Following the Fogarty International Center-supported "Mentoring the Mentors" workshops in South America, Africa, and Asia, approaches and guidelines for mentorship at institutions within these low- and middle-income country (LMIC) contexts, appropriate for the respective regional resources and culture, were implemented. Through the presentation of case studies from these three geographic regions, this article illustrates the institutional mentorship infrastructure before the workshop and the identified gaps used to implement strategies to build mentorship capacity at the Universidad Peruana Cayetano Heredia (Peru), Kenya Medical Research Institute (Kenya), Saint John's Research Institute (India), and Eduardo Mondlane University (Mozambique). These case studies illustrate three findings: first, that mentorship programs in LMICs have made uneven progress, and institutions with existing programs have exhibited greater advancement to their mentoring capacity than institutions without formal programs before the workshops. Second, mentoring needs assessments help garner the support of institutional leadership and create local ownership. Third, developing a culture of mentorship that includes group mentoring activities at LMIC institutions can help overcome the shortage of trained mentors. Regardless of the stage of mentoring programs, LMIC institutions can work toward developing sustainable, culturally effective mentorship models that further the partnership of early career scientists and global health.

An estimated 2.3 million disability-adjusted life years are lost globally from leishmaniasis. In Peru's Amazon region, the department of Madre de Dios (MDD) rises above the rest of the country in terms of the annual incidence rates of human leishmaniasis. Leishmania (Viannia) braziliensis is the species most frequently responsible for the form of disease that results in tissue destruction of the nose and mouth. However, essentially nothing is known regarding the reservoirs of this vector-borne, zoonotic parasite in MDD. Wild rodents have been suspected, or proven, to be reservoirs of several Leishmania spp. in various ecosystems and countries. Additionally, people who live or work in forested terrain, especially those who are not regionally local and whose immune systems are thus naïve to the parasite, are at most risk for contracting L. (V.) braziliensis. Hence, the objective of this study was to collect tissues from wild rodents captured at several study sites along the Amazonian segment of the newly constructed Transoceanic Highway and to use molecular laboratory techniques to analyze samples for the presence of Leishmania parasites. Liver tissues were tested via polymerase chain reaction from a total of 217 rodents; bone marrow and skin biopsies (ear and tail) were also tested from a subset of these same animals. The most numerous rodent species captured and tested were Oligoryzomys microtis (40.7%), Hylaeamys perenensis (15.7%), and Proechimys spp. (12%). All samples were negative for Leishmania, implying that although incidental infections may occur, these abundant rodent species are unlikely to serve as primary reservoirs of L. (V.) braziliensis along the Transoceanic Highway in MDD. Therefore, although these rodent species may persist and even thrive in moderately altered landscapes, we did not find any evidence to suggest they pose a risk for L. (V.) braziliensis transmission to human inhabitants in this highly prevalent region.

A growing body of evidence highlights the importance of competent mentoring in academic research. We describe the development, implementation, and evaluation of four regional 2-day intensive workshops to train mid- and senior-level investigators conducting public health, clinical, and basic science research across multiple academic institutions in low- and middle-income countries (LMICs) on tools and techniques of effective mentoring. Sponsored by the Fogarty International Center, workshops included didactic presentations, interactive discussions, and small-group problem-based learning and were conducted in Lima, Peru; Mombasa, Kenya; Bangalore, India; and Johannesburg, South Africa, from 2013 to 2016. Mid- or senior-level faculty from multiple academic institutions within each region applied and were selected. Thirty faculty from 12 South America-based institutions, 29 faculty from eight East Africa-based institutions, 37 faculty from 14 South Asia-based institutions, and 36 faculty from 13 Africa-based institutions participated, with diverse representation across disciplines, gender, and academic rank. Discussions and evaluations revealed important comparisons and contrasts in the practice of mentoring, and specific barriers and facilitators to mentoring within each cultural and regional context. Specific regional issues related to hierarchy, the post-colonial legacy, and diversity arose as challenges to mentoring in different parts of the world. Common barriers included a lack of a culture of mentoring, time constraints, lack of formal training, and a lack of recognition for mentoring. These workshops provided valuable training, were among the first of their kind, were well-attended, rated highly, and provided concepts and a structure for the development and strengthening of formal mentoring programs across LMIC institutions.

Background

Peru has a concentrated HIV epidemic in which men who have sex with men are particularly vulnerable. We describe the lifetime prevalence of same-sex sexual contact and associated risk behaviors of men in Peru's general population, regardless of their sexual identity.

Methods and results

A probability sample of males from low-income households in three Peruvian cities completed an epidemiologic survey addressing their sexual risk behavior, including sex with other men. Serum was tested for HSV-2, HIV, and syphilis. Urine was tested for chlamydia and gonorrhea. A total of 2,271 18-30 year old men and women were contacted, of whom 1,645 (72.4%) agreed to participate in the study. Among the sexually experienced men surveyed, 15.2% (85/558, 95% CI: 12.2%-18.2%) reported a history of sex with other men. Men ever reporting sex with men (MESM) had a lower educational level, had greater numbers of sex partners, and were more likely to engage in risk behaviors including unprotected sex with casual partners, paying for or providing compensated sex, and using illegal drugs. MESM were also more likely to have had previous STI symptoms or a prior STI diagnosis, and had a greater prevalence of HSV-2 seropositivity.

Conclusions

Many low-income Peruvian men have engaged in same-sex sexual contact and maintain greater behavioral and biological risk factors for HIV/STI transmission than non-MESM. Improved surveillance strategies for HIV and STIs among MESM are necessary to better understand the epidemiology of HIV in Latin America and to prevent its further spread.

Background

Syndromic management is an inexpensive and effective method for the treatment of symptomatic sexually transmitted infections (STIs), but its effectiveness as a method of STI control in at-risk populations is questionable. We sought to determine the potential utility of syndromic management as a public health strategy to control STI transmission in high-risk populations in urban Peru.

Methodology

We surveyed 3,285 at-risk men and women from three Peruvian cities from 2003-05. Participants were asked about the presence of genital ulcers, discharge, or dysuria in the preceding six months. Participants reporting symptoms were asked about subsequent health-seeking and partner notification behavior. Urine and vaginal swab samples were tested for Neisseria gonorrhoeae and Chlamydia trachomatis by nucleic acid testing. Serum was tested for syphilis and Herpes Simplex Virus-Type 2 antibodies.

Findings

Recent urogenital discharge or dysuria was reported by 42.1% of participants with gonorrhea or chlamydia versus 28.3% of participants without infection. Genital ulceration was reported by 6.2% of participants with, and 7.4% of participants without, recent syphilis. Many participants reporting symptoms continued sexual activity while symptomatic, and approximately half of all symptomatic participants sought treatment. The positive and negative predictive values of urogenital discharge or genital ulcer disease in detecting STIs that are common in the study population were 14.4% and 81.5% for chlamydia in women and 8.3% and 89.5% for syphilis among gay-identified men.

Conclusions

In our study, STIs among high-risk men and women in urban Peru were frequently asymptomatic and symptomatic participants often remained sexually active without seeking treatment. Additional research is needed to assess the costs and benefits of targeted, laboratory-based STI screening as part of a comprehensive STI control program in developing countries.

Objective

To determine the relationship between socioeconomic status (SES) and visual impairment (VI) or blindness in the rural Peruvian Amazon, hypothesizing that higher SES would have a protective effect on the odds of VI or blindness.

Methods

In this cross-sectional study of 16 rural communities in the Peruvian Amazon, consenting adults aged ≥ 50 years were recruited from ~30 randomly selected households per village. Each household was administered a questionnaire and had a SES score constructed using principal components analysis. Blindness and VI were determined using a ministry of health 3-meter visual acuity card.

Results

Overall, 207 adults aged ≥ 50 were eligible; 146 (70.5%) completed visual acuity screening and answered the questionnaire. Of those 146 participants who completed presenting visual acuity screening, 57 (39.0%, 95% CI 30.2-47.1) were classified as visually impaired and 6 (4.1%, 95% CI 0.9-7.3) as blind. Belonging to the highest SES tercile had a protective effect on VI or blindness (OR 0.29, 95% CI 0.09 to 0.91, p = 0.034), with a linear trend across decreasing levels of SES (p = 0.019). This observed effect remained significant regardless of how SES groups were assigned.

Conclusion

Belonging to a higher SES group resulted in a lower odds of VI or blindness compared to those in the lowest SES group. The observation of a dose response provides confidence in the observed association, but causality remains unclear. Blindness prevention programs could maximize impact by designing activities that specifically target people with lower SES.

Background

Sexually active heterosexual men may represent an important risk factor for HIV infection and STI transmission to their female partners and unborn children, though little is known about the prevalence of STIs in this population. We sought to determine the prevalence of HIV, herpes simplex virus type 2 (HSV-2), and syphilis infection and associated risk behaviors among male sex partners of pregnant women in Peru.

Methods

Survey and seroprevalence data were collected from 1,835 male partners of pregnant women in four cities in Peru. Serum was tested for antibodies to HIV, HSV-2, and syphilis.

Results

Among the 1,835 male participants, HIV prevalence was 0.8% (95% CI = 0.5-1.4%), HSV-2 16.0% (95% CI = 14.3-17.8%), and syphilis 1.6% (95% CI = 1.0-2.2%). Additionally, 11.0% reported a lifetime history of intercourse with men, and 37.1% with female sex workers. Unprotected intercourse with men during the previous year was reported by 0.9% and with female sex workers by 1.2%.

Conclusion

Pregnant women's sex partners reported lifetime sexual contact with core risk groups, had an elevated prevalence of HSV-2, and demonstrated the potential to spread HIV and other STIs to their partners. Though the prevalence of HIV in the population was not significantly higher than observed in other samples of heterosexuals in Peru, the risk of HIV transmission to their female partners may be exacerbated by their increased prevalence of HSV-2 infection. Further study of heterosexual populations is necessary to fully understand the epidemiology of HIV/STIs in Latin America.

Whole-genome sequencing (WGS) of microbial pathogens from clinical samples is a highly sensitive tool used to gain a deeper understanding of the biology, epidemiology, and drug resistance mechanisms of many infections. However, WGS of organisms which exhibit low densities in their hosts is challenging due to high levels of host genomic DNA (gDNA), which leads to very low coverage of the microbial genome. WGS of Plasmodium vivax, the most widely distributed form of malaria, is especially difficult because of low parasite densities and the lack of an ex vivo culture system. Current techniques used to enrich P. vivax DNA from clinical samples require significant resources or are not consistently effective. Here, we demonstrate that selective whole-genome amplification (SWGA) can enrich P. vivax gDNA from unprocessed human blood samples and dried blood spots for high-quality WGS, allowing genetic characterization of isolates that would otherwise have been prohibitively expensive or impossible to sequence. We achieved an average genome coverage of 24×, with up to 95% of the P. vivax core genome covered by ≥5 reads. The single-nucleotide polymorphism (SNP) characteristics and drug resistance mutations seen were consistent with those of other P. vivax sequences from a similar region in Peru, demonstrating that SWGA produces high-quality sequences for downstream analysis. SWGA is a robust tool that will enable efficient, cost-effective WGS of P. vivax isolates from clinical samples that can be applied to other neglected microbial pathogens.

Importance

Malaria is a disease caused by Plasmodium parasites that caused 214 million symptomatic cases and 438,000 deaths in 2015. Plasmodium vivax is the most widely distributed species, causing the majority of malaria infections outside sub-Saharan Africa. Whole-genome sequencing (WGS) of Plasmodium parasites from clinical samples has revealed important insights into the epidemiology and mechanisms of drug resistance of malaria. However, WGS of P. vivax is challenging due to low parasite levels in humans and the lack of a routine system to culture the parasites. Selective whole-genome amplification (SWGA) preferentially amplifies the genomes of pathogens from mixtures of target and host gDNA. Here, we demonstrate that SWGA is a simple, robust method that can be used to enrich P. vivax genomic DNA (gDNA) from unprocessed human blood samples and dried blood spots for cost-effective, high-quality WGS.

Mentoring is a proven path to scientific progress, but it is not a common practice in low- and middle-income countries (LMICs). Existing mentoring approaches and guidelines are geared toward high-income country settings, without considering in detail the differences in resources, culture, and structure of research systems of LMICs. To address this gap, we conducted five Mentoring-the-Mentor workshops in Africa, South America, and Asia, which aimed at strengthening the capacity for evidence-based, LMIC-specific institutional mentoring programs globally. The outcomes of the workshops and two follow-up working meetings are presented in this special edition of the American Journal of Tropical Medicine and Hygiene. Seven articles offer recommendations on how to tailor mentoring to the context and culture of LMICs, and provide guidance on how to implement mentoring programs. This introductory article provides both a prelude and executive summary to the seven articles, describing the motivation, cultural context and relevant background, and presenting key findings, conclusions, and recommendations.

Background

Anaemia is a public health problem in Peru. In the Loreto region of the Amazon, ≥50% of children may be anaemic, although insufficient information exists for rural villages.

Methods

To generate more data about childhood anaemia in the Peruvian Amazon, haemoglobin was measured as part of a trachoma survey in 21 randomly selected villages. All children 1-9 y of age from 30 randomly selected households per village were recruited. Anaemia was classified according to the World Health Organization guidelines and a socio-economic status (SES) index was created for each household using principal component analysis. Spatial autocorrelation was determined using Moran's I and Ripley's K function.

Results

Of 678 children with complete haemoglobin data, 25.4% (95% confidence interval [CI] 21.2 to 30.1) had mild-or-worse anaemia and 22.1% (95% CI 15.6 to 30.3) had moderate-or-worse anaemia. Mild-or-worse anaemia was more common among children whose primary source of drinking water was surface water (prevalence ratio [PR] 1.26 [95% CI 1.14 to 1.40], p<0.001) and who were in the lowest SES tercile (PR 1.16 [95% CI 1.02 to 1.32], p=0.021). Moderate-or-worse anaemia was more common among boys (PR 1.32 [95% CI 1.09 to 1.60], p=0.005). No evidence of geospatial clustering was found.

Conclusions

Remote villages of the Amazon would benefit from interventions for childhood anaemia and the poorest households would have the most to gain. Integrating anaemia screening into neglected tropical diseases surveys is an opportunity to use public health resources more efficiently.