Short Research Article: Do demographic, socioeconomic and clinical characteristics influence the number of psychological intervention sessions attended by young people in need of mental health care?

BACKGROUND AND METHOD: A cohort study using secondary data assessed associations between baseline characteristics and psychological sessions attended in young persons discharged from a Children and Young People's Mental Health Service in 2019. RESULTS: There were 584 persons who attended a median of seven sessions. On multivariable regression analysis, males attended fewer sessions than females, young people from more affluent communities attended more sessions than those from poorer communities and those presenting with eating disorders and self-harm in particular attended more sessions than those with anxiety. CONCLUSIONS: Addressing why these associations occur may improve mental health care in young persons.

Quality, Equity and Partnerships in Mixed Methods and Qualitative Research during Seven Years of Implementing the Structured Operational Research and Training Initiative in 18 Countries.

Introduction: Qualitative studies are often inadequately reported, making it difficult to judge their appropriateness for decision making in public health. We assessed the publication characteristics and quality of reporting of qualitative and mixed-method studies from the Structured Operational Research and Training Initiative (SORT IT), a global partnership for operational research capacity building. Methods: A cross-sectional analysis of publications to assess the qualitative component using an adapted version of the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Results: In 67 publications involving 18 countries, 32 journals and 13 public health themes, 55 were mixed-methods studies and 12 were qualitative studies. First authorship from low-and-middle-income (LMIC) countries was present in 64 (96%), LMIC last authorship in 55 (82%), and female first authorship in 30 (45%). The mean LMIC institutions represented per publication was five (range 1-11). Sixty-three (94%) publications were open access. Reporting quality was graded as 'good' to 'excellent' in 60 (89%) publications, 'fair' in five (8%) and 'poor' in two (3%). Conclusion: Most SORT IT publications adhered to COREQ standards, while supporting gender equity in authorship and the promotion of LMIC research leadership. SORT IT plays an important role in ensuring quality of evidence for decision making to improve public health.

Lifetime burden of disease due to incident tuberculosis: a global reappraisal including post-tuberculosis sequelae.

BACKGROUND: Many individuals who survive tuberculosis disease face ongoing disability and elevated mortality risks. However, the impact of post-tuberculosis sequelae is generally omitted from policy analyses and disease burden estimates. We therefore estimated the global burden of tuberculosis, inclusive of post-tuberculosis morbidity and mortality. METHODS: We constructed a hypothetical cohort of individuals developing tuberculosis in 2019, including pulmonary and extrapulmonary disease. We simulated lifetime health outcomes for this cohort, stratified by country, age, sex, HIV status, and treatment status. We used disability-adjusted life-years (DALYs) to summarise fatal and non-fatal health losses attributable to tuberculosis, during the disease episode and afterwards. We estimated post-tuberculosis mortality and morbidity based on the decreased lung function caused by pulmonary tuberculosis disease. FINDINGS: Globally, we estimated 122 (95% uncertainty interval [UI] 98-151) million DALYs due to incident tuberculosis disease in 2019, with 58 (38-83) million DALYs attributed to post-tuberculosis sequelae, representing 47% (95% UI 37-57) of the total burden estimate. The increase in burden from post-tuberculosis varied substantially across countries and regions, driven largely by differences in estimated case fatality for the disease episode. We estimated 12·1 DALYs (95% UI 10·0-14·9) per incident tuberculosis case, of which 6·3 DALYs (5·6-7·0) were from the disease episode and 5·8 DALYs (3·8-8·3) were from post-tuberculosis. Per-case post-tuberculosis burden estimates were greater for younger individuals, and in countries with high incidence rates. The burden of post-tuberculosis was spread over the remaining lifetime of tuberculosis survivors, with almost a third of total DALYs (28%, 95% UI 23-34) accruing 15 or more years after incident tuberculosis. INTERPRETATION: Post-tuberculosis sequelae add substantially to the overall disease burden caused by tuberculosis. This hitherto unquantified burden has been omitted from most previous policy analyses. Future policy analyses and burden estimates should take better account of post-tuberculosis, to avoid the potential misallocation of funding, political attention, and research effort resulting from continued neglect of this issue. FUNDING: National Institutes of Health.

Quality, Equity and Utility of Observational Studies during 10 Years of Implementing the Structured Operational Research and Training Initiative in 72 Countries.

Introduction: Observational studies are often inadequately reported, making it difficult to assess their validity and generalizability and judge whether they can be included in systematic reviews. We assessed the publication characteristics and quality of reporting of observational studies generated by the Structured Operational Research and Training Initiative (SORT IT). Methods: A cross-sectional analysis of original publications from SORT IT courses. SORT IT is a global partnership-based initiative aimed at building sustainable capacity for conducting operational research according to country priorities and using the generated evidence for informed decision-making to improve public health. Reporting quality was independently assessed using an adapted version of 'Strengthening the Reporting of Observational Studies in Epidemiology' (STROBE) checklist. Results: In 392 publications, involving 72 countries, 50 journals, 28 publishers and 24 disease domains, low- and middle-income countries (LMICs) first authorship was seen in 370 (94%) and LMIC last authorship in 214 (55%). Publications involved LMIC-LMIC collaboration in 90% and high-income-country-LMIC collaboration in 87%. The majority (89%) of publications were in immediate open access journals. A total of 346 (88.3%) publications achieved a STROBE reporting quality score of >85% (excellent), 41 (10.4%) achieved a score of 76-85% (good) and 5 (1.3%) a score of 65-75% (fair). Conclusion: The majority of publications from SORT IT adhere to STROBE guidelines, while also ensuring LMIC equity and collaborative partnerships. SORT IT is, thus, playing an important role in ensuring high-quality reporting of evidence for informed decision-making in public health.

An Opportunity to END TB: Using the Sustainable Development Goals for Action on Socio-Economic Determinants of TB in High Burden Countries in WHO South-East Asia and the Western Pacific Regions.

The progress towards ending tuberculosis (TB) by 2035 is less than expected in 11 high TB burden countries in the World Health Organization South-East Asia and Western Pacific regions. Along with enhancing measures aimed at achieving universal access to quality-assured diagnosis, treatment and prevention services, massive efforts are needed to mitigate the prevalence of health-related risk factors, preferably through broader actions on the determinants of the "exposure-infection-disease-adverse outcome" spectrum. The aim of this manuscript is to describe the major socio-economic determinants of TB and to discuss how there are opportunities to address these determinants in an englobing manner under the United Nations Sustainable Development Goals (SDGs) framework. The national TB programs must identify stakeholders working on the other SDGs, develop mechanisms to collaborate with them and facilitate action on social-economic determinants in high TB burden geographical areas. Research (to determine the optimal mechanisms and impact of such collaborations) must be an integral part of this effort. We call upon stakeholders involved in achieving the SDGs and End TB targets to recognize that all goals are highly interlinked, and they need to combine and complement each other's efforts to end TB and the determinants behind this disease.

Vitamin D status of tuberculosis patients with diabetes mellitus in different economic areas and associated factors in China.

BACKGROUND: Vitamin D could be a mediator in the association between tuberculosis (TB) and diabetes mellitus (DM). A large scale multi-center study confirmed that TB patients with DM had significantly lower serum vitamin D level compared with those without DM and reported that DM was a strong independent risk factor for vitamin D deficiency. OBJECTIVES: This study was undertaken to determine amongst patients with both TB and DM living in different economically defined areas in China: i) their baseline characteristics, ii) their vitamin D status and iii) whether certain baseline characteristics were associated with vitamin D deficiency. METHODS: In DM-TB patients consecutively attending seven clinics or hospitals, we measured 25 hydroxycholecalciferol at the time of registration using electrochemiluminescence in a COBASE 601 Roche analyser by chemiluminescence immunoassay. Data analysis was performed using chi square test and multivariate logistic regression. RESULTS: There were 178 DM-TB patients that included 50 from economically well-developed areas, 103 from better-off areas and 25 from a poverty area. Median vitamin D levels in well-developed, better-off and poverty areas were 11.5ng/ml, 12.2ng/ml and 11.5ng/ml respectively. Amongst all patients, 149 (84%) had vitamin D deficiency-91 (51%) with vitamin D deficiency (10-19.9 ng/ml) and 58 (33%) with severe deficiency (< 10 ng/ml). There was a significantly higher proportion with vitamin D deficiency in the poverty area. The adjusted odds of vitamin D deficiency (25-(OH)D3 <20 ng/ml) were significantly higher in those with longer history of DM (P = 0.038) and with HbA1c≥10% (P = 0.003). CONCLUSION: Over 80% of TB patients with DM in China were vitamin D deficient, with risk factors being residence in a poverty area, a long duration of DM and uncontrolled DM. TB programme managers and clinicians need to pay more attention to the vitamin D status of their patients.

Does the Structured Operational Research and Training Initiative (SORT IT) continue to influence health policy and/or practice?

BACKGROUND: The Structured Operational Research and Training Initiative (SORT IT) is a successful model of integrated operational research and capacity building with about 90% of participants completing the training and publishing in scientific journals. OBJECTIVE: The study aims at assessing the influence of research papers from six SORT IT courses conducted between April 2014 and January 2015 on policy and/or practice. METHODS: This was a cross-sectional mixed-method study involving e-mail based, self-administered questionnaires sent to course participants coupled with telephone/Skype/in-person responses from participants, senior facilitators and local co-authors of course papers. A descriptive content analysis was performed to generate themes. RESULTS: Of 71 participants, 67 (94%) completed the course. A total of 67 papers (original research) were submitted for publication, of which 61 (91%) were published or were in press at the censor date (31 December 2016). Among the 67 eligible participants, 65 (97%) responded to the questionnaire. Of the latter, 43 (66%) research papers were self-reported to have contributed to a change in policy and/or practice by the course participants: 38 to a change in government policy or practice (26 at the national level, six at the subnational level and six at the local/hospital level); four to a change in organisational policy or practice; and one study fostered global policy development. CONCLUSION: Nearly two-thirds of SORT IT course papers contributed to a change in policy and/or practice as reported by the participants. Identifying the actual linkage of research to policy/practice change requires more robust methodology, in-depth assessment and independent validation of the reported change with all concerned stakeholders.

How has the Zimbabwe mycobacterial culture and drug sensitivity testing system among re-treatment tuberculosis patients functioned during the scale-up of the Xpert MTB/RIF assay?

Background: In Zimbabwe, while the Xpert MTB/RIF assay is being used for diagnosing tuberculosis and rifampicin-resistance, re-treatment tuberculosis (TB) patients are still expected to have culture and drug sensitivity testing (CDST) performed at national reference laboratories for confirmation. The study aim was to document the Xpert MTB/RIF assay scale-up and assess how the CDST system functioned for re-treatment TB patients. Methods: We performed an ecologic study using national aggregate data. Results: Use of the Xpert MTB/RIF assay increased from 11 829 to 68 153 between 2012 and 2016. Xpert assays worked well, with successful tests in more than 90% of cases, TB detection rates at 15-17% and rifampicin resistance in <10%. During Xpert scale-up, the number of sputum specimens from re-treatment TB patients reaching national reference laboratories for CDST increased from 12% to 51%. In terms of laboratory performance, culture contamination increased from 3% to 17%, positive cultures from 13% to 17% and successful CDST from 6% to 14%: the proportion of CDST showing any resistance to rifampicin averaged 44%. From 2009 to 2016, the proportion of notified re-treatment TB patients with successful CDST increased from <1% to 7%. Conclusions: While components of Zimbabwe's CDST system for re-treatment TB patients showed some changes during the scale-up of the Xpert MTB/RIF assay, overall performance was poor. The country must either invest in improving CDST performance or in advanced molecular diagnostic technology.

What can National TB Control Programmes in low- and middle-income countries do to end tuberculosis by 2030?

The international community has committed to ending the tuberculosis (TB) epidemic by 2030. This will require multi-sectoral action with a focus on accelerating socio-economic development, developing and implementing new tools, and expanding health insurance coverage. Within this broad framework, National TB Programmes (NTPs) are accountable for delivering diagnostic, treatment, and preventive services. There are large gaps in the delivery of these services, and the aim of this article is to review the crucial activities and interventions that NTPs must implement in order to meet global targets and milestones that will end the TB epidemic. The key deliverables are the following: turn End TB targets and milestones into national measurable indicators to make it easier to track progress; optimize the prompt and accurate diagnosis of all types of TB; provide rapid, complete, and effective treatment to all those diagnosed with TB; implement and monitor effective infection control practices; diagnose and treat drug-resistant TB, associated HIV infection, and diabetes mellitus; design and implement active case finding strategies for high-risk groups and link them to the treatment of latent TB infection; engage with the private-for-profit sector; and empower the Central Unit of the NTP particularly in relation to data-driven supportive supervision, operational research, and sustained financing. The glaring gaps in the delivery of TB services must be remedied, and some of these gaps will require new paradigms and ways of working which include patient-centered and higher-quality services. There must also be fast-track ways of incorporating new diagnostic, treatment, and prevention tools into program activities so as to rapidly reduce TB incidence and mortality and meet the goal of ending TB by 2030.

HIV-infected presumptive tuberculosis patients without tuberculosis: How many are eligible for antiretroviral therapy in Karnataka, India?

For certain subgroups within people living with the human immunodeficiency virus (HIV) [active tuberculosis (TB), pregnant women, children <5years old, and serodiscordant couples], the World Health Organization recommends antiretroviral therapy (ART) irrespective of CD4 count. Another subgroup which has received increased attention is "HIV-infected presumptive TB patients without TB". In this study, we assess the proportion of HIV-infected presumptive TB patients eligible for ART in Karnataka State (population 60million), India. This was a cross-sectional analysis of data of HIV-infected presumptive TB patients diagnosed in May 2015 abstracted from national TB and HIV program records. Of 42,585 presumptive TB patients, 28,964 (68%) were tested for HIV and 2262 (8%) were HIV positive. Of the latter, 377 (17%) had active TB. Of 1885 "presumptive TB patients without active TB", 1100 (58%) were already receiving ART. Of the remaining 785 who were not receiving ART, 617 (79%) were assessed for ART eligibility and of those, 548 (89%) were eligible for ART. About 90% of "HIV-infected presumptive TB patients without TB" were eligible for ART. This evidence supports a public health approach of starting all "HIV-infected presumptive TB patients without TB" on ART irrespective of CD4 count in line with global thinking about 'test and treat'.

Scaling-up antiretroviral therapy in Malawi.

PROBLEM: In Malawi, health-system constraints meant that only a fraction of people infected with human immunodeficiency virus (HIV) and in immediate need of antiretroviral treatment (ART) received treatment. APPROACH: In 2004, the Malawian Ministry of Health launched plans to scale-up ART nationwide, adhering to the principle of equity to ensure fair geographical access to therapy. A public health approach was used with standardized training and treatment and regular supervision and monitoring of the programme. LOCAL SETTING: Before the scale-up, an estimated 930 000 people in Malawi were HIV-infected, with 170 000 in immediate need of ART. About 3000 patients were on ART in nine clinics. RELEVANT CHANGES: By December 2015, cumulatively 872 567 patients had been started on ART from 716 clinics, following national treatment protocols and using the standard monitoring system. LESSONS LEARNT: Strong national leadership allowed the ministry of health to implement a uniform system for scaling-up ART and provided benchmarks for implementation on the ground. New systems of training staff and accrediting health facilities enabled task-sharing and decentralization to peripheral health centres and a standardized approach to starting and monitoring ART. A system of quarterly supervision and monitoring, into which operational research was embedded, ensured stocks of drug supplies at facilities and adherence to national treatment guidelines.

Impact of rapid molecular diagnostic tests on time to treatment initiation and outcomes in patients with multidrug-resistant tuberculosis, Tamil Nadu, India.

BACKGROUND: India is replacing culture and drug sensitivity testing (CDST) with rapid molecular tests for diagnosing MDR-TB. We assessed the impact of rapid tests on time to initiation of treatment and outcomes in patients with MDR-TB compared with CDST. METHODS: A retrospective cohort study involving MDR-TB patients from six districts in Tamil Nadu state, who underwent CDST (2010-2011) and rapid tests (2012-2013). RESULTS: There were 135 patients in the CDST group and 389 in the rapid diagnostic test group. Median time from sputum receipt at the laboratory to initiation of MDR-TB treatment was 130 days (IQR 75-213) in the CDST group and 22 days (IQR 14-38) in the rapid diagnostic test group (p<0.001). Overall treatment success was 30% with CDST and 41% with rapid tests (p<0.05), but there was high loss to follow-up >30% in both groups and missing data were higher in CDST (13%) compared with rapid tests (3%). There were significantly higher risks of unfavourable treatment outcomes in males (aRR 1.3, 95% CI 1.1-1.5) and those with treatment initiation delays >30 days (aRR 1.3, 95% CI 1.0-1.6). CONCLUSION: Rapid molecular diagnostic tests shortened the time to initiate treatment which was associated with reduced unfavourable outcomes in MDR-TB patients. This supports the policy to scale up these tests in India.

HIV and tuberculosis in prisons in sub-Saharan Africa.

Given the dual epidemics of HIV and tuberculosis in sub-Saharan Africa and evidence suggesting a disproportionate burden of these diseases among detainees in the region, we aimed to investigate the epidemiology of HIV and tuberculosis in prison populations, describe services available and challenges to service delivery, and identify priority areas for programmatically relevant research in sub-Saharan African prisons. To this end, we reviewed literature on HIV and tuberculosis in sub-Saharan African prisons published between 2011 and 2015, and identified data from only 24 of the 49 countries in the region. Where data were available, they were frequently of poor quality and rarely nationally representative. Prevalence of HIV infection ranged from 2·3% to 34·9%, and of tuberculosis from 0·4 to 16·3%; detainees nearly always had a higher prevalence of both diseases than did the non-incarcerated population in the same country. We identified barriers to prevention, treatment, and care services in published work and through five case studies of prison health policies and services in Zambia, South Africa, Malawi, Nigeria, and Benin. These barriers included severe financial and human-resource limitations and fragmented referral systems that prevent continuity of care when detainees cycle into and out of prison, or move between prisons. These challenges are set against the backdrop of weak health and criminal-justice systems, high rates of pre-trial detention, and overcrowding. A few examples of promising practices exist, including routine voluntary testing for HIV and screening for tuberculosis upon entry to South African and the largest Zambian prisons, reforms to pre-trial detention in South Africa, integration of mental health services into a health package in selected Malawian prisons, and task sharing to include detainees in care provision through peer-educator programmes in Rwanda, Zimbabwe, Zambia, and South Africa. However, substantial additional investments are required throughout sub-Saharan Africa to develop country-level policy guidance, build human-resource capacity, and strengthen prison health systems to ensure universal access to HIV and tuberculsosis prevention, treatment, and care of a standard that meets international goals and human rights obligations.

Tuberculosis infection control measures in diabetes clinics in China: a rapid assessment of 10 hospitals.

OBJECTIVE: To assess tuberculosis infection control measures in diabetes mellitus (DM) clinics in China. METHOD: An evaluation questionnaire was developed based on the measures outlined in the WHO policy on TB infection control in healthcare facilities and congregate settings. Ten selected hospitals were assessed between September 2014 and February 2015. RESULTS: All hospitals had an infection control committee, an action plan and training, but there was no focus on activities to prevent airborne transmission of infection, especially from tuberculosis. All DM clinics had natural or artificial ventilation, but at the time of the evaluation half had all windows closed. While all the hospitals provided surgical masks for hospital staff, none had N95-specific respiratory masks and only three provided masks for patients with a cough. There were no policies on identifying DM patients with TB symptoms, minimising the time spent by these patients in the clinics or developing health educational material on diabetes and tuberculosis. CONCLUSION: Infection control measures to prevent airborne transmission in DM clinics are inadequate. More work is needed to better understand and determine the risk of TB infection in DM clinics and to improve their TB infection control practices.

Research to policy and practice change: is capacity building in operational research delivering the goods?

OBJECTIVES: Between 2009 and 2012, eight operational research capacity building courses were completed in Paris (3), Luxembourg (1), India (1), Nepal (1), Kenya (1) and Fiji (1). Courses had strict milestones that were subsequently adopted by the Structured Operational Research and Training InitiaTive (SORT IT) of the World Health Organization. We report on the numbers of enrolled participants who successfully completed courses, the number of papers published and their reported effect on policy and/or practice. DESIGN: Retrospective cohort study including a survey. METHODS: Participant selection criteria ensured that only those proposing specific programme-related and relevant operational research questions were selected. Effects on policy and/or practice were assessed in a standardised manner by two independent reviewers. RESULTS: Of 93 enrolled participants from 31 countries (14 in Africa, 13 in Asia, two in Latin America and two in South Pacific), 83 (89%) completed their courses. A total of 96 papers were submitted to scientific journals of which 89 (93%) were published and 88 assessed for effect on policy and practice. There was a reported effect in 65 (74%) studies including changes to programme implementation (27), adaptation of monitoring tools (24) and changes to existing guidelines (20). CONCLUSION: Three quarters of published operational research studies from these structured courses had reported effects on policy and/or practice. It is important that this type of tracking becomes a standard component of operational research and research in general.

Prevalence of extended treatment in pulmonary tuberculosis patients receiving first-line therapy and its association with recurrent tuberculosis in Beijing, China.

BACKGROUND: In China, it is known that extended treatment is given to patients with pulmonary TB after they have successfully completed 6 months of first-line treatment. This practice is not officially reported to the National Tuberculosis Control Programme, so there are no data on its prevalence, its possible benefits in terms of preventing recurrent disease or the costs. This study aimed to provide information, from a single TB dispensary in Beijing, China, on the prevalence of extended anti-TB treatment and its relationship with recurrent TB. METHODS: Retrospective cohort study using the electronic national TB information system and dispensary medical records. RESULTS: Of 935 patients with pulmonary TB who completed 6-7 months of first-line drug treatment, 399 (43%) were given extended treatment. This was more common in patients with smear-positive disease, and those with lung cavities and more extensive radiographic lobar involvement at the time of diagnosis. Over 3-4 years' follow-up, recurrent disease was not significantly different in patients who received extended treatment (2.8%, 11/399) as compared to those who received the standard 6-month treatment (3.7%, 20/534). The median length of extended treatment was 89 days at a median cost of US$111 for drugs and US$32 for laboratory examinations. CONCLUSIONS: This study shows that extended treatment is common in one TB dispensary in Beijing. Further studies are needed to determine the countrywide prevalence of this practice and ascertain more conclusively the apparent lack of benefit.

Provider-initiated HIV testing and counselling for TB in low HIV prevalence settings: is it worthwhile?

BACKGROUND: We assessed the HIV-positive yield of offering provider-initiated HIV testing and counselling (PITC) for TB and the costs, in Madagascar, which has a low HIV prevalence and a high TB burden. METHODS: A cross-sectional study of routinely collected records from January 2010 to June 2011. RESULTS: A total of 37 596 TB patients were registered in 205 TB centres. HIV testing was available in 95 (46%) of centres where 7524 (40%) of those offered testing accepted it. Only 35 (0.5%) individuals were found HIV positive. Initial costs were about US$1.4 million and annual recurrent costs about US$0.1 million. CONCLUSION: There are concerns of cost investment for countrywide introduction of PITC in a low HIV prevalence setting.

National profile and treatment outcomes of adult smear-negative pulmonary TB patients in Benin.

BACKGROUND: In Benin, patients with smear-negative pulmonary TB (SNPTB) are of low priority in the National Tuberculosis Programme (NTP) and little is known about their profile or treatment outcomes. METHODS: A retrospective cohort study was carried out to determine characteristics and treatment outcomes in all adults registered with SNPTB in 2009. Findings were compared with patients with new smear-positive pulmonary tuberculosis (PTB) diagnosed in the same period. RESULTS: Of 3140 patients with PTB, 273 (8.7%) had SNPTB, with higher rates in northern and southwestern regions. SNPTB was associated with female gender, older age and HIV-positive status (p<0.01). Patients with SNPTB had a higher proportion of unsuccessful treatment outcomes compared with smear-positive PTB owing to death and loss to follow-up (LFU) (p<0.01). The region with the capital city had the highest rate of LFU. Differences in unsuccessful outcomes between SNPTB and smear-positive PTB were more apparent in persons who were HIV-negative, and among HIV-positives not on antiretroviral treatment. CONCLUSION: In Benin, treatment outcomes of SNPTB patients were inferior to those with smear-positive PTB, with LFU being a major problem. The Benin NTP needs to better address the problem of patients with SNPTB in terms of monitoring and reporting, treatment management including that associated with HIV care, and reducing LFU.

Building a national direction for research in the prevention of mother to child transmission of HIV: results from a national prioritization initiative in Malawi.

BACKGROUND: In 2011, Malawi initiated an ambitious program for the prevention of maternal to child transmission (PMTCT) of HIV, called 'Option B+,' which employs a universal test and life-long treatment strategy for all pregnant women. Priority setting should take place in defining a national research agenda for evaluating Option B + rollout in Malawi. METHODS: In April 2011, a three-day workshop took place for all major stakeholders in PMTCT aiming to provide an update on current PMTCT operational research in Malawi, find consensus on key questions not yet being addressed, identify opportunities for collaboration, and develop multi-partner research proposals. RESULTS: Overall, 24 participants attended the workshop including representatives from the Ministry of Health, the National AIDS Commission and 12 multilateral, non-governmental organizations and academic partners.Three interrelated clusters emerged as priorities for research: i) pregnancy intentions and family planning needs; ii) evaluation of models of care; and iii) determinants of uptake, adherence, and retention of women for Option B+. In addition, two cross-cutting themes arose: partner involvement in PMTCT services and cost-effectiveness as a guide to priority setting. Within each cluster a coordinator was designated and a proposed plan for research and potential collaborators were discussed. The results of the workshop were presented to the national technical working groups and the National AIDS Commission. Several large-scale, collaborative proposals have been developed and funded to address the research areas defined. CONCLUSIONS: Option B + represents a significant change in PMTCT policy in Malawi and the process for evaluation of the Malawi PMTCT strategy is outlined. This workshop contributed to defining and coordinating the national agenda for research priorities.