Uganda Genome Resource Enables Insights into Population History and Genomic Discovery in Africa.

Genomic studies in African populations provide unique opportunities to understand disease etiology, human diversity, and population history. In the largest study of its kind, comprising genome-wide data from 6,400 individuals and whole-genome sequences from 1,978 individuals from rural Uganda, we find evidence of geographically correlated fine-scale population substructure. Historically, the ancestry of modern Ugandans was best represented by a mixture of ancient East African pastoralists. We demonstrate the value of the largest sequence panel from Africa to date as an imputation resource. Examining 34 cardiometabolic traits, we show systematic differences in trait heritability between European and African populations, probably reflecting the differential impact of genes and environment. In a multi-trait pan-African GWAS of up to 14,126 individuals, we identify novel loci associated with anthropometric, hematological, lipid, and glycemic traits. We find that several functionally important signals are driven by Africa-specific variants, highlighting the value of studying diverse populations across the region.

Discovery of VH domains that allosterically inhibit ENPP1.

Ectodomain phosphatase/phosphodiesterase-1 (ENPP1) is overexpressed on cancer cells and functions as an innate immune checkpoint by hydrolyzing extracellular cyclic guanosine monophosphate adenosine monophosphate (cGAMP). Biologic inhibitors have not yet been reported and could have substantial therapeutic advantages over current small molecules because they can be recombinantly engineered into multifunctional formats and immunotherapies. Here we used phage and yeast display coupled with in cellulo evolution to generate variable heavy (VH) single-domain antibodies against ENPP1 and discovered a VH domain that allosterically inhibited the hydrolysis of cGAMP and adenosine triphosphate (ATP). We solved a 3.2 Å-resolution cryo-electron microscopy structure for the VH inhibitor complexed with ENPP1 that confirmed its new allosteric binding pose. Finally, we engineered the VH domain into multispecific formats and immunotherapies, including a bispecific fusion with an anti-PD-L1 checkpoint inhibitor that showed potent cellular activity.

Expanding Access to Noninvasive Prenatal Diagnosis for Monogenic Conditions to Consanguineous Families.

BACKGROUND: Cell-free fetal DNA exists within the maternal bloodstream during pregnancy and provides a means for noninvasive prenatal diagnosis (NIPD). Our accredited clinical service offers definitive NIPD for several autosomal recessive (AR) and X-linked conditions using relative haplotype dosage analysis (RHDO). RHDO involves next-generation sequencing (NGS) of thousands of common single nucleotide polymorphism (SNPs) surrounding the gene of interest in the parents and an affected or unaffected offspring to conduct haplotype phasing of the high- and low-risk alleles. NGS is carried out in parallel on the maternal cell-free DNA, and fetal inheritance is predicted using sensitive dosage calculations performed at sites where the parental genotypes differ. RHDO is not currently offered to consanguineous couples owing to the shared haplotype between parents. Here we test the expansion of RHDO for AR monogenic conditions to include consanguineous couples. METHODS: The existing sequential probability ratio test analysis pipeline was modified to apply to SNPs where both parents are heterozygous for the same genotype. Quality control thresholds were developed using 33 nonconsanguineous cases. The performance of the adapted RHDO pipeline was tested on 8 consanguineous cases. RESULTS: The correct fetal genotype was predicted by our revised RHDO approach in all conclusive cases with known genotypes (n = 5). Haplotype block classification accuracies of 94.5% and 93.9% were obtained for the nonconsanguineous and consanguineous case cohorts, respectively. CONCLUSIONS: Our modified RHDO pipeline correctly predicts the genotype in fetuses from consanguineous families, allowing the potential to expand access to NIPD services for these families.

Controlling excited-state dynamics via protonation of naphthalene-based azo dyes.

Azo dyes are a class of photoactive dyes that constitute a major focus of chemical research due to their applications in numerous industrial functions. This work explores the impact of protonation on the photophysics of four naphthalene-based azo dyes. The pKa value of the dyes increases proportionally with decreasing Hammett parameter of p-phenyl substituents from 8.1 (R = -H, σ = 0) to 10.6 (R = -NMe2, σ = -0.83) in acetonitrile. Protonation of the dyes shuts down the steady-state photoisomerization observed in the unprotonated moieties. Fluorescence measurements reveal a lower quantum yield with more electron-donating p-phenyl substituents, with overall lower fluorescence quantum yields than the unprotonated dyes. Transient absorption spectroscopy reveals four excited-state lifetimes (<1 ps, ∼3 ps, ∼13 ps, and ∼200 ps) exhibiting faster excited-state dynamics than observed in the unprotonated forms (for 1-3: 0.7-1.5 ps, ∼3-4 ps, 20-40 ps, 20-300 min; for 4: 0.7 ps, 4.8 ps, 17.8 ps, 40 ps, 8 min). Time-dependent density functional theory (TDDFT) elucidates the reason for the loss of isomerization in the protonated dyes, revealing a significant change in the lowest excited state potential energy nature and landscape upon protonation. Protonation impedes relaxation along the typical rotational and inversion isomerization axes, locking the dyes into a trans-configuration that rapidly decays back to the ground state.

Acid Violet 3: A Base-Activated Water-Soluble Photoswitch.

Acidic azo dyes are widely used for their vibrant colors. However, if their photophysics were better understood and controllable, they could be integrated into many more applications such as photosensing, photomedicine, and nonlinear optics. Here, the proton-controlled photophysics of a widely used acid, hydrazo dye, acid violet 3 (AV3) is explored. Density functional theory is used to predict the ground- and excited-state potential energy surfaces, and the proposed photoisomerization mechanism is confirmed with spectroscopic experiments. The ground-state and first two excited-state surfaces of the three readily accessible protonation states, AV3-H, AV3, and AV3+H, are investigated along both the dihedral rotation and inversion coordinates. The deprotonated AV3-H undergoes photoisomerization with blue light (λex = 453 nm) through a dihedral rotation mechanism. Upon the formation of the cis-isomer, the reversion of AV3-H is predicted to occur through a mixed rotational and inversion mechanism. In contrast, AV3 and its protonated form, AV3+H, do not undergo photoisomerization because there is no driving force for either the rotation or inversion of the azo bond in the excited state. In addition, when the azo bond is acidic, the ground-state dihedral rotation reversion mechanism barrier is lower. The mechanistic insights gained here through the combination of theory and experiment provide a roadmap to control the reactivity of AV3 across 11 orders of magnitude of proton concentration, making them interesting candidates for a range of pharmaceuticals.

Ultra-fast excited-state dynamics of substituted trans-naphthalene azo moieties.

In this work we untangle the ultrafast deactivation of high-energy excited states in four naphthalene-based azo dyes. Through systematic photophysical and computational study, we observed a structure-property relationship in which increasing the electron donating strength of the substituent leads to longer lived excited states in these organic dyes and faster thermal reversion from the cis to trans configuration. In particular, azo dyes 1-3 containing less electron donating substituents show three distinct excited-state lifetimes of ∼0.7-1.5 ps, ∼3-4 ps, and 20-40 ps whereas the most electron donating dimethyl amino substituted azo 4 shows excited-state lifetimes of 0.7 ps, 4.8 ps, 17.8 ps and 40 ps. While bulk photoisomerization of all four moieties is rapid, the cis to trans reversion lifetimes vary by a factor of 30 with τreversion decreasing from 276 min to 8 min with increasing electron donating strength of the substituent. In order to rationalize this change in photophysical behavior, we explored the excited-state potential energy surfaces and spin-orbit coupling constants for azo 1-4 through density functional theory. The increase in excited-state lifetime for 4 can be attributed to geometric and electronic degrees of freedom of the lowest energy singlet excited-state potential energy surface.

Elucidation of complex triplet excited state dynamics in Pd(II) biladiene tetrapyrroles.

Pd(II) biladienes have been developed over the last five years as non-aromatic oligotetrapyrrole complexes that support a rich triplet photochemistry. In this work, we have undertaken the first detailed photophysical interrogation of three homologous Pd(II) biladienes bearing different combinations of methyl- and phenyl-substituents on the frameworks' sp3-hybridized meso-carbon (i.e., the 10-position of the biladiene framework). These experiments have revealed unexpected excited-state dynamics that are dependent on the wavelength of light used to excite the biladiene. More specifically, transient absorption spectroscopy revealed that higher-energy excitation (λexc ∼ 350-500 nm) led to an additional lifetime (i.e., an extra photophysical process) compared to experiments carried out following excitation into the lowest-energy excited states (λexc = 550 nm). Each Pd(II) biladiene complex displayed an intersystem crossing lifetime on the order of tens of ps and a triplet lifetime of ∼20 µs, regardless of the excitation wavelength. However, when higher-energy light is used to excite the complexes, a new lifetime on the order of hundreds of ps is observed. The origin of the 'extra' lifetime observed upon higher energy excitation was revealed using density functional theory (DFT) and time-dependent DFT (TDDFT). These efforts demonstrated that excitation into higher-energy metal-mixed-charge-transfer excited states with high spin-orbit coupling to higher energy metal-mixed-charge-transfer triplet states leads to the additional excitation deactivation pathway. The results of this work demonstrate that Pd(II) biladienes support a unique triplet photochemistry that may be exploited for development of new photochemical schemes and applications.

Pemphigus Vulgaris: More Than Just a Skin Disease.

INTRODUCTION: Pemphigus is a group of autoimmune diseases of the skin and mucous membranes that is characterized by multiple bullae formation. It is caused by autoantibodies directed against the cell surface of keratinocytes, resulting in the loss of cell-cell adhesion of keratinocytes. This disease can be very debilitating and difficult to treat if large surface areas are involved. METHODS: We performed a retrospective review of a complex case of pemphigus vulgaris in a 24-year-old man who develop partial-thickness skin lesions distributed throughout the entire body with a total body surface of 80% short after an episode of strep throat treated with amoxicillin. RESULTS: The patient had a complicated hospital course in which the standard treatment of the disease led to adverse effects that were successfully managed at our busy burn center. CONCLUSIONS: Pemphigus vulgaris is a complex skin disease in which treatment techniques carry their risk and must be tailored to the patient's specific needs. Treatment of this conditions at a burn center would be beneficial as demonstrated with conditions like Stevens-Johnson syndrome and toxic epidermal necrolysis.

An analytical method to separate modality-specific and nonspecific sensory components of event-related potentials.

Several models have been developed to analyse cortical activity in response to salient events constituted by multiple sensory modalities. In particular, additive models compare event-related potentials (ERPs) in response to stimuli from two or more concomitant sensory modalities with the ERPs evoked by unimodal stimuli, in order to study sensory interactions. In this approach, components that are not specific to a sensory modality are commonly disregarded, although they likely carry information about stimulus expectation and evaluation, attentional orientation and other cognitive processes. In this study, we present an analytical method to assess the contribution of modality-specific and nonspecific components to the ERP. We developed an experimental setup that recorded ERPs in response to four stimulus types (visual, auditory, and two somatosensory modalities to test for stimulus specificity) in three different conditions (unimodal, bimodal and trimodal stimulation) and recorded the saliency of these stimuli relative to the sensory background. Stimuli were delivered in pairs, in order to study the effects of habituation. To this end, spatiotemporal features (peak amplitudes and latencies at different scalp locations) were analysed using linear mixed models. Results showed that saliency relative to the sensory background increased with the number of concomitant stimuli. We also observed that the spatiotemporal features of modality-specific components derived from this method likely reflect the amount and type of sensory input. Furthermore, the nonspecific component reflected habituation occurring for the second stimulus in the pair. In conclusion, this method provides an alternative to study neural mechanisms of responses to multisensory stimulation.

Genetic loci implicated in meta-analysis of body shape in Africans.

BACKGROUND AND AIMS: Obesity is one of the leading causes of non-communicable diseases (NCD). Thus, NCD risk varies in obese individuals based on the location of their fat depots; while subcutaneous adiposity is protective, visceral adiposity increases NCD risk. Although, previously anthropometric traits have been used to quantify body shape in low-income settings, there is no consensus on how it should be assessed. Hence, there is a growing interest to evaluate body shape derived from the principal component analysis (PCA) of anthropometric traits; however, this is yet to be explored in individuals of African ancestry whose body shape is different from those of Europeans. We set out to capture body shape in its multidimensional structure and examine the association between genetic variants and body shape in individuals of African ancestry. METHOD AND RESULTS: We performed a genome-wide association study (GWAS) for body shape derived from PCA analysis of anthropometric traits in the Ugandan General Population Cohort (GPC, n = 6407) and the South African Zulu Cohort (SZC, n = 2595), followed by a GWAS meta-analysis to assess the genetic variants associated with body shape. We identified variants in FGF12, GRM8, TLX1NB and TRAP1 to be associated with body shape. These genes were different from the genes been associated with BMI, height, weight, WC and waist-hip ration in continental Africans. Notably, we also observed that a standard deviation change in body shape was associated with an increase in blood pressure and blood lipids. CONCLUSION: Variants associated with body shape, as a composite variable might be different for those of individual anthropometric traits. Larger studies are required to further explore these phenomena.

HIV infection and anaemia do not affect HbA1c for the detection of diabetes in black South Africans: Evidence from the Durban Diabetes Study.

OBJECTIVE: South Africa has a high burden of HIV infection and anaemia. These conditions may cause HbA1c to over- or underestimate glycaemia; however, this has not been comprehensively investigated in African populations. We assessed the association of anaemia, HIV infection and antiretroviral therapy (ART) with HbA1c , and implications for the detection and diagnosis of diabetes, in a black South African population. RESEARCH DESIGN AND METHODS: In this population-based cross-sectional study in eThekwini municipality (Durban), South Africa, we assessed HbA1c and conducted oral glucose tolerance tests (OGTTs), HIV diagnostic tests and full blood count measurements among 1067 participants without a history of diabetes diagnosis. Linear regression was used to examine differences in HbA1c by anaemia (comparator: no anaemia), or HIV and ART (comparator: no HIV) status. HbA1c -based diabetes prevalence was compared with OGTT-based prevalence among individuals with anaemia and with untreated and ART-treated HIV. RESULTS: In adjusted analyses, normocytic and microcytic anaemia were associated with higher HbA1c compared with no anaemia, whereas macrocytic anaemia and ART-treated HIV were associated with lower HbA1c compared with no anaemia and no HIV, respectively. However, magnitudes of association were small (range: ß  = -3.4 mmol/mol or -0.31%, p < 0.001 [macrocytic anaemia] to ß = 2.1 mmol/mol or 0.19%, p < 0.001 [microcytic anaemia]). There was no significant difference in diabetes prevalence based on HbA1c or OGTT among individuals with anaemia (2.9% vs. 3.3%, p = 0.69), untreated HIV (1.6% vs. 1.6% p = 1.00) or ART-treated HIV (2.9% vs. 1.2%, p = 0.08). CONCLUSIONS: Our results suggest that anaemia and HIV status appear unlikely to materially affect the utility of HbA1c for diabetes detection and diagnosis in this population. Further studies are needed to examine these associations in sub-Saharan African populations.

Childhood maltreatment and within-person associations between cortisol and affective experience.

Glucocorticoids exert profound effects on the brain and behavior, but cortisol concentrations are rarely linked to subjectively reported emotional states in humans. This study examined whether the link between cortisol and subjective anxiety varied by childhood maltreatment history. To do this, 97 individuals (60.8% female) participated in a standardized stress task in the laboratory (Trier Social Stress Test, TSST) while providing serial ratings of their feelings of anxiety as well as cortisol samples in blood. These measurements were collected nine times across the laboratory visit, from immediately before the TSST to 65 minutes after stress initiation. We estimated the within-person association between cortisol concentrations and momentary feelings of anxiety for individuals with and without exposure to childhood maltreatment, measured via self-report on the Childhood Trauma Questionnaire (CTQ). Individuals exposed to maltreatment during childhood reported the greatest feelings of anxiety when cortisol concentrations were lowest. This pattern was exaggerated among female participants, those with posttraumatic stress disorder (PTSD), and those exposed to emotional neglect relative to other forms of maltreatment. Early life adversity, such as parental maltreatment, may alter the role of cortisol in affective experiences. This observation may provide preliminary, translational evidence of a novel pathway through which stress may lead to and maintain internalizing symptoms in humans. More studies accounting for the moderating role of childhood maltreatment in biobehavioral pathways are needed.

Synthesis, Electrochemistry, and Photophysics of Pd(II) Biladiene Complexes Bearing Varied Substituents at the sp3-Hybridized 10-Position.

A set of Pd(II) biladiene complexes bearing different combinations of methyl- and phenyl-substituents on the sp3-hybridized meso-carbon (the 10-position of the biladiene framework) was prepared and studied. In addition to a previously described Pd(II) biladiene complex bearing geminal dimethyl substituents a the 10-position (Pd[DMBil]), homologous Pd(II) biladienes bearing geminal methyl and phenyl substituents (Pd[MPBil1]) and geminal diphenyl groups(Pd[DPBil1]) were prepared and structurally characterized. Detailed electrochemical as well as steady-state and time-resolved spectroscopic experiments were undertaken to evaluate the influence of the substituents on the biladiene's tetrahedral meso-carbon. Although all three biladiene homologues are isostructural, Pd[MPBil1] and Pd[DPBil1] display more intense absorption profiles that shift slightly toward lower energies as geminal methyl groups are replaced by phenyl rings. All three biladiene homologues support a triplet photochemistry, and replacement of the geminal dimethyl substituents of Pd[DMBil1] (ΦΔ = 54%) with phenyl groups improves the ability of Pd[MPBil1] (ΦΔ = 76%) and Pd[DPBil1] (ΦΔ = 66%) to sensitize 1O2. Analysis of the excited-state dynamics of the Pd(II) biladienes by transient absorption spectroscopy shows that each complex supports a long-lived triplet excited-state (i.e., τ > 15 µs for each homologue) but that the ISC quantum yields (ΦT) varied as a function of biladiene substitution. The observed trend in ISC efficiency matches that for singlet oxygen sensitization quantum yields (ΦΔ) across the biladiene series considered in this work. The results of this study provide new insights to guide future development of biladiene based agents for PDT and other photochemical applications.

The African Genome Variation Project shapes medical genetics in Africa.

Given the importance of Africa to studies of human origins and disease susceptibility, detailed characterization of African genetic diversity is needed. The African Genome Variation Project provides a resource with which to design, implement and interpret genomic studies in sub-Saharan Africa and worldwide. The African Genome Variation Project represents dense genotypes from 1,481 individuals and whole-genome sequences from 320 individuals across sub-Saharan Africa. Using this resource, we find novel evidence of complex, regionally distinct hunter-gatherer and Eurasian admixture across sub-Saharan Africa. We identify new loci under selection, including loci related to malaria susceptibility and hypertension. We show that modern imputation panels (sets of reference genotypes from which unobserved or missing genotypes in study sets can be inferred) can identify association signals at highly differentiated loci across populations in sub-Saharan Africa. Using whole-genome sequencing, we demonstrate further improvements in imputation accuracy, strengthening the case for large-scale sequencing efforts of diverse African haplotypes. Finally, we present an efficient genotype array design capturing common genetic variation in Africa.

Transient Pancytopenia Subsequently Diagnosed With Acute Leukemia: A Report of 4 Cases of Acute Lymphoblastic Leukemia and Acute Myeloid Leukemia.

A transient pancytopenic phase has been described in pediatric leukemia. The characteristic complete recovery of peripheral counts can obscure a clinician's suspicion for malignancy and may impact subsequent follow-up care. The authors describe 4 pediatric patients that had transient pancytopenia with an initial abnormal marrow finding. These patients were subsequently diagnosed with acute leukemia within 5 months of presentation. Awareness of this phenomenon by the provider and education of families may help with the appropriate and timely diagnosis of subsequent leukemia.

NUP98-NSD1 Driven MDS/MPN in Childhood Masquerading as JMML.

Overlapping myelodysplastic/myeloproliferative neoplasms (MDS/MPN) are clonal hematopoietic disorders with features of myelodysplasia and myeloproliferation. The only well-characterized MDS/MPN in children is juvenile myelomonocytic leukemia, an aggressive disorder of infants and toddlers. The biochemical hallmark of this disease is hyperactivation of the Ras/MAPK signaling pathway caused by mutations in Ras pathway genes in more than 90% of patients. Translocations involving receptor tyrosine kinases have been identified in rare cases. Here, we report a 2-year-old patient who presented with MDS/MPN driven by a cytogenetically cryptic NUP98-NSD1 fusion, a translocation thought to exclusively occur in patients with acute myeloid leukemia.

Multiple Tumor-Associated Intracranial Aneurysms Adjacent to a Suprasellar Germ Cell Tumor: Case Report and Review of Literature.

INTRODUCTION: Tumor-associated intracranial aneurysms are rare and not well understood. CASE PRESENTATION: We describe a 4-year-old female with multiple intracranial aneurysms intimately associated with a suprasellar germ cell tumor (GCT). We provide the clinical history, medical, and surgical treatment course, as well as a comprehensive and concise synthesis of the literature on tumor-associated aneurysms. DISCUSSION: We discuss mechanisms for aneurysm formation with relevance to the current case, including cellular and paracrine signaling pertinent to suprasellar GCTs and possible molecular pathways involved. We review the complex multidisciplinary treatment required for complex tumor and cerebrovascular interactions.

Effect of a Longitudinal Interprofessional Education Passport Program on Nursing Students' Attitudes Toward Interprofessional Practice.

ABSTRACT: To meet the demands of complex health care systems with multiple professions, it is recommended that nursing students have interprofessional educational experiences throughout the curriculum. We assessed longitudinal changes in nursing students' attitudes toward interprofessional collaboration in the context of an Interprofessional Education Passport Program. Students were surveyed using the Interprofessional Attitudes Scale at the beginning and end of the two-year curriculum. Students showed significant improvement from baseline to posttest in three of five subscales: Teamwork, Roles, and Responsibilities; Interprofessional Biases; and Community-Centeredness. A longitudinal interprofessional education curriculum may influence students' attitudes regarding teamwork, roles, responsibilities, and biases.

The paediatric developmental toolkit: Facilitating learning of child development.

BACKGROUND: Recent paediatric and family medicine graduates report feeling unprepared to identify and address children and youth with developmental disorders. Developmental history taking and physical examination alone limit engagement with children and youth in an interactive manner to assess development. The paediatric developmental toolkit (PDT) was developed to provide trainees with the opportunity to interact with a child in a play-based manner. OBJECTIVES: The primary objective of this study was to determine the feasibility of PDT within clinical settings, and qualitatively explore how the PDT can be used by teachers and trainees. METHODS: Trainees and their clinical teachers participated in a qualitative study. Trainees used the PDT in clinical settings and were interviewed following their clinical encounters. Interactions between clinical teachers and trainees following the use of the PDT were also recorded. Teachers were interviewed following the trainees' case presentations and closures of clinic visits. Trainee interviews, teacher and trainee interactions, and teacher interviews were audiotaped, transcribed, and analyzed thematically. RESULTS: Nine trainees (six paediatric residents, two family medicine residents, and one clinical clerk medical student) and four developmental paediatricians participated in the study. Each trainee used the PDT twice in two different clinical encounters. All residents agreed the PDT enabled them to observe a child's developmental skills in a short period of time. Clinical teachers all felt the toolkit allowed trainees to more holistically consider a child's development and diagnosis. CONCLUSIONS: As medical education shifts to a competency-based education curriculum, the PDT is an innovative tool that can be used to enhance paediatric and family medicine residents' learning of child development by enabling opportunities for interaction with children.

Highly Diverse Hepatitis C Strains Detected in Sub-Saharan Africa Have Unknown Susceptibility to Direct-Acting Antiviral Treatments.

The global plan to eradicate hepatitis C virus (HCV) led by the World Health Organization outlines the use of highly effective direct-acting antiviral drugs (DAAs) to achieve elimination by 2030. Identifying individuals with active disease and investigation of the breadth of diversity of the virus in sub-Saharan Africa (SSA) is essential as genotypes in this region (where very few clinical trials have been carried out) are distinct from those found in other parts of the world. We undertook a population-based, nested case-control study in Uganda and obtained additional samples from the Democratic Republic of Congo (DRC) to estimate the prevalence of HCV, assess strategies for disease detection using serological and molecular techniques, and characterize genetic diversity of the virus. Using next-generation and Sanger sequencing, we aimed to identify strains circulating in East and Central Africa. A total of 7,751 Ugandan patients were initially screened for HCV, and 20 PCR-positive samples were obtained for sequencing. Serological assays were found to vary significantly in specificity for HCV. HCV strains detected in Uganda included genotype (g) 4k, g4p, g4q, and g4s and a newly identified unassigned g7 HCV strain. Two additional unassigned g7 strains were identified in patients originating from DRC (one partial and one full open reading frame sequence). These g4 and g7 strains contain nonstructural (ns) protein 3 and 5A polymorphisms associated with resistance to DAAs in other genotypes. Clinical studies are therefore indicated to investigate treatment response in infected patients. Conclusion: Although HCV prevalence and genotypes have been well characterized in patients in well-resourced countries, clinical trials are urgently required in SSA, where highly diverse g4 and g7 strains circulate.