This thesis is concerned with understanding the patient flow from diagnosis of HIV infection to initiation of antiretroviral therapy (ART). Untreated HIV-infected individuals have a high risk of progression to AIDS and death, and of transmitting infection to others. Interventions to ensure prompt linkage into HIV care and ART could have substantial individual and public health benefits. At the turn of the millennium, very few HIV-infected individuals in sub-Saharan Africa had access to lifesaving ART. Since then, national HIV care programmes, supported by international funding, have driven impressive achievements in scaling up ART delivery, with over 9 million people having initiated ART by the end of 2012. Despite these achievements, the majority of HIV infected adults in sub-Saharan Africa remain unaware of their HIV status, meaning that they do not have the opportunity to access ART. Additionally, concerning reports have arisen from a number of HIV care programmes about high rates of patient drop-out and death between diagnosis of HIV and ART initiation. Together, these factors could significantly hinder efforts to achieve universal knowledge of HIV status and coverage of ART. The uptake of HIV testing, and magnitude of and reasons for drop-out of care between HIV diagnosis and initiation of ART were investigated in a prospective cohort study and linked qualitative study at primary care level in Blantyre, Malawi. The main findings were of extremely low uptake of provider-initiated HIV testing and counselling (completed on only 13% of adult facility attendances) and high rates of patient loss to care before ART initiation. Difficulties in completing ART eligibility assessments (WHO clinical staging assessments and measurement of CD4 count) were the major barrier to successful initiation of ART, with over-busy clinics, rushed providers, as well as high patient care- seeking expenses being significant contributory factors. Other sub-Saharan African countries that have implemented the public health approaches to HIV care delivery are likely to face similar problems. To attempt to improve uptake of HTC and linkage into ART care, two novel interventions were investigated. A community-based cluster-randomised trial compared two approaches to improve linkage into HIV care: facility-based initiation of HIV care following home HIV self-testing (HIVST), or optional home initiation of HIV care following HIVST. Uptake of ART, completion of HIVST, reporting of positive HIVST results and retention on and adherence to ART were the outcomes of interest. Over 6-months of HIVST availability, there was a highly significant 3-fold increase in the proportion of the adult population initiating ART, and a doubling of the proportion of adults reporting positive HIVST results to community counsellors where home initiation of HIV care was available, indicating increased willingness to access home-based HIV care. Having identified substantial problems with the use of the WHO clinical staging system for identifying ART eligibility, the accuracy of a brief novel community health worker (CHW) ART eligibility assessment tool was compared against a gold standard of CD4 count. The CWH tool significantly outperformed the WHO clinical staging system in identifying CD4 count of <350 cells/mm3 in terms of sensitivity, positive predictive value, negative predictive value and area under the receiver operator characteristic curve. Nevertheless, overall performance of the CHW tool was still suboptimal with nearly half of ART eligible participants missed, and was worse when compared against the new WHO-recommended ART eligibility threshold of CD4<500 cell/mm3. In conclusion, suboptimal rates of facility-based HTC and subsequent linkage into care are potential major stumbling blocks in efforts to achieve universal access to ART. Current ART eligibility tools are either not widely available (CD4 count measurement), or are insensitive, overly-complex and time-consuming (WHO clinical staging system). Home initiation of HIV care following community-based HIVST overcomes these barriers, with high uptake of HIVST achieved over short time-frame and substantial and significantly increased population-level rates of ART initiation. In an era where “test-and- treat” is increasingly being seen as a strategy to impact upon the HIV epidemic, interventions that improve uptake of testing and linkage into care, such as home HIVST and initiation of HIV care, will be required.

This thesis examines the challenges of managing a population of patients with type 1 diabetes who initially attended a hospital outpatient clinic between 1991 and 1996. These 386 patients are subsequently reviewed in 2001 and 2006. The continued attendance at the clinic, level of glycaemic control and prevalence of microvascular and macrovascular complications are assessed. In demonstrating the outcomes of this cohort of patients they are compared to the patients within the landmark study The Diabetes Control and Complications Trial (DCCT). The DCCT showed conclusively that good glycaemic control decreased the risk of developing microvascular complications when compared to those patients with less tight glycaemic control. The findings of this study definitively demonstrated the benefits of good glycaemic control. What was also apparent, but a less publicised finding of this trial was the increase in episodes of hypoglycaemia and the weight gain seen in the group with intensive control arm. How do patients in the ‘real-world’ compare to those patients within the DCCT study, is such good control achievable outside the setting of a clinical trial? The outcomes of the patients attending the younger adult diabetes clinic are demonstrated to be similar to those patients in the DCCT who were controlled conventionally, despite encouragement to adopt an intensive insulin regime and offered regular clinical review from both diabetes specialist nurses and consultant. The potential causes for the differences in glycaemic control between an outpatient clinic and those patients in the DCCT are explored. The thesis also examines the difficulties in managing the small numbers of patients with type 1 diabetes who are hospital inpatients. In particular, a group of patients with diabetes who are also intravenous drug abusers are studied. This group are compared to other inpatients and the study clearly shows episodes of frequent admissions and very high mortality rates in the study group. In conclusion the thesis highlights the many problems which exist when trying to manage type 1 diabetes in the outpatient setting including clinic non-attendance, prevalence of other medical problems and limiting factors such as weight gain and hypoglycaemia. Discussion is also made of ways in which to address these issues and improve control for this group of patients.

Background: Cerebral malaria is a major cause of mortality and morbidity in African children. Pathology is related to interactions between malaria-infected red blood cells (iRBC) and the endothelium but the aetiology of the neurological compromise remains unclear. Methods: This thesis involved direct and downstream investigation of the endothelium in Malawian children with cerebral malaria and controls in post-mortem samples, plasma and through developing a novel ex vivo method to examine endothelium in subcutaneous tissue. Results: In post-mortem samples of brain in fatal cerebral malaria, there was thrombosis and loss of endothelial protein C receptor (EPCR) associated with iRBC sequestration. iRBC associated loss of EPCR and thrombomodulin was also demonstrated in post- mortem samples of gut and subcutaneous tissue but this was less marked than in the brain and rarely associated with thrombosis. Subcutaneous biopsies taken on admission with cerebral malaria demonstrated reduced EPCR and thrombomodulin ex vivo, showing that loss of these receptors is present at the time of presentation and are not just agonal events. Examination of coagulation in blood demonstrated activation of coagulation, as indicated by raised thrombin-anti-thrombin complexes and reduced protein C and antithrombin levels. However this was compensated as there was normal prothrombin fragment (F1+2)-to-activated protein C ratios and only mildly altered clotting times. Examination of markers of endothelial activation (soluble Intracellular Adhesion 2 Molecule-1 [sICAM-1] and Angiopoetin-2 [Ang-2]) and inflammation (C-reactive protein [CRP]) revealed endothelial activation and inflammation at presentation and during recovery and demonstrated that in cerebral malaria and in uncomplicated malaria there is persistent endothelial activation after parasites are cleared, up to a month after presentation. Complexes of very low density lipoprotein (VLDL) and CRP were also raised in cerebral and uncomplicated malaria. Conclusions: In cerebral malaria in Malawian children there is localised microvascular loss of endothelial anticoagulant receptors at sites of iRBC sequestration. In the brain, where constitutive expression of EPCR and thrombomodulin is low, this is accompanied by thrombosis; outside the brain, where constitutive EPCR and thrombomodulin expression is high, coagulation is compensated. This activation of coagulation and of the endothelium in response to acute infection leaves a residual imprint as detected by markers of endothelial activation and inflammation even in uncomplicated malaria several weeks after parasites are cleared. Since children in sub-Saharan African frequently suffer repeated infections these endothelial alterations may have important consequences both for subsequent infections and for long-term health. These mechanisms highlight potential targets for therapy.

Introduction: Household air pollution (HAP) affects one half of the world population, comprises 90% of global particulate exposure, and is associated with mortality from respiratory infections. Particulates are known to alter cellular redox balance, including that of the alveolar macrophage (AM). We investigate redox balance as a mechanism to explain the link between particulate exposure and failure of innate immune function. Methods: Bronchoalveolar lavage was performed on healthy human volunteers in the UK (low HAP) and Malawi (high HAP). Antioxidant capacity was determined (concentrations of oxidised and reduced glutathione, and antioxidant capacities of glutathione peroxidase and superoxide dismutase). AM function was assessed by capacity to phagocytose, and to produce oxidative burst and proteolysis activity within the phagosome using reporter-fluorophore coated silica beads. AM cytokine responses to lipopolysaccharide and to respirable size wood smoke particles were measured before and after ex vivo treatment to reduce glutathione content. Personal exposure to particulates was estimated by the cytoplasmic content of black carbon within AM. Results: AM glutathione was similar in UK and Malawi non-smokers (of which 4.3% was in oxidised form). One quarter of Malawians exhibited a high oxidised glutathione phenotype (8.6% of total). Malawians exhibited higher levels of extracellular glutathione, and intracellular malondialdehyde and particulate content than UK volunteers. Nrf2 levels in Malawian AM were proportional to levels of particulate matter. We demonstrated no association between particulate matter content and AM cytokine responses to lipopolysaccharide or wood. Glutathione depletion did not consistently alter AM cytokine production. In vivo particulate exposure correlates with reduced AM phagosomal oxidative capacity, and increased cellular Nrf-2 concentration, but phagocytosis and phagosomal proteolysis are unaffected. Conclusion: Malawians have high levels of AM particulate exposure, as expected from HAP surveys. This is associated with evidence of oxidative stress (lipid peroxidation), antioxidant upregulation (raised extracellular glutathione, intracellular Nrf2) and a specific defect in AM function (reduced oxidative burst). Antibacterial function of the AM is key to preventing pulmonary infection: in a population subjected to high levels of household air pollution, particulate related defects in AM function could explain the high prevalence of infective respiratory illness.

Despite widespread roll out of anti-retroviral therapy (ART), cryptococcal meningitis (CM) remains a significant cause of morbidity and mortality among HIV-infected persons in sub-Saharan Africa. Host immune response is central to the pathogenesis, and not only influences susceptibility to infection, but clinical presentation and outcome. Animal studies suggest that macrophage activation is a crucial component of the host immune response but human studies are limited. This thesis aims to characterize the activation state of CSF macrophages and blood monocytes in persons with HIV-associated CM, assess the effect of ART on the immune response, and identify immune correlates of severe disease and poor outcome. A prospective cohort study was conducted in Cape Town, South Africa (Innate Immunity in Cryptococcal Disease (IICD)). Persons with HIV-associated CM were enrolled and the immune response in CSF and blood examined using flow cytometry and cytokine analysis. Soluble markers of macrophage activation (sCD14, sCD163) and the ex vivo responses of whole blood and monocytes to TLR ligands and cryptococcal preparations were also measured. Additional CSF and serum samples were obtained from the Cryptococcal Optimal ART timing (COAT) trial (South Africa and Uganda) to examine the immune consequences of earlier ART initiation in cryptococcal meningitis. In this trial, earlier ART was associated with increased mortality in CM compared with a deferred ART strategy (8 days vs. 5 weeks post CM diagnosis respectively). CSF flow cytometry showed that CD8 T cells were the most common cells in the CSF followed by neutrophils and CD4 T cells. Both CD14+ and CD14- CSF macrophages were identified and expressed a range of surface markers associated with different activation states. Cryptococci were identified using flow cytometry as CD45 negative cells; cryptococcal counts using flow cytometry showed a very strong correlation with quantitative culture. There was no suggestion that raised intracranial pressure occurred as a result of a pro-inflammatory response; instead, persons with high intracranial pressure had a greater CSF fungal burden, a significantly reduced CSF cellular infiltrate (particularly CD4 T cells, CD8 T cells and double negative T cells) and larger cryptococcal cells. Contrary to animal studies, there was no association between macrophage activation and fungal burden. ART appeared to have a more profound effect on the immune response at site of disease (CSF) compared to the blood. In the IICD study, ART was associated with an increased frequency of CD4 T cells and decreased frequency of CD8 T cells in the CSF, along with increased expression of CD206 and CD16 on the surface of CSF monocyte- macrophages, suggesting an alternatively activated (M2) phenotype. These changes were closely related to plasma HIV viral load, even in subjects not taking ART. In the COAT trial, participants who received earlier ART initiation were more likely to have a CSF cellular infiltrate by day 14 compared to those in the deferred ART arm (8 days vs. 5 weeks post CM diagnosis respectively). This primarily occurred among persons with an initial paucity of CSF cellular response, the same sub-group identified in the COAT trial to be at highest risk of mortality following early ART initiation, and the same group previous shown in cohort studies to be at increased risk of IRIS. Furthermore, participants in the Kampala earlier ART arm had increased sCD14 and sCD163 concentrations in their CSF at day 14 suggesting increased macrophage activation in the central nervous system (CNS). These findings are supportive of the hypothesis that the increased mortality associated with earlier ART initiation in the COAT trial was immunologically driven. Finally, immune correlates of fatal outcome were examined. Persons who died by week 12 in the IICD study were noted to have a lower proportion of double negative T cells and lower concentrations of IFN-γ in the CSF at baseline. Non-survivors also had evidence of increased immune activation in the blood, elevated IL-10, decreased monocyte HLA-DR expression, impaired monocyte TNF-α response to LPS, and decreased IFN-γ responses to LPS in whole blood. These features are consistent with those of monocyte anergy and the compensatory anti-inflammatory response syndrome. The cause for this immune signature among persons with HIV-associated cryptococcal meningitis was not clear and warrants further study; the downstream effects of HIV-1 induced immune activation or the immune modulatory effects of cryptococcal capsule are both possibilities.

Background: Obstructive Sleep Apnoea (OSA) is associated with cardiovascular disease. The current evidence regarding the effects of OSA in individuals with severe obesity is limited and has hitherto been largely unexplored. With the growing population of diabetes and obesity globally, the identification of severely obese individuals who have OSA is important given the risk of adverse outcomes associated with OSA. In this regard, the use of urinary proteomic (urinary peptide) profiling as a potential tool to characterise adult severely obese patients for the diagnostic assessment of OSA remains to be investigated. Aims: The aims of the studies described in this thesis were to (1) investigate the effects of OSA in severe obesity in relation to measures related to cardiovascular risk, specifically, arterial stiffness and serum urate; (2) assess current clinical practice of OSA assessment; and (3) explore the use of urinary proteomics in characterising subjects with severe obesity and OSA. Methods: In the arterial stiffness, urate and urinary proteomic studies, patients with severe obesity, were assessed at baseline and at follow-up. Anthropometric, respiratory and cardio-metabolic parameters were measured. All subjects had overnight polysomnography. Subjects with OSA were initially naive to OSA treatment at baseline were subsequently offered CPAP. For the arterial stiffness studies, pulse wave analysis (PWA) was performed. In the urate studies, serum urate measurements were taken to identify associations between OSA and urate at baseline; and CPAP with change in urate at follow-up. OSA assessment in diabetes clinical practice was explored by a national survey in relation to the International Diabetes Federation (IDF) guidance. In the urinary proteomics studies, urine samples were analysed by capillary electrophoresis-mass spectrometry (CE-MS) at baseline and at follow-up. Results: Severely obese patients with OSA had increased arterial stiffness. Although sleepiness and blood pressure improved with CPAP in severe obesity, CPAP alone was not sufficient to modify PWA measures to levels comparable with non-OSA patients. In the urate study, serum urate was associated with OSA in severely obese females and there was a trend for reduced urate levels in CPAP-treated patients. The questionnaire study revealed a disappointing low awareness of the IDF statements and of the perceived importance of assessing for OSA in type 2 diabetes. The urinary proteomic studies identified trends in the urinary peptide profiles suggesting that there may be inherent differences between OSA and non-OSA patients, even following a period of effective CPAP treatment. The identified peptide panel included collagens, cadherin and fibrinogen subtypes. Conclusions: The theme that links the studies in this thesis has been the importance of OSA in relation to cardiovascular risk. Severely obese patients with OSA have increased arterial stiffness that may increase cardiovascular risk. Likewise, in severely obese individuals with OSA who have hyperuricaemia or recurrent gout, there may be a need to consider OSA assessment as elevated urate levels are associated with increased cardiovascular risk. From the questionnaire study, it is clear that more work needs to be done to raise awareness about OSA assessment in diabetes teams as obesity is a risk factor for type 2 diabetes. Urinary proteomic CE-MS profiling has provided novel insights into the urinary proteome in OSA, with and without CPAP. Although there is insufficient evidence to support its use for OSA diagnosis, the urinary peptides identified may be linked with mechanisms underlying cardiovascular disease in OSA and may be associated with treatment effects of CPAP on OSA progression that influences expression of urinary peptides.

A better understanding of cutaneous leishmaniasis (CL) epidemiology will lead to improved intervention methods to combat CL outbreaks and prevent disease re-emergence. CL is endemic throughout the Kingdom of Saudi Arabia (KSA), and new disease control tools are needed. In this thesis, I studied various aspects essential to the design of a new CL control strategy, including parasite species identification, patient response to anti-leishmanial drug treatment, sandfly species identification, assessment of sandfly biting exposure and risk of disease transmission, implementation of an integrated control strategy, and development of a potential new CL diagnostic tool for use in CL endemic setting. It was found that Leishmania major (responsible for zoonotic CL) and Leishmania tropica (responsible for anthroponotic CL) are the main causative agents of CL in KSA, with over 75% of all human cases caused by the former. The current national CL treatment regimen consists of application of topical clotrimazole/fucidine cream followed by 1-2 courses of intralesional sodium stibogluconate; however, treatment efficacy is highly variable and the reasons for this are not well understood. As part of this PhD study, tests to determine the efficacy of this standard CL treatment regime in several endemic regions of KSA were performed. Most L. major patients responded favourably to drug treatment, although treatment success varied greatly depending on geographical location. In contrast, 60% of L. tropica cases proved completely unresponsive to the same treatment protocol. Furthermore, the development of secondary infections (SI) around or within the CL lesion significantly favoured the treatment response of L. major patients, but had no effect on L. tropica cases. These findings indicate that there is an urgent need to implement alternative CL treatment protocols based on these parameters, and also indicate a possible increase in drug-resistant parasites. In this epidemiological study, the potential correlation between the type of immunity generated after exposure to sandfly bites and disease outcome was monitored by measuring anti-SP32 antibody levels. Constant exposure of the local residents to sandflies may help prevent development of severe CL disease outcomes. Notably, comparison of the levels of anti-saliva antibodies of local individuals with migrant labour indicated that the latter had significantly higher levels of anti-saliva marker and also developed a more severe pathology. This implies that the corresponding governmental sectors need to assess all transmission risk areas, as well as greatly improve housing conditions to minimize the risk of non-local construction workers contracting CL. This is essential as CL drug treatment is costly and currently non-local workers comprise around one third of the KSA population. Additionally, a disease control strategy based on a combination of vector and reservoir control methods was designed to combat zoonotic CL outbreaks. Construction sites at Al-Ahsa, known to be highly endemic for zoonotic CL, were monitored by a vector control team between 2012 and 2014. The control strategy was applied following the outbreak using mechanical, reservoir and vector control methods. No CL cases were reported after the control team’s intervention. This case study suggests that implementation of a health impact assessment should be carried out, as well as a control strategy, in areas that share a similar CL ecology and environment in order to minimize incidence cases. As part of my PhD, I developed a potential new diagnostic tool by using an ELISA assay method to measure the levels of anti-α-galactosyl antibodies in human sera using synthetic neoglycoproteins (NGPs). The assay sensitivity was 96% for L. major (95% CI 94%–98%) and 91% for L. tropica (95% CI 86%–98%). In addition, the assay had higher sensitivity than microscopy analysis, which only detected 68% and 45% of L. major and L. tropica infections, respectively. Furthermore, improvement of the selectivity in recognizing different α-galactosylated NGPs suggests that this assay could potentially be developed into a rapid diagnostic test for use in resource-poor settings. Overall, this thesis should help set a basis for designing a national strategy for CL elimination in KSA.

Onchocerciasis affects an estimated 37 million people in Sub-Saharan Africa and Latin America, causing debilitating skin and eye disease and accounting for a global loss of 1 million Disability-Adjusted Life-Years. The discovery of Wolbachia bacterial endosymbionts in filarial nematodes, including Onchocerca volvulus, has revolutionised the understanding of the parasite’s biology and immunopathogenic mechanisms of disease, and has offered a novel approach to its treatment and control with anti-Wolbachia antibiotics. Treatment with doxycycline is effective at sterilising and killing adult O. volvulus worms, proving superior to standard microfilaricidal treatment with ivermectin and of great potential as an alternative strategy for the control of onchocerciasis. Although the length of the required treatment has raised concerns about the use of doxycycline in Mass Drug Administration (MDA) strategies, a recent trial in Cameroon demonstrated the feasibility of a six week course of doxycycline MDA delivered with a community-directed approach. In the work presented here we found a significant reduction in microfilaridermia prevalence and loads four years after doxycycline MDA distribution, demonstrating its long-term effectiveness and supporting its implementation in existing control strategies. Wolbachia peptidoglycan-associated lipoprotein stimulates innate and adaptive immune responses, contributing to disease pathogenesis through the induction of pro-inflammatory cytokines and recruitment of neutrophils. These features together with the cytokine milieu induced by filarial nematodes could support the development of a pro-inflammatory Type-17 immune response. In this work, PBMC from patients with onchocerciasis were found to produce only minimal levels of IL-17 in response to filarial extracts. On the contrary, a rich IL-17+ cell infiltrate was found surrounding adult worms in Wolbachia positive onchocercomas using immunohistochemistry (IHC), which was depleted from onchocercomas following doxycycline treatment. Although a high percentage of Th17 cells were present in this infiltrate compared to other diseases, the majority of IL-17 producing cells in nodules were neutrophils, within an extracellular trap-like structure. This unexpected result was consistent with the reported IL-17 production by human neutrophils using IHC in the literature, but could not be confirmed at the protein or the transcription level in vitro in this work. Wolbachia is responsible for an abundant neutrophil infiltration in Onchocerca-infected tissues. However, the role of neutrophils in the immune response to filarial parasites and their interaction with Wolbachia is poorly known. The work presented here showed that Wolbachia lipoprotein activates human neutrophils in vitro, supporting previous studies demonstrating the link between Wolbachia and neutrophils in the host inflammatory responses to O. volvulus infection. These results also indentify Wolbachia lipoprotein as a key molecule driving human neutrophil recruitment and activation.

Background: Advanced heart failure is receiving increasing attention from clinicians and policy makers as a major chronic condition associated with poor quality of life in an ageing population. Aim: To explore how we could tailor health interventions to individual patients with advanced heart failure at the end of life. Design: (1) A systematic review of national and international chronic heart failure guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and a data extraction framework based on the holistic needs assessment of the Gold Standards Framework (GSF). (2) A longitudinal qualitative study of 15 patients with New York Heart Association grade 3 or 4 heart failure recruited through two community based heart failure services. Semi-structured interviews were conducted with patients at 3 monthly intervals for 1 year (n= 52 interviews). A refined ‘case-based’ method as described by Griffiths et al. was adopted to identify the ideal type categories of adjustment and adaptation and assess how these categories change over time for each patient. This involved understanding individuals as complex systems, subject to internal and external influences, with the potential for transformation. The analysis drew on the theoretical concept of the emergent present - as developed by Adam - the current period of time when all domains of life have expression. Results: (1) A total of 19 guidelines were included in the review. Across all guidelines the lowest scoring domains were applicability and stakeholder involvement. Qualitative assessment showed that most guidelines adopt a disease-orientated approach to addressing need. In particular, domains on continuity of care and out of hours care were poorly covered. (2) Four distinct patterns of adjustment and adaptation were identified. The largest group was the Stuck and struggling category, which was characterised by participants wanting to move on but being unable to do so. Participants in the integrating group were able to accommodate the problems that they faced from moment to moment despite anticipating an uncertain future. Those in the submerged group were completely immersed in their illness and any expectation of a meaningful future had completely disappeared. The Past reminder group was characterised by a narrative based in the emergent present that was dominated by their experience of previous events. It was shown that some participants transformed from one category to another as a result of the care they received. For others, there was no change over the course of the study. Conclusion: This thesis identifies important differences between the ‘objective’ patient represented in clinical guidelines and the ‘subjective’ experience of the individual. The illness experiences of people living with advanced heart failure are diverse and do not lend themselves to standardised care. This raises important questions for the way knowledge is currently translated into clinical practice. Attending to the emergent present may be a clinically useful approach for supporting health care professionals to tailor care to needs of patients at the end of life.

EPLIN (Epithelial Protein Lost In Neoplasm) is a cytoskeletal associated protein whose expression is often reduced in cancer cells. It may function as a tumour suppressor through its effects on cancer cell migration and invasion. To date, its role in wound healing has not been elucidated. We examine the impact of EPLIN on keratinocyte migration and its implications in wound healing. A mammalian expression construct containing the full EPLIN coding sequence was used to overexpress EPLIN in human keratinocyte cell (HaCaT). Following overexpression verification, the impact of EPLIN on HaCaT cell migration was assessed using a conventional scratch wounding assay and an electric cell-substrate impedance sensing (ECIS) system-based assay. Protein expression was examined using western blot, ICC and IFC analysis. Transfection of HaCaT cells with the EPLIN expression construct successfully resulted in enhanced HaCaT EPLIN expression. Enhanced EPLIN levels were seen to negatively impact on cell migration as determined by both the scratch wound assay and the ECIS model system with migration rates of HaCaT cells overexpressing EPLIN being substantially less than the control HaCaT cells. Overexpression of EPLIN was found to slow keratinocyte migration rates using two independent assays as well as show convincing association and interaction with two NWASP and E-Cadherin. These important findings suggest novel routes to positively manipulate the wound healing process and has significance in further translational research.