Improving HIV surveillance systems: Country experiences and a proposal for evaluation framework

1. Improving HIV surveillance systems: Country experiences and a proposal for evaluation framework Virginia Loo1*, Evelyn Kim2, Edgar Monterroso2, Thuy Nguyen3, Tobi Saidel4, Neha Shah2, DCS Reddy5, Jesus Garcia-Calleja6 jHASE 2009

2. Background: • Resources for second generation surveillance (SGS) have increased tremendously in the decade after the 2000 guidelines for SGS were first published by UNAIDS/WHO. • Systematic evaluation of the effectiveness of these systems is needed.

3. INTRODUCTION • HIV surveillance is an essential tool for tracking the size and changing trajectory of an epidemic. • The SGS approach emphasizes the integration of size estimates of risk groups and tracking the behaviors driving the epidemic with sero-prevalence trends to characterize the epidemic in smaller, homogenous geographic units.

4. In general, programmes conduct evaluations to determine whether systems are meeting their objectives, serving a useful public health function, and operating as efficiently as possible. • The system objectives are to identify where new infections are coming from and understand the rate of growth of the epidemic.

5. In 2001, the U.S. Centers for Disease Control and Prevention (CDC) published broad guidelines to address the evaluation of public health surveillance systems. • These guidelines recommended a general process for conducting the evaluation: engaging stakeholders, • describing the surveillance system , • focusing the design, • gathering evidence regarding system performance, • making recommendations, • and ensuring the use of evaluation findings and lessons learned.

6. The CDC guidelines structure the evaluation around nine key system attributes: • simplicity, • flexibility, • data quality, • acceptability, • sensitivity, • predictive value positive, • representativeness, • timeliness, • and stability.

7. Meeting that took place in Bangkok, Thailand in March 2009 describing a new framework for evaluation of HIV surveillance systems and the experiences of evaluations in a range of countries and regions with different epidemic contexts.

8. Method • The three examples of surveillance system evaluation presented during the meeting come from China, India, and Central America.

9. China • Guangdong Province • HIV prevalence is about 0.1% of persons between ages 15 – 49 years • heterosexual transmission accounted for 40.6% of those living with HIV and injection drug use accounted for 38.1% • About 9.9% of all of China’s HIV cases (Most)

10. The key evaluation questions were whether the surveillance system could provide an accurate characterization of the epidemic and whether the system supported the use of surveillance data to guide prevention and control efforts. • Including case-based reporting, sentinel surveillance, behavioural surveillance and some special surveys.

11. The evaluation found mixed results for system usefulness and simplicity. Key findings included high scores for flexibility and timeliness across the different surveillance activities, • but poor ratings on representativeness and completeness of data in the case reporting system.

12. India • National HIV prevalence is 0.3% • prevalence varies by state and is much higher among populations of men who have sex with men, female sex workers, and injection drug users

13. the optimal combination of methods for collection of biological and behavioural markers among most-at-risk-populations; • setting criteria for which groups should be covered through facility-based sentinel surveillance; • the appropriate use of AIDS case and death reporting data; • strengthening STI surveillance; • and advancing laboratory services in surveillance.

14. Central America • From 2004 to 2007, a series of HIV/AIDS surveillance system evaluations were conducted in seven countries within the Central American Region: Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama and the Dominican Republic. • most-at-risk populations such as female sex workers and men who have sex with men. • pregnant women as high as 3.6%

15. Evaluation of HIV/AIDS case reporting found that across countries, systems suffered from considerable delays, lack of supervision, and limited analysis and communication of findings. Additionally, laboratory assessments revealed the lack of standardized diagnostic algorithms and quality control measures.

16. Discuss • Ensuring stakeholders buy-in • Clearly articulating the scope and purpose • Dedicating human resources to evaluation activities • Thoroughly documenting process and findings • Discussing and taking action based on the results

17. Given the many components of SGS systems and the complex transmission dynamics of HIV epidemics, surveillance evaluations must address multiple dimensions. • Each of the evaluations presented were tailored to the specific country context, a framework providing systematic guidance for surveillance evaluations would be a significant tool for future efforts.

18. The proposed SGS evaluation framework then defines a logical sequence of questions that provide a systematic approach for conducting an evaluation. These evaluation questions follow the general process of design and implementation of the surveillance system itself.

20. Conclusion • Using Concrete Parameters and Targets to Strengthen the System Over the Long-term • an evaluation which will result in actionable recommendations requires good planning, clear objectives, and a process appropriate for the epidemic context and the maturity of the surveillance system being evaluated.

21. The framework draws upon updated guidance on the second generation surveillance systems as well as lessons learned from assessing, updating, and revising HIV surveillance systems in a variety of regions and contexts. • The framework will be further strengthened as it is applied in more settings and users with varying levels of experience and resources.