Atuhaire Arnold

Abstract Background and objective Reducing low-value care may improve clinical practice and preserve scarce resources, but lower use alone does not demonstrate better allocation. We examined how selected African studies define inappropriate care, assess whether patients receive needed care, and report resource consequences and subsequent use. Methods We narratively reviewed English- and non-English-language clinical, implementation, economic, and health-system evidence. Database searches covered publications from 2000 through October 1, 2026, using PubMed/MEDLINE, Scopus, Web of Science Core Collection, and African Journals Online (AJOL). We also searched citations backward and forward. We selected sources purposively to illustrate different clinical criteria, study designs, and resource outcomes, and linked reports from the same program. We compared 27 program evaluations; audits and financing studies provided context. The selection was illustrative rather than exhaustive. Results Evidence concentrated on malaria management, antimicrobial stewardship, and laboratory testing. Some interventions reduced care judged inappropriate against explicit criteria; others reduced total prescribing under clinical algorithms. Diagnostic trials also reported null or mixed effects, and prescribing improvements sometimes coexisted with missed indicated care. Economic findings included estimated drug costs, avoided laboratory charges, recorded expenditure, and modeled outcomes. Diagnostic and implementation costs could offset reductions in other inputs. None of the 27 evaluations, including linked reports, established that reducing inappropriate care made net resources available, led to intentional reinvestment, and improved outcomes in a receiving service. This finding is limited to the selected reports. Conclusion Selected African interventions improved prescribing or reduced inappropriate care, but the evidence did not establish subsequent benefit from deliberate resource reallocation. By linking clinical and economic reports, this review distinguishes clinical improvement, additional indicated care within a service, and benefit from reinvestment. Evaluations should measure the outcomes needed to support the benefit claimed. Clinical improvement remains valuable even when it does not release funds. Keywords: low-value care; medical overuse; healthcare underuse; de-implementation; resource allocation; reinvestment; Africa. Description: Extended data supporting the narrative review “Reducing low-value care in African health systems: a narrative review of clinical and resource outcomes” (F1000Research manuscript 192075). The document contains four supporting tables: Table S1. Selected African program evaluations and their reported outcomes: evidence from 27 evaluations, covering effects on care, indicated care and safety, and resource outcomes. Table S2. SANRA assessment of the review: the author’s self-assessment using the Scale for the Assessment of Narrative Review Articles. Table S3. Supporting database search strategies: search strings for PubMed/MEDLINE, Scopus, Web of Science Core Collection, and African Journals Online, with search dates, publication limits, and explanatory notes. Table S4. Program grouping and outcome classifications: classification of the 27 programs and their linked reports by practice outcomes, indicated care or follow-up, and monetary evidence. These materials summarise evidence from published sources and document the review’s methods. No newly collected participant-level data are included. Reference numbers correspond to the accompanying manuscript, and full references cited in the extended data are included in the document.

Introduction Program evaluation in medical education often emphasizes outcomes such as examination performance, competency attainment and learner satisfaction, but these indicators do not fully explain why programs with similar structures can produce different educational results. This review introduces collective educator efficacy as a potentially important but underexamined determinant of program implementation and program quality. Methods We conducted a structured narrative review with conceptual synthesis, drawing literature from medical education, collective efficacy research, organizational psychology, faculty development and program evaluation. The review used transparent search and selection procedures and was guided by published standards for high-quality narrative reviews. Results The literature suggests that educational outcomes are shaped not only by curriculum design, but also by faculty coordination, shared expectations, psychological safety, assessment calibration and the collective capacity to implement, adapt and sustain educational practices. Foundational work on collective efficacy shows that shared group efficacy beliefs are associated with performance and persistence, while adjacent health professions education literature on programmatic assessment, faculty development, interprofessional learning and communities of practice highlight the importance of shared mental models and collaborative culture. Synthesizing these literatures, we define collective educator efficacy as a faculty group’s shared belief in its capability to work together to achieve educational goals and propose a framework for evaluating it within medical programs. Discussion A collective educator efficacy-informed approach may help explain variation between structurally similar programs and provide a practical lens for program improvement, faculty development and evaluation design. Empirical work is now needed to operationalize and validate the construct in medical education.

Background: Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by rapidly progressive, painful cutaneous ulceration and remains a diagnosis of exclusion because no single laboratory or histopathological test is diagnostic. Establishing a clinically well-supported diagnosis is particularly challenging in resource-limited settings where histopathology and other advanced investigations are often unavailable, necessitating reliance on structured clinical assessment and validated diagnostic frameworks. Case Presentation: A 26-year-old multiparous woman from South-Western Uganda presented with recurrent, progressively painful multifocal ulcerations involving both lower limbs and upper extremities. The initial episode developed during the first month of pregnancy as pruritic pustules that rapidly evolved into ulcerative lesions following minor trauma, with recurrence occurring two years later from a persistent non-healing ulcer. Comprehensive clinical evaluation found no evidence suggestive of inflammatory bowel disease (IBD) or other major associated systemic conditions, while wound cultures were sterile, supporting a non-infectious process. Because histopathology, gastrointestinal endoscopy, and other advanced investigations were unavailable, diagnosis relied on careful clinical assessment, systematic exclusion of important differential diagnoses, characteristic lesion morphology, pathergy, previous response to immunosuppressive therapy, and a PARACELSUS score supportive of PG. The patient was treated with oral prednisolone, cyclosporine, structured wound care, supportive therapy, and physiotherapy, resulting in marked clinical improvement at three-month follow-up. Conclusion: This case demonstrates how structured clinical reasoning and validated diagnostic frameworks can support a clinically well-substantiated diagnosis of probable PG when confirmatory investigations are inaccessible. It also describes a temporal association between disease onset during early pregnancy and pregnancy loss, an observation that should be interpreted cautiously and requires further investigation rather than implying causality. Careful exclusion of alternative causes of ulceration remains fundamental before initiating immunosuppressive therapy. Keywords: pyoderma gangrenosum, pregnancy-associated dermatosis, PARACELSUS criteria, Delphi consensus criteria, case report, resource-limited settings, Uganda

Background: Lenacapavir (LEN), a first-in-class HIV-1 capsid inhibitor administered subcutaneously twice yearly, has demonstrated near-perfect efficacy in Phase 3 trials, generating justified enthusiasm for its potential to reconfigure HIV prevention. However, its revolutionary success obscures critical spatiotemporal vulnerabilities. We critically examined the protective envelope of LEN, specifically focusing on the gap between systemic pharmacokinetics (PK) and mucosal distribution, the dynamics of the prolonged PK tail, and the clinical emergence of capsid resistance. Methods: A systematic narrative synthesis was conducted through April 2026. We integrated screening and data parameters from the PURPOSE and CAPELLA trials alongside advanced PK-PD modeling and structural biology datasets to comprehensively map the spatiotemporal parameters of lenacapavir-based PrEP. Findings: We characterize the Limitations of Systemic Surrogacy, highlighting that no published empirical data exist characterizing LEN concentrations in human mucosal sanctuary sites; the sole registered tissue distribution trial (Pro00043856) remains unpublished four years post-registration. While modeling baseline assumptions establish a wild-type 95% preventive plasma concentration (EC 95 ) of 5.8 ng/mL, the terminal absorption-limited elimination phase creates a definitive 106– 235 day Mutant Selection Window (MSW) following drug discontinuation. Based on the 58 studies included in the full synthesis, falling sub-therapeutic drug concentrations during this tail phase exert selective pressure that favors high-fitness capsid substitutions (eg, Q67H), lowering the genetic barrier for complex, high-level resistance mutations (eg, N74D). Clinical breakthrough infections observed across the CAPELLA trial (19%) and rare PURPOSE infections (0.07 per 100 person-years) validate this corridor of vulnerability, highlighted by a recorded seroconversion occurring 16 months post-injection. Conclusion: Optimizing the public health impact of lenacapavir requires transitioning from simple serum-based monitoring toward tissue-informed clinical stewardship. Unlike conventional oral PrEP, twice-yearly lenacapavir involves an extended pharmacological commitment of nearly 12 months, requiring pre-planned clinical protocols for bridging therapy during drug discontinuation. Implementation requires the evaluation of high-sensitivity viral surveillance tools ( LOD ≤ 10 copies/mL) and global access reconfigurations to resolve the economic and licensing barriers separating low-cost generic synthesis from international list prices, protecting the long-term viability of the capsid inhibitor class across all implementation sectors. A flowchart detailing three phases: active prophylaxis, discontinuation and clinical stewardship. Keywords: lenacapavir, HIV pre-exposure prophylaxis, pharmacokinetics, drug resistance, viral, global health equity, capsid inhibitor, area under curve

Background Sub-Saharan Africa (SSA) bears the world’s greatest HIV burden, prompting sustained interest in host genetic modifiers of susceptibility, including the ABO blood group system. Yet reported associations between ABO phenotype and HIV infection remain inconsistent, and whether they reflect true biological effects or uncontrolled population structure is unresolved. Methods We conducted a PRISMA-informed structured narrative review of studies examining ABO phenotype and HIV infection in SSA, searched across PubMed/MEDLINE, Google Scholar, Scopus, Web of Science, Embase, and African Journals Online. Given marked heterogeneity in design, denominators, and reporting across eligible studies, a formal meta-analysis was not undertaken. Instead, for studies reporting extractable population-level ABO frequencies, we explicitly tested whether HIV-associated phenotype patterns were distinguishable from background distribution. Results Fifteen studies from nine SSA countries met inclusion criteria. Blood group O was the most prevalent phenotype both in the general population and among HIV-positive individuals in every study reporting background data. Among six studies with quantifiable denominators, only one (Korir et al., Kenya) used an independent background comparator; its HIV-positive proportion (45.6%, 95% CI 39.8–51.4%) fell squarely within the background range (45–49%), showing no detectable excess. The remaining five studies derived HIV and background estimates from the same sample, precluding independent confounding assessment. A notable outlier — 46.2% blood group AB among an HIV-exposed infant cohort (Okonkwo et al.) versus an expected 3–5% — represented the largest deviation observed, though based on a small subgroup requiring replication. Only two of fifteen studies reported adjusted estimates. Conclusion Existing SSA evidence does not support a reproducible, confounding-independent association between ABO phenotype and HIV infection; apparent group-O associations largely reflect background prevalence. Standardized reporting of adjusted estimates and population phenotype distributions is needed going forward.

Introduction: Access to timely prehospital trauma care (PTC) remains a public health challenge in Uganda. Consequently, communities rely heavily on informal first responders such as bystanders. Despite their critical role, there is no national synthesis of their contributions or integration into the formal health system. Aim: To synthesize evidence on the roles, outcomes, and system integration of community-based trauma responders in Uganda’s PTC. Methods: A scoping review was conducted using PubMed and Google Scholar to identify studies describing community responders involved in PTC in Uganda. Studies outside Uganda or hospital-based were excluded. Data extracted included responder types, study characteristics, outcomes, barriers, enablers, and health system integration. Thematic synthesis was guided by the WHO Emergency Care Systems (ECS) Framework. Results: Of 92 articles screened, 17 met inclusion criteria, spanning 2009-2025. 53% focused on urban areas, mainly Kampala. The most covered ECS domains were Training and Knowledge (59%), Barriers and Enablers (53%), and System Integration (41%). Community Acceptability and Sustainability (24%) and Activation and Coordination (12%) were less frequently addressed. Boda-boda riders and police officers were the most reported responders. Conclusion: Community-based responders are pivotal yet under-recognized in Uganda’s trauma care. Enhanced training, formal support, and improved system integration are urgently needed to strengthen prehospital emergency response.