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Global health partnerships (GHPs) can be the cornerstone for advancing research and public health. The steps to build a global research partnership focus on sharing a common research agenda, identifying key partners in the community, and establishing goals and expectations for partnerships. Moreover, upholding important values, such as communication, trust, and transparency is essential for building successful partnerships. Ethical dilemmas can propose challenges to researchers in global health. These challenges can be overcome by creating a shared vision for a research agenda, maintaining communication, and providing bidirectional training.

Background The field of global health has grown with multiple different public and private stakeholders engaging in the effort to improve health outcomes for underserved populations around the world. There is, however, only limited published guidance on how to promote successful partnerships between academia and the biopharmaceutical industry. Objective This analysis will provide a framework for developing successful partnerships around five central principles. This framework will then be applied to two representative pharmacy collaboration case studies focused on training and donations. Framework description and case study findings Within the Academic Model Providing Access to Healthcare (AMPATH), successful collaborations between the biopharmaceutical industry philanthropic entities and academic partners have consistently prioritized 1) contextualization, 2) collaboration, 3) local priorities, 4) institutional commitment, and 5) integration. In the first case study, the application of this framework to clinical pharmacy training activities sponsored by Celgene and implemented by the Purdue Kenya Partnership has helped the program transition from an entirely donor dependent training program to a revenue generating, locally administered program which is now recognized and accredited by the Kenyan government. In the second case study, medication donations from Eli Lilly and Company have been converted from a traditional donation program in one Kenyan health facility to a replicable and sustainable supply chain model which has been expanded to more than 70 public sector facilities across western Kenya. Conclusion Adherence to the five core principles of the proposed framework can help guide partnerships between academic institutions and the biopharmaceutical industry to advance healthcare services for underserved populations around the world. As large-scale government-based development agencies continue to primarily focus on specific disease states, biopharmaceutical industry-based collaborations can help initiate activities in underfunded therapeutic areas such as non-communicable diseases.

Many barriers for patient access to medications for opioid use disorder (MOUD) exist in current care practices. Previous literature has evaluated subsets of pharmacists, patients, and prescribers; however, few have collectively evaluated the perspectives of all 3 groups.The objective of the study was to identify barriers, facilitators, and opportunities for improvement in Indiana community pharmacy MOUD care practices from the perspectives of peer recovery coaches, community pharmacists, and prescribers to optimize patient care.Individual semistructured interviews were conducted with each participant. Interviews explored stakeholders' perspectives on their current role in MOUD care practices and how current pharmacy practices could be improved. Data were analyzed using preconceived deductive and iterative inductive codes. The first author analyzed all transcripts, of which 3 were also analyzed separately by the last author to confirm consistent utilization of codes. All transcripts were coded once, followed by a second coding to ensure inductive codes were thoroughly applied.Ten peer recovery coaches, 10 pharmacists, and 6 prescribers were included. Interviews identified barriers, facilitators, and opportunities for improvement in current MOUD care practices. Stigma was a major barrier identified by all groups. Other barriers identified included limited patient engagement at pharmacies and lack of access to patient-specific health information in community pharmacy settings. Pharmacists also identified additional barriers including Drug Enforcement Administration regulations and difficulties balancing patient care with external factors like insurance and legal policies. Positive prescriber/pharmacist relationships were identified as a facilitator of care. Opportunities for improvement included having community MOUD resource information available at pharmacies, further education on MOUD for pharmacists, and increased collaboration between pharmacists and prescribers.Many barriers exist in current MOUD care practices. Additional pharmacist MOUD education and intentional collaboration between pharmacists, peer recovery coaches, and prescribers would facilitate better care and leverage the accessibility of pharmacists within their communities.

In March 2020, the SARS-CoV-2 (COVID-19) pandemic disrupted education nationwide. To safely deliver in-person classes, Purdue University contracted One-to-One Health, creating the Protect Purdue Health Center (PPHC). The PPHC was a central location for information, testing, and case management for Purdue students, staff, faculty and their dependents. Contact tracing is a proven public health measure that has been utilized to control the spread of infectious diseases by identifying and isolating potential active cases. The communicative nature of contact tracing, along with its need for clinical decision-making skills makes the student pharmacist an ideal candidate for aiding in this pandemic response. In an effort to support the PPHC in navigating the necessary protocols to keep Purdue open, operating, and safe, the College of Pharmacy formed Experiences in Public Health, a service-learning course which enrolled ten student pharmacists. The students served as contact tracers, participated in group discussions surrounding emerging COVID-19 health information, and reflected on their experiences as members of the community. As contact tracers, they aimed to decrease secondary spread of COVID-19 by identifying and following-up with close contacts of lab-confirmed cases, educating on quarantine/isolation protocols, and scheduling tests for those with symptoms or exposure history. Active participation in a pandemic response is a meaningful opportunity for professional growth in patient-centered care and communication. Students actively improved upon skills taught in the Doctor of Pharmacy program such as motivational interviewing, active listening, and open communication to fulfill their role as contact tracers. Additionally, the students gained proficiency in patient education and clinical decision-making, and through class discussions, enhanced their abilities to answer COVID-19-related questions with scientific resources. Through volunteering at the PPHC and engagement in peer-led topic discussions, the Experiences In Public Health service-learning course allowed student pharmacists to apply professional skills to become an active force in mitigating the spread of COVID-19. This service-learning opportunity provided several key takeaways. Student pharmacists who participated in this initiative attest that they are more comfortable providing patient care, better able to handle a rapidly developing clinical situation, and further prepared for their future careers in various fields of pharmacy practice.

Background Elevated blood pressure (BP) is the leading risk of death globally, and its burden continues to rise, disproportionately so in low- and middle-income countries. Non-adherence to antihypertensive medications is a major cause of uncontrolled hypertension, leading to cardiovascular morbidity and mortality. Ensuring consistent medication access and possession is crucial in addressing non-adherence. Community-based medication delivery is a strategy that can lead to improvement in medication possession, medication adherence, and subsequently BP reduction. Purpose Our program in western Kenya piloted a community medication delivery program for hypertensive patients, aiming to remove structural barriers to medication possession and ensuring consistent access to antihypertensive medications. Here, we reviewed secondary clinical data to evaluate the impact of this program on BP reduction and medication adherence. Methods We conducted a retrospective analysis using clinical records of hypertensive patients who participated in the medication delivery program. Between September 2019 and March 2020, patients who received care from our community-based chronic disease management program also received anti-hypertensive medications delivered to them at their doorstep. We compared differences in self-reported medication adherence and BP reduction between patients who got medication deliveries versus those who did not. Mixed effect models, controlling for baseline measurements, age, gender, and health insurance status were used to analyze outcomes of interest. Results A total of 124 patient records (80.6% female) were reviewed. Baseline systolic blood pressure (SBP) was 155.7 mmHg and baseline self-reported adherence per the Voils DOSE-Nonadherence measure was 2.7, with 1 being perfect adherence and 5 representing poor adherence. 48.4% of patients received at least 1 successful medication delivery. Patients who did not receive any medication deliveries had an SBP increase of 1.5 mmHg relative to baseline, whereas patients who received 1 medication delivery had an SBP reduction of 8 mmHg and patients who received 2 or more medication deliveries had an SBP reduction of 15.2 mmHg (Figure 1). Similarly, change in self-reported medication adherence was poorer in patients who received no medication deliveries (+0.1) versus those who received one medication delivery (−0.5) or 2 or more deliveries (−0.7). Mixed-effect model estimates demonstrated that relative to patients who did not receive any medication deliveries, mean SBP reduction was significantly greater among individuals who did receive medication deliveries (Table 1). Conclusions A community medication delivery program in western Kenya led to improved medication adherence and systolic blood pressure reduction. This is a promising strategy to improve hypertension outcomes for patients with uncontrolled hypertension by removing structural barriers to medication possession. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Purdue University Gloria Franke Pharmacy Practice Advancement Grant Change in blood pressure and adherenceMixed-effect model estimates

Field tests to detect substandard antibiotics are sorely needed in many low and middle-income countries (LMICs). We created a field screening test for amoxicillin capsules and ampicillin tablets based on USP method . To measure the amount of antibiotic, the user dissolves the contents of the capsule in water, carries out a simple chemical degradation, and adds drops of the sample to a paper test card. The test card performs a titration and displays a series of blue dots for visual comparison to standard images. Pharmaceutical samples were collected in western Kenya and analyzed using a blinded methodology to validate the test card's quantitative performance against HPLC assay. Within the quantification range of the test card, the absolute assay error for dosage forms was 4.4% for amoxicillin and 5.3% for ampicillin, and inter-operator precision was 2%. Users correctly categorized 94% of amoxicillin (n = 84) and 88% of ampicillin (n = 56) samples as either containing less than or greater than 90% of the expected amount of antibiotic, which is the lower regulatory limit. The test card detected several lot numbers of a substandard amoxicillin product, confirmed by HPLC analysis to contain only 40–60% of the stated amoxicillin content. IR, PXRD, and gravimetric analysis revealed that talc made up the remainder of the adulterated medications.

In Western Kenya, the burden of chronic wounds and lymphedema has a significant impact on functionality and quality of life. Major barriers to provision of care include availability, affordability, and accessibility of bandages. At the Academic Model Providing Access to Healthcare, dermatologists and pharmacists collaborated to develop a 2-component compression bandage modeled after the Unna boot, using locally available materials, that is distributed through a revolving fund pharmacy network. In partnership with nursing, use of these bandages at a national referral hospital and a few county facilities has increased, but increasing utilization to an expanded catchment area is needed.

IntroductionCompression therapy is well-established standard of care for chronic leg ulcers from venous disease and lymphedema. Chronic leg ulcers and lymphedema have a significant impact on quality of life, driven by pain, foul odor, and restricted mobility. Provision of layered compression therapy in resource-limited settings, as in Western Kenya and other regions of sub-Saharan Africa, is a major challenge due to several barriers: availability, affordability, and access to healthcare facilities. When wound care providers from an Academic Model Providing Access to Healthcare (AMPATH) health center in Western Kenya noted that a donated, finite supply of two-component compression bandages was helping to heal chronic leg ulcers, they began to explore the potential of finding a local, sustainable solution. Dermatology and pharmacy teams from AMPATH collaborated with health center providers to address this need.MethodsFollowing a literature review and examination of ingredients in prepackaged brand-name kits, essential components were identified: elastic crepe, gauze, and zinc oxide paste. All of these materials are locally available and routinely used for wound care. Two-component compression bandages were made by applying zinc oxide to dry gauze for the inner layer and using elastic crepe as the outer layer. Feedback from wound clinic providers was utilized to optimize the compression bandages for ease of use.ResultsAdjustments to assembly of the paste bandage included use of zinc oxide paste instead of zinc oxide ointment for easier gauze impregnation and cutting the inner layer gauze in half lengthwise to facilitate easier bandaging of the leg, such that there were two rolls of zinc-impregnated gauze each measuring 5inches×2m. Adjustments to use of the compression bandage have included increasing the frequency of bandage changes from 7 to 3days during the rainy seasons, when it is difficult to keep the bandage dry. Continuous local acquisition of all components led to lower price quotes for bulk materials, driving down the production cost and enabling a cost to the patient of 200KSh (2USD) per two-component compression bandage kit. Wound care providers have provided anecdotal reports of healed chronic leg ulcers (from venous stasis, trauma), improved lymphedema, and patient tolerance of compression.ConclusionsLow-cost locally sourced two-component compression bandages have been developed for use in Western Kenya. Their use has been initiated at an AMPATH health center and is poised to meet the need for affordable compression therapy options in Western Kenya. Studies evaluating their efficacy in chronic leg ulcers and Kaposi sarcoma lymphedema are ongoing. Future work should address adaptation of compression bandages for optimal use in Western Kenya and evaluate reproducibility of these bandages in similar settings, as well as consider home- or community-based care delivery models to mitigate transportation costs associated with accessing healthcare facilities.

Alexander R. Mills received his Doctor of Pharmacy degree in May 2017 and has completed a PGY-1 community-based pharmacy practice resident with Walgreen Company and Purdue University College of Pharmacy. During his time at Purdue, he was heavily involved with Purdue’s chapter of The American Red Cross Club, serving as the president and coordinator of community outreach programs. Upon completing his PGY-1, he will continue to pursue his aspirations to care for the medically underserved while currently completing a PGY-2 residency specializing in ambulatory care and academia at the University of Mississippi in Jackson.

Background: HIV-infected patients are at an increased risk of developing venous thromboembolism (VTE), and minimal data are available to describe the need for extended treatment. Objective: To evaluate the frequency of and determine predictive risk factors for extended anticoagulation of VTE in HIV-infected patients in rural, western Kenya. Methods: A retrospective chart review was conducted at the Anticoagulation Monitoring Service affiliated with Moi Teaching and Referral Hospital and the Academic Model Providing Access to Healthcare. Data were collected on patients who were HIV-infected and receiving anticoagulation for lower-limb deep vein thrombosis. The need for extended anticoagulation, defined as receiving ≥7 months of warfarin therapy, was established based on patient symptoms or Doppler ultrasound–confirmed diagnosis. Evaluation of the secondary outcomes utilized a univariate analysis to identify risk factors associated with extended anticoagulation. Results: A total of 71 patients were included in the analysis; 27 patients (38%) required extended anticoagulation. The univariate analysis showed a statistically significant association between the need for extended anticoagulation and achieving a therapeutic international normalized ratio within 21 days in both the unadjusted and adjusted analysis. Patients with a history of opportunistic infections required an extended duration of anticoagulation in the adjusted analysis: odds ratio = 3.42; 95% CI = 1.04-11.32; P = 0.04. Conclusions: This study shows that there may be a need for increased duration of anticoagulation in HIV-infected patients, with a need to address the issue of long-term management. Guideline recommendations are needed to address the complexity of treatment issues in this population.

Infective endocarditis (IE) is a rare, life-threatening disease with a mortality rate of 25% and significant debilitating morbidities. Although much has been reported on contemporary IE in high-income countries, conclusions on the state of IE in low- and middle-income countries (LMICs) are based on studies conducted before the year 2000. Furthermore, unique challenges in the diagnosis and management of IE persist in LMICs. This article reviews IE studies conducted in LMICs documenting clinical experiences from the year 2000 to 2016. Presented are the causes of IE, management of patients with IE, and prevailing challenges in diagnosis and treatment of IE in LMICs.

The collaboration between Purdue University College of Pharmacy and the USAID—AMPATH partnership gives student pharmacists the opportunity to complete an internal medicine experience in Eldoret, Kenya. Student pharmacists act as the pharmaceutical resource on multidisciplinary teams at Moi Teaching and Referral Hospital (MTRH). Adding to the experience, the sewing initiative is one of numerous service-learning opportunities that have evolved in this resource-constrained setting. The initiative takes place at the Sally Test Pediatric Center, a place for children to learn and play while in the hospital. The program teaches sewing, an income-generating skill, to parents of hospitalized children. Students assist with sewing lessons, provide health care education for parents, and care for children while their parents learn a skill that can potentially provide a sustainable income. This program aids student pharmacists in balancing service and learning while working in a resource-constrained setting. This article describes the implementation of the sewing initiative, the goals of the project, the participants and students, and the initial impact. Karolina M. Grzesiak; Craig A. Vargo, PharmD, BCOP; Ellen M. Schellhase, PharmD; Monica L. Miller, PharmD, MS; Rakhi Karwa, PharmD, BCPS; Sonak D. Pastakia, PharmD, MPh, BCPS; and Beatrice Jakait, BPharm, PharmD

Introduction Targeted spontaneous reporting (TSR) is a pharmacovigilance method that can enhance reporting of adverse drug reactions related to antiretroviral therapy (ART). Minimal data exist on the needs or capacity of facilities to conduct TSR. Objectives Using data from the International epidemiologic Databases to Evaluate AIDS (IeDEA) Consortium, the present study had two objectives: (1) to develop a list of facility characteristics that could constitute key assets in the conduct of TSR; (2) to use this list as a starting point to describe the existing capacity of IeDEA-participating facilities to conduct pharmacovigilance through TSR. Methods We generated our facility characteristics list using an iterative approach, through a review of relevant World Health Organization (WHO) and Uppsala Monitoring Centre documents focused on pharmacovigilance activities related to HIV and ART and consultation with expert stakeholders. IeDEA facility data were drawn from a 2009/2010 IeDEA site assessment that included reported characteristics of adult and pediatric HIV care programs, including outreach, staffing, laboratory capacity, adverse event monitoring, and non-HIV care. Results A total of 137 facilities were included: East Africa (43); Asia–Pacific (28); West Africa (21); Southern Africa (19); Central Africa (12); Caribbean, Central, and South America (7); and North America (7). Key facility characteristics were grouped as follows: outcome ascertainment and follow-up; laboratory monitoring; documentation—sources and management of data; and human resources. Facility characteristics ranged by facility and region. The majority of facilities reported that patients were assigned a unique identification number (n = 114; 83.2 %) and most sites recorded adverse drug reactions (n = 101; 73.7 %), while 82 facilities (59.9 %) reported having an electronic database on site. Conclusion We found minimal information is available about facility characteristics that may contribute to pharmacovigilance activities. Our findings, therefore, are a first step that can potentially assist implementers and facility staff to identify opportunities and leverage their existing capacities to incorporate TSR into their routine clinical programs.

Objective. To describe a novel training model used to create a sustainable public health-focused pharmacy residency based in Kenya and to describe the outcomes of this training program on underserved populations. Design. The postgraduate year 2 residency was designed to expose trainees to the unique public health facets of inpatient, outpatient, and community-based care delivery in low and middle-income countries. Public health areas of focus included supply chain management, reproductive health, pediatrics, HIV, chronic disease management, and teaching. Assessment. The outcomes of the residency were assessed based on the number of new clinical programs developed by residents, articles and abstracts written by residents, and resident participation in grant writing. To date, six residents from the United States and eight Kenyan residents have completed the residency. Eleven sustainable patient care services have been implemented as a result of the residency program. Conclusion. This pharmacy residency training model developed accomplished pharmacists in public health pharmacy, with each residency class expanding funding and clinical programming, contributing to curriculum development, and creating jobs.

Objective: To review the use of efungumab as an adjunctive agent in the treatment of invasive candidiasis (IC) and to provide guidance on formulary placement. Data Sources: Searches of MEDLINE (1966–June 2009) and EMBASE (1974–June 2009) were conducted using the terms efungumab, Mycograb, heat shock protein 90, and invasive candidiasis. Other resources included www.clinicaltrials.gov and article bibliographies. Study Selection and Data Extraction: All studies and case reports evaluating efungumab use in IC were included. Literature review was limited to the English language. Data Synthesis: Efungumab is a monoclonal antibody targeted against heat shock protein 90 (HSP 90). It binds to HSP 90, preventing a conformational change needed for fungal viability. In vitro data show that HSP 90 inhibition may decrease resistance against antifungal agents and increase antifungal activity. Efungumab shows activity against Candida spp. when used alone and synergism when combined with fluconazole, caspofungin, and amphotericin B. A randomized controlled trial evaluated combination therapy of efungumab 1 mg/kg twice daily and liposomal amphotericin B versus amphotericin B therapy alone. At day 10, a favorable response was seen in 84% of patients in the efungumab group compared with 48% of patients in the placebo group (OR 5.76; 95% CI 2.4 to 13.8). Mortality at day 33 was also lower in the efungumab group, 4% versus 18%, respectively (OR 0.168; 95% CI 0.036 to 0.797). Although adverse effects were similar in this trial (10% vs 7%), case reports revealed an increased incidence of blood pressure fluctuations. Cytokine release syndrome has also been linked to efungumab use, warranting further exploration of its safety. Conclusions: Efungumab is a new antifungal agent with a novel mechanism of action. Available clinical data and synergy studies support the use of efungumab in combination with other antifungal agents for the treatment of IC. Further safety data are needed before formulary recommendations can be made.

Summary. Background: It is recommended that warfarin therapy should be managed through an anticoagulation monitoring service to minimize the risk of bleeding and subsequent thromboembolic events. There are few studies in Sub-Saharan Africa that describe warfarin management in spite of the high incidence of venous thromboembolism (VTE) and rheumatic heart disease. Objective: To examine the feasibility of the Moi Teaching and Referral Hospital anticoagulation monitoring service and compare its performance with clinics in resource-rich settings. Methods: A retrospective chart review compared the percentage time in the therapeutic range (TTR) and rates of bleeding and thromboembolic events to published performance targets using the inference on proportions test. Wilcoxon’s rank sum analyses were used to establish predictors of TTR. Results: For the 178 patients enrolled, the mean TTR was 64.6% whereas the rates of major bleeds and thromboembolic events per year were 1.25% and 5%, respectively. In the primary analysis, no statistically significant differences were found between the results of TTR, major bleeds and thromboembolic events for the clinic and published performance rates. In the secondary analysis, having an artificial heart valve and a duration of follow-up of > 120 days were positively associated with a higher TTR (P

BACKGROUND: The initial focused effort on addressing the HIV pandemic in ***sub-Saharan Africa has helped set the groundwork for addressing many of the other areas of the health-care system requiring support in resource-constrained settings. With the growing prevalence of diabetes in this setting, the US Agency for International Development—Academic Model Providing Access to Healthcare Partnership (USAID-AMPATH) has begun developing infrastructure to meet the growing need for diabetes care. OBJECTIVE: To describe the evolution of diabetes care in the rural, resource-constrained setting of western Kenya and to analyze preliminary data on the current status of glucose control of patients. METHODS: Through partnerships, USAID-AMPATH has facilitated the provision of basic modalities of diabetes care, including reliable stocks of insulin, hemoglobin A1c (A1C) testing, and point-of-care glucose-testing supplies. RESULTS: Through the introduction of A1C testing, the poor quality of diabetes care was revealed, as the average A1C for the clinic population was 10.4%, with insulin-dependent patients constituting the majority of individuals with markedly elevated A1C levels. To address this, a contextualized electronic medical record and a cell phone-based home glucose monitoring program were created to improve glycemic control, which has led to significant reductions in A1C levels. CONCLUSIONS: Through the inclusion of clinical data within the electronic medical record, there is an ongoing effort to research various aspects of diabetes care in this understudied population, with the goal of addressing many of the unanswered questions surrounding diabetes care in sub-Saharan Africa. The lessons learned from this pilot program will be used to create sustainable infrastructure for diabetes care in partnership with the Kenyan government and will serve as a model for similar programs.

Background Rifampicin’s ability to induce hepatic enzymes is responsible for causing a clinically significant drug interaction with warfarin. Little data exists to guide clinicians on managing this interaction, especially in Sub-Saharan Africa where many patients are exposed to this combination due to a higher burden of tuberculosis. Objective The objective of the case series is to provide insight to practicing clinicians of the unique dynamics of this drug interaction in resource-constrained settings. The case series will provide details on commonly encountered scenarios and the dosage adjustments required to maintain a therapeutic INR. Methods A retrospective chart review was conducted of patients attending the Moi Teaching and Referral Hospital anticoagulation clinic in Eldoret, Kenya. Patients were included if they had a history of concurrent rifampicin and warfarin therapy and a minimum follow up of 2 months. Descriptive statistics were used to explain the demographic characteristics, time to therapeutic INR and average weekly warfarin dose. The inference on proportions test was conducted to compare the time in the therapeutic range (TTR) for patients on concurrent rifampicin to the rest of the patients not receiving rifampicin in the clinic. Results Of the 350 patient charts evaluated, 10 met the inclusion criteria. The median percentage increase of the weekly warfarin dose from baseline was 15.7 %. For the patients in this analysis, the median TTR was 47 %. Discussion Patients on concurrent therapy should be rigorously monitored with regular INR checks and warfarin dosage adjustments. Empiric dosage adjustments of warfarin should be avoided but patient characteristics can aid in understanding the alterations seen in INR.