Hutchinson Centre Research Institute in Uganda

To formally quantify the level of under-detection of Trypanosoma brucei rhodesiense sleeping sickness (SS) during an epidemic in Uganda, a decision tree (under-detection) model was developed; concurrently, to quantify the subset of undetected cases that sought health care but were not diagnosed, a deterministic (subset) model was developed. The values of the under-detection model parameters were estimated from previously published records of the duration of symptoms prior to presentation and the ratio of early to late stage cases in 760 SS patients presenting at LIRI hospital, Tororo, Uganda during the 1988--1990 epidemic of SS. For the observed early to late stage ratio of 0.47, we estimate that the proportion of under-detection in the catchment area of LIRI hospital was 0.39 (95% CI 0.37--0.41) i.e. 39% of cases are not reported. Based on this value, it is calculated that for every one reported death of SS, 12.0 (95% CI 11.0--13.0) deaths went undetected in the LIRI hospital catchment area - i.e. 92% of deaths are not reported. The deterministic (subset) model structured on the possible routes of a SS infection to either diagnosis or death through the health system or out of it, showed that of a total of 73 undetected deaths, 62 (CI 60-64) (85%) entered the healthcare system but were not diagnosed, and 11 (CI 11--12) died without seeking health care from a recognized health unit. The measure of early to late stage presentation provides a tractable measure to determine the level of rhodesiense SS under-detection and to gauge the effects of interventions aimed at increasing treatment coverage.

PURPOSE: "Endemic" Burkitt lymphoma (BL) is a common childhood cancer in Africa. Social and treatment factors may contribute to poor survival. With the aim of improving BL outcomes in Uganda, we undertook a comprehensive project (BL Project) that provided diagnostic support, access to standard chemotherapy, nutritional evaluations, and case management. We evaluated survival of children with BL in the context of the project. PATIENTS AND METHODS: Patients followed by the BL Project who consented to research were enrolled in this study. Children with a pathology diagnosis consistent with BL were eligible. Data were collected prospectively. First-line chemotherapy generally consisted of six cycles of cyclophosphamide, vincristine, low-dose methotrexate (COM). We used Kaplan-Meier and Cox regression analyses to evaluate factors associated with overall survival (OS). RESULTS: Between July 2012 and June 2017, 341 patients with suspected BL presented to the BL Project. One hundred eighty patients with a pathology-based diagnosis were included in this study. The median age was seven years (interquartile range, 5-9), 74% lived ≥100 km from the Uganda Cancer Institute, 61% had late-stage disease, 84% had ECOG performance status < 3, 63% reported B-symptoms, and 22% showed neurologic symptoms. Fewer than 10% abandoned therapy. The four-year OS rate was 44% (95% CI, 36%-53%). In a multivariate model, ECOG status was significantly associated with mortality. CONCLUSION: The BL Project reduced effects of lacking supportive care and oncology resources, and allowed patients from Uganda to receive curative intent therapy with minimal loss to follow-up. Nonetheless, OS remains unacceptably low. Improved therapeutic approaches to endemic BL are urgently needed in Africa.

BACKGROUND: HIV infection is associated with more rapid progression of some comorbidities. This study assessed the impact of HIV-infection on the presentation and outcome of HCC. METHODS: HCC patients attending the Mulago National Referral Hospital in Uganda were enrolled into a natural history study of HCC between March 2015 and February 2019. Standardized methods were used to collect clinical, ultrasound and laboratory data at enrolment. HCC cases were confirmed and enrolled based on a combination of clinical, ultrasound, tumor marker and pathology data. Follow-up contact was made at one, three, six, and twelve months post-enrolment to determine vital status. Symptoms and signs at diagnosis and subsequent survival were compared by HIV status. Kaplan Meier curves were used to assess HCC survival. RESULTS: Of 441 persons with HCC, 383 (87.0%) died within 12 months following HCC diagnosis. The median (IQR) survival was 42 (20, 106) days. HIV infection was present in 79 (18%) cases. After adjusting for baseline demographic and clinical characteristics, HIV infection was associated with increased mortality but only among those with severe HIV-associated immunosuppression (CD4 count < 200 cells per cubic milliliter), aHR (95% C) = 2.12 (1.23-3.53), p = 0.004, and not among PLWH with ≥ 200 CD4 cells per cubic milliliter, aHR (95% C) = 1.15 (0.82-1.60), p = 0.417. CONCLUSION: Among relatively young Ugandans, HCC is a devastating disease with rapid mortality that is especially rapid among people living with HIV(PLWH). HIV was associated with slightly higher mortality, notably among PLWH with lower CD4 cell counts. As a substantial majority of PLWH diagnosed with HCC were engaged in HIV care, further investigation should determine the effectiveness of incorporating screening and early identification of HCC among high-risk individuals into existing HIV care programs. Concurrent with growing access to curative localized treatment for HCC in sub-Saharan Africa, leveraging HIV care infrastructure affords opportunities for earlier HCC intervention.

BACKGROUND: Cervical cancer mortality remains high in sub-Saharan Africa, especially among women living with HIV (WLWH). Characterization of prevalent high-risk human papillomavirus (hrHPV) types and immune function in WLWH with cervical abnormalities despite antiretroviral therapy (ART) can inform prevention strategies. SETTING: Kampala, Uganda. METHODS: From 2017 to 2020, we enrolled Ugandan women with cervical dysplasia detected with visual inspection with acetic acid (VIA). WLWH were required to be on ART >3 months with plasma HIV RNA <1000 copies/mL. Biopsies from VIA-positive lesions underwent histopathologic grading and cervical swab specimens were tested for hrHPV. Clinical correlations were evaluated with Poisson regression to estimate adjusted prevalence ratios (aPR). RESULTS: One hundred eighty-eight WLWH and 116 HIV-seronegative women participated. Among WLWH, median ART duration was 6 years and median CD4 667 cells/µL. Cervical intraepithelial neoplasia (CIN) grade 2/3 was found in 29% of WLWH versus 9% of HIV-seronegative women. In women with CIN1 or without histopathology-confirmed dysplasia, hrHPV (aPR [95% confidence interval]: 2.17 [1.43 to 3.29]) and multiple hrHPV (aPR 3.73 [1.07 to 13.1]) were more common in WLWH, as were vaccine-targeted and vaccine-untargeted hrHPVtypes. Differences in hrHPV prevalence by HIV serostatus were not observed in women with CIN2/3 (interaction P < 0.01). Among WLWH, low CD4/8 ratio was associated with hrHPV while detectable plasma HIV RNA (20-1000 copies/mL) was associated with CIN2/3 or invasive cancer. CONCLUSION: Despite ART, WLWH with cervical VIA abnormalities remain at elevated risk for multiple hrHPV and high-grade dysplasia. Cervical cancer prevention and research tailored for WLWH are warranted in the ART era.

INTRODUCTION: Cancer treatment options in sub-Saharan Africa are scarce despite an increasing burden of disease. Identification of those cancer patients who would benefit most from the limited resources available would allow broader and more effective therapy. METHODS: We conducted a retrospective analysis of patients over the age of 18 at the time of a pathologic diagnosis of NHL between 2003 and 2010 who were residents of Kyandondo County (Uganda) and presented to the Uganda Cancer Institute for care. RESULTS: A total of 128 patients were included in this analysis. Chemotherapy was recommended to 117 (91.4%) of the patients; the odds of recommending chemotherapy decreased for each additional month of reported symptoms prior to diagnosis. Of the 117 patients to whom chemotherapy was recommended, 111 (86.7%) patients received at least 1 cycle of chemotherapy; HIV infected patients, as well as those with a lower hemoglobin and advanced disease at the time of diagnosis were significantly less likely to complete therapy. Among the patients who initiated chemotherapy, twenty patients died prior to treatment completion (including nine who died within 30 days). Hemoglobin level at the time of presentation was the only variable associated with early mortality in the adjusted model. CONCLUSION: In resource-poor areas, it is essential to align health care expenditures with interventions likely to provide benefit to affected populations. Targeting cancer therapy to those with a favorable chance of responding will not only save limited resources, but will also prevent harm in those patients unlikely to realize an effect of cancer-directed therapy.

BACKGROUND: Mental health conditions are a significant public health problem globally, responsible for >8 million deaths per year. In addition, they lead to lost productivity, exacerbate physical illness, and are associated with stigma and human rights violations. Uganda, like many low- and middle-income countries, faces a massive treatment gap for mental health conditions, and numerous sociocultural challenges exacerbate the burden of mental health conditions. OBJECTIVE: This study aims to describe the development and formative evaluation of a digital health intervention for improving access to mental health care in Uganda. METHODS: This qualitative study used user-centered design and design science research principles. Stakeholders, including patients, caregivers, mental health care providers, and implementation experts (N=65), participated in focus group discussions in which we explored participants' experience of mental illness and mental health care, experience with digital interventions, and opinions about a proposed digital mental health service. Data were analyzed using the Consolidated Framework for Implementation Research to derive requirements for the digital solution, which was iteratively cocreated with users and piloted. RESULTS: Several challenges were identified, including a severe shortage of mental health facilities, unmet mental health information needs, heavy burden of caregiving, financial challenges, stigma, and negative beliefs related to mental health. Participants' enthusiasm about digital solutions as a feasible, acceptable, and convenient method for accessing mental health services was also revealed, along with recommendations to make the service user-friendly, affordable, and available 24×7 and to ensure anonymity. A hospital call center service was developed to provide mental health information and advice in 2 languages through interactive voice response and live calls with health care professionals and peer support workers (recovering patients). In the 4 months after launch, 456 calls, from 236 unique numbers, were made to the system, of which 99 (21.7%) calls went to voicemails (out-of-office hours). Of the remaining 357 calls, 80 (22.4%) calls stopped at the interactive voice response, 231 (64.7%) calls were answered by call agents, and 22 (6.2%) calls were not answered. User feedback was positive, with callers appreciating the inclusion of peer support workers who share their recovery journeys. However, some participant recommendations (eg, adding video call options) or individualized needs (eg, prescriptions) could not be accommodated due to resource limitations or technical feasibility. CONCLUSIONS: This study demonstrates a systematic and theory-driven approach to developing contextually appropriate digital solutions for improving mental health care in Uganda and similar contexts. The positive reception of the implemented service underscores its potential impact. Future research should address the identified limitations and evaluate clinical outcomes of long-term adoption.

PURPOSE Acute leukemias are associated with substantial morbidity and mortality, particularly in the adult population. Despite an increasing burden of acute leukemia in developing countries, there are limited data on clinical outcomes and prognostic factors in this setting. In this study, we aimed to describe the clinical characteristics, survival, and prognostic factors of adults with acute leukemia at the Uganda Cancer Institute (UCI). METHODS A retrospective cohort study was conducted between January 2009 and December 2018, reviewing data of patients 18 years or older with a cytopathologic diagnosis of acute leukemia at UCI. Data were extracted on clinical and laboratory characteristics, response to treatment, and survival. Cox-proportional hazards regression and survival analysis were performed to determine survival rates and associated factors. P &lt; .05 was considered statistically significant. RESULTS In total, 233 participants were enrolled. Most (59.2%. n = 138) participants were male, with a median age of 32 years (IQR, 23-48 years), and 136 (58.4%) had AML. Overall, the 1-year survival was 16.5%, with a median survival time of 47 (IQR, 21-219) days. Predictors of mortality were being a female (adjusted hazard ratio [aHR], 2.8; 95% CI, 1.2 to 6.7; P = .022) and overweight (aHR, 4.2; 95% CI, 1.3 to 13.4; P = .015). Among the patients who had AML, the predictors were poor Eastern Cooperative Oncology Group (ECOG; aHR, 3.1; 95% CI, 1.6 to 6.2; P = .001) and HIV (aHR, 6.0; 95% CI, 1.7 to 20.5; P = .004). Among the patients who had ALL, the predictors were poor ECOG (aHR, 2.3; 95% CI, 1.3 to 4.1; P = .006). CONCLUSION Patients with acute leukemia in Uganda have poor overall survival. Prospective studies are recommended to better understand causes of early mortality.

Abstract Background Cancer patients are at risk of developing severe infections. Empiric management of infections is complicated by emerging antimicrobial resistance and changing local epidemiology of organisms. We sought to determine predominant species causing bacteremia, their antimicrobial resistance profiles, and their contribution to mortality among hematologic cancer patients with febrile neutropenia at the Uganda Cancer Institute. Methods Blood drawn from participants during a febrile neutropenic episode (FNE; fever ≥37.5°C and neutrophil count ≤1,000 cells/µL) was cultured in the BACTEC 9120 blood culture system. Bacteria from positive cultures were identified biochemically. Antimicrobial susceptibility testing was performed with the disc diffusion method. Logistic regression and proportional hazards regression were applied to estimate associations between participant characteristics and FNE, bacteremia, and mortality. Results Of 246 participants, 74 (30%) had an FNE. During the first FNE, 6/21 (29%) participants with acute lymphocytic leukemia (ALL) developed bacteremia compared with 16/31 (52%) with acute myeloid leukemia (AML) (OR 2.22 (0.65, 7.4)). AML patients were specifically at higher risk of Gram-negative bacteremia (OR 4.59 (1.09, 19.3). Of the 41 aerobic bacteria isolated, 32 (78%) were Gram-negative, the most common being Klebsiella pneumoniae (11; 34%). Seventeen (53%) of the Gram-negative bacteria displayed the extended spectrum β lactamase phenotype and 5 (16%) were resistant to carbapenems. One of the eight Enterococcus species was vancomycin resistant. Overall survival among patients with FNE was 54% at 30 days and 19% at 100 days. Bacteremia was associated with higher mortality within 30 days (HR 2.1 (0.99, 4.45)) and 100 days (31% vs.10%; HR 2.23 (1.09, 4.59)). Conclusion Multidrug-resistant bacteria are the main cause of bacteremia and increase mortality in febrile neutropenic hematologic cancer patients at the UCI. Enhanced microbial surveillance, infection control and antimicrobial stewardship programs are needed to guide therapy and address emerging antimicrobial resistance at our institution. Disclosures All authors: No reported disclosures.

BACKGROUND: Harnessing mobile health (mHealth) solutions could improve the delivery of mental health services and mitigate their impact in Uganda and similar low-resource settings. However, successful adoption requires that mHealth solutions have good usability. We have previously implemented a telephone service to provide mental health information and advice in English and Luganda, utilizing an automated interactive voice response (IVR) system linked to live agents, including mental health care workers and peer support workers. OBJECTIVE: This study aims to assess the usage and usability of this mental health telephone service. METHODS: We obtained usage data from the system's call logs over 18 months to study call volumes and trends. We then surveyed callers to gather their characteristics and assess usability using the Telehealth Usability Questionnaire. Additionally, call recordings were evaluated for conversation quality by 3 independent health care professionals, using the Telephone Nursing Dialogue Process, and correlations between quality and usability aspects were investigated. RESULTS: Over 18 months, the system received 2863 meaningful calls (ie, calls that went past the welcome message) from 1125 unique telephone numbers. Of these, 1153 calls (40.27%) stopped at the prerecorded IVR information, while 1710 calls (59.73%) opted to speak to an agent. Among those who chose to speak with an agent, 1292 calls (75.56%) were answered, 393 calls (22.98%) went to voicemail and were returned in the following working days, and 25 calls (1.46%) were not answered. Usage was generally sustained over time, with spikes in call volume corresponding to marketing events. The survey (n=240) revealed that most callers were caregivers of patients with mental health issues (n=144, 60.0%) or members of the general public (n=46, 19.2%), while a few were patients with mental health issues (n=44, 18.3%). Additionally, the majority were male (n=143, 59.6%), spoke English (n=180, 75.0%), had postsecondary education (n=164, 68.3%), lived within 1 hour or less from Butabika Hospital (n=187, 77.9%), and were aged 25-44 years (n=160, 66.7%). The overall usability score for the system was 4.12 on a 5-point scale, significantly higher than the recommended target usability score of 4 (P=.006). The mean scores for usability components ranged from 3.66 for reliability to 4.41 for ease of use, with all components, except reliability, scoring higher than 4 or falling within its CI. Usability scores were higher for Luganda speakers compared with English speakers, but there was no association with other participant characteristics such as sex, distance from the hospital, age, marital status, duration of symptoms, or treatment status. The quality of call conversations (n=50) was rated at 4.35 out of 5 and showed a significant correlation with usability (Pearson r=0.34, P=.02). CONCLUSIONS: We found sustained usage of the mental health telephone service, along with a positive user experience and high satisfaction across various user characteristics. mHealth solutions like this should be embraced and replicated to enhance the delivery of health services in Uganda and similar low-resource settings.

Abstract Background We determined the etiology, risk factors, and outcomes associated with bacteremia in patients with hematologic malignancies and febrile neutropenia (FN) at the Uganda Cancer Institute (UCI). Methods UCI adult and pediatric inpatients with hematologic malignancies and FN were prospectively enrolled and followed up to determine 30-day mortality. Blood drawn from participants with FN was cultured in the BACTEC 9120 blood culture system. Antimicrobial susceptibility testing was performed with the disk diffusion method on identified bacteria. Logistic regression and Cox proportional hazards regression were applied to estimate associations between participant characteristics and FN, bacteremia, and mortality. Results Of 495 participants, the majority (n = 306 [62%]) were male. Median age was 23 years (interquartile range, 11–42 years). Of the 132 participants who experienced FN, 43 (33%) had bacteremia. Participants with younger age (odds ratio [OR], 0.98; P = .05), severe neutropenia (OR, 2.9; P = .01), hypotension (OR, 2.46; P = .04), mucositis (OR, 2.77; P = .01), and receipt of chemotherapy (OR, 2.25; P = .03) were more likely to have bacteremia. Fifty (78%) bacteria isolated were gram negative. Escherichia coli (n = 25 [50%]) was predominant. Thirty-seven of 43 (86%) episodes were caused by multidrug-resistant (MDR) bacteria. Thirty-day overall survival for participants with bacteremia was significantly lower than that for participants with no bacteremia (P = .05). MDR bacteremia (hazard ratio, 1.84; P = .05) was associated with increased risk of death. Conclusions Bacteremia was frequent in patients with hematologic cancer and FN and was associated with poor survival. MDR bacteria were the main cause of bacteremia and mortality. There is a need for robust infection control and antimicrobial stewardship programs in cancer centers in sub-Saharan Africa.

PURPOSE: Patients with diffuse large B-cell lymphoma (DLBCL) who are treated in low-resource settings have inferior outcomes compared with those in high-resource settings. Rituximab, an anti-CD20 monoclonal antibody, when combined with chemotherapy, improves overall survival (OS) for DLBCL. However, in part due to the limited availability of infusion centers in low-resource countries, rituximab is rarely used. Subcutaneous rituximab (sqR) is a potential solution; however, its safety and efficacy have not been tested in low-income countries. METHODS: This open-label phase I study enrolled patients 18 years or older with newly diagnosed DLBCL. The first cohort (n = 6) received intravenous rituximab plus CHOP. This cohort received sqR for subsequent cycles. The second cohort (n = 12) received sqR plus CHOP for all cycles. Safety and tolerability were evaluated; secondary outcomes included response rates and treatment completion. RESULTS: Between October 25, 2019, and October 7, 2022, 18 patients, with a median age of 36.5 years, were enrolled; 10 were male, and 10 presented with advanced-stage disease. The most common hematologic toxicity was neutropenia (n = 9, 50%). Fifteen of the 18 participants completed treatment; 14 (93.3%) patients achieved a complete response, and one patient (6.7%) had a partial response. The OS and progression-free survival (PFS) at 12 months were 83% (95% CI, 68 to 100) and 67% (95% CI, 48 to 92), respectively. The OS and PFS at 24 months were 66% (95% CI, 47 to 92) and 67% (95% CI, 48 to 92), respectively. CONCLUSION: As demonstrated in other parts of the world, sqR together with CHOP was safe, well-tolerated, and efficacious among Ugandan patients with DLBCL. The very high OS rates are nearly double those of historical controls and comparable with outcomes expected in resource-rich settings. This study demonstrated the feasibility, safety, and efficacy of sqR-CHOP, increased the research infrastructure in Uganda, and will improve care in other resource-limited settings.

Abstract Background Bloodstream infections (BSI) are associated with significant mortality in hematologic cancer patients with febrile neutropenia. Poor clinical outcomes are associated with presence of multidrug resistant (MDR) organisms and polymicrobial infections. We sought to determine antimicrobial resistance and outcomes of polymicrobial bloodstream infections in hematologic cancer patients with febrile neutropenic episodes (FNEs) at the Uganda Cancer Institute. Methods Blood drawn from participants during an FNE (fever ≥ 37.5°C and neutrophil count ≤ 1000 cells/µL) was cultured in the BACTEC 9120 blood culture system. Bacteria from positive cultures were identified biochemically. Antimicrobial susceptibility testing was performed with the disc diffusion method. Participants were followed for 30 days from first FNE onset for death from any cause. Cox regression was used to estimate hazard ratios (HR) and 95% confidence intervals (95%). Results Six hundred and twenty-nine participants were followed for FNE. Two hundred and twenty-eight FNEs in 159 participants were observed. Of 181 FNEs with blood cultures completed, 65 (36%) had pathogenic organism isolated. A total of 74 Gram negative and 18 Gram positive bacteria were isolated. Forty-eight (74%) FNEs had monomicrobial (MBSI) and 17 (26%) had polymicrobial (PBSI) bloodstream infections. Gram negative - Gram negative (10 out of 17, 59%) was the most frequent PBSI combination (Fig 1). Up to 75% (12 out of 16) of Gram-negative PBSI were MDR. The most common organism isolated was E. coli (38% of isolates). Participants with PBSI had higher early mortality rates at 7 days compared to MBSI and negative cultures (44%, 22%, and 16% for PBSI, MBSI, and negative respectively; HR (95% CI): 3.63 (1.49, 8.86) for PBSI v. negative/MBSI cultures). Similarly, PBSI was associated with higher mortality within 30 days of FNE onset (63%, 52%, and 38% for PBSI, MBSI, and negative respectively; HR (95% CI): 2.17 (1.09, 4.32) for PBSI v. negative/MBSI) (Fig 2). Figure 1. Bar graph showing combinations for polymicrobial bloodstream infections (PBSI). GNGN: Gram-negative – Gram-negative; GNGP: Gram-negative – Gram-positive; GNO: Gram-negative – Other (fungi); GPGP: Gram-positive – Gram-positive Figure 2. Kaplan-Meier failure curves of participants with negative cultures, monomicrobial infections and polymicrobial infections Conclusion PBSI episodes were more likely to be multidrug resistant and are associated with higher mortality. Empirical therapy for patients with PBSI should consider multidrug resistant Gram-negative bacteria Disclosures All Authors: No reported disclosures

582 Background: Breast cancer, the most common cancer in sub-Saharan Africa (SSA), is characterized by poor survival compared with resource-rich regions. A variety of factors are responsible for this disparity and include late stage at presentation, limited diagnostic and therapeutic options, and potentially biologically more aggressive disease. The application of next generation sequencing to cancer specimens in resource-rich regions has identified new molecular mechanisms. However, such molecular testing has generally not been applied to tumors from SSA where the aggressive nature and younger age of women with breast cancer argues for the potential for novel pathogenic mechanisms. Here, we describe the somatic mutation profile of breast cancer in Uganda. Methods: We enrolled 100 consecutive women with a new diagnosis of invasive breast cancer at the Uganda Cancer Institute (UCI) in Kampala - the primary cancer center of Uganda and neighboring countries. Histopathologic classification was performed at the UCI and revaluated in a blinded fashion at the Fred Hutchinson Cancer Center (Seattle, WA). Demographic and clinical data were obtained. A biopsy specimen of the tumor tissue was obtained, snap frozen, processed using standard protocols to obtain DNA, and sequenced using the clinically-validated UW-OncoPlex assay, identifying all classes of variants and mutations. Results: We analyzed data from 100 women with a histologically-confirmed diagnosis of breast cancer between the ages of 35 and 65 - the vast majority of whom presented with either stage 3 or stage 4 (92%). All 100 tumor specimens were successfully sequenced, with, 96 (96%) demonstrating somatic mutations. The most commonly altered gene was TP53, with mutations in 65% of patients, with identified variant classes including truncations (18), missense (19), and copy loss (33). PIK3CA mutations were identified in 36% of patients, while copy gain or amplification were identified in MYC (50%), CCND1 (31%), FGFR1 (26%). EGFR (9%), and ERRB2 (24%). Nearly half of the women had either a mutation in BRCA1 (24%) or BRCA2 (24%); 6 (6%) of the tumors expressed mutations in both BRCA1 and BRCA2. Conclusions: We identified a diverse landscape of somatic mutations - the prevalence of BRCA1, BRCA2, and PIK3CA mutations are considerably higher than in other documented populations. A better understanding of the mutational profile can provide biological insights, inform prognosis, and serve as a predictive biomarker. As mutations in BRCA1/2 and PIK3CA can potentially be treated with targeted therapies (e.g. PARP inhibitor, PI3K inhibitor), such data can inform policymakers, allow for inclusion of these therapeutics in the formulary and in the WHO Model List of Essential Medicines, and reduce health disparities. Notably, all cases were successfully sequenced, with 96% of cases demonstrated somatic mutations, even without employing specific enrichment strategies commonly used in high-income countries.

Abstract Kaposi sarcoma-associated herpesvirus (KSHV) is the etiologic agent of Kaposi sarcoma (KS), which causes significant morbidity and mortality worldwide, particularly in people living with HIV (PLWH) and in sub-Saharan Africa where KSHV seroprevalence is high. Postulating that T-cells specific for KSHV and HIV would be attracted to KS tumors, we performed transcriptional profiling and T-cell receptor (TCR) repertoire analysis of tumor biopsies from 144 Ugandan adults with KS, 106 of whom were also living with HIV. We show that CD8 + T-cells and M2-polarized macrophages are the most common immune cells in KS tumors. The TCR repertoire of T-cells associated with KS tumors is shared across spatially and temporally distinct tumors from the same individual. Clusters of T-cells with predicted shared specificity for uncharacterized antigens, potentially encoded by KSHV or HIV, comprise ∼25% of the T-cells in KS tumors. Single-cell RNA-sequencing of blood from a subset of 9 adults captured 4,283 unique αβ TCRs carried in 14,698 putative KSHV- or HIV-specific T-cells, which carried an antigen-experienced effector phenotype. T-cells engineered to express a representative sample of these TCRs showed high-avidity recognition of KSHV- or HIV-encoded antigens. These results suggest that a polyspecific, high-avidity KSHV- and HIV-specific T-cell response, potentially inhibited by M2 macrophages, migrates to and localizes with KS tumors. Further analysis of KSHV- and HIV-specific T-cells in KS tumors will provide insight into the pathogenesis of KS and could guide the development of specific immune therapy based on adoptive transfer or vaccination. Author Summary In this work, we set out to examine Kaposi Sarcoma (KS) tumor tissue, as well as peripheral blood cells from individuals with KS, both living with and without HIV. Our goal was to identify T-cells that specifically recognize antigens encoded by Kaposi sarcoma-associated herpesvirus (KSHV) or HIV. By analyzing the T-cell repertoire in KS tumor biopsies from people in Uganda with different types of KS, we uncovered clusters of T-cells with previously unknown ability to recognize these viruses. Through single-cell sequencing of peripheral blood cells, we also observed that many of these T-cells had cell-killing properties. Notably, they often coexisted with a subset of macrophages with immunosuppressive properties, which we suspect may be suppressing the function of virus-targeting T-cells. Our findings suggest that additional studies of these virus-targeting T-cells and their interaction with immunosuppressive macrophages could significantly advance the development of effective therapeutics against KS.

Kaposi sarcoma is a frequently aggressive malignancy caused by Kaposi sarcoma herpesvirus. People with immunodeficiencies, including human immunodeficiency virus (HIV), are at increased risk for developing Kaposi sarcoma, but our understanding of the contributions of the cellular genome to Kaposi sarcoma pathogenesis remains limited. To determine if there are cellular genetic alterations in Kaposi sarcoma that might provide biological or therapeutic insights, we performed whole-exome sequencing on 78 Kaposi sarcoma tumors and matched normal control skin from 59 adults with Kaposi sarcoma (46 with HIV-associated Kaposi sarcoma and 13 with HIV-negative Kaposi sarcoma) receiving treatment at the Uganda Cancer Institute in Kampala, Uganda. We found a very low mutational burden in all but one specimen (median = 11 mutations), which is the lowest number of mutations among all 33 tumor types in The Cancer Genome Atlas. No recurrent mutations were seen, and the most commonly affected oncogenic pathway was RTK/RAS. Mutational signatures included defective DNA mismatch repair and smoking. There was no evidence suggesting that multiple tumors from the same patient originated from the same original clone. The number of genome copy alterations per genome was higher in tumors from those without HIV infection and in tumors from participants with advanced stage disease, suggesting that lesions that take longer to develop may accumulate more alterations, although the number of alterations remains low compared with other cancers. Implications: Our findings indicate that the pathogenesis of Kaposi sarcoma differs from other malignancies and that the primary driver of carcinogenesis is Kaposi sarcoma-associated herpesvirus infection and expression of viral oncogenes, rather than clonal oncogenic transformation.

Cancer is an increasing threat to the health of individuals in low- and middle-income countries (LMIC), with two-thirds of cancer cases projected to occur in these regions by 2020. With growing options for cancer treatment in LMIC, establishing an accurate pathologic diagnosis of cancer is an urgent global health priority but is not possible in many LMIC. The Fred Hutchinson Cancer Research Center has a longstanding collaboration with the Uganda Cancer Institute (UCI) located in Kampala, Uganda. In May 2015, state-of-the-art cancer treatment, research, and education center was opened on the UCI campus that includes outpatient adult and pediatric clinics, research clinic, training facilities, chemotherapy infusion rooms, and diagnostic laboratories including a histopathology lab. Extensive efforts were made to build the capacity to provide accurate histologic diagnoses for cancer at the new facility. These efforts included extensive planning during the construction of the new facility to accommodate a histopathology laboratory, training of histology technicians, developing resource-appropriate laboratory protocols, identifying sources for high-quality reagents, consumables and equipment support, and rigorous quality control. These activities have resulted in a functional laboratory capable of grossing, fixation, paraffin processing, embedding, sectioning, and basic staining (hematoxylin and eosin) of clinical specimens to render cancer diagnoses in Uganda. Future capabilities of the laboratory will seek to expand staining to include immunohistochemistry, and to build the infrastructure for robust telepathology with international colleagues.

Going Forward: Ongoing challenges include the low participation rate in the debriefing session. This challenge is partly due to stu-

In resource-limited settings, healthcare providers face unique structural barriers to antibiotic delivery. Process mapping (PM) is a low-cost, low-technology approach used to understand the antibiotic delivery process and systematically identify barriers to timely antibiotic initiation. In this paper, we will use a 5-phase PM framework to provide the readers with a guide to developing antibiotic delivery process maps, identifying barriers to antibiotic delivery, and prioritizing the order in which these barriers should be addressed. We will then use our experience at the Uganda Cancer Institute in Kampala, Uganda as a case study to describe how we used PM to identify barriers to antimicrobial delivery for patients with neutropenic fever. We will also provide information about how to use low-cost supplies and open-access software to develop and analyze the process map. By the end of the paper, the reader will have the necessary tools to develop and analyze their own antibiotic delivery process maps. This will allow the reader to systematically identify barriers to antimicrobial delivery and understand how to prioritize which barriers to address using targeted interventions.

Poster: ECR 2017 / C-0271 / Ultrasound guided fragmentation for shoulder calcific tendinitis without aspiration of calcium and steroid injection. by: M. Kawooya ; KAMPALA/UG

Abstract Introduction The association of mucosal shedding of human simplex virus (HSV)-2, Kaposi’s sarcoma-associated herpesvirus (KSHV) and cytomegalovirus (CMV) after antiretroviral therapy (ART) initiation in women-living-with-HIV (WLWH) with systemic inflammation is unclear. Methods We recruited 187 ART-naive adult WLWH in south-central Uganda. HSV-1, HSV-2, CMV, and Varicella Zoster Virus (VZV) in vaginal secretions and Kaposi’s sarcoma-associated herpesvirus (KSHV) in oral swabs were quantified by PCR. Plasma biomarkers of systemic inflammation were measured by ELISA or electrochemiluminescence before and after ART initiation (weeks 8, 12, and 24). Results Participants had a baseline median age of 28 years and CD4 count of 413 cells/μL. Viral shedding rates were similar for all tested viruses between baseline and post-ART timepoints in the overall study population. CMV shedding significantly increased from a baseline rate of 53% to 77% at week 4 visit (P-value = .016), and 73% at week 8 visit (P-value = .027) in participants with a baseline CD4 count ≤200 cells/µL. CRP, TNFα, and TNFR1 levels associated with CMV shedding at week 8, IL-6 associated with HSV-2 shedding at week 4, while sCD14 and TNFR1 associated with HSV-2 shedding at week 8. Also, CRP and IL-27 were associated with KSHV shedding at week 4 and week 8, respectively. Conclusions Although ART initiation was not associated with increased herpesvirus shedding overall, CMV shedding increased in women with advanced HIV-1. The association of mucosal shedding of CMV, HSV-2, and KSHV in post-ART timepoints with different baseline biomarkers of systemic inflammation suggest that distinct immunological functions are implicated in the control of their viral replication.