Conducting HIV Treatment Research in Resource Poor

Pontiano Kaleebu MD PhDUganda Virus Research Institute

ENTEBBE

Eric Arts PhDJoint Clinical Research Centre CFAR Uganda Laboratory Core

KAMPALA

Summary of presentation

History of UVRI and JCRC and what is involved in setting up basic research in a developing country

Examples of successfully conducted basic research and clinical trials

Some challenges/frustrations Tips for collaboration

Sophisticated research has been limited to developed countries

Mostly observational epidemiology and clinical care in Africa

Very little basic science research Laboratories were collection and shipment sites A few centres of excellence Basic science not attractive due to limited training and

experience of the native population Trained African scientists and clinicians migrate to better

opportunities

Past research practices

Why Basic research in RPC

Address local problems Partnership and trust Capacity building More affordable in the long-term

Uganda Virus Research Institute(UVRI)

Established 1936 as Yellow Fever Research Institute, funded by the Rockfeller Foundation

1950- East African Virus Research Institute 1972- Ida Amin, political turmoil, break from

the East African Community- became the UVRI and the departure of most staff

1986- New Government and AIDS Epidemic

Achievements Identification of 124 strains of new viruses

mostly from mosquitoes, e.g Chikungunya, O’nyong-nyong, West Nile etc

Research on Yellow fever transmission Currently, the national reference lab for HIV

screening; Primary WHO/UNAIDS lab for HIV characterization; Measles, Polio and Arboviruses reference centre

Collaboration with a number of programmes; Rakai project, MRC, CDC, and IAVI

The Rakai project Started 1988: A multi-displinary programme Looking at HIV epidemiology and factors

affecting spread including STDs Now looking at HIV-1 molecular epidemiology

and preparations for vaccine trials Collaboration of Columbia University, Johns

Hopkins, Makerere University, UVRI and Walter Reed Army Institute of Research

MRC programme on AIDS in Uganda

Started in 1988: To investigate the epidemiology of HIV-1 infection and natural history of HIV-1 associated disease in rural Uganda.

Multi-disciplinary (clinical, epidemiology, social science, basic science, community activities)

Over 130 publications

CDC-Uganda

Activities started in 1994 - HIV-1 molecular epidemiology studies

2000- GAP-Research in care and HIV-1 prevention

Capacity building

ICSC-World Laboratory

International Center for Scientific Culture (ICSC) - World Laboratory

Provided considerable equipment for containment level 3 lab and molecular lab

Work on etiopathogenesis of KS

Some MRC selected publications

S. McAdam et al. AIDS 1998; 12:571-579 A.M. Elliott et al. Int J. Tuber Lung Dis 1999; 3; 239-247 Kaleebu P et al. AIDS Res Human Retroviruses 2000;16:621-625 Jones G.J. et al. AIDS 2001;15: 1657-1663 Kaleebu P. et al. AIDS 2001, 15:293-299 Hadson W.S. et al. AIDS 2001,15:467-475 Kaleebu P. et al. JID 2002;185:1244-50 Cao H. et al. JID 2003;187:887-95

RECENT ABSRTRACTS (Barcelona conference): MoOrA 1055 Kebba A. et al. (Paper accepted JID) TuPeA4352 Nankya I.L. et al. ThPeA7097 Rutebemberwa A. et al. (Paper submitted ARHR)

Important new studies in MRC

DART (Development of ARV therapy for Africa).

Multi-centre study: Uganda (JCRC,UVRI) and Zimbabwe (Harare)

3000 patients with CD4 <200 First randomisation CMO vs LCM Second randomisation (Continuous vs STI) Drugs: First line Combivir, tenofovir, Abacavir,

Niverapine,

Basic science studies under DART

Base-line resistance Monitor virological response Development of resistance in CMO and LCM Development of resistance in STI Efficacy of a new combination

(Tenofovir/combivir) Immune reconstitution under STI/Continuous

IAVI-UVRI

International AIDS Vaccine Initiative Started 2001 Phase I vaccine trial Following international ethical standards Data handling and QA Laboratory-QA/QC; Core lab in London Immunogenicity- Elisopot and flowcytometer

A phase I vaccine trial

NIH/CWRU/JCRC/UVRI Safety and immunogenicity of Live recombinant

ALVAC HIV vCP205 (Aventis Pasteur) funded by NIH First vaccine trial in Africa Trial followed GLP and GCP Accreditation-CAP, WHO etc Capacity building Immunogenicity and safety data (Cao et al. JID 2003;

187: 887-95)

Techniques at UVRI Viral culture and isolation (HIV, Measles, Polio) Intracellular cytokine assay by flow cytometry Elispot assays Whole blood cytokine assays Real time PCR Proliferation assays Polymerase Chain Reaction and Heteroduplex mobility assay Viral load assays (Roche and branched DNA) Standard Chemistry, heamatology assays UK certified laboratory, external QA programmes

Local training

Our programme has trained PhDs in Immunology and virology- students perform their work at UVRI (Register with Imperial College, London).

MSc of Makerere University

Frustrations

Political instability (Uganda currently stable) Lack of local financial resources Lack of trained personnel and brain drain Power and Internet services (at UVRI now

much better) Logistics e.g Reagent shipments Equipment mantainance/service contracts Ethics and regulatory issues Literature/information

Tips for collaboration

Openness and equal partnership Understand local research needs Balance sponsor and local interests Respect and understand local culture

Summary

With good training and investment in infrastructure, good clinical and basic research can be conducted in RPC

We need partners in research with plans to develop capacity

Uganda – Case Western Reserve University CollaborationUganda – Case Western Reserve University Collaboration

•Initiated by the late Frederick Robbins (Nobel Laureate) in 1988Initiated by the late Frederick Robbins (Nobel Laureate) in 1988

•Over 50 research projects have been completed or are ongoingOver 50 research projects have been completed or are ongoing

•Involves direct collaboration between at least 20 US and Ugandan Involves direct collaboration between at least 20 US and Ugandan principle investigators, currently employees over 200 Ugandans on site, principle investigators, currently employees over 200 Ugandans on site, and is supported by approximately $8 million/yrand is supported by approximately $8 million/yr

•Collaboration projects include:Collaboration projects include:

•studies of HIV-1 pathogenesisstudies of HIV-1 pathogenesis

•vertical transmissionvertical transmission

•neurodevelopment of HIV-infected childrenneurodevelopment of HIV-infected children

•HIV and tuberculosis interactionHIV and tuberculosis interaction

•IND phase I/II trials of promising immunoadjuvants for TB IND phase I/II trials of promising immunoadjuvants for TB treatmenttreatment

•HIV seroincidenceHIV seroincidence

•preparation for AIDS vaccinespreparation for AIDS vaccines

•the first phase I HIV preventive vaccine trial on the African continent the first phase I HIV preventive vaccine trial on the African continent (recombinant canarypox vector vaccine - ALVAC HIV vCP205)(recombinant canarypox vector vaccine - ALVAC HIV vCP205)

Grants and Contracts Supporting Uganda-Case CollaborationGrants and Contracts Supporting Uganda-Case Collaboration

•Tuberculosis Research Unit – NIAID, NIH contractTuberculosis Research Unit – NIAID, NIH contract

•Fogarty AIDS International Training and Research ProgramFogarty AIDS International Training and Research Program – NIAID, – NIAID, NIH grantNIH grant

•Hormonal contraception and the risk of HIV acquisitionHormonal contraception and the risk of HIV acquisition – NICHD, NIH – NICHD, NIH contractcontract

•Center for AIDS Research – NIAID, NIH grantCenter for AIDS Research – NIAID, NIH grant

•Oral Combination Chemotherapy in AIDS-Related Non-Hodgkin’s Oral Combination Chemotherapy in AIDS-Related Non-Hodgkin’s Lymphoma in Africa - NCI, NIH grantLymphoma in Africa - NCI, NIH grant

•Six R01 grants and several other awards from various agenciesSix R01 grants and several other awards from various agencies

JOINT CLINICAL RESEARCH CENTREJOINT CLINICAL RESEARCH CENTREKampala, Uganda

Director – Dr. Peter Mugyenyi

Joint Clinical Research Centre

Mulago Hospital

Figure 1

CWRU/UHC CFAR International Core (CCIC)CWRU/UHC CFAR International Core (CCIC)Proposed structure and organization

Joint Clinical Research Centre, Mengo Hill, Kampala, UgandaJoint Clinical Research Centre, Mengo Hill, Kampala, Uganda

CFAR-JCRC Virology LaboratoryCFAR-JCRC Virology Laboratory JCRC Medical ClinicJCRC Medical Clinic

Figure 2

Joint Clinical Research CentreJoint Clinical Research CentreMain site of laboratory analyses on patient samples for CFAR and other Case-related activities

A B

Figure 3

CFAR/JCRC Virology LaboratoryCFAR/JCRC Virology Laboratory

Figure 4. JCRC Immunology laboratory

TBRU/JCRC Immunology LaboratoryTBRU/JCRC Immunology Laboratory

Advisory CommitteePontiano Kaleebu, Ph.D.

Cissy Kityo, MDPeter Mugyenyi, MD

Eric Arts, Ph.D.Robert Salata, MD

Advisory CommitteePontiano Kaleebu, Ph.D.

Cissy Kityo, MDPeter Mugyenyi, MD

Eric Arts, Ph.D.Robert Salata, MD

DirectorsEric Arts, Ph.D.

Peter Mugyenyi, MD  

DirectorsEric Arts, Ph.D.

Peter Mugyenyi, MD  

HIV drug resistancePhenotypic and genotypic

HIV drug resistancePhenotypic and genotypic

HIV isolation and characterization

HIV isolation and characterization

HIV-related viral infectionse.g. KSHV, HCV, HPV

HIV-related viral infectionse.g. KSHV, HCV, HPV

HIV-related immunologye.g. CTL, neutr. Ab

HIV-related immunologye.g. CTL, neutr. Ab

Core PersonnelKorey Demers, on-site

directorFred Kyeyune, research

assistantStanley Bulime, research

assistant

Core PersonnelKorey Demers, on-site

directorFred Kyeyune, research

assistantStanley Bulime, research

assistant

Ugandan-CWRU collaborationUgandan-CWRU collaboration  

CWRU CFAR-JCRCCWRU CFAR-JCRCHIV/Virology Core LaboratoryHIV/Virology Core Laboratory

Ugandan-CWRU collaborationUgandan-CWRU collaboration  

CWRU CFAR-JCRCCWRU CFAR-JCRCHIV/Virology Core LaboratoryHIV/Virology Core Laboratory

LABORATORY EQUIPMENT AND LABORATORY EQUIPMENT AND INFRASTRUCTUREINFRASTRUCTURE

• Approximately 1000 sq. feet in the Joint Clinical Research Centre. The Approximately 1000 sq. feet in the Joint Clinical Research Centre. The centre is located on Mengo Hill, Kampala, Uganda.centre is located on Mengo Hill, Kampala, Uganda.

• Laboratory space is shared with CTL/Immunology laboratory (Director – Laboratory space is shared with CTL/Immunology laboratory (Director – Huyen Cao, MD)Huyen Cao, MD)

• The HIV/virology laboratory contains all of the necessary equipment for The HIV/virology laboratory contains all of the necessary equipment for virus tissue culture and molecular virology/biology analyses (e.g. PCR virus tissue culture and molecular virology/biology analyses (e.g. PCR amplifications, DNA sequencing, radioactive reverse transcriptase amplifications, DNA sequencing, radioactive reverse transcriptase assays). assays). Equipment purchased by CFAR is highlighted.Equipment purchased by CFAR is highlighted.

HIV/VirologyHIV/VirologyVisible Genetic Automated DNA sequencer Visible Genetic Automated DNA sequencer Sorval refridgerated micro-ultracentrifuge Sorval refridgerated micro-ultracentrifuge Agarose and polyacrylamide gel electrophoresis set-upSAgarose and polyacrylamide gel electrophoresis set-upSPCR thermocyclersPCR thermocyclers

CTL/ImmunologyCTL/ImmunologyBeta scintillation counterBeta scintillation counterFlow cytometryFlow cytometryELISPOT readerELISPOT reader

Cost of service (anticipated samplesa)

Type of Assay CFAR-DEV cost/sample

CFAR cost/sample

Non-CFAR cost/sample

Non-CWRU cost/sample

Special considerations

Sample processing $3 (500)

4 (>5000)

4.50 (NAb)

5 (NAb)

Extensive processing/sample transfers will result in a higher fee.

PBMC isolation $30 (500)

40 (>2000)

45 (NA)

50 (NA)

Plasma and sera cyropreservation and storage

$3 (500)

4 (>3000)

4.5 (NA)

5 (NA)

This price includes long term storage at -70ºC and entering information into repository files. Liquid nitrogen storage is an addition $2/sample.

Viral load assays <100 samples >100 samples - ultra/fluids

$50 $40 $75

(100)

$55 $45 $80

(5,000)

$60 $50 $90

(NA)

$65 $55

$100 (NA)

Roche Amplicor 1.5 kit. Ultrasensitive assays or viral loads performed on other fluids require ultracentrifugation.

HIV-1 propagation from PBMC

$300 (50)

$350 (200)

$400 (NA)

$500 (NA)

Does not include the cost for PBMC isolations but includes assays to monitor virus production and storage costs.

TCID50 assays for infectious units

$800 $900 (50)

$1000 (NA)

$1100 (NA)

This assay does include cost for RT assays to monitor virus production.

‘virtual’ TCID50 measurement

$110 (50)

$120 (200)

$125 (NA)

$130 (NA)

Investigators will be advised to use this method rather than the latter.

RT assay $0.50 (100)

$0.55 (2000)

$0.60 (NA)

$0.65 (NA)

HIV-1 gag or env sequencing (350 nt)

$75 (100)

80 (200)

85 (NA)

95 (>100)

Requires the use of two sequencing primers. Note: this price includes PCR amplification, sequencing of the gag or env gene, and phylogenetic analyses.

ARV resistance testing or pol sequencing (1200nt)

$110 (<50)

$120 (>200)

$130 (NA)

$140 (>200)

Note: this price includes all sample preparation and assays following the blood draw. Physicians or IRB-approved research are provided an ARV drug resistance report form.

ELISA or ELISPOT assay

$140/plate (>50)

$155/plate (>200)

$165/plate (NA)

$175/plate (>100)

This fee is proportionally adjusted for ELISA assays that require less than a full plate of samples.

Flow cytometry assays - surface - intracellular

$5 (<50) $10 (<50)

$6 (>200) $12 (>200)

$7 (NA) $14 (NA)

$8 (>100) $15 (>100)

Cost per labeled antibody plus $5 per tube. The intracellular assays cost are greater due to the requirement for special fixing and membrane-permeating reagents.

BACTEC culturing of M.tb

$20 (NA)

$25 (1000)

$30 (NA)

$35 (NA)

Extra charge for bacterial drug susceptibility testing done with isoniazid, rifampin, streptomycin, and pyrazinamide.

Multiplex PCR identification of STD pathogens

$100 (200)

$110 (200)

$120 (NA)

$125 (NA)

Detects NG, CT, and TV and three Genital Ulcer pathogens of HD, HSV and TP

CFAR Uganda laboratory core servicesCFAR Uganda laboratory core services

CURRENT PROJECTS USING CFAR FACILITIESCURRENT PROJECTS USING CFAR FACILITIES

Antiretroviral drug resistant in Ugandans infected with non-clade B HIV-1 Antiretroviral drug resistant in Ugandans infected with non-clade B HIV-1 isolates and treated with antiretroviralsisolates and treated with antiretrovirals

PI – Eric Arts, Cissy Kityo, Peter MugyenyiFunded by Fogarty International AIDS Training Grant

Prevelance of nevirapine and zidovudine resistance substitutions in mothers and Prevelance of nevirapine and zidovudine resistance substitutions in mothers and their infants their infants

PI – Chris Whalen, Francis Bajunirwe, and Eric ArtsFunded by Fogarty International AIDS Training Grant

Analysis of viral fitness in Zimbabwean and Ugandan women newly infected with Analysis of viral fitness in Zimbabwean and Ugandan women newly infected with non-clade B HIV-1non-clade B HIV-1

PI – Eric ArtsContract with NICHD, NIH and R01 from NIAID, NIH

HIV-1 shedding in genital secretionsHIV-1 shedding in genital secretionsPI – Robert SalataContract with NICHD, NIH

Prevelance and subtyping of HPV in HIV-infected UgandansPrevelance and subtyping of HPV in HIV-infected UgandansPI – Robert Salata, Fred KambuguContract with NICHD, NIH

Identification and analysis of KSHV in HIV-infected Ugandans treated for NHLIdentification and analysis of KSHV in HIV-infected Ugandans treated for NHLPI – Rolf Renne, Scot Remick, Edward MbiddeFunded by NCI, NIH

Impact of tuberculosis on HIV-1 heterogeneity and disease progressionImpact of tuberculosis on HIV-1 heterogeneity and disease progressionPI – Zahra Toossi, Eric Arts, Harriet Mayanja-KizziFunded by NHLBI, NIH and NIAID, NIH

Investigating the sensitivity of HIV-1 isolates in Uganda to inhibition by RANTES Investigating the sensitivity of HIV-1 isolates in Uganda to inhibition by RANTES derivatives and an analyses of CCR5 polymorphismsderivatives and an analyses of CCR5 polymorphisms

PI – Michael Lederman, Peter Zimmerman, Eric ArtsGrant from NIAID, NIH

Measuring the expression of level of Beta defensins in vaginal tract of HIV negative Measuring the expression of level of Beta defensins in vaginal tract of HIV negative and positive womenand positive women

PI – Miguel Quinones-MateuGrant from NICHD, NIH

CURRENT PROJECTS USING CFAR FACILITIESCURRENT PROJECTS USING CFAR FACILITIES

HIV-1 DRUG RESISTANCEHIV-1 DRUG RESISTANCE

Obtain blood sample from patientObtain blood sample from patient

Extract DNA from cells, PCR amplify Extract DNA from cells, PCR amplify PR-RT sequence, perform DNA PR-RT sequence, perform DNA sequencingsequencing

Perform phylogenetic analyses Perform phylogenetic analyses and determine drug resistance and determine drug resistance genotypegenotype

Drug resistant Drug resistant mutations in JCR55mutations in JCR55

L74V, K103N, M184V in RTNone in PR

Predicted phenotypic Predicted phenotypic drug resistancedrug resistance

High level resistance to ddI, ddC, 3TC, EFV, NVPModerate level resistance to ABC, DLV

0

5

10

15

20

25

30

35

AZT 3TC ddI d4T NNRTI PI

nu

mb

er o

f p

arti

cip

ants

(m

ax 5

1)

number currently treated with ARV

number with resistance to the ARV

association between resistance and current treatment with the ARV

number receiving ARV in past

number maintaining the ARV in current treatment regimen from previous

Figure 1. Richard et al., 2003

Emergence of ARV resistance in ARV-treated Emergence of ARV resistance in ARV-treated Ugandans at the JCRCUgandans at the JCRC

Over 50% of ARV-treated patients at the JCRC harbor drug resistant virus

EFFECTS OF TB ON HIV-1 EFFECTS OF TB ON HIV-1 DIVERSITYDIVERSITY

Effect of TB on HIV-1 heterogeneity in co-infected UgandansEffect of TB on HIV-1 heterogeneity in co-infected Ugandans

HIV-1 diversity was 2 to 3-fold HIV-1 diversity was 2 to 3-fold greater in blood of HIV/TB as greater in blood of HIV/TB as compare to that of HIV-infected compare to that of HIV-infected Ugandans matched for CD4 cell Ugandans matched for CD4 cell countcount

Collins et al., J. AIDS 2000

Increased HIV-1 diversity upon Increased HIV-1 diversity upon co-infection with TB is due to co-infection with TB is due to expansion of HIV-1 in the TB-expansion of HIV-1 in the TB-affected organ (pleura or lung) affected organ (pleura or lung) and migration of diverse HIV-1 and migration of diverse HIV-1 clones from these compartments clones from these compartments into the blood.into the blood.

Collins et al., J. Virol. 2002

Impact of TB on HIV-1 heterogeneityImpact of TB on HIV-1 heterogeneity

Active M.tb replication leads to immune activation, release of Active M.tb replication leads to immune activation, release of cytokines and chemokines that can upregulate HIV-1 replicationcytokines and chemokines that can upregulate HIV-1 replication

Collins et al., AIDS Rev. 2002Collins et al., AIDS Rev. 2002

HIV-1 FITNESS AND DISEASE HIV-1 FITNESS AND DISEASE PROGRESSIONPROGRESSION

Worldwide Distribution of Worldwide Distribution of HIV-1 subtypes HIV-1 subtypes

A – 50%A – 50%D – 40%D – 40%C – 8%C – 8%

Others - 2%Others - 2%C - >95%C - >95%

Others - <5%Others - <5%

HIV-1 fitness increases during disease progressionHIV-1 fitness increases during disease progression

Patients that are characterized as slow progressor tend to have less fit Patients that are characterized as slow progressor tend to have less fit virus than patients than patients that progress rapidly to diseasevirus than patients than patients that progress rapidly to diseaseQuinones-Mateu et al., J. Virol. 2000

Subtype C is now dominating the epidemicSubtype C is now dominating the epidemic

Ugandans infected with subtype D appear to progress more rapidly than Ugandans infected with subtype D appear to progress more rapidly than those infected with subtype Athose infected with subtype AKaleebu et al., JID 2002

Can different subtypes alter the course of Can different subtypes alter the course of disease progression? Transmission? The disease progression? Transmission? The epidemic?epidemic?

Relationship between HIV-1 subtype, fitness and Relationship between HIV-1 subtype, fitness and disease progressiondisease progression

Intrasubtype competitionsIntrasubtype competitions

B vs. BB vs. B C vs. CC vs. C

Paired T test, p > 0.5Paired T test, p > 0.5 Paired T test, p > 0.5Paired T test, p > 0.5

There is no significant difference in intrasubtype competition involving B or C isolates

Y a

xis

win

sX

axi

s w

ins

Ball et al., J. Virol. 2003Ball et al., J. Virol. 2003

Intersubtype competitionsIntersubtype competitions

C vs. BC vs. B C vs. BC vs. BPaired T test, p < 0.0001Paired T test, p < 0.0001

B w

ins

C w

ins

Subtype C isolates are significantly less fit than subtype B isolates

Ball et al., J. Virol. 2003Ball et al., J. Virol. 2003

HIV-1 shedding from the genital tractHIV-1 shedding from the genital tract

1. To compare shedding of HIV-1 from the genital tracts to hormonal contraceptive use

2. To determine if HIV-1 shedding/viral loads is related to HIV-1 subtype

HIV-1 fitness study: comparing HIV-1 HIV-1 fitness study: comparing HIV-1 fitness to disease progression in patients fitness to disease progression in patients infected with subtypes A, C, and D infected with subtypes A, C, and D HIV-1 isolatesHIV-1 isolates

1. To compare HIV-1 fitness upon primary infection

2. Analyze the changes in fitness during disease progression

3. Relate fitness and disease progression to the infecting HIV-1 subtype

4. Determine if hormonal contraceptive use affects HIV-1 fitness in the genital tract

Processing of GS/VF SamplesProcessing of GS/VF Samples

Endocervical/Vaginal Swabs(RNA Later)

Aliquot and Freeze –70oC

Viral loads

Blood (Red Top)

Aliquot SerumFreeze –70oC

HSV Testing(JCRC)

Syphilis Testing (JCRC)

RepositorySample processing(pelleting and RNA

extraction)

Processing of GS/VF SamplesProcessing of GS/VF Samples

Blood (EDTA)

Isolate PBMCs(Buffy coat)

Viral PropagationsCo-culture

DBS

Repository

MeasurementCD4+/CD8+ lymph.

(JCRC)

Harvest virus for viral fitness

Repository

Extract DNA

PCR andsequencing

Subtyping

Clone for fitnessstudies

EDTA blood

PBMC isolation DNA extraction External PCR withEnvB-ED14

DNA sequencing with fluorescent tagged primers and using the

Visible Genetic Sequencer

Nested PCR withE80-E125

HIV-1 subtypingHIV-1 subtyping

1-516-10187-6

1-516-11039-6

1-515-10378-7

1-515-10039-1

1-515-10298-4

1-515-10407-2

1-516-10673-2

1-525-10008-2

1-516-10685-6

A

A

B*

D

D

D

D

CRF11-cpx**

D

*Likely lab contamination**complex of A,E,G, and J. Subtype A in env and gag

Patient ID Number Subtype

Phylogenetic analysesPhylogenetic analyses

GS Sample Analysis of fitnessGS Sample Analysis of fitness

Blood (EDTA)

Isolate PBMCs(Buffy coat)

Viral PropagationsCo-culture

Harvest virus for viral fitness

RepositoryExtract DNA

Clone for fitnessstudies

Determination of virus titer

Competitions with reference isolates

Personal observations after 6 years of research in UgandaPersonal observations after 6 years of research in Uganda

Setting up a laboratory is extremely time consuming, difficult, but incredibly rewarding

However, establishing strong collaborations with pre-existing facilities (if present) and strengthening their capabilities avoids unnecessary duplication

Communication is the key to success. Obvious comment but difficult to accomplish

Do not take anything for granted!

Know your wattage, voltage, current, stablizers, power backups, frequency, step-down converters, and a very good electrician

There are no Amersham, Invitrogen, BioRad or any other biotech even remotely interesting in installing a freezer

Establish good shipping routes and don’t expect anything to arrive on time

Where can I develop my radiographic film?How do get a radiation license? And who the hell will ship it to me?What do I do when my thermocycler dies or a bulb burns out on my plate reader?Always send a Ugandan to buy from local merchantsAnother yeast contamination, time to formaldehyde bomb this place

When all else fails there is always Nile Special beer and Waragi