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

In Nigeria the current prevalence of HIV is 4.1% with over 3.5 million infected and estimated 1.5 million in need of anti-retroviral treatment. Epidemiological and implementation studies are necessary for monitoring and evaluation of interventions. To define research areas which can be addressed by participants of the Nigeria Field Epidemiology and Training Programme (NFELTP) a workshop was held in April 2013 in Abuja, Nigeria. Priority research areas were identified using criteria lists for ranking of the relevance of research questions. Based on a research matrix, NFELTP residents developed the aims and objectives, study design for HIV-related research proposals. This workshop was the first workshop held by the NFELTP to establish an inventory of research questions which can be addressed by the residents within their training period. This inventory will help to increase HIV/AIDS-related activities of NFELTP which are in accordance with research needs in Nigeria and PEPFAR objectives.


Introduction
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)  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 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/AIDSrelated 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.  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%) Page number not for citation purposes 4 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] Table 3. 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

Competing interests
The authors have no conflict of interest to declare.       Table 6: Scoring of HIV/AIDS-related research questions Table 1: Summary of the 20 HIV/AIDS-research questions with the highest average scores based on the pre-workshop questionnaire (lines highlighted in grey: more than 10% of the respondents were undecided to give high or low priority).  What community strategies can effectively increase PMTCT uptake?

Research areas Topics Undecided (%) Average
What are the strategies to ensure retention of pregnant women throughout the PMTCT cascade especially delivery in health facilities?
What are the roles of community women (e.g. market women) in PMTCT?
What are the socio-cultural (religious) factors that hinder access to PMTCT services?
What is the role of male involvement in PMTCT?
What is the availability of uniform PMTCT protocols?
What are the challenge of integration of PMTCT services and conventional health services?

Family planning
What are the factors that influence the decision on HIV positive pregnant women to get pregnant?
What are the contraceptive needs and choices of HIV positive women of reproductive age group?

Pregnancy/delivery
Why do women prefer to deliver with TBAs?
What can be the roles of the traditional birth attendants in PMTCT?
What is the role of the private sector in PMTCT?

Feedingoptions
How best can HIV positive pregnant women be supported to adhere with their chosen infant feeding methods?

EID
How to ensure provision of early detection and confirmatory test facilities at all levels of care?
What is the level HIV drug resistance in HIV-positive children in Nigeria? What is the prevalence of HIV-related malignancies; what is their impact on presentation?
What is the prevalence of co-infection in certain groups /sub-populations, e.g. prisoners, (para) military, and high at risk groups?

Co-morbidity
How can the diagnosis of opportunistic infections be optimized? What clinical or lab approaches  What data dissemination plans are in place?

Surveillance
What are the determinants of limited activities in STI surveillance?
What are the challenges of the AIDS case reporting system?
What is the HIV prevalence among health care providers at hospitals?
What are the factors contributing to the different HIV prevalence on the state level?
How can a HIV drug resistance surveillance system be established?

Epidemiology
What are the factors associated with high and low HIV prevalence rates at ANC sentinel sites?
What is the association between HCT services uptake and the epidemiology of HIV/AIDS among women attending ANC in high and low sentinel sites in Nigeria?
What factors are associated with high or low epidemics in four highest and lowest sentinel sites in Nigeria?
Page number not for citation purposes 11 What is the burden of and diagnostic challenges of non-tuberculous mycobacterium among HIV-infected individuals?
What are the best strategies for co-management and referral for TB and HIV cases after diagnosis?
What are the TB type and molecular characterics among HIV positive TB patients?

Comanagement
What is the extent of TB-HIV service integration? What models are being used and what are the challenges to optimal integration of these services?
What is the level of TB infection control in our ART facilities? What are the challenges in TB infection control?
Are there infection control committees & guidelines in place?

Treatment
How do we improve adherence to medications in patients with TB/HIV/Hepatitis B? Can provision of DOTS (at facility and community levels) improve outcome of treatment? Does provision of treatment to partner improve outcome?
How do we reduce attrition rates in our ART programs? What factors contribute to this? How do we tract these patients?
How do we optimize retention of these patients within the programs? What is the treatment success rate of TB-treatment in PLWAs?
What are socio-economic and socio-cultural factors hindering co-treatment of TB and HIV?
What are the determinants of the high rate of loss to follow-up? How do we tract the patient (phone number)?
What are the challenges to the provision of ART/PMTCT services in private health facilities?

Drug resistance
What is the burden of HIV-drug resistance and Drug resistant TB(DR-TB)?
What are the challenges in TB-HIV co-infection management in the presence drug resistance?

Co-infection
What is the outcome of managing TB-HIV co-infection in the presence of hepatitis? Whatarethechallengesoftreatment?

Support
What is the role played by patients support groups in improving socio-economic status of PLWAs?
Page number not for citation purposes 12 Socio-economic and socio-cultural factors hindering the co-management of TB and HIV 6.7

Care andtreatment
Assessment of challenges of optimizing quality in care 8.0 Factors associated with adherence to antiretroviral drugs 7.9 What are the contributions of the private health sector to ART services 7.9 What are the challenges and prospects of optimizing gene expert in TB diagnosis among TB suspect HIV positive patients? 7.8 Pharmacovigilance: What is the level of integration in ART services in Nigeria?

7.8
What are the factors associated with compliance to National Guidelines? 7.7 What are the outcomes and challenges of post-exposure prophylaxis among health care workers?

7.6
What are the challenges of IPT utilization in ART facilities? 7.6