Using GRADE as a framework to guide research on the sexual and reproductive health and rights (SRHR) of women living with HIV – methodological opportunities and challenges

ABSTRACT

In March 2016, WHO reviewed evidence to develop global recommendations on the sexual and reproductive health and rights (SRHR) of women living with HIV. Systematic reviews and a global survey of women living with HIV informed the guideline development decision-making process. New recommendations covered abortion, Caesarean section, safe disclosure, and empowerment and self-efficacy interventions. Identification of key research gaps is part of the WHO guidelines development process, but consistent methods to do so are lacking. Our method aimed to ensure consistency and comprised the systematic application of a framework based on GRADE (Grading of Recommendations, Assessment, Development and Evaluation) to the process. The framework incorporates the strength and quality rating of recommendations and the priorities reported by women in the survey to inform research prioritisation. For each gap, we also articulated: (1) the most appropriate and robust study design to answer the question; (2) alternative pragmatic designs if the ideal design is not feasible; and (3) the methodological challenges facing researchers through identifying potential biases. We found 12 research gaps and identified five appropriate study designs to address the related questions: (1) Cross-sectional surveys; (2) Qualitative interview-driven studies; (3) Registries; (4) Randomised controlled trials; and (5) Medical record audit. Methodological challenges included selection, recruitment, misclassification, measurement and contextual biases, and confounding. In conclusion, a framework based on GRADE can provide a systematic approach to identifying research gaps from a WHO guideline. Incorporation of the priorities of women living with HIV into the framework systematically ensures that women living with HIV can shape future policy decisions affecting their lives. Implementation science and participatory research are appropriate over-arching approaches to enhance uptake of interventions and to ensure inclusion of women living with HIV at all stages of the research process.

KEYWORDS:

• HIV
• GRADE
• sexual and reproductive health and rights
• research gaps
• WHO

Acknowledgements

We thank Avni Amin (WHO, Department of Reproductive Health and Research) for her helpful comments on the final draft. We would like to acknowledge the valuable inputs of the WHO Guideline Development Group for the Guideline on SRHR of women living with HIV: Pascale Allotey (School of Medicine and Health Sciences, Monash University Malaysia), Elham Ahmed Abdulla Atalla (Al Hoora Health Center, Arad Health Center, Ministry of Health, Kingdom of Bahrain), Susan Bewley (Women’s Health Academic Centre, King’s College London, London, United Kingdom), Shalini Bharat (School of Health Systems Studies, Tata Institute of Social Sciences, Maharashtra State, India), Elizabeth Anne Bukusi (Research Care Training Program (RCTP), Center for Microbiology Research, Nairobi, Kenya) (Co-Chair), Caroline Phiri Chibawe (Mother and Child Health, Ministry of Health, Lusaka, Zambia), Sophie Dilmitis (International Community of Women Living with HIV, Harare, Zimbabwe), Raoul Fransen-Dos Santo (International Civil Society Support, Amsterdam, The Netherlands), Asha George, (University of Cape Town, South Africa), Selma Hajri (African Network for Medical Abortion (ANMA), Tunis, Tunisia), Maurice Tomas Hiza (Reproductive and Child Health, Ministry of Health, Dar es Salaam, Tanzania), Mona Loutfy (Women’s College Research Institute, Women’s College Hospital, University of Toronto, Toronto, Canada), Chisale Mhango (Royal College of Obstetrics and Gynaecology, College of Medicine, Blantyre, Malawi), Glen Douglas Liddell Mola (School of Medicine and Health Services, Papua New Guinea), Rejoice Nkambule (Public Health Services, Ministry of Health, Kingdom of Swaziland), Vera SilviaFacciolla Paiva (PST & NEPAIDS, University of Sao Paulo, Brazil), Trang Thi Thu Quach (Center for Creative Initiatives in Health and Population (CCIHP), Ha Noi, Viet Nam), Paul Van Look (Independent Consultant, Belgium and Switzerland) (co-Chair), Alice Welbourn (Salamander Trust, London, United Kingdom), Anandi Yuvaraj (Independent Community Health Activist, Gender, SRH and HIV, Uttar Pradesh, India). The following additional WHO staff were part of the Steering Group: Avni Amin (Department of Reproductive Health and Research), Rachel Baggaley (Department of HIV), John Beard (Department of Aging and Life Course), Ana Pilar Betran (Department of Reproductive Health and Research), Francoise Bigirimana (AFRO Regional Office), Sonja Caffe (AMRO/PAHO Regional Office), Rebekah Bosco Thomas (Gender, Equity and Rights Team), Nathalie Broutet (Department of Reproductive Health and Research),Tarun Dua (Department of Mental Health and Substance Abuse), Shaffiq Essajee (Department of HIV), Jane Ferguson (Department of Maternal, Neonatal, Child and Adolescent Health), Mario Festin (Department of Reproductive Health and Research), Bela Ganatra (Department of Reproductive Health and Research), Claudia García Moreno (Department of Reproductive Health and Research), Fahmy Hanna (Department of Mental Health and Substance Abuse), Rajat Khosla (Department of Reproductive Health and Research), Gunta Lazdane (EURO Regional Office), Ramez Mahaini (EMRO Regional Office), Leopold Ouedraogo (AFRO Regional Office), Razia Pendse (WHO Regional Office for South-East Asia), Sheryl van der Poel (Department of Reproductive Health and Research), Joanna Vogel (Department of Maternal, Neonatal, Child and Adolescent Health).

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This paper was funded by the World Health Organization.