Table 1 Main challenges, lessons learned, and recommendations

 Contracts and regulatory approvals

• Contracts and agreements between multiple international institutions can cause delays.

• Obtaining ethics and regulatory approvals in Malawi is a complex process that required significant time and effort from study staff.

• Begin the process of getting partner agreements even before the grant is approved.

• Confirm commitment of subcontractors during the grant process.

• Ensure the site has dedicated in-country person experienced with the ethics and regulatory agencies to focus on the processes and check outcomes. In particular, they should:

 ° Facilitate study team’s finalization of protocols and other documents to keep them in line with submission dates.

 ° Check on progress immediately after review deadline.

 ° Ensure that approval documents are received.

 ° Check returned documents for accuracy.

 Trial insurance

• Obtaining trial insurance in Malawi is complicated.

• The sponsor had to work through an institutionally sanctioned insurance broker.

• The broker contracted with a multinational insurance company who then contracted with a local insurance firm in Malawi.

• Additionally, a local insurance firm then had to front the policy before it could be endorsed by the National Commission for Science and Technology (NCST).

• Sponsor and study team should coordinate with each other and with the various companies in order to keep the process moving and ensure that requirements are met.

 Staffing

• It takes planning, creativity, and tenacity to recruit and retain excellent study personnel.

• Experienced personnel were generally already under a contract either with a different MLW clinical trial or other research institutions in the country.

• When promising clinicians (without specific clinical trial experience) are hired, training, oversight, mentorship, and timely feedback can ensure that staff succeed.

• Plan hiring early.

• Contact investigators whose studies are ending.

• Whenever possible, draw from study teams that have implemented similar studies.

• When promising staff are hired:

 ° Provide basic theoretical training on clinical trials/clinical research.

 ° Provide specific hands-on training.

 ° Ensure ongoing support/supervision from experienced local and partner lab and clinical personnel.

 Information about study population

• Adequate information about the study population is key.

• The number of potential subjects that would meet inclusion criteria and fail due to exclusion criteria was unknown, e.g., an exclusion criteria of potassium < 3.5 mEq/L was almost universal in this population with prolonged diarrhea.

• Conduct pilot study specific to the planned trial in order to gain a clear understanding of the realities.

• Focus especially on data that relates to inclusion and exclusion criteria.

• For correctable inclusion criteria, such as potassium levels, consider correction and a needed retesting value.

 Slow enrollment rate

• Expected enrollment rate was based on a preliminary study that did not match study requirements.

• Climate change is affecting weather patterns; this impacts the prevalence of pathogens.

• Oral potassium supplements can address hypokalemia within the recruitment time period, thus allowing subject eligibility.

• Chest X-rays and sputum GeneXpert alone are not reliable in detecting TB; urine LAM identifies undiagnosed TB in immunocompromised HIV-infected patients.

• Hospital-based recruitment was insufficient; expanding to outreach sites led to an increase in the number of potential subjects approached and subjects enrolled.

• Conduct pilot study in line with study parameters, particularly related to study population.

• Verify the climate conditions that existed when baseline data re: recruitment rate was gathered.

• Plan for changing weather patterns, i.e., conduct the trial in multiple sites simultaneously.

• Be more conservative about estimates when preliminary study inclusion/exclusion criteria do not match study criteria.

• Identify strategies for dealing with slower than expected enrollment.

• Consider setting study enrollment target off-ramps.

 Study population health status

• Potential participants were severely immunocompromised and had multiple opportunistic infections.

• Many were failing on ARV treatment.

• Related to above, many subjects were found to have undiagnosed TB early in the study.

• Local clinical staff are able to ensure that subjects can access available and appropriate treatment.

• Ensure consultation with expert clinicians.

• Consider ramifications of potential participants failing first-line ARV treatment, thus eligible for second-line treatments (identified in exclusion criteria) rendering them ineligible.

• Plan for extensive screening procedures (such as urine LAM to rule out extrapulmonary TB) to isolate exclusionary conditions.

• Facilitate referral for care and management.

• Provide clear instructions at discharge related to worsening conditions and follow-up with subjects.

 High mortality rate

• Subjects with diarrhea, HIV, and Cryptosporidium had CD4 counts uniformly under 100 and had multiple underlying conditions that contributed to the mortality rate.

• Mortality rate of 20% in part A was higher than the anticipated rate of 15% (projected from published data re: HIV+ individuals with diarrhea).

• Experienced HIV clinicians at the Data and Safety Monitoring Board (DSMB) concluded that mortality rate seen in this study was not unexpected.

• Before study begins, get input from experienced in-country clinicians about expected mortality rates for the specific population.

• Ensure that clinicians refer very ill subjects to appropriate clinics to ensure proper care and management.

 Lab equipment

• Identification of suppliers and acquisition of critical lab equipment and supplies took more time than anticipated.

• Maintenance of one malfunctioning piece of equipment not easily obtainable in Malawi (in this case, the Thermal Cycler, polymerase chain reaction [PCR] machine) caused significant delays.

• Study team, including partners, should collaborate to identify suppliers well ahead of trial initiation. Establish realistic delivery timelines.

• Develop close communication with suppliers to emphasize the critical importance of equipment to the study to ensure equipment is delivered in a timely manner and maintained.

• Maintain close contact with technical personnel from suppliers to facilitate resolution of malfunctioning equipment.

• Identify backup labs early to use when lab machine is faulty, or reagents have run out.

 Lab testing

• Study required new skill sets for site staff, particularly lab staff.

• Viability of ultra-cold cell specimens is not guaranteed.

• Clinical lab at site hospital did not run samples quickly and not at night nor over weekends, causing unanticipated delays.

• PK sample collection and other procedures spaced too closely together can lead to errors.

• Enrollment rate of 2 subjects per week allowed adequate time for processing of lab tests.

• Provide expert trainers to work with the site lab personnel to establish new complicated techniques and maintain feedback for ongoing troubleshooting.

• Consider sending lab personnel to partner labs to observe routine processes before initiating the trial.

• Develop a backup plan for cell culture including backup shipments and alternative substrates.

• Ensure adequate and ongoing supply of reagents.

• Make arrangements to do clinical labs via study labs or contract with the clinical lab to run the samples immediately.

• Consider rolling admission days to ensure adequate time for PK and other studies.

 Randomization timing

• Some procedures required study staff with regular weekday hours to come in on holidays and weekends.

• Ensure that protocol is in line with work schedules to ensure that adequate staffing is available.

 Protocol amendments

• Getting protocol amendments in place (and adjusting related study documents) took more effort and time than anticipated.

• Protocol revisions impact all downstream data entry and document revisions.

• This can slow the progress of the study.

• Anticipate protocol amendments when conducting studies in new areas.

• Plan for the impact of amendments and ensure that study deadlines can be reached.

•Try to ensure quick consensus on proposed protocol amendments by all concerned staff and partners.

 Data collection forms (DCFs) and data entry

• DCFs contained unclear or incorrect fields.

• Missing data fields and data entry errors early in the study caused numerous data queries.

• Significant staff time was required to correct the forms and resolve the queries.

• Perform mock run-throughs of completing DCFs and data entry with the clinical and data entry staff at site initiation visit.

• Site data entry staff perform ongoing audits of data fields before submitting.

• Ensure continuous and open communication among the clinical, data entry, and CRO staff to discuss queries and related data issues.

 Physical space

• Lack of space at QECH prevented separate clinic rooms for subjects.

• Part B (non-diarrheic, non-Cryptosporidium-infected individuals) needed separate inpatient space to prevent exposure to Cryptosporidium oocysts.

• If study had recruited the expected number of subjects, trial participants could have taken beds needed for non-study participants.

• QECH infrastructure had to be upgraded to create office space for the clinical staff.

• Analyze space availability at study site against study space needed (including office space).

• Ensure that adequate space is available to support good health outcomes for both study participants and non-study participants.

 Site Internet connectivity

• Internet connection is critical when an electronic data system is used.

• When electronic systems are key to study implementation, ensure the study site has a strong Internet connection and identify backup plans, several if possible.

• Consider cellular data as a way to ensure nearly continuous connectivity.

 Blood draws

• Superstition can cause subjects, their families, and communities to object to study procedures.

• Uninformed ward staff can perpetuate misinformation about study-related procedures.

• Staff awareness of community perceptions and potential threats to the study is extremely useful to prevent problems.

• Ensure strong links to District Health Offices.

• Suspend community recruitment during volatile periods.

• Provide ongoing community, subject, and ward staff education on the need for frequent blood draws and the small amount of blood being taken.

• Ensure proper consenting with subjects and guardians.

• Draw blood in a separate room, away from the ward.

 Food supplement palatability

• Some subjects disliked the selected food supplement, and one could not eat it.

• Mixing food supplement with instant maize porridge (a common food staple) improved subjects’ ability to consume it.

• Perform quick assessment before study initiation to ensure the target population can consume supplement.

• Adjust supplement, if needed, to make it more suitable.