Discussion

The contribution of MENA to the global HIV literature is still meagre at just over 1%, though MENA's population comprises nearly 10% of the world's population. Nevertheless, the results of our study indicate that MENA has witnessed a rapid growth in HIV research over the last decade. The results were consistent on this conclusion regardless of the index used to measure the progress. The pace of growth continues and at a faster rate compared to the global literature (figure 2A). The widely held perceptions of limited HIV data in MENA, if not inaccurate, exaggerate the limitations of our epidemic knowledge in this region. Though there are still large gaps in HIV evidence, these should not prevent us from appreciating what has been achieved in just a few years over the last decade.

This advancement in the quantity of studies masks a remarkable progress in the quality of studies, which has greatly improved over the last few years. Studies in earlier years tended to have methodological limitations, were mostly descriptive or qualitative in nature and were conducted on convenience samples that are not necessarily representative, such as facility-based or venue-based samples.4 ,6–8 However, the region has witnessed recently a clear shift in the nature of evidence with multiple studies being conducted with state-of-the-art research methodologies (further discussion of study quality can be found in4 ,6–8). An example of quality studies are the integrated bio-behavioural surveillance surveys using innovative sampling methodologies for hard to reach populations such as respondent-driven sampling. Some countries such as Afghanistan, Egypt, Iran, Pakistan and Tunisia have now several rounds of surveillance among high-risk populations providing longitudinal data to track the evolution of the epidemic.9 Other countries have conducted their first round of surveillance; and in most of these, subsequent rounds are either planned or being implemented.7–9 All in all, the last decade in MENA can be described as a ‘brave new world’ in HIV research, after years in which the mere recognition that HIV is present and circulating in MENA countries was a taboo.4 ,10 ,11 It is not known, however, whether the ongoing global financial crisis, and the regional political instability, may impede this progress.

This progress, nevertheless, was not uniform across MENA countries. The last decade is marked by a widening disparity in HIV efforts (figure 2B). While few countries have made impressive strides, other countries continue to be far behind in terms of their will and capacity to conduct HIV research. Ironically, HIV research output does not appear to correlate with the country's per capita income. The Arabian Gulf countries that have the highest per capita income in the region have contributed minimally to this progress. Meanwhile, countries with constrained financial resources have made sizable contributions. In part, this reflects the fact that limited resource countries in the region, whenever they had strong commitment to advance HIV research, had access to funds through international donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.12 This external support did not only provide Financial Resources to conduct studies, but most often contributed to capacity building within the countries through collaborative partnerships with international organisations working in the region, or through involvement of international consultants or experts.12

Morocco provides a notable example in this regards. Thanks to strong national commitment, and despite the limited resources, Morocco established surveillance systems with a national reach, submitted quality applications to the Global Fund that succeeded in securing financial and technical support and facilitated an environment for the civil society and non-governmental organisations to play an important role in HIV efforts.13 ,14

The Synthesis Project Index provides an indication of how a large volume of research in MENA never reaches the stage of publication in scientific journals (figure 1). This is a structural weakness that reflects multiple factors, one of which is probably insufficient interest in academic publications. Many of the studies are conduced or supported through national programmes with limited interest in using the data beyond informing HIV policy and programmes at the national level.4 ,6 Limitations in the capacity to draft scientific publications, issues related to ownership of data and political sensitivity of the findings of some of the studies, may have further strained the efforts towards publication and dissemination to a wider audience.

Each of the four indices has its own limitations in capturing the diverse aspects that characterise the progress of HIV research in MENA. Some of the limitations in any specific index are addressed by the strengths of the other indices. However, this is not necessarily true for all limitations. For example, the total number of citations retrieved through PubMed and Embase is only a proxy of the number of publications that actually have primary data on HIV in the region. Nonetheless, screening of these two searches as part of previous systematic reviews conducted by the authors6–8 ,13 ,15 ,16 confirmed a strong correlation between the total number of citations retrieved and the number of citations with actual data, with substantially more data being published in recent years.

Another limitation in our study is that the active systematic phase of the Synthesis Project to collect non-published HIV literature has ended in early 2009; a fact reflected in the drop in the number of records through this index after 2008. The drop accordingly does not reflect a true reduction in the number of new records of unpublished literature, as much as it is an artefact of the Synthesis Project process. Similarly, the drop in the HIV Prevalence Index after 2008 appears to reflect limitations in reporting to or updating the US Census Bureau HIV/AIDS Surveillance database with new data entries in the last few years.

In conclusion, MENA has been witnessing a rapid growth in HIV research in the last few years despite significant challenges. Nevertheless, the region's contribution to global literature remains small relative to its population size and actual needs. There are knowledge gaps waiting to be filled, and the overall quality of studies still needs to be improved. Ongoing research efforts should be supported in a sustainable fashion to ensure the durability of the progress. Research should be conducted up to academic standard leading to scientific publications. Countries lagging in terms of research output should vigorously expand their research efforts to address the emerging HIV epidemics in this region.6 ,7 ,15 Surveillance systems and research studies should be geared primarily towards high-risk populations who are most affected by the epidemic. Integrated bio-behavioural surveillance surveys among these populations need to be conducted and repeated every few years. Risk-group size estimations, mapping and ethnographic studies and a better understanding of the sexual and injecting networks are warranted. General population sexual behaviour surveys will add useful data on the profile of risk behaviour in the population at large. Studies on HIV infected persons to improve case management are required. All of such studies are not only important for their direct benefits, but also important indirectly by facilitating and powering mathematical modelling and cost-effectiveness analyses.