Setting Research Priorities for HIV/AIDS-related research in a post-graduate training programme: lessons learnt from the Nigeria Field Epidemiology and Laboratory Training Programme scientific workshop

Setting Research Priorities for HIV/AIDS-related research in a post-graduate training programme: lessons learnt from the Nigeria Field Epidemiology and Laboratory Training Programme scientific workshop

 

Gabriele Poggensee^1,&, Ndadilnasiya Endie Waziri¹, Adebobola Bashorun^1,4, Patrick Mboya Nguku¹, Olufunmilayo Ibitola Fawole^1,2, Kabir Sabitu^1,3

 

¹Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria, ²Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Nigeria, ³Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria, ⁴HIV/AIDS Division, Federal Ministry of Health, Abuja, Nigeria

 

 

^&Corresponding author
Gabriele Poggensee, Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria

 

 

 

 

Although HIV prevalence is much lower in Nigeria than in other African countries such as South Africa and Zambia, the size of Nigeria’s population (estimated population 162 million) means that by the end of 2009, there were an estimated 3.3 million people living with HIV [1]. The trend of HIV prevalence among women attending ante-natal has been dynamic with a steady increase from 1.8% (1991) to 4.6% (2007). The current prevalence is 4.1% (2012) with over 3.5 million infected and estimated 1.5 million are in need of anti-retroviral treatment. The epidemic is generalized, however, showing wide geographical variations. In response to the epidemic HIV prevention, care and treatment have scaled up in the last decade; however, the barriers to effectively replicate evidence-based interventions need to be investigated. The National Strategic Framework aims amongst others to conduct research in order to ensure evidence-based interventions [1]. Implementation research, epidemiological studies and impact studies are said to be necessary for monitoring and evaluation of interventions [2].

 

The Field Epidemiology and Laboratory Training Program (FELTP) is a two-year master’s level training in applied /field epidemiology. FELTP serves to build local capacity in order to improve and strengthen countries’ public health systems and infrastructure [3]. In Nigeria, the Field Epidemiology Laboratory Training Program (NFELTP) has been working to build capacity in the public health workforce since 2008.

 

With support from the Federal Ministry of Health (FMOH), US Presidents Emergency Plans for Aids Relief (PEPFAR) {through the Centers for Disease Control and Prevention (CDC)} and two indigenous leading Nigerian universities, the NFELTP trains field public health laboratory, medical epidemiology, and veterinary epidemiology residents to work in leadership and technical positions in the Federal Ministries of Health (FMOH) and Agriculture and Rural Development (FMARD) in addition to leadership and technical positions at the state level. This two-year program helps improve public health systems within the country by increasing knowledge and skills in field epidemiology and laboratory epidemiology and management by building a cadre of skilled and well-trained health professionals (www.nigeria-feltp.net).

 

NFELTP has assisted in the detection, investigation and response of public health emergencies including disease outbreaks. Surveillance system evaluations and secondary data analyses have been carried out by NFELTP residents. HIV/AIDS-related research activities cover the evaluation of HIV surveillance systems in different states, HIV epidemiology (risk factors for HIV in different zones and high risk groups), prevention (acceptance of prevention of mother-to-child transmission of HIV (PMTCT) services), and HIV care (opportunistic infections).

 

However, there is a need to develop a comprehensive inventory of priority research areas of interest. The inventory will integrate the research needs identified by stakeholders involved in HIV prevention and care in Nigeria. Furthermore, the inventory will help for future NFELTP residents to decide on research topics of public health relevance in the early phase of their training. Duplications of research not adding new knowledge will thus be omitted.

 

In order to define research areas and research questions which can be worked on within the frame of the programme a workshop was held from 15th – 17th April 2013 in Abuja, Nigeria. Here we report the results of the workshop. The workshop aimed to encourage and support NFELTP residents to develop HIV/AIDS-related relevant research topics.

 

The expected outcomes were: 1) development of an inventory of relevant HIV/AIDS-related research topics which can be addressed by NFELTP residents; 2) development of draft study proposals by (future) residents.

 

Altogether 54 participants attended the workshop. From the Nigeria Field Epidemiology and Laboratory Training Program 44 residents, graduates, academic and program supervisor participated having clinical, laboratory, epidemiological and program working experience in HIV/AIDS. Furthermore, external experts from the National AIDS and STI Control Programme, Nigeria Centre for Disease Control, Federal Ministry of Health; AIDS Prevention Initiative in Nigeria (APIN); Center of Disease Control and Prevention Nigeria and Aminu Kano Teaching Hospital university, Kano, were invited as keynote speakers on treatment, care and support, HIV monitoring and evaluation, prevention of mother-to-child transmission (PMTCT) of HIV and Early Infant Diagnosis of HIV (EID), HIV epidemiology and surveillance and HIV/AIDS operational research. The first day of the workshop consisted of plenary sessions where the research setting was defined for each area. This was followed by deliberations in subgroups of participants with special interest in the specific topic area. The groups were moderated by the external experts and NFELTP academic and programme supervisors. The views of the participants and experts with regard to HIV/AIDS-related research gaps and research needs in Nigeria were assessed in a systematic manner using the following methods.

 

Prior to the workshop date, desk review of available literatures was conducted to better understand the priority research and gaps. Using a semi-structured questionnaire the workshop participants were also asked before the workshop to rate the relevance of HIV/AIDS related research questions. The questionnaire consisted of two parts: i) rating of broad research areas : prevention, HIV care, PMTCT, support, capacity building, monitoring & evaluation, data quality assurance and epidemiology; ii) rating of specific research questions on HIV prevention, PMTCT, epidemiology, HIV and tuberculosis, HIV care, HIV support, monitoring, evaluation and data usage. The development of the questionnaire was based on the outputs of literature search using PubMed and google scholar with the following keyword: research priorities, HIV/AIDS, Africa, resource-limited setting. The items were rated using the following scale: strong need (1), need (2), less need (3), no need (4) and undecided (0). For each item an average was calculated and the percentages of undecided answers were given. Additionally workshop participants could include in each area suggestions of relevant research questions. At the end of the first workshop day an inventory of research questions following the broad topic outline of the questionnaire was established based on the inputs from participants by questionnaire and discussion.

 

A criteria list for the ranking of the relevance of HIV-related research questions was developed including criteria on answerability and ethics, efficacy and impact, deliverability, affordability, scalability and sustainability, health systems, partnership and community involvement, equity achieved by research outputs. Points between 0 (low score) and 10 (high score) could be given to 15 questions. For each research question an average score was calculated.

 

Residents were asked to submit concept notes for an HIV/AIDS-related research proposal. Based on a research matrix, residents discussed in the working groups the aims and objectives, the study design and data sources for proposed research ideas. The outputs for individual research topics were presented and discussed in the plenum.

 

 

Ranking of HIV/AIDS-relating research questions

 

The pre-workshop questionnaire was used to assess the ranking of research areas and specific research questions. Altogether 29 questionnaires were returned (return rate: 53%). The 20 highest ranking of research areas are summarized in Table 1.

 

During the first day of the workshop presentations were provided by the key note speaker focusing on knowledge gaps in the following relevant research areas: Prevention of mother-to-child transmission of HIV (PMTCT) and early infant diagnosis of HIV (EID); HIV treatment, care and support; HIV monitoring and evaluation; Epidemiology and surveillance; HIV and tuberculosis (TB).

 

In the following research questions for the above mentioned areas identified by the participants of the workshop are presented:

 

Inventory of HIV/AIDS-relating research questions

 

Prevention of mother-to-child transmission of HIV and early infant diagnosis of HIV: Nigeria belongs to the 10 highest burden countries with 210,000 HIV positive pregnant women in 2008 [4]. PMTCT is a focused intervention that should begin ideally prior to pregnancy and ends at delivery or slightly thereafter. Eliminating paediatric HIV/AIDS is achievable and PMTCT is considered an essential maternal, newborn and child health care. Four main comprehensive approaches to PMTCT include; primary HIV prevention among women of reproductive age, prevention of unintended pregnancies among HIV positive women, prevention of HIV transmission from infected pregnant women to their children ,and treatment, care and support for HIV infected women, their children, and families [4]. The main research questions identified are summarized in Table 2.

 

HIV Treatment Care and Support: Of the estimated 1.5 million PLHIV eligible for treatment 29.8% at the end of 202 were on treatment for both adults and children. Adherence challenges among patients attending ART clinics in Nigeria [1]. There are great disparities in access to health care among different population groups in Nigeria, with those in rural areas having limited access to health care due to low level of education, socio-cultural barriers and poor infrastructure. It is estimated that only about a quarter (26%) of women in rural areas deliver with the assistance of a doctor or nurse/midwife, in contrast to about 59% of women in urban areas. Using number of births attended to by skilled health workers, as a proxy, it is estimated that only 34% of the general population have access to basic health care. Significantly, unlike most of sub-Saharan Africa, rural areas in Nigeria have a higher HIV prevalence than urban areas, which compounds the issue of accessibility to health care services given the high rural – urban disparities in the country [5].

 

Nigeria has established the following targets with regard to HIV care and treatment [5]: 1) Increase access to HIV counselling and testing (HCT) 80% by 2015; 2)Place 1.5 million people living with HIV/AIDS (PLWAs) on antiretroviral treatment (ART) by 2015 Decrease the prevalence and incidence of sexually transmitted infections (STIs) among PLWAs to 50 % by 2015; 3) Place at least 400,000 new patients on ART in 2013.

 

A wide range of research questions have been identified which are presented in Table 3.

 

Epidemiology and surveillance

 

At the end of 2012, about 3.5 million people were living with HIV in Nigeria. This accounted for 9.4 % of the global burden and 13.6% of the burden in Sub-Saharan Africa. The median national prevalence decreased in the recent years, however, the absolute number of PLWHIV increased by half a million and AIDS mortality has increased to about 217,000 annual death attributed to AIDS accounting for 13.7% of global AIDS deaths and 19.4% of AIDS deaths in Sub-Saharan Africa. Actually the following surveillance efforts in HIV are on-going: 1) HIV incidence study; 2) Surveillance of HIV drug resistance; 3) Early Warning Indicator Survey (EWI) for HIV drug resistance; 4) Determination of level of HIV infections among TB clients.

 

Identified knowledge gaps with regard to surveillance and epidemiology are listed in Table 4.

 

HIV and tuberculosis: The spread of HIV has fuelled the tuberculosis epidemic. Tuberculosis is a major cause of death among people living with HIV and accounts for about 22% of HIV-related deaths globally. In 2012, 1.1 million of the 8.8 million incident cases of TB worldwide were among people living with HIV [6]. HIV is one of the main reasons for failure to meet tuberculosis control targets in high HIV settings. Identified research question raised regarding TB-HIV co-infection are summarized in Table 5.

 

Scoring of research questions: Scoring exercise was done for a limited number of research questions for the following areas: Tuberculosis and HIV-co-infection, PMTCT and HIV care and support. For each research question an average score was calculated from the scores of the 15 questions (Table 6).

 

Development of research proposals: Eighteen residents submitted concept notes on HIV/AIDS-related research ideas and developed draft study proposals which were presented and discussed with the workshop participants.

 

 

The workshop on HIV/AIDS-related research questions was the first workshop held by the Nigeria Field Epidemiology and Training Programme to establish an inventory of research questions which can be addressed by the residents within their training periods. This inventory will help to increase HIV/AIDS-related activities of NFELTP which are in accordance with research needs in Nigeria and PEPFAR goals.

 

Overall the participants agreed that the workshop was satisfactory (4.4; maximum score 5), that the work objectives were met (4.5) and that the workshop was useful for the job (4.6). However, time constraints were criticized by the participants. In the comments participants observed three days was too short, that more time should be given to the group work and the presentations of the group work. Some participants regarded the material provided for the preparation of the workshop as not useful. The interactive approach used in this workshop allowing an exchange between the residents of different cohorts and the facilitators was rated positively.

 

The workshop on HIV/AIDS-related research questions was the first workshop held by the Nigeria Field Epidemiology and Training Programme to establish an inventory of research questions which can be addressed by the residents. This inventory will help to increase HIV/AIDS-related activities of the programme which are in accordance with research needs in Nigeria.

 

 

The next step should be the scoring and prioritization of identified research questions. A two to three days workshop needs to be organized. Possible participants for the workshop should be representatives from National HIV/AIDS and Sexually Transmitted Diseases Control Programme (NASCP), National Agency for the Control of AIDS (NACA), academic supervisors from Ahmadu Bello University, Zaria and University of Ibadan, the program director and staff from Nigeria Field Epidemiology and Training Programme (NFELTP), Centers for Disease and Prevention Nigeria (CDC) staff and residents working in the area of HIV/AIDS. Further action points are: develop full protocols for some of the research areas and carry out the research; support a national HIV research prioritization workshop and develop research priority areas for other public health issues.

 

 

The authors have no conflict of interest to declare.

 

 

GP organized the workshop, designed and analyzed the pre-workshop questionnaire, and wrote the final manuscript; NEW supported the organization of the workshop, wrote the first report draft, revised and edited the manuscript; AB supported the organization of the workshop; PMN developed the concept for the workshop, reviewed and edited the manuscript; OIF and KB reviewed and edited the manuscript. All authors have approved the final version of the manuscript.

 

 

We are grateful for all the support to organize the workshop from the NFELTP staff with special thanks to Mrs Chinyere Gana and Mrs Gloria Okara. This publication was made possible by support from the President´s Emergency Plan for AIDS Relief through cooperative agreement (No 5U2GGH000431) from the HHS/Centers for Disease Control and Prevention (CDC), Global AIDS Program. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

 

 

Table 1: Summary of the 20 HIV/AIDS-research questions with the highest average scores based on the pre-workshop questionnaire

Table 2: PMTCT/EID-related research questions

Table 3: Identified research areas for HIV care and support

Table 4: Epidemiology and Surveillance gaps for HIV/AIDS

Table 5: Research questions identified for HIV-TB-co-infection

Table 6: Scoring of HIV/AIDS-related research questions

 

 

1. National Agency for the Control of AIDS. Federal Republic of Nigeria, global AIDS response, Country Progress Report. 2012. Abuja. NACA.


2. Hirschhorn Lisa, OjikutuBisola, Rodriguez William. Research for change: using implementation research to strengthen HIV care and treatment scale-up in resource-limited settings. JID. 2007; 196(Suppl):S516–22. PubMed | Google Scholar


3. Nsubuga Peter,Johnson Kenneth, Tetteh Christopher, Oundo Joseph, et al. Field Epidemiology and Laboratory Training Programs in sub-Saharan Africa from 2004 to 2010: need, the process, and prospects. Pan Afr Med J. 2011; 10:24. PubMed | Google Scholar


4. World Health Organization. PMTCT strategic vision 2010–2015: preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals. 2010. Geneva. WHO. Google Scholar


5. National Agency for the Control of AIDS. The National HIV and AIDS Monitoring and Evaluation Plan 2011-2016. The Nigeria National Response Information Management System (NNRIMS) Operational Plan II. 2011. Abuja. NACA.


6. World Health Organization. Global tuberculosis report 2013. 2013. Geneva. WHO.