Correction: Experiences of doctoral students enrolled in a research fellowship program to support doctoral training in Africa (2014 to 2018): The Consortium for Advanced Research Training in Africa odyssey.

[This corrects the article DOI: 10.1371/journal.pone.0252863.].

Lifting all boats: strategies to promote equitable bidirectional research training opportunities to enhance global health reciprocal innovation.

Inequities in global health research are well documented. For example, training opportunities for US investigators to conduct research in low-income and middle-income countries (LMIC) have exceeded opportunities for LMIC investigators to train and conduct research in high-income countries. Reciprocal innovation addresses these inequities through collaborative research across diverse global settings.The Fogarty International Center of the US National Institutes of Health (NIH) promotes research capacity building in LMICs. Fogarty K-grants for mentored career development in global health are available for both US and LMIC investigators, whereas the D43 is the standard grant to support institutional training programmes in LMIC. Other NIH institutes fund T32 training grants to support biomedical research training in the USA, but very few have any global health component. Most global health training partnerships have historically focused on research conducted solely in LMIC, with few examples of bidirectional training partnerships. Opportunities may exist to promote global health reciprocal innovation (GHRI) research by twinning K-awardees in the USA with those from LMIC or by intentionally creating partnerships between T32 and D43 training programmes.To sustain independent careers in GHRI research, trainees must be supported through the path to independence known as the K (mentored grantee)-to-R (independent grantee) transition. Opportunities to support this transition include comentorship, research training at both LMIC and US institutions and protected time and resources for research. Other opportunities for sustainability include postdoctoral training before and after the K-award period, absorption of trained researchers into home institutions, South-South training initiatives and innovations to mitigate brain drain.

A Global Health Reciprocal Innovation grant programme: 5-year review with lessons learnt.

Unilateral approaches to global health innovations can be transformed into cocreative, uniquely collaborative relationships between low-income and middle-income countries (LMICs) and high-income countries (HIC), constituted as 'reciprocal innovation' (RI). Since 2018, the Indiana Clinical and Translational Sciences Institute (CTSI) and Indiana University (IU) Center for Global Health Equity have led a grants programme sculpted from the core elements of RI, a concept informed by a 30-year partnership started between IU (Indiana) and Moi University (Kenya), which leverages knowledge sharing, transformational learning and translational innovations to address shared health challenges. In this paper, we describe the evolution and implementation of an RI grants programme, as well as the challenges faced. We aim to share the successes of our RI engagement and encourage further funding opportunities to promote innovations grounded in the RI core elements. From the complex series of challenges encountered, three major lessons have been learnt: dedicating extensive time and resources to bring different settings together; establishing local linkages across investigators; and addressing longstanding inequities in global health research. We describe our efforts to address these challenges through educational materials and an online library of resources for RI projects. Using perspectives from RI investigators funded by this programme, we offer future directions resulting from our 5-year experience in applying this RI-focused approach. As the understanding and implementation of RI grow, global health investigators can share resources, knowledge and innovations that have the potential to significantly change the face of collaborative international research and address long-standing health inequities across diverse settings.

Reversing the trend: a scoping review of health innovation transfer or exchange from low- and middle-income countries to high-income countries.

The transfer of innovations from low and middle-income countries (LMICs) to high-income countries (HICs) has received little attention, leaving gaps in the understanding of the process, its benefits and the factors influencing it. This scoping review, part of a National Institutes of Health (NIH) project and the focus for a 2022 NIH-sponsored workshop on Global Health Reciprocal Innovation, sought to identify publications describing health innovations that were researched, developed and implemented in LMICs and adapted to address similar health challenges in HICs. A protocol was written a priori and registered on Open Science Framework. Four databases were searched for articles published in English from 2000 to 2022 and described health innovations developed in LMICs and were transferred to HICs. Using Covidence, two reviewers initially screened the title and abstract and then the full text; discrepancies were resolved through discussion. Two reviewers collected the data from each article using Covidence and Microsoft Excel; discrepancies were resolved by a separate third reviewer. 7191 records were retrieved and screened of which 12 studies were included. Various frameworks and methodologies were employed in these studies, with a particular emphasis on adaptation and adoption of innovations. The review uncovered different paradigms of LMIC to HIC innovation transfer and exchange, including unidirectional transfers from LMICs to HICs as well as bidirectional or multidirectional mutually beneficial exchanges. The use of both qualitative and quantitative data collection methods was common across all the included articles. Facilitators for innovation transfers included stakeholder engagement, relevance of local context, simplicity, and sufficient funding, promotion and branding. Barriers to transfers were mostly the opposite of the facilitators. Our results highlighted the underexplored field of LMIC to HIC innovation transfer and exchange and lay the foundation for future research studies.

Institutional capacity to prevent and manage research misconduct: perspectives from Kenyan research regulators.

BACKGROUND: Research misconduct i.e. fabrication, falsification, and plagiarism is associated with individual, institutional, national, and global factors. Researchers' perceptions of weak or non-existent institutional guidelines on the prevention and management of research misconduct can encourage these practices. Few countries in Africa have clear guidance on research misconduct. In Kenya, the capacity to prevent or manage research misconduct in academic and research institutions has not been documented. The objective of this study was to explore the perceptions of Kenyan research regulators on the occurrence of and institutional capacity to prevent or manage research misconduct. METHODS: Interviews with open-ended questions were conducted with 27 research regulators (chairs and secretaries of ethics committees, research directors of academic and research institutions, and national regulatory bodies). Among other questions, participants were asked: (1) How common is research misconduct in your view? (2) Does your institution have the capacity to prevent research misconduct? (3) Does your institution have the capacity to manage research misconduct? Their responses were audiotaped, transcribed, and coded using NVivo software. Deductive coding covered predefined themes including perceptions on occurrence, prevention detection, investigation, and management of research misconduct. Results are presented with illustrative quotes. RESULTS: Respondents perceived research misconduct to be very common among students developing thesis reports. Their responses suggested there was no dedicated capacity to prevent or manage research misconduct at the institutional and national levels. There were no specific national guidelines on research misconduct. At the institutional level, the only capacity/efforts mentioned were directed at reducing, detecting, and managing student plagiarism. There was no direct mention of the capacity to manage fabrication and falsification or misconduct by faculty researchers. We recommend the development of Kenya code of conduct or research integrity guidelines that would cover misconduct.

Reciprocal innovation: A new approach to equitable and mutually beneficial global health partnerships.

Global health researchers often discount mutual learning and benefit to address shared health challenges across high and low- and middle-income settings. Drawing from a 30-year partnership called AMPATH that started between Indiana University in the US and Moi University in Kenya, we describe an innovative approach and program for mutual learning and benefit coined 'reciprocal innovation.' Reciprocal innovation harnesses a bidirectional, co-constituted, and iterative exchange of ideas, resources, and innovations to address shared health challenges across diverse global settings. The success of AMPATH in Kenya, particularly in HIV/AIDS and community health, resulted in several innovations being 'brought back' to the US. To promote the bidirectional flow of learning and innovations, the Indiana CTSI reciprocal innovation program hosts annual meetings of multinational researchers and practitioners to identify shared health challenges, supports pilot grants for projects with reciprocal exchange and benefit, and produces educational and training materials for investigators. The transformative power of global health to address systemic health inequities embraces equitable and reciprocal partnerships with mutual benefit across countries and communities of academics, practitioners, and policymakers. Leveraging a long-standing partnership, the Indiana CTSI has built a reciprocal innovation program with promise to redefine global health for shared wellbeing at a global scale.

How health systems can adapt to a population ageing with HIV and comorbid disease.

As people age with HIV, their needs increase beyond solely managing HIV care. Ageing people with HIV, defined as people with HIV who are 50 years or older, face increased risk of both age-regulated comorbidities and ageing-related issues. Globally, health-care systems have struggled to meet these changing needs of ageing people with HIV. We argue that health systems need to rethink care strategies to meet the growing needs of this population and propose models of care that meet these needs using the WHO health system building blocks. We focus on care provision for ageing people with HIV in the three different funding mechanisms: President's Emergency Plan for AIDS Relief and Global Fund funded nations, the USA, and single-payer government health-care systems. Although our categorisation is necessarily incomplete, our efforts provide a valuable contribution to the debate on health systems strengthening as the need for integrated, people-centred, health services increase.

Experiences of doctoral students enrolled in a research fellowship program to support doctoral training in Africa (2014 to 2018): The Consortium for Advanced Research Training in Africa odyssey.

BACKGROUND: The Consortium for Advanced Research Training in Africa (CARTA) aims to transform higher education in Africa. One of its main thrusts is supporting promising university faculty (fellows) to obtain high quality doctoral training. CARTA offers fellows robust support which includes funding of their attendance at Joint Advanced Seminars (JASes) throughout the doctoral training period. An evaluation is critical in improving program outcomes. In this study; we, CARTA fellows who attended the fourth JAS in 2018, appraised the CARTA program from our perspective, specifically focusing on the organization of the program and its influence on the fellows' individual and institutional development. METHODS: Exploratory Qualitative Study Design was used and data was obtained from three focus group discussions among the fellows in March 2018. The data were analyzed using thematic approach within the framework of good practice elements in doctoral training-Formal Research Training, Activities Driven by Doctoral Candidates, Career Development as well as Concepts and Structures. RESULTS: In all, 21 fellows from six African countries participated and all had been in the CARTA program for at least three years. The fellowship has increased fellows research skills and expanded our research capacities. This tremendously improved the quality of our doctoral research and it was also evident in our research outputs, including the number of peer-reviewed publications. The CARTA experience inculcated a multidisciplinary approach to our research and enabled significant improvement in our organizational, teaching, and leadership skills. All these were achieved through the well-organized structures of CARTA and these have transformed us to change agents who are already taking on research and administrative responsibilities in our various home institutions. Unfortunately, during the long break between the second and the third JAS, there was a gap in communication between CARTA and her fellows, which resulted in some transient loss of focus by a few fellows. CONCLUSION: The CARTA model which builds the research capacity of doctoral fellows through robust support, including intermittent strategic Joint Advanced Seminars has had effective and transformative impacts on our doctoral odyssey. However, there is a need to maintain the momentum through continuous communication between CARTA and the fellows all through this journey.

Perceptions of occurrence of research misconduct and related factors among Kenyan investigators engaged in HIV research.

We report on occurrence and correlates of self-reported research misconduct (RM) by 100 Kenyan researchers who had received ethics approval for an HIV research in the 5 years preceding the survey. The survey used the Scientific Misconduct Questionnaire-Revised tool uploaded on a Research Electronic Data Capture (REDCAP) platform. The response rate was low at 17.3% (100 out of 577) with 53.9% reporting awareness of an incident of RM in the preceding 5 years. Awareness was associated with being in academia, perception of vulnerability to being caught, and the severity of possible punishment, if discovered. Two-thirds (68.3%) reported ever-involvement in any misconduct. Self-report of involvement in misconduct was associated with knowledge of rules and procedures on RM and a disposition to support such rules and regulations. Nearly 36% reported ever-involvement infabrication, falsification and/or plagiarism (FFP). Self-report of ever-involvement in FFP was associated with number of years in the academic position, perceived likelihood of being caught, and the perceived severity of the sanctions, if caught. We conclude that the occurrence of RM is not uncommon, and efforts to create awareness about RM as well as to establish institutional structures and policies on RM are needed.

Challenges with seeking HIV care services: perspectives of older adults infected with HIV in western Kenya.

BACKGROUND: While younger adults (15-49 years) form the majority of the population living with HIV, older adults (≥50 years) infected with HIV face multiple challenges related to the aging process and HIV. We explored the experiences of older persons infected with HIV at the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya to understand the challenges faced when seeking HIV care services. METHODS: Between November 2016 and April 2017, a total of 57 adults aged 50 years and above were recruited from two AMPATH facilities - one rural and one urban facility. A total of 25 in-depth interviews and four focus group discussions were conducted, audio-recorded, transcribed and thematic analysis performed. RESULTS: Study participants raised unique challenges with seeking HIV care that include visits to multiple healthcare providers to manage HIV and comorbidities and as a result impact on their adherence to medication and clinical visits. Challenges with inadequate quality of facilities and poor patient-provider communication were also raised. Participants' preference for matched gender and older age for care providers that serve older patients were identified. CONCLUSION: Results indicate multiple challenges faced by older adults that need attention in ensuring continuous engagement in HIV care. Targeted HIV care for older adults would, therefore, significantly improve their access to and experience of HIV care. Of key importance is the integration of other chronic diseases into HIV care and employing staff that matches the needs of older adults.

HIV testing and counselling experiences: a qualitative study of older adults living with HIV in western Kenya.

BACKGROUND: Finding HIV infected persons and engaging them in care is crucial in achieving UNAIDS 90-90-90 targets; diagnosing 90% of those infected with HIV, initiating 90% of the diagnosed on ART and achieving viral suppression in 90% of those on ART. To achieve the first target, no person should be left behind in their access to HIV testing services. In Kenya, HIV prevention and testing services give less emphasis on older adults. This article describes HIV testing experiences of older adults living with HIV and how their age shaped their interaction and treatment received during HIV testing and diagnosis. METHODS: We conducted a qualitative study in two HIV clinics (rural and urban) in western Kenya, and recruited 57 HIV infected persons aged ≥50 years. We conducted in depth interviews (IDIs) with 25 participants and 4 focus group discussions (FGDs) with a total of 32 participants and audio recorded all the sessions. Participants recruited were aged between 54 and 79 years with 43% being females. We transcribed audio records and analyzed the data using thematic content analysis method. RESULTS: Older persons' experiences with HIV testing depended on where they tested (hospital or community setting); whether they actively sought the testing or not; and the age and gender of the healthcare provider who conducted the test. Participants expressed concerns with ageist discrimination when actively seeking HIV care testing services in hospital settings, characterized by providers' reluctance or refusal to test. The testing and counseling sessions were described as short and hurried within the hospital settings, whereas the interactions with service providers in home-based testing were experienced as appropriate and supportive. Participants in this study expressed preference for healthcare providers who were older and of similar gender. CONCLUSION: HIV testing services are still not tailored to target older adults' needs in our setting resulting in late diagnosis among older persons. We argue that a scale-up of community level testing services that provide adequate testing and counselling time and actively reach out to older adults is key to attaining the UNAIDS targets of having 90% of PLWH know their status.

Correction to: Housing gaps, mosquitoes and public viewpoints: a mixed methods assessment of relationships between house characteristics, malaria vector biting risk and community perspectives in rural Tanzania.

Following publication of the original article [1], the author flagged that the clause "and competing household priorities" was missing from the second sentence of the conclusion section of the Abstract; while this clause was in the Conclusion section of the main article text.

Understanding the persistence of vertical (stand-alone) HIV clinics in the health system in Uganda: a qualitative synthesis of patient and provider perspectives.

BACKGROUND: Although there is mounting evidence and policy guidance urging the integration of HIV services into general health systems in countries with a high HIV burden, vertical (stand-alone) HIV clinics are still common in Uganda. We sought to describe the specific contexts underpinning the endurance of vertical HIV clinics in Uganda. METHODS: A qualitative research design was adopted. Semi-structured interviews were conducted with the heads of HIV clinics, clinicians and facility in-charges (n = 78), coupled with eight focus group discussions (64 participants) with patients from 16 health facilities purposively selected, from a nationally-representative sample of 195 health facilities across Uganda, because they run stand-alone HIV clinics. Data were analyzed by thematic approach as guided by the theory proposed by Shediac-Rizkallah & Bone (1998) which identifies; Intervention characteristics, organizational context, and broader environment factors as potentially influential on health programme sustainability. RESULTS: Intervention characteristics: Provider stigma was reported to have been widespread in the integrated care experience of participating health facilities which necessitated the establishment of stand-alone HIV clinics. HIV disease management was described as highly specialized which necessitated a dedicated workforce and vertical HIV infrastructure such as counselling rooms. Organizational context: Participating health facilities reported health-system capacity constraints in implementing integrated systems of care due to a shortage of ART-proficient personnel and physical space, a lack of laboratory capacity to concurrently conduct HIV and non-HIV tests and increased workloads associated with implementing integrated care. Broader environment factors: Escalating HIV client loads and external HIV funding architectures were perceived to have perpetuated verticalized HIV programming over the past decade. CONCLUSION: Our study offers in-depth, contextualized insights into the factors contributing to the endurance of vertical HIV clinics in Uganda. Our analysis suggests that there is a complex interaction in supply-side constraints (shortage of ART-proficient personnel, increased workloads, laboratory capacity deficiencies) and demand-side factors (escalating demand for HIV services, psychosocial barriers to HIV care) as well as the specialized nature of HIV disease management which pose challenges to the integrated-health services agenda.

Housing gaps, mosquitoes and public viewpoints: a mixed methods assessment of relationships between house characteristics, malaria vector biting risk and community perspectives in rural Tanzania.

BACKGROUND: House improvement and environmental management can significantly improve malaria transmission control in endemic communities. This study assessed the influence of physical characteristics of houses and surrounding environments on mosquito biting risk in rural Tanzanian villages, and examined knowledge and perceptions of residents on relationships between these factors and malaria transmission. The study further assessed whether people worried about these risks and how they coped. METHODS: Entomological surveys of indoor mosquito densities were conducted across four villages in Ulanga district, south-eastern Tanzania. The survey involved 48 sentinel houses sampled monthly and other sets of 48 houses randomly recruited each month for one-off sampling over 12 months. Physical characteristics of the houses and surrounding environments were recorded. Questionnaire surveys were administered to 200 household heads to assess their knowledge and concerns regarding the observed housing and environmental features, and whether they considered these features when constructing houses. Focus group discussions, were conducted to clarify emergent themes on people's perceptions on relationships between housing or environmental factors and malaria transmission. RESULTS: The entomological surveys showed statistically higher indoor densities of the malaria vectors (Anopheles arabiensis and Anopheles funestus) in houses with mud walls compared to plastered or brick walls, open eaves compared to closed eaves and unscreened windows compared to screened windows. Most respondents reported that their houses allowed mosquito entry, at least partially. Participants were aware that house structure and environmental characteristics influenced indoor mosquito densities and consequently malaria transmission. They were concerned about living in poorly-constructed houses with gaps on eaves, walls, windows and doors but were constrained by low income. CONCLUSION: In rural south-eastern Tanzania, significant proportions of people still live in houses with open eaves, unscreened windows and gaps on doors. Though they are fully aware of associated mosquito biting and pathogen transmission risks, they are constrained by low-income levels. The study proposes that community-based house improvement initiatives combined with targeted subsidies could lower the financial barriers, improve access to essential construction materials or designs, and significantly accelerate malaria transmission control in these communities.

Prevalence, Risk Factors, and Pathophysiology of Dysglycemia among People Living with HIV in Sub-Saharan Africa.

OBJECTIVE: To review available literature on the prevalence, risk factors, pathophysiology, and clinical outcomes of dysglycemia among people living with HIV (PLHIV) in sub-Saharan Africa (SSA). METHODS: Database search on PUBMED for eligible studies describing the prevalence, risk factors, pathophysiology, or clinical outcomes of dysglycemia in SSA PLHIV. RESULTS: Prevalence of diabetes mellitus (DM) and pre-DM among SSA PLHIV ranged from 1% to 26% and 19% to 47%, respectively, in 15 identified studies. Older age and an elevated body mass index (BMI) were common risk factors for dysglycemia. Risk factors potentially more specific to PLHIV in SSA included exposure to older-generation thymidine analogues or protease inhibitors, malnutrition at ART initiation, a failure to gain fat mass on treatment, and elevated serum lipids. There is evidence of higher nephropathy and neuropathy rates among PLHIV in SSA with comorbid DM compared to HIV-negative individuals with DM. CONCLUSION: There is a need for longitudinal studies to enhance understanding of the risk factors for dysglycemia among PLHIV in SSA, further research into optimal therapies to reduce pre-DM progression to DM among SSA PLHIV, and studies of the burden and phenotype of diabetic complications and other health outcomes among PLHIV with comorbid DM in SSA.

Retention in care among older adults living with HIV in western Kenya: A retrospective observational cohort study.

BACKGROUND: Retention, defined as continuous engagement in care, is an important indicator for quality of healthcare services. To achieve UNAIDS 90-90-90 targets, emphasis on retention as a predictor of viral suppression in patients initiated on ART is vital. Using routinely collected clinical data, the authors sought to determine the effect of age on retention post ART initiation. METHODS: De-identified electronic data for 32965 HIV-infected persons aged ≥15 years at enrolment into the Academic Model Providing Access to Healthcare program between January 2008 and December 2014 were analyzed. Follow-up time was defined from the date of ART initiation until either loss to follow-up or death or close of the database (September 2016) was observed. Proportions were compared using Pearson's Chi-square test and medians using Mann-Whitney U test. Logistic regression model was used to assess differences in ART initiation between groups, adjusting for baseline characteristics. Cox proportional hazards model adjusting for baseline characteristics and antiretroviral therapy (ART) status was used to compute hazard ratios. Kaplan-Meier survival function was used to compare retention on ART at 12, 24, and 36 months post ART initiation. RESULTS: Of the total sample, 3924 (12.0%) were aged ≥50 years at enrolment. The median (IQR) age of young adults and older adults were 32.5 (26.6, 36.9) and 54.9 (51.7, 59.9) respectively. ART initiation rates were 70.5% among older adults and 68.2% among younger adults. Retention rates in care at 12, 24 and 36 months post ART initiation were 73.9% (95% CL: 72.2, 75.5), 62.9% (95% CL: 61.0, 64.7) and 55.4% (95% CL: 53.5, 57.3) among older adults compared to 69.8% (95% CL: 69.1, 70.4), 58.1% (95% CL: 57.4, 58.8) and 49.3% (95% CL: 48.6, 50.0) among younger adults (p <0.001). A higher proportion of older adults were retained in HIV care post ART initiation compared to younger adults, Adjusted Hazard Ratio (AHR): 0.83 (95% CI: 0.78, 0.87) though they were more likely to die, AHR: 1.35 (95% CI: 1.19, 1.52). CONCLUSION: A higher proportion of older adults are initiated on ART and have better retention in care at 12, 24 and 36 months post ART initiation than younger adults. However, older adults have a higher all-cause mortality rate, perhaps partially driven by late presentation to care. Enhanced outreach and care to this group is imperative to improve their outcomes.

Assessing the impact of a primary care electronic medical record system in three Kenyan rural health centers.

OBJECTIVE: Efficient, effective health care requires rapid availability of patient information. We designed, implemented, and assessed the impact of a primary care electronic medical record (EMR) in three rural Kenyan health centers. METHOD: Local clinicians identified data required for primary care and public health reporting. We designed paper encounter forms to capture these data in adult medicine, pediatric, and antenatal clinics. Encounter form data were hand-entered into a new primary care module in an existing EMR serving onsite clinics serving patients infected with the human immunodeficiency virus (HIV). Before subsequent visits, Summary Reports were printed containing selected patient data with reminders for needed HIV care. We assessed effects on patient flow and provider work with time-motion studies before implementation and two years later, and we surveyed providers' satisfaction with the EMR. RESULTS: Between September 2008 and December 2011, 72 635 primary care patients were registered and 114 480 encounter forms were completed. During 2011, 32 193 unique patients visited primary care clinics, and encounter forms were completed for all visits. Of 1031 (3.2%) who were HIV-infected, 85% received HIV care. Patient clinic time increased from 37 to 81 min/visit after EMR implementation in one health center and 56 to 106 min/visit in the other. However, outpatient visits to both health centers increased by 85%. Three-quarters of increased time was spent waiting. Despite nearly doubling visits, there was no change in clinical officers' work patterns, but the nurses' and the clerks' patient care time decreased after EMR implementation. Providers were generally satisfied with the EMR but desired additional training. CONCLUSIONS: We successfully implemented a primary care EMR in three rural Kenyan health centers. Patient waiting time was dramatically lengthened while the nurses' and the clerks' patient care time decreased. Long-term use of EMRs in such settings will require changes in culture and workflow.

"These are good problems to have ": establishing a collaborative research partnership in East Africa.

In the context of a long-term institutional 'twinning' partnership initiated by Indiana and Moi Universities more than 22 years ago, a vibrant program of research has arisen and grown in size and stature. The history of the AMPATH (Academic Model Providing Access to Healthcare) Research Program is described, with its distinctive attention to Kenyan-North American equity, mutual benefit, policies that support research best practices, peer review within research working groups/cores, contributions to clinical care, use of healthcare informatics, development of research infrastructure and commitment to research workforce capacity. In the development and management of research within our partnership, we describe a number of significant challenges we have encountered that require ongoing attention, many of which are "good problems" occasioned by the program's success and growth. Finally, we assess the special value a partnership program like ours has created and end by affirming the importance of organizational diversity, solidarity of purpose, and resilience in the 'research enterprise.'