Saldanha, Ian

Public Health


South Africa

South Africa - Collaborative Outcomes Study in Meta-Analyses in HIV/AIDS (COSMAHA)

The Cochrane Collaboration is an international nonprofit organization that prepares, maintains, and promotes the accessibility of systematic reviews and meta-analyses of healthcare interventions. The Collaboration, started about 20 years ago, includes approximately 28,000 individuals working across 102 countries, most of them volunteers and all working towards the common interest of improving global access to healthcare information. Systematic reviews and meta-analyses play an important role in knowing what preventive and treatment strategies work best. Systematic reviews are useful regardless of whether the decision-maker is in a low, middle, or high income country, though the populations, interventions, and conditions may vary in important ways. Because Cochrane reviews produced by a global network of contributors, they are, by design, useful to populations worldwide.The Johns Hopkins Cochrane group is engaged both in doing systematic reviews and in methodological research on how to do them better and to make them relevant to specific populations. Clinical and patient-important outcomes are two key indicators of the success of healthcare interventions. For example, patients, healthcare providers, and researchers wishing to know the comparative effectiveness of two drugs available for treating early angle closure glaucoma would want to know the drugs' effects on a patient's field of vision. To find this out, a researcher would combine data from multiple studies addressing the same question in a systematic review and meta-analysis. Sometimes, it is not possible to combine the results of studies because the way that the outcome is measured (in this example, visual field) is too variable. To make meaningful comparisons among available healthcare options, the available research (clinical trials, systematic reviews, and meta-analyses) should be consistent in its assessment of outcomes. The importance of similarities in outcomes measurement across studies of intervention effectiveness is only now being recognized as a very important issue.

I spent approximately two months from June to August 2013 working on a project called the Collaborative Outcomes Study of Meta-Analyses in HIV/AIDS (COSMAHA) at the South African Cochrane Centre (SACC) in Cape Town, South Africa.

This would be the longest I have lived anywhere other than my hometown in Mumbai, India and my current home in Baltimore, USA. Naturally, this caused logistical challenges and some feelings of anxiety. However, my advisor Dr. Kay Dickersin and individuals at the Johns Hopkins Center for Global Health (CGH) and the SACC helped make the process move along seamlessly. Anxiety was soon replaced by excitement and anticipation for what lay ahead!

What surprised me about my trip was how much I fell in love with Cape Town! I had heard and read about/seen how beautiful the city is, but was most impressed when I experienced it for myself. Undoubtedly, Cape Town is the most beautiful place I have ever been in, with its wonderful people, breathtaking sights, and delicious food.

A critical challenge facing South Africa and other parts of Africa is developing a workforce for evidence-based healthcare in general and HIV/AIDS in particular. The SACC, which hosts the Cape Town Satellite of the Cochrane HIV/AIDS Review Group, is successfully working towards this important capacity-building goal. One of our objectives in working with the SACC was to contribute to our understanding of South African investigator-partners and their needs, so that in current and future collaborations we work towards mutually important goals (and not just our own). This is essential to assisting with building research capacity and productivity. I worked in two areas that contributed to capacity building.

First, the SACC supports systematic review authors all around Africa and conducts methods research related to conducting systematic reviews. This is exactly where the COSMAHA project fits in. The objectives of the project are (1) to assess completeness and consistency of outcome pre-specification in systematic reviews and (2) to assess the extent of usage of patient-reported and patient-important outcomes in systematic reviews. I collected data for this project while at the SACC and am currently writing up the findings for publication.

Second, in addition to research, members of the SACC are involved in systematic review methods training activities, such as hosting training workshops and teaching courses at universities. During my stay at the SACC, I helped teach the Systematic Reviews and Meta-Analysis course for students receiving a Master’s degree in Clinical Epidemiology at the University of Stellenbosch. While I had already been involved with teaching methods for systematic reviews, clinical trials, and other types of epidemiologic studies here at Johns Hopkins, working with a different team of individuals exposed me to different effective teaching methods and styles. I was also requested by the faculty to provide feedback regarding the content and teaching methods in the course. This teaching experience will undoubtedly help me achieve one of my career goals, namely becoming an effective teacher of evidence-based healthcare and epidemiology.

My experience in South Africa helped crystallize some of my research ideas on the importance of defining outcomes that are measured in systematic reviews and other studies. I also learned new lessons about the importance of collaboration and capacity-building. As researchers and public health workers, we need to understand local needs before we can assist in global health efforts. Being able to apply creative and critical thinking skills in the COSMAHA project further enhanced my learning experience, as did mentoring by my advisor and our collaborators in South Africa. I learned that my work can only grow stronger and more effective through collaboration and the creation of mutual learning environments.

I am very grateful to all involved, especially my advisor Dr. Dickersin, the SACC, the CGH, for this professional growth opportunity. I hope to travel to South Africa again soon! To students who might be considering opportunities like this, I’d say: “Go for it!”


May 2023




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