Singletary finished with 13 rebounds for a double-double.
Destiny Campbell led Scotland with 16 points and 12 rebounds and nine blocks. Sellers also had a double-double with 12 points and 19 rebounds.
Lumberton boys near playoff berth
LAURINBURG — Lumberton pulled away in the second half of a must-win game at Scotland on Wednesday to move one step closer to the Southeastern Conference's final playoff berth.
The Pirates (12-10, 5-4) beat the Scots 62-49 to move into third place in the conference standings and can clinch the playoff berth by beating Purnell Swett on Friday.
After leading 23-22 at halftime, Lumberton used interior defense to slow down Scotland (6-13, 5-5), winning the rebound battle and forcing turnovers.
"We did a better job of rebounding in the second half. They outrebounded us by about 20 the first time we played us, and we just had to do a better job on the boards," Lumberton coach Mackie Register said.
Lumberton's Travis Suggs led all scorers with 21 points and Darius Floyd added 12.
Scotland coach Michael Malpass said Lumberton played harder, and that was the difference in the end. Jaylend Ratliffe led Scotland with 15 points.
"I don't think we played hard all night. They played harder and wanted it more and I'll never understand that when you have to win," Malpass said.
Corbin Ensminger of the Laurinburg Exchange contributed to this report.
Box Score
Fairmont 103, South Columbus 50
South Columbus 18 3 10 19 — 50
Fairmont29 20 25 29 — 103
SOUTH COLUMBUS — Soles 12, C. McGill 2, Fink 3, Chesnut 3, Miller 20, Chatman 2, Daniels 5.
FAIRMONT — Alshaquan Williams 20, Kashawn Leonard 17, Jarrod Neal 13, Shyheim Hines 12, McQueen 10, Lambert 2, Fields 4, Malik Milton 15, Barfield 4, Powell 2, Watson 5.
3-Point Goals — SC: Miller 4, Soles, Fink, Chesnut, Daniels. FMT: Neal, Milton 3, McQueen.
Records — Fairmont 17-5, 12-1; South Columbus 11-10, 6-6.
South Columbus 43, Fairmont 32
South Columbus 11 8 11 13 — 43
Fairmont69 10 7 — 32
SOUTH COLUMBUS — Dayton 14, Harris 9, Spencer 8, Turbarila 5, McPherson 3, Newman 2.
FAIRMONT — Carrington Mitchell 12, Ingram 8, Clewis 5, Hicks 4, Reed 2, Henderson 1.
Records — Fairmont 3-16, 3-10; South Columbus 5-14, 2-11.


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NBC Universal is reorganizing its sales force for its cable networks, giving team leaders a broader reach and expanded duties. The move, according to this report, is partially due to the recent acquisitions of networks such as Oxygen and consolidations at some cable providers.
View Full Article in:Broadcasting & Cable
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Dr. Gallo is a 1987 graduate of the Ohio State University College of Veterinary Medicine. Sam joined the CDAEC team in 1992 after 5 years in primary care practice.
Dr. Gavin grew up in neighboring Glenville, NY. She attended Tufts University College of Veterinary Medicine.
Dr. Pabin is originally from Ohio and received her Bachelors degree from The Ohio State University, followed by her Doctor of Veterinary Medicine from Cornell College of Veterinary Medicine in 2002.
Originally from Westchester County, NY, Dr. Rogers earned a Bachelor of Science degree at Binghamton University.
Dr. Tuffey graduated from the University of Pennsylvania School of Veterinary Medicine in 2003.
Dr. Nikki Blanchette graduated from SUNY Geneseo with a BS in Biology in 1994 and obtained her DVM from Ross University 1998, attending her senior year at Oklahoma State.
Dr. Rachel Hannum grew up in Georgia and Virginia and received her DVM from VA-MD College of Veterinary Medicine in 2004.