D Heather Watts

Eunice Kennedy Shriver National Institute of Child Health and Human Development, Maryland, United States

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Publications (122)718.21 Total impact

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    ABSTRACT: Most studies examining the association of prenatal antiretroviral (ARV) exposures with congenital anomalies (CAs) in children born to human immunodeficiency virus (HIV)-infected women have been reassuring, but some evidence suggests an increased risk with specific ARV agents.
    JAMA Pediatrics 11/2014; · 4.28 Impact Factor
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    ABSTRACT: : In resource-limited countries, interventions to prevent mother-to-child HIV transmission (PMTCT) have not yet realized their full potential health impact, illustrating the common gap between the scientific proof of an intervention's efficacy and effectiveness and its successful implementation at scale into routine health services. For PMTCT, this gap results, in part, from inadequate adaptation of PMTCT interventions to the realities of the implementation environment, including client and health care worker behaviors and preferences, health care policies and systems, and infrastructure and resource constraints. Elimination of mother-to-child HIV transmission can only be achieved through understanding of key implementation barriers and successful adaptation of scientifically proven interventions to the local environment. Central to such efforts is implementation science (IS), which aims to investigate and address major bottlenecks that impede effective implementation and to test new approaches to identifying, understanding, and overcoming barriers to the adoption, adaptation, integration, scale-up, and sustainability of evidence-based interventions. Advancing IS will require deliberate and strategic efforts to facilitate collaboration, communication, and relationship-building among researchers, implementers, and policy-makers. To speed the translation of effective PMTCT interventions into practice and advance IS more broadly, the US National Institutes of Health, in collaboration with the President's Emergency Plan for AIDS Relief launched the National Institutes of Health/President's Emergency Plan for AIDS Relief PMTCT IS Alliance, comprised of IS researchers, PMTCT program implementers, and policy-makers as an innovative platform for interaction and coordination.
    Journal of acquired immune deficiency syndromes (1999). 11/2014; 67 Suppl 2:S163-S167.
  • AIDS research and human retroviruses. 10/2014; 30 Suppl 1:A267-8.
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    ABSTRACT: To estimate the effects of infection by HIV on the type-specific cumulative detection of cervicovaginal infection by human papillomavirus (HPV).
    AIDS (London, England) 09/2014; · 4.91 Impact Factor
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    ABSTRACT: We evaluated the pharmacokinetics (pk) of raltegravir in HIV-infected women during pregnancy and postpartum.
    Journal of acquired immune deficiency syndromes (1999). 08/2014;
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    Lynne M Mofenson, D Heather Watts
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    ABSTRACT: Lynne Mofenson and Heather Watts discuss the context and implications of the study by J. Sibuide and colleagues, which provides a detailed analysis of birth defects in infants with in utero antiretroviral drug exposure in the French Perinatal Cohort. Please see later in the article for the Editors' Summary.
    PLoS Medicine 04/2014; 11(4):e1001636. · 15.25 Impact Factor
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    ABSTRACT: Plasma HIV RNA levels have been associated with risk of human papillomavirus (HPV) and cervical neoplasia in HIV-seropositive women. However, little is known regarding local genital tract HIV RNA levels and their relation with cervical HPV and neoplasia. In an HIV-seropositive women's cohort with semi-annual follow-up, we conducted a nested case-control study of genital tract HIV RNA levels and their relation with incident high-grade squamous intraepithelial lesions sub-classified as severe (severe HSIL), as provided for under the Bethesda 2001 classification system. Specifically, 66 incident severe HSIL were matched to 130 controls by age, CD4+ count, HAART use, and other factors. We also studied HPV prevalence, incident detection, and persistence in a random sample of 250 subjects. Risk of severe HSIL was associated with genital tract HIV RNA levels (odds ratio comparing HIV RNA ≥ the median among women with detectable levels versus undetectable [ORVL] 2.96; 95% CI:0.99-8.84; Ptrend=0.03). However, this association became non-significant (Ptrend=0.51) following adjustment for plasma HIV RNA levels. There was also no association between genital tract HIV RNA levels and the prevalence of any HPV or oncogenic HPV. However, the incident detection of any HPV (Ptrend=0.02) and persistence of oncogenic HPV (Ptrend=0.04) were associated with genital tract HIV RNA levels, after controlling plasma HIV RNA levels. These prospective data suggest that genital tract HIV RNA levels are not a significant independent risk factor for cervical pre-cancer in HIV-seropositive women, but leave open the possibility that they may modestly influence HPV infection, an early stage of cervical tumoriogenesis.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 04/2014; · 4.65 Impact Factor
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    ABSTRACT: Objective To examine maternal characteristics associated with adverse pregnancy outcomes among women infected with HIV. DesignProspective cohort study. SettingMultiple sites in Latin America and the Caribbean. PopulationWomen infected with HIV enrolled in the Perinatal (2002–2007) and the Longitudinal Study in Latin American Countries (LILAC; 2008–2012) studies of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) International Site Development Initiative (NISDI). Methods Frequencies of adverse pregnancy outcomes assessed among pregnancies. Risk factors investigated by logistic regression analysis. Main outcome measuresAdverse pregnancy outcomes, including preterm delivery (PT), low birthweight (LBW), small for gestational age (SGA), stillbirth (SB), and neonatal death. ResultsAmong 1512 women, 1.9% (95% confidence interval, 95% CI, 1.3–2.7) of singleton pregnancies resulted in a stillbirth and 32.9% (95% CI 30.6–35.4) had at least one adverse pregnancy outcome. Of 1483 singleton live births, 19.8% (95% CI 17.8–21.9) were PT, 14.2% (95% CI 12.5–16.1) were LBW, 12.6% (95% CI 10.9–14.4) were SGA, and 0.4% (95% CI 0.2–0.9) of infants died within 28 days of birth. Multivariable logistic regression modelling indicated that the following risk factors increased the probability of having one or more adverse pregnancy outcomes: lower maternal body mass index at delivery (odds ratio, OR, 2.2; 95% CI 1.4–3.5), hospitalisation during pregnancy (OR 3.3; 95% CI 2.0–5.3), hypertension during pregnancy (OR 2.7; 95% CI 1.5–4.8), antiretroviral use at conception (OR 1.4; 95% CI 1.0–1.9), and tobacco use during pregnancy (OR 1.7; 95% CI 1.3–2.2). The results of fitting multivariable logistic regression models for PT, LBW, SGA, and SB are also reported. Conclusions Women infected with HIV had a relatively high occurrence of adverse pregnancy outcomes, and some maternal risk factors were associated with these adverse pregnancy outcomes. Interventions targeting modifiable risk factors should be evaluated further.
    BJOG An International Journal of Obstetrics & Gynaecology 03/2014; · 3.76 Impact Factor
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    ABSTRACT: Abstract Other than CD4+ count, the immunologic factors that underlie the relationship of HIV/AIDS with persistent oncogenic HPV (oncHPV) and cervical cancer are not well understood. Plasmacytoid dendritic cells (pDCs) and regulatory T-cells (Tregs) are of particular interest. pDCs have both effector and antigen presenting activity and, in HIV-positive patients, low pDC levels are associated with opportunistic infections. Tregs downregulate immune responses, and are present at high levels in HIV-positives. The current pilot study shows for the first time that low pDC and high Treg levels may be significantly associated with oncHPV persistence in both HIV-positive and HIV-negative women. Larger studies are now warranted.
    Viral immunology 02/2014; 27(1):20-5. · 1.78 Impact Factor
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    ABSTRACT: To estimate the long term cumulative risk for cervical intraepithelial neoplasia grade 3 or worse after an abnormal cervical Pap test and to assess the effect of HIV infection on that risk. Participants in the Women's Interagency HIV Study were followed semiannually for up to 10 years. Pap tests were categorized according to the 1991 Bethesda system. Colposcopy was prescribed within 6 months of any abnormality. Risk for biopsy-confirmed CIN3 or worse after abnormal cytology and at least 12 months follow-up was assessed using Kaplan-Meier curves and compared using log-rank tests. Risk for CIN2 or worse was also assessed, since CIN2 is the threshold for treatment. After a median of 3 years of observation, 1,947 (85%) women subsequently presented for colposcopy (1,571 [81%] HIV seropositive, 376 [19%] seronegative). CIN2 or worse was found in 329 (21%) of HIV seropositive and 42 (11%) seronegative women. CIN3 or worse was found in 141 (9%) of seropositive and 22 (6%) seronegative women. In multivariable analysis, after controlling for cytology grade HIV seropositive women had an increased risk for CIN2 or worse (H.R. 1.66, 95% C.I 1.15, 2.45) but higher risk for CIN3 or worse did not reach significance (H.R. 1.33, 95% C.I. 0.79, 2.34). HIV seropositive women with abnormal Paps face a marginally increased and long-term risk for cervical disease compared to HIV seronegative women, but most women with ASCUS and LSIL Pap results do not develop CIN2 or worse despite years of observation.
    International Journal of Cancer 10/2013; · 6.20 Impact Factor
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    ABSTRACT: To estimate the frequency of abnormal Pap and human papillomavirus (HPV) positivity among human immunodeficiency virus (HIV)-seropositive and -seronegative women who have sex with women (WSW). Pap and HPV DNA polymerase chain reaction tests were obtained every 6 months from women in a US cohort of HIV-seropositive and -seronegative women. Women who have sex with women were women reporting no male and at least 1 female sex partner for 5 years. They were frequency matched 1:5 to women reporting sex only with men (WSM) and assessed using multivariable generalized estimating equation logistic regression models. Paps at study entry were abnormal in 12 (21%) of 49 HIV-seropositive WSW, 151 (64%) of 245 HIV-seropositive WSM, 3 (9%) of 24 HIV-seronegative WSW, and 16 (11%) of 120 HIV-seronegative WSM. Human papillomavirus was found at entry in 18 (42%) HIV-seropositive WSW, 109 (52%) HIV-seropositive WSM, 6 (27%) HIV-seronegative WSW, and 13 (13%) HIV-seronegative WSM. After controlling for HIV serostatus and CD4 count, WSW had marginally lower odds than WSM of Pap abnormality (odds ratio = 0.59, 95% confidence interval = 0.33-1.03) and of HPV (odds ratio = 0.53, 95% confidence interval = 0.32-0.89). After controlling for partner's gender, HIV seropositivity and lower CD4 count were associated with any HPV, oncogenic HPV, any abnormal Pap result, and high-grade squamous intraepithelial lesion or worse (p < .0001 for all). Although risks for abnormal Pap and HPV are modestly lower in WSW than in WSM, both are common in HIV-seropositive women regardless of sexual preference. Both WSW and WSM should be screened similarly.
    Journal of Lower Genital Tract Disease 08/2013; · 1.21 Impact Factor
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    ABSTRACT: Starting lifelong antiretroviral therapy (ART) in HIV-infected pregnant women may decrease HIV progression and transmission but adherence after delivery may be difficult, especially for asymptomatic women. We evaluated disease progression among HIV-infected women not on ART with CD4+ lymphocyte counts above 200 cells/uL at delivery. We analysed risk of death, progression to AIDS (stage IV or CD4 < 200 cells/uL), or to CD4+ count < 350 one year after delivery among postpartum women enrolled to a prevention of breastfeeding transmission trial using Kaplan-Meier methods. In the primary analysis, women were censored if ART was initiated. Among 1285 women who were < WHO stage IV at 6 weeks postpartum, 49 (4.3%) progressed to stage IV/CD4 < 200 cells/uL or death by one year. Progression to CD4 < 200 or death occurred among 16 (4.3%) of 441 women with CD4 count of 350-549 and 10 (1.6%) of 713 with CD4 counts > 550 at delivery. CD4 < 350 by 12 months postpartum occurred among 116 (37.0%) of 350 women with CD4 count 400-549 and 48 (7.4%) of 713 > 550 at delivery. Progression to AIDS or CD4 count < 350 is uncommon through one year postpartum for women with CD4 counts over 550 at delivery, but occurred in over one third of those with CD4 counts under 550. ART should be continued after delivery or breastfeeding among women with CD4 counts < 550 if follow up and ARV adherence can be maintained.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 07/2013; · 4.65 Impact Factor
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    ABSTRACT: Abstract Evidence-based guidance regarding use of nearly all pharmaceuticals by pregnant and lactating women is limited. Models for performing research may assist in filling these knowledge gaps. Internationally, reproductive age women are at high risk of human immunodeficiency virus (HIV) acquisition. Susceptibility to HIV infection may be increased during pregnancy, and risk of maternal-child transmission is increased with incident HIV infection during pregnancy and lactation. A multidisciplinary meeting of experts was convened at the United States National Institutes of Health to consider paradigms for drug research in pregnancy and lactation applicable to HIV prevention. This report summarizes the meeting proceedings and describes a framework for research on candidate HIV prevention agent use during pregnancy and lactation that may also have broader applications to other pharmaceutical products.
    Journal of Women's Health 06/2013; · 1.90 Impact Factor
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    ABSTRACT: BACKGROUND:: Systemic and mucosal inflammation may play a role in HIV control. A cross-sectional comparison was conducted among women in the Women's Interagency HIV Study (WIHS) to explore the hypothesis that compared to HIV-uninfected participants, women with HIV and in particular, those with high plasma viral load (PVL) have increased levels of mucosal and systemic inflammatory mediators and impaired mucosal endogenous antimicrobial activity. Methods: 19 HIV-uninfected, 40 HIV-infected on antiretroviral therapy (ART) with PVL ≤ 2600 copies/ml (low viral load) (HIV-LVL), and 19 HIV-infected on or off ART with PVL >10,000 (high viral load) (HIV-HVL) were evaluated. Immune mediators and viral RNA were quantified in plasma and cervicovaginal lavage (CVL). CVL antimicrobial activity was also determined. Results: Compared to HIV-uninfected, HIV-HVL women had higher levels of mucosal, but not systemic pro-inflammatory cytokines and chemokines, higher Nugent scores, and lower E. coli bactericidal activity. In contrast, there were no significant differences between HIV-LVL and HIV-uninfected controls. After adjusting for PVL, HIV genital tract shedding was significantly associated with higher CVL concentrations of IL-6, IL-1β, MIP-1α, and RANTES and higher plasma concentrations of MIP-1α. High PVL was associated with higher CVL levels of IL-1β and RANTES, as well as with higher Nugent scores, lower E. coli bactericidal activity, smoking and lower CD4 counts; smoking and CD4 count retained statistical significance in a multivariate model. Conclusion: Further study is needed to determine if the relationship between mucosal inflammation and PVL is causal and to determine if reducing mucosal inflammation is beneficial.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 04/2013; · 4.65 Impact Factor
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    ABSTRACT: BACKGROUND:: Reduced atazanavir exposure has been demonstrated during pregnancy with standard atazanavir/ritonavir dosing. We studied an increased dose during the third trimester of pregnancy. METHODS:: IMPAACT 1026s is a prospective, non-blinded pharmacokinetic study of HIV-infected pregnant women taking antiretrovirals for clinical indications, including two cohorts (with or without tenofovir) receiving atazanavir/ritonavir 300/100 mg once daily during the 2 trimester (2 trim), 400/100 mg during the 3 trimester (3 trim) and 300/100 mg postpartum (PP). Intensive steady-state 24-hour pharmacokinetic profiles were performed. Atazanavir concentrations were measured by HPLC. Pharmacokinetic targets were the 10 percentile atazanavir AUC (29.4 mcg*hr/mL) in non-pregnant adults on standard dose and 0.15 mcg/mL, minimum trough concentration. RESULTS:: Atazanavir pharmacokinetic data were available for 37 women without tenofovir, 35 with tenofovir; Median (range) pharmacokinetic parameters are presented for 2, 3 trim and PP and number who met target/total. * indicates p<0.05 compared to PP. Atazanavir without tenofovir: AUC 30.5 (9.19-93.8), 45.7 (11-88.3), and 48.8 (9.9-112.2) mcg-hr/mL, and 8/14, 29/37 and 27/34 met target. C24h was 0.49 (0.09-4.09), 0.71 (0.14-2.09), and 0.90 (0.05-2.73) mcg/mL; 13/14, 36/37 and 29/34 met target. Atazanavir with tenofovir: AUC 26.2 (6.8-60.9)*, 37.7 (0.72-88.2)*, and 58.6 (6-149) mcg-hr/mL, and 7/17, 23/32 and 27/29 met target. C24h was 0.44 (0.12-1.06)*, 0.57 (0.02-2.06)*, and 1.26 (0.09-5.43) mcg/mL; 7/17, 23/32 and 27/29 met target.Atazanavir/ritonavir was well tolerated with no unanticipated adverse events. CONCLUSIONS:: Atazanavir/ritonavir increased to 400/100mg provides adequate atazanavir exposure during the third trimester and should be considered during the second trimester.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 02/2013; · 4.65 Impact Factor
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    ABSTRACT: Background. HIV-infected, pregnant women may have particular vulnerability to 2009 pH1N1 infection. The safety and immunogenicity of pH1N1 vaccination in HIV-infected, pregnant women are unknown.Methods. HIV-infected women between 18-39 years old and 14-34 weeks gestation on antiretroviral therapy received two 30 mcg doses of unadjuvanted, inactivated pH1N1 vaccine 21 days apart. Hemagglutination inhibition titers were measured at entry, 21 days post-dose #1, and 10 and 21 days post-dose #2, and, in mothers and infants, at delivery and three and six months post-delivery.Results. No severe vaccine-related adverse events were observed among 127 subjects. At entry, 21% had seroprotective (≥1:40) titers. Seroprotection and seroresponse (≥4-fold rise) occurred in 73% and 66% post-dose #1 and 80% and 72% post-dose #2, respectively. Of women lacking seroprotection at entry, 66% attained seroprotective titers after dose #1 and 75% after dose #2. Seroprotective titers were present in 67% of mothers and 65% of infants at delivery (median 66 days post-dose #2), 60% of mothers and 26% of infants at three months post-delivery, and 59% of mothers and 12% of infants at six months post-delivery. Vaccine response was associated with maternal CD4%.Conclusions. Two 30 mcg doses of pH1N1 vaccine were moderately immunogenic in HIV-infected, pregnant women. No concerning vaccine-related safety signals were observed. Seroprotection persisted in most women post-partum. Efficient transplacental antibody transfer occurred, but seroprotection in infants waned rapidly. Vaccination to protect HIV-infected, pregnant women and their newborns from new influenza strains is feasible, but more immunogenic platforms should be evaluated.Clinical Trials Registration. NCT00992017 (www.clinicaltrials.gov).
    Clinical Infectious Diseases 02/2013; · 9.37 Impact Factor
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    ABSTRACT: AIM: To describe the pharmacokinetics and safety of indinavir boosted with ritonavir (IDV/r) during the second and third trimesters of pregnancy and in the postpartum period. METHODS: IMPAACT P1026s is an on-going, prospective, non-blinded study of antiretroviral pharmacokinetics (PK) in HIV-infected pregnant women with a Thai cohort receiving IDV/r 400/100 mg twice daily during pregnancy through 6-12 weeks postpartum as part of clinical care. Steady-state PK profiles were performed during the second (optional) and third trimesters and at 6-12 weeks postpartum. PK targets were the estimated 10(th) percentile IDV AUC (12.9 μg.h/mL) in non-pregnant historical Thai adults and a trough concentration of 0.1 μg/mL, the suggested minimum target. RESULTS: Twenty-six pregnant women were enrolled; thirteen entered during the second trimester. Median (range) age was 29.8 (18.9-40.8) years and weight 60.5 (50.0-85.0) kg at the third trimester PK visit. The 90% confidence limits for the geometric mean ratio of the indinavir AUC(0-12) and Cmax during the second trimester and postpartum (ante/post ratios) were 0.58 (0.49-0.68) and 0.73 (0.59-0.91), respectively; third trimester/postpartum AUC(0-12) and Cmax ratios were 0.60 (0.53-0.68) and 0.63 (0.55-0.72), respectively. IDV/r was well tolerated and 21/26 women had a HIV-1 viral load <40 copies/mL at delivery. All twenty-six infants were confirmed HIV negative. CONCLUSION: IDV exposure during the second and third trimesters was significantly reduced compared to postpartum and ∼30% of women fail to achieve a target trough concentration. Increasing the dose of IDV/r during pregnancy to 600/100 mg twice daily may be preferable to ensure adequate drug concentrations.
    British Journal of Clinical Pharmacology 01/2013; · 3.69 Impact Factor
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    ABSTRACT: Background. Use of antiretroviral drugs (ARVs) during pregnancy has been associated with higher risk of preterm birth.Methods. The PHACS Surveillance Monitoring of ART Toxicities study is a US-based cohort of HIV-exposed uninfected children. We evaluated maternal ARV use during pregnancy and risk of total and spontaneous (occurring after preterm labor or membrane rupture without other complications) preterm birth (<37 weeks gestation), and small for gestational age (< 10(th) percentile) (SGA). Multivariable logistic regression models were used to evaluate association of ARVs and timing of exposure while adjusting for maternal characteristics.Results. Among 1869 singleton births, 18.6% were preterm, 10.2% were spontaneous preterm, and 7.3% were SGA. 89% used 3-drug combination ARV regimens during pregnancy. In adjusted models, both preterm and spontaneous preterm birth were increased with 1(st) trimester use of protease inhibitors (adjusted odds ratios [aOR's]=1.55 and 1.59 respectively) but not with non-nucleoside reverse transcriptase inhibitor or triple nucleoside regimens. Combination ARV exposure starting later in pregnancy was not associated with increased risk. No associations were observed between SGA and exposure to combination ARV regimens.Conclusions. Protease inhibitor use early in pregnancy may be associated with increased risk for prematurity.
    The Journal of Infectious Diseases 11/2012; · 5.85 Impact Factor
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    ABSTRACT: OBJECTIVE: To assess whether there was a difference in HIV seroprevalence between eligible women who declined and those who agreed to participate in a study of voluntary counseling and testing among women entering labor with unknown HIV status in South Africa. METHODS: Anonymous cord blood specimens were collected-as dried blood spots-from all women approached for participation in a cluster-randomized trial. No patient identifiers were included on the cord blood specimens. The dried blood spots were analyzed for HIV antibody via enzyme immunoassay and western blotting. RESULTS: Of 7238 women screened for study participation, 1041 (14.4%) had undocumented HIV status; of these women, 542 were eligible for inclusion and 343 enrolled. Based on 513 evaluable samples, the overall seroprevalence was 13.3% (95% confidence interval [CI], 10.4-16.5), which was similar to the 13.1% (95% CI, 9.7-17.2) seroprevalence among the 343 enrolled women. CONCLUSION: Seroprevalence among eligible women was similar to that among enrolled women, which indicates that study participation did not select for a group with an HIV seroprevalence substantially different from that among women who declined to enroll.
    International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 11/2012; · 1.41 Impact Factor
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    D Heather Watts, Lynne M Mofenson
    The Journal of Infectious Diseases 10/2012; · 5.85 Impact Factor

Publication Stats

2k Citations
718.21 Total Impact Points

Institutions

  • 2003–2014
    • Eunice Kennedy Shriver National Institute of Child Health and Human Development
      Maryland, United States
    • University of Washington Seattle
      • Department of Obstetrics and Gynecology
      Seattle, WA, United States
  • 2013
    • Chiang Mai University
      Amphoe Muang Chiang Mai, Chiang Mai, Thailand
    • University of Pittsburgh
      • Department of Obstetrics, Gynecology and Reproductive Sciences
      Pittsburgh, PA, United States
  • 2012
    • University of California, Los Angeles
      • Division of Infectious Diseases
      Los Angeles, CA, United States
  • 2005–2012
    • Albert Einstein College of Medicine
      • • Department of Medicine
      • • Department of Epidemiology & Population Health
      New York City, NY, United States
    • Brigham and Women's Hospital
      • Department of Obstetrics and Gynecology
      Boston, MA, United States
  • 2000–2012
    • National Institute of Child Health and Human Development
      Maryland, United States
  • 2011
    • Magee-Womens Hospital
      Pittsburgh, Pennsylvania, United States
    • Boston University
      • Department of Pediatrics
      Boston, MA, United States
  • 2010
    • City of Hope National Medical Center
      Duarte, California, United States
  • 2007–2010
    • National Institutes of Health
      Maryland, United States
    • Southern Illinois University School of Medicine
      • Department of Obstetrics and Gynecology
      Springfield, IL, United States
    • Rush University Medical Center
      • Section of Infectious Diseases
      Chicago, IL, United States
  • 2003–2010
    • State University of New York Downstate Medical Center
      • Department of Obstetrics and Gynecology
      Brooklyn, NY, United States
  • 2009
    • University of Illinois Springfield
      Спрингфилд, Florida, United States
  • 2008
    • Washington University in St. Louis
      • Department of Obstetrics and Gynecology
      San Luis, Missouri, United States
  • 2006
    • University of California, San Francisco
      • Drug Research Unit (DRU)
      San Francisco, California, United States
    • University of Southern California
      • Division of Hematology
      Los Angeles, CA, United States
  • 2004
    • Maimonides Medical Center
      Brooklyn, New York, United States