SUMMARY Globally, people living with HIV (PLHIV) are living longer due to highly effective antiretroviral therapies (ART). As they age, many PLHIV are experiencing conditions and diseases associated with aging at both higher rates and at younger ages compared to those without HIV. In Kenya, more than 60% of people living with HIV (PLHIV) are women who may experience conditions like osteoporosis and frailty as they live longer. Little research on aging is taking place in sub-Saharan Africa (SSA) which makes it challenging to develop guidelines and practices. In this supplement to our D43 award, Women and HIV: Translation of Research into Practice (TW009783), we propose to determine the prevalence and correlates of frailty and osteoporosis, two conditions associated with aging that are overrepresented among women. We will conduct an observational cohort study among women ≥50 years old with and without HIV in Nairobi, Kenya and characterize the impact of these conditions on their functional status and quality of life. We will also explore the barriers and facilitators of accessing care for these conditions through conversations with study participants, their caregivers and clinic providers. Drawing from our results and stakeholder meetings, we will then initiate work with the Kenyan Ministry of Health to simplify and adapt existing screening tools for HIV clinics across the country. Not only will this work build the evidence on aging among women living with HIV in SSA, it will lay a strong foundation for future studies that could change practice and care for PLHIV as they age, especially women. The study is being proposed as a supplement to the Fogarty-funded D43 award entitled, Women and HIV: Translation of Research into Policy (TW009783) and will seek to address the gap in research and training on HIV and aging among women in Kenya. A KEMRI post-doctoral fellow, Dr. Shradha Doshi, will lead study implementation with support as needed from Dr. Sarah Masyuko, (UW), Dr. Elizabeth Bukusi (KEMRI) and Dr. Carey Farquhar (UW). In addition to guidance provided by the program leaders, Dr. Doshi and a second pre-doctoral trainee will be supported by a mentorship team of research and subject-area experts from KEMRI and the UW. This integrated approach will provide an outstanding opportunity to spur research in HIV and aging with the potential to inform the design of HIV and aging policies and guidelines, while also providing training of researchers in epidemiology and implementation research in HIV and aging in Kenya.

SPECIFIC AIMS People living with HIV (PLHIV) are living longer due to highly effective antiretroviral therapy and as they age many are experiencing conditions and diseases associated with aging at higher rates - and at younger ages - than those without HIV. Conditions associated with aging include frailty, osteoporosis, cognitive impairment, and the morbidity and polypharmacy associated with developing cardiometabolic diseases and other chronic conditions.1,2 In Kenya, nearly 60% of PLHIV are women and they may have premature menopause which can exacerbate conditions like osteoporosis which is a risk factor for those with frailty who are prone to falls. For this reason, these two conditions, frailty, and osteoporosis, will be the focus of this study. There is a paucity of data on aging in sub-Saharan Africa (SSA), with even less known about reproductive aging among those with HIV, which greatly limits efforts to screen and tailor interventions for women who would benefit from services. We propose to determine the prevalence and correlates of frailty and osteoporosis, two conditions associated with aging that are overrepresented among women. We will conduct the study among women ≥50 years old with and without HIV in an urban center in Kenya and characterize the impact of these conditions on their functional status and quality of life. We will also explore the barriers and facilitators of accessing care for these conditions through conversations with study participants, their caregivers and clinic providers. Drawing from our results and stakeholder meetings, we will then initiate work with the Kenyan Ministry of Health to simplify and adapt existing screening tools for HIV clinics across the country. Not only will this work build the evidence on aging among women living with HIV in SSA, it will also lay a strong foundation for future studies that could change practice and care for PLWH as they age, especially women. The proposed project will leverage an ongoing cross-sectional study of 200 PLHIV and 200 HIV-negative adults over the age of 45 years which seeks to understand the prevalence of early structural heart disease in HIV. From this study, we will enroll 100 women living with HIV and 100 HIV negative women aged ≥50 years and follow them for 6 months, conducting geriatric assessments at two timepoints, and dual-energy x-ray absorptiometry (DEXA) scans and in-depth interviews for a subset at one timepoint. A Kenya Medical Research Institute (KEMRI) post-doctoral trainee will lead the project which is based at Kenyatta National Hospital in Nairobi, Kenya. The research study proposed in this supplement will build on the goals of the parent grant to strengthen research capacity in Kenya on HIV and women, providing advanced research training opportunities for emerging researchers. The specific aims of this study are: 1. Compare the prevalence and correlates of frailty and osteoporosis among 200 women ≥50 years old with and without HIV in Kenya (1:1). We will survey participants recruited from the parent study at their enrollment into this study and at their 6-month follow-up visit using screening tools from the Comprehensive Geriatric Assessment (CGA) and perform DEXA scans on the subset who are 1) diagnosed with frailty, 2) post- menopausal, 3) have sustained fractures, or 4) >64 years old. 2. Determine the impact of HIV, frailty and osteoporosis on functional status and quality of life among 200 women ≥50 years old with and without HIV. An activities of daily living survey and the World Health Organization health-related quality of life (WHOQOL-HIV) survey will be administered at enrollment and 6 months, with comparisons of results for those with and without HIV 3. Evaluate the patient, provider and system related barriers and facilitators to care for these conditions among women aging with HIV in Kenya through in-depth interviews and focus group discussions. 4. Develop culturally appropriate, simpler screening tools for frailty, osteoporosis and other conditions of aging using data from Aims 1 and 2 and engaging stakeholders. Our supplement builds on the aims of the parent D43 which is focused on training researchers at the Kenya Medical Research Institute (KEMRI) and the Ministry of Health (MOH) to conduct locally relevant research that will improve the lives of women affected by HIV in Kenya and other parts of sub-Saharan Africa. This research will provide preliminary data that will spur research to design and tailor interventions for those aging with HIV. We envision that it will impact policy guidelines and clinical practice in HIV clinics for older PLHIV. RESEARCH STRATEGY AND TRAINING PLAN SIGNIFICANCE More than half of the people living with HIV globally are women and HIV is associated with reproductive aging including earlier onset of menopause. It is estimated that menopause occurs 5 years earlier in women with HIV compared to women without HIV.3 Reproductive aging is also further accelerated among women living in sub-Saharan Africa putting them at an increased risk of aging related conditions and they may also occur earlier.1,2,4-6 Some of these conditions include cardiovascular disease, metabolic disorders, frailty, osteoporosis, and cognitive impairment. These conditions commonly co-occur and exacerbate each other resulting in adverse health outcomes that further decrease quality of life and functional status, and can even lead to death (Figure 17).8 In Kenya, 58% of PLHIV are women with the largest the majority being aged between 40-54 years.9. As PLHIV are surviving longer, the proportion who are in the older age bracket is continuously increasing. HIV is an independent risk factor for osteoporosis and bone fractures. PLHIV have a 2-fold increased risk of fractures compared to their HIV- negative controls, and these occur about 10 years earlier than in those without HIV.10-12This is also heightened among postmenopausal women and those using protease inhibitors or Tenofovir-based regimens Figure 1. Constellation of obesity, vascular, bone, frailty and brain aging factors against a background of health disparities in aging women with chronic HIV infection (Gustafson et al)7 which form part of the ART regimens in Kenya. 13,14 In addition to osteoporosis, women living with HIV also are at higher risk and earlier onset of frailty, a condition characterized by declining function across multiple physiological systems and associated with a greater risk of adverse outcomes.6,15,16 Data on frailty is mainly from high income countries showing that frailty is associated with more frequent fractures and falls,11 higher and longer hospitalizations, and higher mortality.17-19 While tools for screening of age-related conditions are available, few PLHIV undergo comprehensive geriatric assessment (CGA). The CGA is a multidisciplinary evaluation of the functional status, psychosocial, cognitive, and medical status to identify geriatric syndromes to allow development of treatment plans for older adults.20 It has been found to be effective in improving the quality of life of older adults.21 It has largely been used outside SSA with a few applications in SSA.22-25 There is a paucity of data on its use among PLHIV in SSA. Some of the challenges of its use is the lengthy time required for the evaluation, coordination of multiple disciplines, training needs of health providers, and the perceptions of patients.26,27 There has been effort to outline key domains that are key for PLHIV. To get simpler and culturally appropriate screening tools, we need to understand the perspectives of patients, their caregivers, health providers and policy makers to understand what really matters to them. This will be addressed through the aim 3 and 4. This supplement will fill the gap in research and training on HIV and aging among women in Kenya. While a large number of people are aging with HIV, the health system is not prepared to handle this problem. There is limited research on the magnitude of this problem and the implementation strategies to address aging in HIV in Kenya. In addition, while the HIV guidelines prioritizes screening for non-communicable diseases, it does not provide guidance on the screening and management of osteoporosis and frailty and other geriatric syndromes. This supplement will provide outstanding opportunities to spur research in HIV and aging while providing training of researchers and trainees in Kenya in both epidemiology and implementation research in HIV and aging. This also has the potential to inform the design of HIV and aging policies and guidelines. INNOVATION The proposed study is innovative and will represent a substantial advance for the field of HIV and aging in Kenya and globally among women living with HIV in the following ways: • To the best of our knowledge, it is the first study on women aging with HIV in Kenya using the comprehensive geriatric assessment and will complement the few studies in SSA on HIV and aging. • Adaptation of the comprehensive geriatric assessment focusing on its feasibility and acceptability in a lower middle income country will be an important methodological advance in aging and implementation science. APPROACH We propose to implement a 6-month observational cohort study of 100 women ≥50 years of age living with HIV and 100 without HIV at Kenyatta National Hospital. We will also collect qualitative data through focus group discussion (FGD), key informant interviews and stakeholder workshops. Details are included below. Study team The proposed research program will be directed by Dr. Sarah Masyuko and KEMRI post-doctoral fellow Dr. Shradha Doshi will lead study implementation, with support from Elizabeth Bukusi at KEMRI and Dr. Carey Farquhar as needed. Both Drs. Farquhar and Bukusi are the MPIs on the parent grant and have substantial experience with Fogarty training programs, as well as other training programs in Kenya. They have been successfully co-directing the Women and HIV: Translation of Research into Policy training program since it was funded 9 years ago. Several mentors at KEMRI and UW will support Dr. Doshi, as listed below. Dr. Sarah Masyuko, PhD is an Assistant Professor with the Department of Global Health. She will be the study PI for this research. She received her MPH in Global Health and her PhD in Global Health-Implementation Science from the University of Washington. She has been the lead of the HIV Testing Services and Pre Exposure Prophylaxis (PrEP) program at the National AIDS and STI Control Program (NASCOP) with the Kenyan Ministry of Health. Dr. Masyuko has been involved in research that spans from designing, implementing, disseminating and bringing to scale evidence-based health interventions. Her research interests are in implementation science with the direct translation of research results into policy and practice in HIV Prevention, Care and Treatment and Non-communicable diseases in low- and middle-income countries. Dr. Shradha Doshi, MBChB, MMed, MPHc is an MPH student in the Cardiometabolic Research and Training Program at UW, funded by the Fogarty International Training Center, who will graduate in August 2023. She has been selected by KEMRI to receive a post-doctoral fellowship for the proposed research. Dr. Doshi is also a Consultant Physician with more than 17 years of experience in the medical field. Her research interests include the use of cardiovascular biomarkers as diagnostic, prognostic, and predictive markers in heart failure. She is working on an assessment of the association of renal impairment with coronary artery disease phenotypes and plaque parameters among persons living with HIV. When she was doing residency training at Kenyatta National Hospital she worked in cardiology and the HIV Comprehensive Care Center. Mentors Mentorship will be a critical component of this research project and has key to the success of the parent grant. The post-doc fellow and study team will meet weekly and the KEMRI fellows the entire team (fellows and mentors) will meet monthly to report on research updates. In addition to the program leaders, the mentorship team at KEMRI and UW includes: Dr. Nauzley Abedini MD MSc, Division of Gerontology and Geriatric Medicine, University of Washington; Co-lead, Global and Cross-Cultural Palliative Care Initiative. Dr. Abedini is an Assistant Professor of Medicine in the Division of Gerontology and Geriatric Medicine at the UW. Clinically, Dr. Abedini is an attending physician in general medicine and palliative medicine at Harborview Medical Center and is passionate about providing high quality, equitable palliative and end of life care to patients and families of diverse backgrounds. She obtained her MD from the University of Michigan Medical School and completed residency in Internal Medicine at the UW. Dr. Abedini's scholarly interests focus on applying pragmatic and scalable educational and health system interventions to improve the ability to meet the palliative care needs of all patients and families dealing with serious illness. She currently serves as the Assistant Program Director for Wellness in the Internal Medicine Residency Program at the UW, and leads several research initiatives aiming to enhance training and capacity to care for diverse, seriously ill patients locally and globally. Dr. Abedini is the Founder, and formerly served as Chair, of the Global Palliative Care Working Group - an interdisciplinary working group at the Consortium of Universities for Global Health. Rose Bosire, MBChB, MPH PhD, Senior Research Officer, KEMRI. Dr. Bosire is a senior medical research scientist at KEMRI and involved in collaborative HIV/AIDS research projects between University of Washington and Kenyan institutions, namely, KEMRI, University of Nairobi, Kenyatta National Hospital and Coptic Mission Hospital in the last 20 years. She completed a Master of Public Health degree at the University of Washington, with Drs Grace John-Stewart, Carey Farquhar and Julie Overbaugh. Since joining KEMRI she has been involved in teaching Epidemiology, Global health, Communicable Disease Control and Prevention, and Research methods classes to Masters and PhD students in addition to supervising their theses. In this capacity, Dr. Bosire has played a key role in curriculum development and improving the quality of training delivery. Dr. Alfred Osoti, Senior Lecturer, Department of Obstetrics and Gynecology, University of Nairobi. Dr. Osoti is PI of an NIH K43 grant evaluating incidence of metabolic syndrome after delivery, a risk factor for future cardiovascular disease, and MPI for NIH R21 grant evaluating subclinical cardiac dysfunction using speckle tracking echocardiography after hypertensive disorders in pregnancy. Dr Osoti received his MBChB and MMed in Obstetrics and Gynecology degrees from the University of Nairobi. He is an alumnus of the NIH Fogarty International Centre Scholar and Fellow program. Dr. Osoti obtained MPH and PhD training from the University of Washington, Seattle. He has also supervised 30 postgraduate students, 20 to completion. His research interests are on cardiovascular disease risk after delivery, prevention of HIV transmission, maternal health interventions to reduce maternal morbidity and mortality from hemorrhage and hypertension, and m-health. Dr. Chris Longenecker, Director, Global Cardiovascular Health Program, University of Washington; Director, Harborview HIV-Cardiology Clinic. Dr. Longenecker is a non-invasive cardiologist and Associate Professor in the Division of Cardiology and Department of Global Health at the University of Washington School of Medicine. He is the inaugural Director of the Global Cardiovascular Health Program, a joint initiative of cardiology and global health. Clinically, he attends on the Harborview cardiology consultative service and is director of a unique HIV-Cardiology clinic within the Madison Clinic at Harborview Medical Center. Dr. Longenecker’s research, which is primarily conducted in the USA and Uganda, focuses on mechanisms and prevention of cardiovascular disease in people living with HIV, with a secondary focus on quality of care and outcomes for people living with rheumatic heart disease. His research has been funded by the NIH, the American Heart Association, and Medtronic Philanthropy. Study design and population This study will be a 6-month observational cohort study of 100 women living with HIV and 100 women without HIV at Kenyatta National Hospital. We will also collect qualitative data through FGD, key informant interviews and stakeholder workshops. To improve the efficiency of recruitment, we will leverage a study led by Dr. Shakil Saate, a cardiologist who is currently a Fogarty International Center funded Northern Pacific Global Fellows program. Her study, “Early Structural Heart Disease, HIV, and Tuberculosis in East Africa (ASANTE)” is recruiting 400 men and women; 200 of whom are living with HIV. The study will assess the risk factors for cardiovascular disease (CVD) and presence of structural heart disease and examine their relationship with latent Tuberculosis Infection in persons living with HIV (PLHIV) compared with HIV-uninfected adults. The parent study will recruit 200 PLHIV from the Kenyatta National Hospital (KNH) HIV Comprehensive Care Clinic (CCC), including 100 females and 100 males. The study will also recruit 200 people without HIV from the KNH HIV Voluntary Testing Centers, of whom 100 are females and 100 are males, who will act as controls. The study will include participants who are >35 years old at enrollment and the PLHIV should be on antiretroviral therapy (ART) for >6 months. Exclusion criteria include known history of myocardial infarction or heart failure and pregnancy. The study will conduct echocardiograms and coronary CT angiography to assess for structural heart disease. Our study will recruit 100 women living with HIV and 100 without HIV from the parent study. This will include women aged 50 years and older. As the parent study has an earlier age of recruitment, we will include all women aged 50 years and above from the parent study as well as recruit additional participants from KNH until the sample size is reached. Aims 1 and 2: Compare the prevalence and correlates of frailty and osteoporosis and determine the impact of HIV, frailty and osteoporosis on functional status and quality of life among 200 women ≥50 years old with and without HIV during a 6 month period. Study procedures: During the routine clinic visit, the research assistants will review records of the parent study to identify those Using a tablet with the screening form and baseline questionnaire programmed into Open Data kit (ODK), the study nurse will consent and enroll the participants into the study. They will then collect data on sociodemographic and HIV disease status. We will then validated questionnaires and tools from the core domains of the comprehensive geriatric assessment including functional status, frailty, fall risk, cognition, mood, polypharmacy using validated tools (Table 1) We will assess the bone mineral density using the Dual-energy x-ray absorptiometry (DEXA) scans on a subset of women who are 1) diagnosed with frailty, 2) post- menopausal, 3) have sustained fractures or 4) >64 years old. We will also measure quality of life using the WHO-QOL-Bref-HIV validated for PLHIV. 28 We will abstract data on CVD risk factors, structural heart disease, fasting blood glucose and lipids including total cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL), and triglycerides, as well as viral load and CD4 count from the parent study. The participants will then be called back in 6 months to Table 1. Key domains of the comprehensive geriatric assessment Domains Screening Methods Baseline 6 months Function AND Lawton Instrumental Activities of Daily Living (IADL) The Katz Index of Independence X X in Activities of Daily Living Mobility/falls Falls in the past 12 months and the Timed Up and Go (TUG) test X X Frailty Fried frailty phenotype X X Cognition Montreal Cognitive Assessment (MoCA) X X Mood: Depression and PTSD PHQ-2/PHQ-9 and PTSD Checklist for DSM-5 (PCL-5) X X Polypharmacy “Brown bag” method X X Social: caregiver burnout and elder Zarit Burden Interview (ZBI) and Elder Abuse Suspicion Index X abuse (EASI) Osteoporosis Fracture Risk Assessment Tool and DEXA scans X Health related quality of life WHO-QOL-HIV-Bref X X undergo similar assessments as per table 1. The comprehensive geriatric assessment and physical examination will take about 1hr 15min to be completed. Referral and 6 month follow up: Patients who have any abnormal assessment will be referred and escorted to the medical outpatient clinic at KNH where they will receive treatment. We will then follow them up and call them after at least 6 months to undergo similar assessments as per table 1. This will be done during their routine clinic visit. Outcomes: The primary outcomes include 1) Change in prevalence and severity of frailty (frailty 1–2 = prefrail, 3–5 = frail) from baseline to 6months, 2) prevalence and severity of osteoporosis (T-score of-1.0 and -2.5 =low bone density/osteopenia and T-score -2.5 or below=osteoporosis), 3) change in functional status (ADL score of 4 =moderate impairment , 2 or less= severe functional impairment), 4)change in health related quality of life scores ( higher scores = better health) from baseline to 6months. Secondary outcomes will include 1) prevalence of falls ( TUG of >12 seconds) , 2) prevalence of multimorbidity (>2 chronic conditions), 3) prevalence of cognitive decline (MoCA score <26), 4) prevalence of depression (PHQ 2/9), 5) prevalence of polypharmacy. We hypothesize that these geriatric syndromes will be higher among women living with HIV compared to those without HIV and they will be improvement 6 months after treatment. Data collection, analysis and sample size calculations: Data will be captured in tablets programmed with ODK forms that will allow real time as well as offline data capture and uploading. The data is encrypted, and password protected. We will summarize continuous variables using mean and standard deviation for normally distributed variables and median and inter-quartile range (IQR) for non-normally distributed variables. Participant characteristics will be summarized at baseline and at 6 months and stratified by HIV status. We will then test for differences in baseline characteristics and prevalence using chi-square tests for categorical subgroups and a 2- group independent means t-test for continuous variables. We will calculate the prevalence of osteoporosis, frailty and other geriatric syndromes. We will use multivariable logistic regression to estimate the association between HIV and geriatric syndromes and their impact on functional status and quality of life. Unadjusted and adjusted models will be fit to evaluate associations with or without potential confounders (including age, education, smoking, alcohol use, healthy diet and exercise). We will also calculate 95% confidence intervals (95%CI) and use a significance (α) level of 0.05. Using estimates from a study comparing people living with and without HIV, we anticipated a 5% difference in prevalence of frailty among women living with and without HIV and standard deviation of 3.29 With an estimated 5% difference in women living with and without HIV, we will have over 90% power to reject the null hypothesis that the prevalence in these two groups is equal. The Type I error probability associated with this test of this null hypothesis is 0.05. Aim 3: Evaluate the patient, provider and system related barriers and facilitators to care for these conditions among women aging with HIV in Kenya using qualitative research methods. Qualitative data collection: We will use data from multiple sources including focus group discussions, key informant interviews, and stakeholder workshops. The instruments/guides will be tailored to each target audience and aligned with constructs in Implementation Outcomes Framework.30 FGD: We will conduct 2 FGD with 6-10 patients and 2 FGD with 6-10 health providers to collect data on acceptability and feasibility of integrating the comprehensive geriatric assessment for women living with HIV. The health providers will include physicians, clinical officers, nurses, medical assistants, record officers, community health volunteers and other volunteers. Key informant interviews (KII): We will conduct 10 in person/ phone semi-structured interviews with clinic leaders, facility managers, and policy makers at county and national levels. This will allow understanding of key informant perspectives on acceptability, feasibility and system level factors that may hinder or facilitate geriatric assessments among women aging with HIV. Qualitative data analysis: Interviews and focus group discussions will be conducted by trained interviewers accompanied by a note taker, audio-recorded and uploaded to a secure server. Interviews and focus groups will be conducted in English or Kiswahili, depending on the participant’s preferences and translated to English where necessary. Digital recordings will be transcribed verbatim with all personal identifiers removed. Two analysts will code the transcripts and conduct a thematic analysis mainly with deductive coding using a codebook. Finally, representative quotes and associated codes that represent key themes will be identified through consensus with the research team. The data will be managed using the ATLAS ti qualitative software. Aim 4: Develop culturally appropriate, simpler screening tools for frailty, osteoporosis and other conditions of aging using data from Aims 1 and 2 and engaging stakeholders. Data collection and analysis: We will have 3 stakeholder workshops consisting of groups of 8-10 participants each: one for recipients of care, another for health providers and another for program managers and policy makers. The 2 key questions that will pose include: a) What aspects of the geriatric assessment matters the most to you? b) How can the tools be made simpler and culturally acceptable? Figure 4: Go zone plots The 4 steps to be followed include: Step 1: Generate ideas: Stakeholders will independently write down the key aspects of the assessment that matters the most to them. Step 2: Record ideas: Each stakeholder will share one aspect of the geriatric assessment that matters to them until all aspects have been presented being careful to avoid duplications. Step 3: Discuss ideas: The participants will discuss the aspects presented and may add or merge related aspects. We will present the aspects of the CGA to identify any missing aspects. Step 4: Ranking ideas: Stakeholders will rank the top 5 aspects on two aspects i.e. importance and frequency on a scale of 0 (least) to 5 (most). The research team will then present aspects on the go zones plots with the right upper quadrant reflecting aspects with high frequency and importance (Figure 4). The output will be selection of 5 key aspects. A trained research staff will facilitate the session supported by a note taker. The sessions will be audio recorded and transcribed. Trainees and Training activities Through this supplement, the WHIV program will provide research opportunities, training and mentorship on HIV and aging to 1 post-doctoral fellow (see biosketch for Dr. Shradha Doshi) on HIV and aging and 1 pre-doctoral trainee from KEMRI recruited to assist with study coordination. This one-year mentored research project will provide funding for them to progress their research career and prepare them with tools and experience to build an independent career. To achieve their research and training goals, we have assembled a training and mentoring plan consisting of three components: a multidisciplinary mentorship team, didactic, and hands-on training (Table 2). 1) Mentorship: The trainees will participate in weekly study calls on the research and monthly calls with their core multidisciplinary mentorship team to provide guidance on the research and advice regarding career development. The trainees will have quarterly review meetings with their mentor team of content and methods experts and the project directors. They will also present at the Fogarty IARTP seminars and the Kenya Research Training Centre allowing them to present their works in progress and receive feedback from a larger team of faculty and students in Seattle and Kenya.2) Didactic and hands-on training: They will receive additional training in the HIV and aging, Fundamentals of Implementation Science (eDGH online course) and qualitative methods at UW as well as attend conferences on HIV and aging ( Table 2). They will also be expected to submit abstracts to the UoN Collaborative meeting and other local and international conferences. We expect that each trainee will submit at least one manuscript to a peer-reviewed journal, begin to apply for a career grant e.g. the K43 award, and provide mentorship to junior researchers and students at KNH, UoN and KEMRI. Table 2: Summary of training aims, courses and mentorship plan Training goal Formal courses Format Content Q1 Q2 Q3 Q4 elderly adults HIV among National HIV curriculum -UW directed online course Self Accentuated Aging, Screening and Detection of HIV in Older Adults, ART in the Older Patient with HIV, Common Comorbid Conditions in Older Persons with HIV, Life Expectancy, Age of Death, and Advanced Care Planning Background of HIV and aging, Accelerated versus X X Qualitative research GH 538 Advanced Qualitative Methods in Anthropology and Public Health-UW (5) Online Spring Qualitative research, questions, design, and data analysis X ATLAS ti workshop-UW Online Spring ATLAS ti for qualitative data analysis X Implementation Science Fundamentals of Implementation Science-(eDGH) UW Online Fall Implementation science methods including qualitative research, theories, models and frameworks, how to write an implementation science proposal Training goal Mentorship Format Y1 Y2 Y3 Y4 Qualitative research CFAR Behavioral core / Junior Investigator Group-UW Online Technical assistance in behavioral science, mentorship on manuscript writing X X X X HIV and aging Consortium CFAR HIV and Aging Research Online aging Workshops and technical assistance on HIV and X X X X Timeline We will recruit the trainees to start in September 2023. The training and mentorship plan will occur as per Table 2. The research plan is summarized in Table 3. Table 3: Research Plan Timeline Q1 Q2 Q3 Q4 Protocol development and Human Subjects Approval (modification of parent study) Aim 3 and 4 Preparation of interview guides Aim 1, 2,3,4 Data collection Aim 1, 2,3,4 Data analysis, manuscript preparation Dissemination