Search

Nathanael Sirili,1 Doreen Mloka,2 Lilian Mselle,3 Rodrick Kisenge,4 Erasto Mbugi,5 Dennis Russa,6 Obadia Nyongole,7 Stephen E Mshana,8 Rose Laisser,9 Kien Mteta,10 Levina Msuya,11 Eligius Lyamuya,12 Judith Martin-Holland,13 Gideon Kwesigabo,14 Ephata Kaaya15 1Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; 2Department of Pharmaceutical Microbiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; 3Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; 4Department of Pediatrics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; 5Department of Biochemistry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; 6Department of Anatomy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; 7Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; 8Department of Microbiology and Immunology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania; 9Archbishop Anthony Mayalla School of Nursing, Catholic University of Health and Allied Sciences, Mwanza, Tanzania; 10Department of Surgery, Kilimanjaro Christian Medical University College, Moshi, Tanzania; 11Department of Paediatrics and Child Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania; 12Department of Microbiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; 13Department of Physiological Nursing, University of San Francisco California, San Francisco, CA, USA; 14Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania; 15Department of Pathology, Kilimanjaro Christian Medical University College, Moshi, TanzaniaCorrespondence: Nathanael Sirili, Email drnsirili@gmail.comBackground: In 2012, the Muhimbili University of Health and Allied Sciences (MUHAS) embarked on structured competency-based curricula (CBC) for its programmes. Other health profession training institutions continued with their traditional way of teaching and thus causing variability in the competencies of the graduates. We aimed to analyze the experiences of different stakeholders on the implementation of CBC specifically on biomedical sciences by MUHAS to inform the development of harmonized competency-based curricula in three health professional training institutions in Tanzania.Methods: We adopted an exploratory case study to analyse the implementation of CBC in programmes of Medicine and Nursing involving MUHAS graduates, immediate supervisors at the employment sites, faculty, and continuing students at MUHAS. Kiswahili guides were used to conduct the in-depth interviews (IDIs) and focus group discussions (FGDs). Qualitative content analysis was adopted for analysis.Results: From the 38 IDIs and 15 FGDs, four categories of human resources teaching and learning environment; curriculum content; and support systems emerged. Human resources were attributed to the shortage of an adequate number of faculty and teaching skills variation. The curriculum content category was linked to the redundancy of courses or topics, poor sequencing of some topics or courses, and limited time for teaching some essential courses or topics. Training and practice area mismatch, accommodation to students, teaching space, and library were the sub-categories linked to teaching and learning environment. Lastly, support systems related to teaching methods and opportunities for improving teaching and learning were revealed.Conclusion: The findings of this study highlight the challenges and opportunities for the implementation of CBC. The solutions to the revealed challenges are beyond the training institutions’ capacity. The latter call for multi-stakeholder engagement including those from the public and private sectors in health, higher education and finance for common and sustainable solutions.Keywords: competency-based curricula, biomedical sciences, teaching pedagogy, health training institutions, harmonized training, Tanzania

Background Febrile Neutropenia (FN) caused by bacteria in cancer patients is associated with poor prognosis. The aim of this study was to determine the prevalence of FN and associated factors among cancer patients on chemotherapy at Ocean Road Cancer Institute (ORCI), Tanzania. Methods A cross-sectional study was conducted from June to September 2019. Study participants were conveniently recruited. A desk review of participants medical records was performed. Standard microbiological procedures used to culture and identify the bacterial isolates from the positive blood cultures of participants that presented with FN. Kirby-Bauer disc diffusion was used to perform the antibiotics susceptibility testing. SPSS version 20.0 and MS Excel were used in data entry and analysis. Chi-Square was used as a measure of association between various factors and neutropenia. P-Value less than 0.05 was considered statistically significant. Results A total 213 participants were enrolled. Of these 76.1% were female. Most of the participants came from the Coast region. Majority of participants presented with breast Cancer (36.2%) and GIT (20.2%). The prevalence of FN and bacteremia was 5.6% and 35.3% respectively. Staphylococcus Aureus (60%) and Coagulase-Negative Staphylococci (40%) were the main isolates. Of the 6 isolates tested most were resistant to Co-Trimoxazole 4/6 (66.7%) and Doxycycline 3/6 (50%). FN was positively associated with chemotherapy regimen (P = 0.0001), platelets count (P = 0.0001) and use of G-CSF (P = 0.0001). Conclusion The prevalence of FN among the cancer patients on chemotherapy in Tanzania

In many low- and middle-income countries, there seems to be a mismatch between graduate skills and healthcare industry requirements due to variability in curricula. With the current increased global demand for competent health profession graduates, harmonizing competency-based curricula (CBC) is necessary to address this mismatch. This paper describes how three health professions training universities in Tanzania and their two long-standing United States partners embarked on developing harmonized CBC for undergraduate medicine and nursing degrees. The main goal of the activity was to develop templates to harmonize curricula that would support graduates to acquire mandatory national Graduate Minimum Essential Competencies (GMEC) irrespective of the institution of their training. The paper describes the processes of engaging multiple institutions, the professions of medicine and nursing and various stakeholders to develop mandatory curricula generic competencies, creating milestones for assessing competencies, training faculty at each of the three partnering institutions in curriculum delivery and assessments, resulting in the adoption of the curricula by the University leadership at each institution. Ultimately the Tanzania Commission for Universities (TCU) a regulatory body required all schools of medicine and nursing in the country to adopt the curricula, thus creating a harmonized national standard for teaching medicine and nursing beginning October 2022.

Introduction: The emergence of coronavirus disease 2019 (COVID-19) pandemic has caused a shift in education training both in high, middle and low-income countries with an increased need of adapting the e-Learning system to encounter the lockdown situation and social distancing. This article provides an overview of the effects of COVID-19 pandemic on e-Learning and mitigations done among three medical universities in Tanzania that implements the Transforming Health Professional Education in Tanzania (THET) project. Methods: The study was conducted at Muhimbili University of Health and Allied Sciences (MUHAS), Kilimanjaro Christian Medical University College (KCMUCo), and the Catholic University of Health and Allied Sciences (CUHAS). Information on e-Learning use before and after the university closure and social distancing observation period, and the measures taken to enhance e-Learning was retrieved from Information Communication and Technology Departments (ICT) in each respective university. The e-Learning usability and the number of courses that adopted e-Learning was tracked and compared within the universities before, during and after the pandemic. The challenges encountered were noted as well as lessons learned from the process. Results: The institution's efforts and desire to continue with training led to accelerated utilization of e-Learning and digital platforms in medical education in Tanzania. In each institution, the effort led to more courses adopting e-Learning and online training. Scaling up of e-Learning was done in parallel with increased training to faculty members as well as students accessing the online system in both universities. Challenges such as poor internet connection, knowledge of both students and academic staff on proper utilization of e-Learning as well as access to devices outside the university environment even for those who used e-Learning prior to the closure were noted. Conclusion: The implementation and use of e-Learning is possible in medical universities in Tanzania. It is high time for all medical universities to increase investment on e-Learning as one of the elements of the adopted competency-based curriculum and emergency preparedness for training institutions during pandemics which may necessitate closure of institutions. The efficacy of e-Learning on the quality of medical education to produce desired outcomes and exploring barriers for e-Learning implementation calls for further research.

International audience; Background: Global HIV-1 genetic diversity and evolution form a major challenge to treatment and prevention efforts. An increasing number of distinct HIV-1 recombinants have been identified worldwide, but their contribution to the global epidemic is unknown. We aimed to estimate the global and regional distribution of HIV-1 recombinant forms during 1990-2015.Methods: We assembled a global HIV-1 molecular epidemiology database through a systematic literature review and a global survey. We searched the PubMed, Embase (Ovid), CINAHL (Ebscohost), and Global Health (Ovid) databases for HIV-1 subtyping studies published from Jan 1, 1990, to Dec 31, 2015. Unpublished original HIV-1 subtyping data were collected through a survey among experts in the field who were members of the WHO-UNAIDS Network for HIV Isolation and Characterisation. We included prevalence studies with HIV-1 subtyping data collected during 1990-2015. Countries were grouped into 14 regions and analyses were done for four time periods (1990-99, 2000-04, 2005-09, and 2010-15). The distribution of circulating recombinant forms (CRFs) and unique recombinant forms (URFs) in individual countries was weighted according to the UNAIDS estimates of the number of people living with HIV in each country to generate regional and global estimates of numbers and proportions of HIV-1 recombinants in each time period. The systematic review is registered with PROSPERO, CRD42017067164.Findings: Our global data collection yielded an HIV-1 molecular epidemiology database of 383 519 samples from 116 countries in 1990-2015. We found that the proportion of recombinants increased over time, both globally and in most regions, reaching 22·8% (7 978 517 of 34 921 639) of global HIV-1 infections in 2010-15. Both the proportion and the number of distinct CRFs detected increased over time to 16·7% and 57 CRFs in 2010-15. The global and regional distribution of HIV-1 recombinants was diverse and evolved over time, and we found large regional variation in the numbers (0-44 CRFs), types (58 distinct CRFs), and proportions (0-80·5%) of HIV-1 recombinants. Globally, CRF02_AG was the most prevalent recombinant, accounting for 33·9% (2 701 364 of 7 978 517) of all recombinant infections in 2010-15. URFs accounted for 26·7% (2 131 450 of 7 978 517), CRF01_AE for 23·0% (1 838 433), and other CRFs for 16·4% (1 307 270) of all recombinant infections in 2010-15. Although other CRFs accounted for small proportions of infections globally (

Background: The WHO estimates that approximately 600 million people fall ill after consumption of contaminated food and over 420 000 die every year, resulting in loss of 33 million healthy life years. Hand hygiene is considered by the WHO to be the most effective preventive measure for infectious diseases including food borne diseases.Methods: A laboratory-based study involving convenient sampling of common brands alcohol-based hand sanitizers (ABHS) from retail community pharmacies and local supermarkets was conducted in Ilala District, Dar es salaam, Tanzania. The study was conducted, between December 2018 to January 2019. A modified protocol of The European Norm (EN) 1500 was used for in vivo testing of sampled ABHs. Efficacy was evaluated using standard strain of Escherichia coli. A total of 26 healthy volunteers were used for hand sanitization. The percentage of bioburden/microbial reduction was assessed at baseline and after treatment, and the log reduction factor calculated.Results: A total of 10 gel ABHS were purchased and assayed for antibacterial efficacy. Majority (70%) of ABHS were imported products and contained ethanol as the sole active ingredient. About 60% of them did not correctly indicate the label disclosure information on concentration of active ingredients. Only one product was efficacious against E. coli with log reduction of 3.75; while majority (70%) of the samples had poor bacterial efficacy with log reduction ranging from 0.140 -0.664.Conclusions: Most of ABHS gel products available in the Dar es Salaam market were not efficacious as per FDA and EN 1500 guidelines. Post market surveillance is recommended of the circulating ABH to safe guard consumers. Keywords: Hand sanitizers, efficacy, E. coli, EN 1500.

Background The worldwide emergence of antibiotic-resistant bacteria threatens to overshadow the dramatic advances in medical sciences since the discovery of antibiotics. Antibiotic resistance has rendered some antibiotics obsolete, creating a reliance on synthetic drugs. In some instances, bacteria can be resistant to all antibiotics. The problem of antibiotic resistance is eminent in resource-limited countries like Tanzania, where systematic surveillance and routine susceptibility tests are rarely conducted. Therefore, this study aimed to investigate the magnitude of beta-lactamase-producing Gram-positive pathogens and Enterobacteriaceae with extended-spectrum beta-lactamase (ESBL) in Dar es Salaam, Tanzania. Methodology This multi-site cross-sectional study involved three private hospitals in Dar es Salaam, Tanzania. The study was conducted between July and September 2008. Bacterial isolates were collected, identified, and subjected to antibiotic-sensitivity testing against cephalosporins, including ceftriaxone, cefuroxime and cefotaxime, and clavulanic acid, which are antibiotics readily available on the Tanzanian market at the time of the study. The microdilution method was employed to determine beta-lactamase and ESBL production per the Clinical Laboratory and Standards Institute (CLSI) protocol. Cephalosporins, including ceftriaxone, cefuroxime and cefotaxime, the beta-lactamase inhibitor, and clavulanic acid, were serially diluted with concentrations ranging from 0.011 mg/ml to 200 mg/ml. Each of these antibiotics was subjected to sensitivity tests by determining the minimum inhibitory concentrations (MIC) of the clinical isolates of bacteria using a 96-well microdilution plate. Five microliters of bacterial suspension were inoculated into each well-containing 120µl of sterile Mueller-Hinton broth before incubation overnight. Results A total of 111 bacterial isolates were tested. Of the 111 tested bacterial isolates, 85 (76.6%) and 26 (23.4%) were Gram-negative and Gram-positive bacteria, respectively. Fifty-six clinical isolates (50.4%) were

Cockroaches are common pests in homes and hospitals. They cause allergic reactions in some individuals and are potential vectors for various infectious pathogens. The study investigated the extent to which hospital cockroaches act as vectors and reservoirs of medically important fungal pathogens on their external surfaces.Cockroaches were captured from the selected hospital locations including the burn unit, adult surgical wards, pediatric oncology wards, intern hostel kitchen, and the central kitchen of a national referral teaching hospital in Tanzania. Normal saline washings from the external surface of cockroaches were cultured on standard mycological media to facilitate isolation and identification of medically important molds and yeasts. The susceptibility ofA total of 69 cockroaches were captured from various hospital sites between February and April 2017. All cockroaches captured were shown to carry medically important fungi. A total of 956 medically important fungi were isolated; 554 (57.9%) were of Cockroaches from this hospital may act as reservoirs of medically important opportunistic fungi exhibiting resistance to fluconazole.

Introduction: Immune reconstitution inflammatory syndrome (IRIS) is referred to as the flare up of an underlying, previously undiagnosed infection or the worsening of a previously treated infection soon after antiretroviral therapy (ART) is started. Information about the prevalence and associated risk factors for IRIS in resource-constrained countries like Tanzania where access to ART is increasing is scarce. Therefore, this study was conducted to determine the prevalence and risk factors associated with IRIS among patients attending care and treatment clinic at Muhimbili National Hospital (CTC-MNH). Methods: A retrospective cohort study was conducted in patients receiving highly active antiretroviral therapy (HAART) who attended CTC-MNH between July 2016 and June 2018. Mann Whitney test was used to compare median CD4+ cells count and viral load at baseline and after 6 months of treatment. Associated factors were analysed using multi-logistic regression. Statistics were done using GraphPad Prism 7 software and a p-value < 0.05 was considered statistically significant. Results: Of 318 patients, 8.5% encountered IRIS. Compared to baseline readings, there were significant increases in CD4+ cells (P < 0.0001) and decrease in viral load count (P < 0.0001). Patients who did not adhere to HAART were more likely to develop IRIS [Adjusted Odds Ratio (AOR) = 4.2, 95% CI; 1.14-15.60, P = 0.03]. Conclusion: This study found relatively low prevalence of IRIS as compared to those reported elsewhere. Moreover, poor adherence to HAART was found to be a risk factor for IRIS.

BackgroundCockroaches are common pests in homes and hospitals. They are known to cause allergic reactions in certain individuals and have found to be potential vectors for various bacterial and parasitic pathogens. This study assessed the potential of hospital cockroaches to act as vectors of medically important fungal pathogens on their external surfaces.MethodsCockroaches were captured from the main Intensive care unit (ICU), burn unit, adult surgical wards , pediatric oncology wards, intern hostel kitchen and the central kitchen of a national referral teaching hospital in Tanzania. Normal saline washings from the external surface of cockroaches were cultured on standard mycological media to facilitate isolation and identification of medically important molds and yeasts. Susceptibility of Candida sp isolates to fluconazole was tested using the CLSI M27-A3 microdilution method.ResultsAt total of 72 cockroaches were captured from various sites of the hospital between February and March 2015. All cockroaches captured were shown to carry medically importance fungi. A total of 956 medically important fungi were isolated, 57.9 % were Candida sp., 23.2%, Aspergillus sp. , 3.1% Cladosporium sp., 1.8% Rhizopus sp., 1.2 % Geotrichum sp., 0.9 % Pencillum sp. , 0.7% Alternaria sp, 0.6 % Fusarium sp , 0.3% Mucor sp and 10.1% others. Aspergillus fumigatus (50.0%) was the most commonly isolated followed by Aspergillus niger ( 15.8%) among the Aspergillus isolates.Over 16.3 % of the Candida isolates not intrinsically resistant to fluconazole showed resistance to this drug.mResistance was most frequently found in Candidapseudotropicalis (23.8%) and Candida glabarata (20.0%) and least in isolates of Candida albicans ( 6.3%). ConclusionThe external surfaces of cockroaches from this hospital may act as reservoirs of medically important opportunistic fungi exhibiting resistance to fluconazole.

Background Prescription of antibiotics based on microbiological investigations is a commendable rational use of antibiotics and help in fighting the spread of resistance. Although shortage of microbiology laboratory is indicated to impair this practice but prescription without microbiological investigation has been reported even in settings with laboratory facilities. Methods Semi structured key informant interviews with 31 prescribing medical doctors in Dar es Salaam, Tanzania were conducted from January to June 2019. The purpose of the interviews was to obtain the insight into the prescriptions of antibiotics without microbiological investigations especially in hospitals with laboratory facilities. Results Majority of participants (26/31) were ready to prescribe antibiotics without microbiological investigations. In addition, a total of four major themes were identified as the basis for this practice; i) clinical condition of the patient ii) past experience with the clinical condition and/or patient iii) an intention to prevent the spread of infection and iv) patient’s history and physical examination were adequate to establish the management plan. Conclusion In recognition of the urgent need to improve antibiotic use in hospitals, this study highlights the need to implement hospital Antibiotic Stewardship Programs in Dar es Salaam, Tanzania.

Introduction Antiretroviral therapy (ART) has been successfully introduced in low-middle income countries. However an increasing rate of ART failure with resistant virus is reported. We therefore described the pattern of drug resistance mutations at antiretroviral treatment (ART) failure in a real-life Tanzanian setting using the remote genotyping procedure and thereafter predicted future treatment options using rule-based algorithm and the EuResist bioinformatics predictive engine. According to national guidelines, the default first-line regimen is tenofovir + lamivudine + efavirenz, but variations including nevirapine, stavudine or emtricitabine can be considered. If failure on first-line ART occurs, a combination of two nucleoside reverse transcriptase inhibitors (NRTIs) and boosted lopinavir or atazanavir is recommended. Materials and methods Plasma was obtained from subjects with first (n = 174) or second-line (n = 99) treatment failure, as defined by clinical or immunological criteria, as well as from a control group of ART naive subjects (n = 17) in Dar es Salaam, Tanzania. Amplification of the pol region was performed locally and the amplified DNA fragment was sent to Sweden for sequencing (split genotyping procedure). The therapeutic options after failure were assessed by the genotypic sensitivity score and the EuResist predictive engine. Viral load was quantified in a subset of subjects with second-line failure (n = 52). Results The HIV-1 pol region was successfully amplified from 55/174 (32%) and 28/99 (28%) subjects with first- or second-line failure, respectively, and 14/17 (82%) ART-naive individuals. HIV-1 pol sequence was obtained in 82 of these 97 cases (84.5%). Undetectable or very low (

Muhimbili University of Health and Allied Sciences (MUHAS) strives to instill in its graduates skills and competencies appropriate to serving the Tanzanian population well. MUHAS leadership, working in collaboration with educators from the University of California San Francisco (UCSF), selected and trained an interdisciplinary group of faculty members to promote effective teaching. We describe the development of this group of faculty change agents – now known as the Health Professions Educators Group (HPEG). The HPEG invigorated the education environment at MUHAS by: engaging many colleagues in special training events that introduced new methods for teaching and assessment; encouraging innovation; and developing strong mentoring relationships. HPEG members piloted courses in education to prepare all postgraduate students as peer educators, teaching assistants, and as candidates for faculty future appointments. Creation of a ‘teaching commons’ reinforces the new focus on innovative teaching as faculty members share experiences and gain recognition for their contributions to quality education.

Well-educated and competent health professionals influence the health system in which they work to improve health outcomes, through clinical care and community interventions, and by raising standards of practice and supervision. To prepare these individuals, training institutions must ensure that their faculty members, who design and deliver education, are effective teachers. We describe the experience of the Muhimbili University of Health and Allied Sciences (MUHAS) in encouraging improvements in the teaching capacity of its faculty and postgraduate students triggered by a major institutional transition to competency-based education. We employed a multi-stage process that started by identifying the teaching and learning needs and challenges of MUHAS students and faculty. Collaborating with the University of California San Francisco (UCSF), MUHAS responded to these needs by introducing faculty to competency-based curricula and later to strategies for long term continuing improvement. We demonstrate that teaching faculty members are keen for local institutional support to enable them to enhance their skills as educators, and that they have been able to sustain a program of faculty development for their peers.

HIV-1 diversity, frequency of recombinants, and dual infection were determined in two populations with different HIV risk behavior. A high-risk cohort of 600 female bar workers and a normal-risk population of 1,108 antenatal clinic attendees and blood donors were recruited. Behavioral data were assessed and blood for HIV- 1 diagnosis and genotyping was sampled. HIV-1 subtypes were defined through the multiregion hybridization assay (MHA(acd)). HIV-1 prevalence differed significantly among the two populations. The prevalence was 67.8% in the population of bar workers and 17% in the normal-risk population (antenatal care attendees and blood donors). Within the normal-risk population the HIV-1 prevalence was lowest in the group of volunteer blood donors. The frequency of HIV-1 infection in women was 1.7 times higher than in men. The overall subtype distribution was A (8.5%), C (40.8%), D (3.8%), AC (25.4%), AD (5.4%), CD (8.8%), and ACD (7.3%). In the high-risk population there was a higher percentage of HIV-1 recombinant strains (54% vs. 40%, p0.05) and a higher frequency of dual infections (19% vs. 9%, p0.02) compared to the normal-risk population. High-risk populations may play an important role in the evolution of HIV, as they can provide an opportunity for the virus to coinfect, recombine, and adapt to the host-specific genetic background.

BACKGROUND: Global genetic diversity of HIV-1 is a major challenge to the development of HIV vaccines. We aimed to estimate the regional and global distribution of HIV-1 subtypes and recombinants during 1990-2015. METHODS: We searched PubMed, EMBASE (Ovid), CINAHL (Ebscohost), and Global Health (Ovid) for HIV-1 subtyping studies published between Jan 1, 1990, and Dec 31, 2015. We collected additional unpublished HIV-1 subtyping data through a global survey. We included prevalence studies with HIV-1 subtyping data collected during 1990-2015. We grouped countries into 14 regions and analysed data for four time periods (1990-99, 2000-04, 2005-09, and 2010-15). The distribution of HIV-1 subtypes, circulating recombinant forms (CRFs), and unique recombinant forms (URFs) in individual countries was weighted according to the UNAIDS estimates of the number of people living with HIV (PLHIV) in each country to generate regional and global estimates of HIV-1 diversity in each time period. The primary outcome was the number of samples designated as HIV-1 subtypes A, B, C, D, F, G, H, J, K, CRFs, and URFs. The systematic review is registered with PROSPERO, number CRD42017067164. FINDINGS: This systematic review and global survey yielded 2203 datasets with 383 519 samples from 116 countries in 1990-2015. Globally, subtype C accounted for 46·6% (16 280 897/34 921 639 of PLHIV) of all HIV-1 infections in 2010-15. Subtype B was responsible for 12·1% (4 235 299/34 921 639) of infections, followed by subtype A (10·3%; 3 587 003/34 921 639), CRF02_AG (7·7%; 2 705 110/34 921 639), CRF01_AE (5·3%; 1 840 982/34 921 639), subtype G (4·6%; 1 591 276/34 921 639), and subtype D (2·7%; 926 255/34 921 639). Subtypes F, H, J, and K combined accounted for 0·9% (311 332/34 921 639) of infections. Other CRFs accounted for 3·7% (1 309 082/34 921 639), bringing the proportion of all CRFs to 16·7% (5 844 113/34 921 639). URFs constituted 6·1% (2 134 405/34 921 639), resulting in recombinants accounting for 22·8% (7 978 517/34 921 639) of all global HIV-1 infections. The distribution of HIV-1 subtypes and recombinants changed over time in countries, regions, and globally. At a global level during 2005-15, subtype B increased, subtypes A and D were stable, and subtypes C and G and CRF02_AG decreased. CRF01_AE, other CRFs, and URFs increased, leading to a consistent increase in the global proportion of recombinants over time. INTERPRETATION: Global and regional HIV diversity is complex and evolving, and is a major challenge to HIV vaccine development. Surveillance of the global molecular epidemiology of HIV-1 remains crucial for the design, testing, and implementation of HIV vaccines. FUNDING: None. ispartof: LANCET INFECTIOUS DISEASES vol:19 issue:2 pages:143-155 ispartof: location:United States status: published