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Emmanuel G, Folayan M, Undelikwe G, Ochonye B, Jayeoba T, Yusuf A, Aiwonodagbon B, Bilali C, Umoh P, Ojemeiri K, Kalaiwo A. Community perspectives on barriers and challenges to HIV pre-exposure prophylaxis access by men who have sex with men and female sex workers access in Nigeria. BMC Public Health 2020; 20:69. [PMID: 31941469 PMCID: PMC6964078 DOI: 10.1186/s12889-020-8195-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 01/10/2020] [Indexed: 05/09/2023] Open
Abstract
Background Men who have sex with men (MSM), female sex workers (FSW) have critical needs for effective HIV prevention tools. This study identified perspectives of MSM, FSW and policy makers on the needs for, barriers to, and challenges with pre-exposure HIV prophylaxis (PrEP); and the logistics required to support roll-out of PrEP for MSM and FSW in Nigeria. Methods Qualitative and quantitative data were collected through a cross-sectional study. The quantitative data were collected through an online survey administered to 519 MSM, FSW and transgender respondents. The qualitative data were collected through 22 focus group discussions with 140 MSM and 80 FSW, and a two-day consultative workshop with 65 participants. Two open-ended questions in the online survey were also a source of qualitative data. Results of the quantitative data were reported descriptively; the qualitative data were inductively examined with a content analytic approach to construct descriptive categories. The findings from the quantitative and qualitative responses were triangulated. Results Four hundred and ninety-four (95.2%) online respondents had heard about PrEP through community dialogue (71.3%), and 439 (84.6%) supported its use by MSM and FSW. Fewer than half of the respondents were aware of the clinical care required for PrEP, and misconceptions about PrEP were common. Stated barriers to PrEP uptake were stigma, cost, frequency of HIV counseling and treatment services required, and possible drug-drug interactions. Concerns included possible condom migration, increased risk for sexually transmitted infections and pregnancy for FSW, and poor adherence to medication and hospital schedules. Participants felt that trained peer educators and HIV-test counselors could provide information and refer clients to clinics that provide PrEP. PrEP can be provided through peer-led facilities for MSM and FSW, though its access should be expanded to all persons who are at substantial risk for HIV to prevent negative labeling of PrEP. Public awareness about the use of antiretrovirals for HIV prevention is needed to prevent labeling of PrEP users as being HIV positive. Conclusion Although MSM and FSW are interested in the use of PrEP, numerous individual and structural barriers need to be addressed to facilitate access to it in Nigeria.
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Affiliation(s)
- G Emmanuel
- Heartland Alliance International, Chicago, Nigeria
| | - M Folayan
- New HIV Vaccine and Microbicide Advocacy Society, Lagos, Nigeria. .,Department of Child Dental Health, Obafemi Awolowo University, Ife, Nigeria.
| | - G Undelikwe
- Joint United Nations Programme on HIV/AIDS, Lagos, Nigeria
| | - B Ochonye
- Heartland Alliance International, Lagos, Nigeria
| | - T Jayeoba
- Heartland Alliance International, Lagos, Nigeria
| | - A Yusuf
- Heartland Alliance International, Lagos, Nigeria
| | | | - C Bilali
- Heartland Alliance International, Lagos, Nigeria
| | - P Umoh
- Joint United Nations Programme on HIV/AIDS, Lagos, Nigeria
| | - K Ojemeiri
- Heartland Alliance International, Lagos, Nigeria
| | - A Kalaiwo
- United States Agency for International Development, Abuja, Nigeria
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Cáceres CF, Mayer KH, Baggaley R, O'Reilly KR. PrEP Implementation Science: State-of-the-Art and Research Agenda. J Int AIDS Soc 2015; 18:20527. [PMID: 26198351 PMCID: PMC4581083 DOI: 10.7448/ias.18.4.20527] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Cáceres CF, Koechlin F, Goicochea P, Sow PS, O'Reilly KR, Mayer KH, Godfrey-Faussett P. The promises and challenges of pre-exposure prophylaxis as part of the emerging paradigm of combination HIV prevention. J Int AIDS Soc 2015; 18:19949. [PMID: 26198341 PMCID: PMC4509895 DOI: 10.7448/ias.18.4.19949] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 03/26/2015] [Accepted: 04/15/2015] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Towards the end of the twentieth century, significant success was achieved in reducing incidence in several global HIV epidemics through ongoing prevention strategies. However, further progress in risk reduction was uncertain. For one thing, it was clear that social vulnerability had to be addressed, through research on interventions addressing health systems and other structural barriers. As soon as antiretroviral treatment became available, researchers started to conceive that antiretrovirals might play a role in decreasing either susceptibility in uninfected people or infectiousness among people living with HIV. In this paper we focus on the origin, present status, and potential contribution of pre-exposure prophylaxis (PrEP) within the combination HIV prevention framework. DISCUSSION After a phase of controversy, PrEP efficacy trials took off. By 2015, daily oral PrEP, using tenofovir alone or in combination with emtricitabine, has been proven efficacious, though efficacy seems heavily contingent upon adherence to pill uptake. Initial demonstration projects after release of efficacy results have shown that PrEP can be implemented in real settings and adherence can be high, leading to high effectiveness. Despite its substantial potential, beliefs persist about unfeasibility in real-life settings due to stigma, cost, adherence, and potential risk compensation barriers. CONCLUSIONS The strategic synergy of behavioural change communication, biomedical strategies (including PrEP), and structural programmes is providing the basis for the combination HIV prevention framework. If PrEP is to ever become a key component of that framework, several negative beliefs must be confronted based on emerging evidence; moreover, research gaps regarding PrEP implementation must be filled, and appropriate prioritization strategies must be set up. Those challenges are significant, proportional to the impact that PrEP implementation may have in the global response to HIV.
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Affiliation(s)
- Carlos F Cáceres
- Center for Interdisciplinary Studies in Sexuality, AIDS and Society, Universidad Peruana Cayetano Heredia, Lima, Peru
- Network for Multidisciplinary Studies in ARV-Based HIV Prevention (NEMUS), Lima, Peru;
| | | | - Pedro Goicochea
- Network for Multidisciplinary Studies in ARV-Based HIV Prevention (NEMUS), Lima, Peru
- Center for AIDS Prevention Studies, University of California - San Francisco, San Francisco, CA, USA
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Zalenskaya IA, Joseph T, Bavarva J, Yousefieh N, Jackson SS, Fashemi T, Yamamoto HS, Settlage R, Fichorova RN, Doncel GF. Gene Expression Profiling of Human Vaginal Cells In Vitro Discriminates Compounds with Pro-Inflammatory and Mucosa-Altering Properties: Novel Biomarkers for Preclinical Testing of HIV Microbicide Candidates. PLoS One 2015; 10:e0128557. [PMID: 26052926 PMCID: PMC4459878 DOI: 10.1371/journal.pone.0128557] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 04/28/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Inflammation and immune activation of the cervicovaginal mucosa are considered factors that increase susceptibility to HIV infection. Therefore, it is essential to screen candidate anti-HIV microbicides for potential mucosal immunomodulatory/inflammatory effects prior to further clinical development. The goal of this study was to develop an in vitro method for preclinical evaluation of the inflammatory potential of new candidate microbicides using a microarray gene expression profiling strategy. METHODS To this end, we compared transcriptomes of human vaginal cells (Vk2/E6E7) treated with well-characterized pro-inflammatory (PIC) and non-inflammatory (NIC) compounds. PICs included compounds with different mechanisms of action. Gene expression was analyzed using Affymetrix U133 Plus 2 arrays. Data processing was performed using GeneSpring 11.5 (Agilent Technologies, Santa Clara, CA). RESULTS Microarraray comparative analysis allowed us to generate a panel of 20 genes that were consistently deregulated by PICs compared to NICs, thus distinguishing between these two groups. Functional analysis mapped 14 of these genes to immune and inflammatory responses. This was confirmed by the fact that PICs induced NFkB pathway activation in Vk2 cells. By testing microbicide candidates previously characterized in clinical trials we demonstrated that the selected PIC-associated genes properly identified compounds with mucosa-altering effects. The discriminatory power of these genes was further demonstrated after culturing vaginal cells with vaginal bacteria. Prevotella bivia, prevalent bacteria in the disturbed microbiota of bacterial vaginosis, induced strong upregulation of seven selected PIC-associated genes, while a commensal Lactobacillus gasseri associated to vaginal health did not cause any changes. CONCLUSIONS In vitro evaluation of the immunoinflammatory potential of microbicides using the PIC-associated genes defined in this study could help in the initial screening of candidates prior to entering clinical trials. Additional characterization of these genes can provide further insight into the cervicovaginal immunoinflammatory and mucosal-altering processes that facilitate or limit HIV transmission with implications for the design of prevention strategies.
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Affiliation(s)
- Irina A Zalenskaya
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | - Theresa Joseph
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | - Jasmin Bavarva
- Virginia Bioinformatics Institute, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, United States of America
| | - Nazita Yousefieh
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | - Suzanne S Jackson
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | - Titilayo Fashemi
- Laboratory of Genital Tract Biology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Hidemi S Yamamoto
- Laboratory of Genital Tract Biology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Robert Settlage
- Virginia Bioinformatics Institute, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, United States of America
| | - Raina N Fichorova
- Laboratory of Genital Tract Biology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Gustavo F Doncel
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, United States of America
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Gautam R, Borgdorff H, Jespers V, Francis SC, Verhelst R, Mwaura M, Delany-Moretlwe S, Ndayisaba G, Kyongo JK, Hardy L, Menten J, Crucitti T, Tsivtsivadze E, Schuren F, van de Wijgert JHHM. Correlates of the molecular vaginal microbiota composition of African women. BMC Infect Dis 2015; 15:86. [PMID: 25887567 PMCID: PMC4343073 DOI: 10.1186/s12879-015-0831-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 02/11/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Sociodemographic, behavioral and clinical correlates of the vaginal microbiome (VMB) as characterized by molecular methods have not been adequately studied. VMB dominated by bacteria other than lactobacilli may cause inflammation, which may facilitate HIV acquisition and other adverse reproductive health outcomes. METHODS We characterized the VMB of women in Kenya, Rwanda, South Africa and Tanzania (KRST) using a 16S rDNA phylogenetic microarray. Cytokines were quantified in cervicovaginal lavages. Potential sociodemographic, behavioral, and clinical correlates were also evaluated. RESULTS Three hundred thirteen samples from 230 women were available for analysis. Five VMB clusters were identified: one cluster each dominated by Lactobacillus crispatus (KRST-I) and L. iners (KRST-II), and three clusters not dominated by a single species but containing multiple (facultative) anaerobes (KRST-III/IV/V). Women in clusters KRST-I and II had lower mean concentrations of interleukin (IL)-1α (p < 0.001) and Granulocyte Colony Stimulating Factor (G-CSF) (p = 0.01), but higher concentrations of interferon-γ-induced protein (IP-10) (p < 0.01) than women in clusters KRST-III/IV/V. A lower proportion of women in cluster KRST-I tested positive for bacterial sexually transmitted infections (STIs; ptrend = 0.07) and urinary tract infection (UTI; p = 0.06), and a higher proportion of women in clusters KRST-I and II had vaginal candidiasis (ptrend = 0.09), but these associations did not reach statistical significance. Women who reported unusual vaginal discharge were more likely to belong to clusters KRST-III/IV/V (p = 0.05). CONCLUSION Vaginal dysbiosis in African women was significantly associated with vaginal inflammation; the associations with increased prevalence of STIs and UTI, and decreased prevalence of vaginal candidiasis, should be confirmed in larger studies.
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Affiliation(s)
- Raju Gautam
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.
| | - Hanneke Borgdorff
- Amsterdam Institute for Global Health and Development and Academic Medical Center, Amsterdam, The Netherlands.
| | | | - Suzanna C Francis
- London School for Hygiene and Tropical Medicine, MRC Tropical Epidemiology Group, London, UK.
| | - Rita Verhelst
- Ghent University, International Centre for Reproductive Health, Ghent, Belgium.
| | - Mary Mwaura
- International Centre for Reproductive Health Kenya, Mombasa, Kenya.
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Research Institute, Witwatersrand University, Johannesburg, South Africa.
| | | | | | | | - Joris Menten
- Institute of Tropical Medicine, Antwerp, Belgium.
| | | | | | | | - Janneke H H M van de Wijgert
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK. .,Rinda Ubuzima, Kigali, Rwanda. .,Department of Clinical Infection, Immunology and Microbiology, Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, West Derby Street, Liverpool, L69 7BE, UK.
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Morris GC, Wiggins RC, Woodhall SC, Bland JM, Taylor CR, Jespers V, Vcelar BA, Lacey CJ. MABGEL 1: first phase 1 trial of the anti-HIV-1 monoclonal antibodies 2F5, 4E10 and 2G12 as a vaginal microbicide. PLoS One 2014; 9:e116153. [PMID: 25546420 PMCID: PMC4278856 DOI: 10.1371/journal.pone.0116153] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 12/03/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Monoclonal antibodies (mAbs) which potently neutralize a broad range of HIV isolates are potential microbicide candidates. To date, topical application of mAbs in humans and their stability in vaginal secretions has not been studied. OBJECTIVES To assess the pharmacokinetics and safety of the mAbs 2F5, 4E10 and 2G12 when applied vaginally in women. DESIGN A randomized, double-blind, placebo-controlled phase 1 trial. METHODS Twenty-eight healthy, sexually abstinent women administered 2.5 g of gel daily for 12 days containing either 10 or 20 mg/g of each mAb (MABGEL) or placebo. Main clinical evaluations and sampling occurred at baseline, 1, 8, and 24 hours post-1st dose and 12 and 36 hours post-12th dose. RESULTS After adjustment for dilution factors, median levels of 2F5, 4E10 and 2G12 in vaginal secretions at 1 hour post high-dose MABGEL were 7.74, 5.28 and 7.48 mg/ml respectively. Levels of 2F5 and 4E10 declined exponentially thereafter with similar estimated half-lives (4.6 and 4.3 hours). In contrast, 2G12 levels declined more rapidly in the first 8 hours, with an estimated half-life of 1.4 hours during this period. There was no evidence of systemic absorption. There were no significant differences in local or systemic adverse event rates or vaginal flora changes (by qPCR) between active and placebo gel arms. Whilst at least 1 adverse event was recorded in 96% of participants, 95% were mild and none were serious. CONCLUSIONS Vaginal application of 50 mg of each mAb daily was safe over a 12 day period. Median mAb concentrations detected at 8 hours post dose were potentially sufficient to block HIV transmission.2G12 exhibited more rapid elimination from the human vagina than 4E10 and 2F5, likely due to poor stability of 2G12 in acidic human vaginal secretions. Further research is needed to develop mAb-based vaginal microbicides and delivery systems. TRIAL REGISTRATION ISRCTN 64808733 UK CRN Portfolio 6470.
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Affiliation(s)
- Georgina C. Morris
- Centre for Immunology and Infection, Hull York Medical School, University of York, York, United Kingdom
| | - Rebecca C. Wiggins
- Centre for Immunology and Infection, Hull York Medical School, University of York, York, United Kingdom
| | - Sarah C. Woodhall
- Centre for Immunology and Infection, Hull York Medical School, University of York, York, United Kingdom
| | - J. Martin Bland
- Department of Health Sciences, University of York, York, United Kingdom
| | - Carol R. Taylor
- Hull York Medical School Experimental Medicine Unit, York Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | | | | | - Charles J. Lacey
- Centre for Immunology and Infection, Hull York Medical School, University of York, York, United Kingdom
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McKinnon LR, Hughes SM, De Rosa SC, Martinson JA, Plants J, Brady KE, Gumbi PP, Adams DJ, Vojtech L, Galloway CG, Fialkow M, Lentz G, Gao D, Shu Z, Nyanga B, Izulla P, Kimani J, Kimwaki S, Bere A, Moodie Z, Landay AL, Passmore JAS, Kaul R, Novak RM, McElrath MJ, Hladik F. Optimizing viable leukocyte sampling from the female genital tract for clinical trials: an international multi-site study. PLoS One 2014; 9:e85675. [PMID: 24454917 PMCID: PMC3893217 DOI: 10.1371/journal.pone.0085675] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 12/06/2013] [Indexed: 11/18/2022] Open
Abstract
Background Functional analysis of mononuclear leukocytes in the female genital mucosa is essential for understanding the immunologic effects of HIV vaccines and microbicides at the site of HIV exposure. However, the best female genital tract sampling technique is unclear. Methods and Findings We enrolled women from four sites in Africa and the US to compare three genital leukocyte sampling methods: cervicovaginal lavages (CVL), endocervical cytobrushes, and ectocervical biopsies. Absolute yields of mononuclear leukocyte subpopulations were determined by flow cytometric bead-based cell counting. Of the non-invasive sampling types, two combined sequential cytobrushes yielded significantly more viable mononuclear leukocytes than a CVL (p<0.0001). In a subsequent comparison, two cytobrushes yielded as many leukocytes (∼10,000) as one biopsy, with macrophages/monocytes being more prominent in cytobrushes and T lymphocytes in biopsies. Sample yields were consistent between sites. In a subgroup analysis, we observed significant reproducibility between replicate same-day biopsies (r = 0.89, p = 0.0123). Visible red blood cells in cytobrushes increased leukocyte yields more than three-fold (p = 0.0078), but did not change their subpopulation profile, indicating that these leukocytes were still largely derived from the mucosa and not peripheral blood. We also confirmed that many CD4+ T cells in the female genital tract express the α4β7 integrin, an HIV envelope-binding mucosal homing receptor. Conclusions CVL sampling recovered the lowest number of viable mononuclear leukocytes. Two cervical cytobrushes yielded comparable total numbers of viable leukocytes to one biopsy, but cytobrushes and biopsies were biased toward macrophages and T lymphocytes, respectively. Our study also established the feasibility of obtaining consistent flow cytometric analyses of isolated genital cells from four study sites in the US and Africa. These data represent an important step towards implementing mucosal cell sampling in international clinical trials of HIV prevention.
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Affiliation(s)
- Lyle R. McKinnon
- Department of Medicine, University of Toronto, Toronto, Canada
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Sean M. Hughes
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Stephen C. De Rosa
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
| | - Jeffrey A. Martinson
- Department of Immunology and Microbiology, Rush University Medical Center, Chicago, Illinois, United States of America
| | - Jill Plants
- Department of Immunology and Microbiology, Rush University Medical Center, Chicago, Illinois, United States of America
| | - Kirsten E. Brady
- Department of Immunology and Microbiology, Rush University Medical Center, Chicago, Illinois, United States of America
| | - Pamela P. Gumbi
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Devin J. Adams
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Lucia Vojtech
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Christine G. Galloway
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Michael Fialkow
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Gretchen Lentz
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Dayong Gao
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, United States of America
| | - Zhiquan Shu
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, United States of America
| | - Billy Nyanga
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Preston Izulla
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Joshua Kimani
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Steve Kimwaki
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Alfred Bere
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Zoe Moodie
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Alan L. Landay
- Department of Immunology and Microbiology, Rush University Medical Center, Chicago, Illinois, United States of America
| | - Jo-Ann S. Passmore
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Cape Town, South Africa
| | - Rupert Kaul
- Department of Medicine, University of Toronto, Toronto, Canada
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Department of Medicine, University Health Network, Toronto, Canada
| | - Richard M. Novak
- College of Medicine, University of Illinois, Chicago, Illinois, United States of America
| | - M. Juliana McElrath
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Florian Hladik
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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