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STI Surveillance for Second Generation Surveillance: Feasibility and added value—fact or fiction?

STI Surveillance for Second Generation Surveillance: Feasibility and added value—fact or fiction?. Francis Ndowa George Schmid WHO, Geneva. Introduction to 2nd Generation HIV Surveillance. UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance.

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STI Surveillance for Second Generation Surveillance: Feasibility and added value—fact or fiction?

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  1. STI Surveillance for Second Generation Surveillance: Feasibility and added value—fact or fiction? Francis Ndowa George Schmid WHO, Geneva

  2. Introduction to 2nd Generation HIV Surveillance UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance Introduction to 2nd Generation HIV Surveillance

  3. Guidelines for 2nd Generation HIV Surveillance Second Generation Surveillance for HIV: The Next Decade Published 2000

  4. HIV/AIDS: Data Needs • What are the levels and trends in HIV infection? • Who is getting infected? • Who is at risk for or vulnerable to HIV infection? • What is the impact of the epidemic? • Is the response effective? Introduction to 2nd Generation HIV Surveillance

  5. HIV/AIDS: Data Needs • What are the levels and trends in HIV infection? • Who is getting infected? • Who is at risk for or vulnerable to HIV infection? • What is the impact of the epidemic? • Is the response effective? Introduction to 2nd Generation HIV Surveillance

  6. Strengths Relatively simple and cheap Increase awareness and raise commitment Generating response Target activities Monitor success Weaknesses No risk behaviours Poor early warning Little use of other sources of data “One size fits all” Not suitable for “slow” or “mature” epidemics It is difficult to derive HIV prevalence estimates LESSONS LEARNED from HIV surveillance Introduction to 2nd Generation HIV Surveillance

  7. 2nd generation HIV surveillance • It is not “new or different” but “improved” • Builds on the lessons learnt in the first decade of surveillance for HIV • Attempts to capture the diversity of the HIV epidemics in different areas • Considers the state of the epidemic • low-level • concentrated • generalised • Integrates biological surveillance (AIDS, HIV) with“RISK”surveillance (behaviours, STI) • Looks at new methodologies and improved ways for using HIV epidemiological data Introduction to 2nd Generation HIV Surveillance

  8. Data management Data analysis HIV estimates and projections Use of data for action 2nd generation HIV surveillance STI surveillance HIV surveillance behavioural surveillance AIDS reporting Introduction to 2nd Generation HIV Surveillance

  9. HIV PREVALENCE SURVEILLANCE AIDS DEATHS “RISK” SURVEILLANCE HIV INCIDENCE SURVEILLANCE AIDS CASE SURVEILLANCE “WINDOW” PERIOD HIV ILLNESS or AIDS ASYMPTOMATIC PERIOD DEATH INFECTION = VIRAL LOAD = HIV ANTIBODIES Introduction to 2nd Generation HIV Surveillance

  10. It is Remarkable How Little Guidance on STIs was Given Introduction to 2nd Generation HIV Surveillance

  11. Subsequent Documents • Initiating Second Generation HIV Surveillance Systems: Practical Guidelines (2002) • Little help • Guidelines for Conducting HIV Sentinel Serosurveys among Pregnant Women and Other Groups (2003) • Not mentioned • Pre-surveillance Assessment (2005) • One paragraph • Surveillance for STIs (2006—SEARO) • Better! • Other current documents • STI Prevalence Study Methodology (1999)—old • STI Surveillance (1999)--old • Non-UN Agency guidance—limited • UCSF? • WHO Collaborative Centre for Capacity Building in HIV Surveillance(training for STI surveillance)

  12. It's been 9 years since 2000 How're we doing with the STI part of SGS?

  13. 2nd generation HIV surveillance • Integrates biological surveillance (AIDS, HIV) with “RISK” surveillance (behaviours, STI) Introduction to 2nd Generation HIV Surveillance

  14. STIs There are about 30 STIs or disease syndromes that result from STIs

  15. STI Syndromes • No symptoms or signs • Urethral discharge/discomfort (urethritis) in males • N. gonorrhoeae • C. trachomatis • U. urealyticum • Testicular pain (epididymitis) • N. gonorrhoeae • C. trachomatis • Abdominal pain in women (pelvic inflammatory disease) • N. gonorrhoeae • C. trachomatis • Flora of bacterial vaginosis • ? Mycoplasma genitalium

  16. STI Syndromes (continued) • Vaginal discharge/inflammation in women • Trichomonas vaginalis • Candida species (candidiasis) • Bacterial vaginosis • Genital “growths” • Human papillomavirus • Genital ulcers • Herpes simplex virus • Haemophilus ducreyi • Treponema pallidum

  17. The Happy Young Person

  18. Chancroid Gonorrhea Syphilis Infection increasingly asymptomatic Sex practices increasingly risky Chlamydia Genital herpes Trichomonas Human papillomavirus Glasier A et al. Lancet 2006;268:1-12

  19. Chancroid Gonorrhea Syphilis Infection increasingly asymptomatic Sex practices increasingly risky Chlamydia Genital herpes Trichomonas Human papillomavirus Glasier A et al. Lancet 2006;268:1-12

  20. 10% Risk

  21. 10% Risk 2% Risk 8% Risk 12% Risk 20% Risk

  22. Unfortunately, we've given insufficient guidance People in the field are uncertain what to do (maybe we are, ourselves)

  23. What might a successful program using SGS and STI biomarkers look like? • For an understanding of sexual behaviour in the population, monitor a disease with moderate-high infectivity, few symptoms • For an understanding of sexual behaviour with immediate understanding of risk, a disease with "high infectivity, short incubation…and little immunity"—bacterial STIs1 1Rehle T et al. Bull WHO 2004;82:121

  24. What might a successful program using SGS and STI biomarkers look like? • What is the sexual risk in the population? • General population-based surveys using serology, e.g., every 5 years • HSV-2, syphilis

  25. Prevalence of Antibody to HSV-2, Europe Smith J, Robinson J. J Infect Dis 2002; 186(S):S3

  26. Prevalence of Antibody to HSV-2 Sub-Saharan Africa Smith J, Robinson J. J Infect Dis 2002; 186(S):S3

  27. What might a successful program using SGS and STI biomarkers look like? • What is the sexual risk in the population? • General population-based surveys using serology, e.g., every 5 years • HSV-2, syphilis • ANC syphilis testing (should be routine) • STI surveillance (if accurate, ongoing data collection possible) • Sentinel surveillance likely best • Urethral discharge (syndrome) • Gonorrhea and chlamydia (noninvasive testing) and syphilis testing, possibly via periodic surveys (etiologic)

  28. What might a successful program using SGS and STI biomarkers look like--2? • What is the sexual risk in high risk groups? • STI surveillance (if accurate, ongoing data collection possible) • Sentinel surveillance likely best • MSM • Gonorrhea (noninvasive testing) and syphilis testing, possibly via periodic surveys (etiologic)

  29. Syphilis Among MSM, San Francisco, 1998-2007 Early latent Secondary Primary 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007Year San Francisco Dept of Public Health, HIV/AIDS Epidemiology Annual Report, 2007

  30. What might a successful program using SGS and STI biomarkers look like--2? • What is the sexual risk in high risk groups? • STI surveillance (if accurate ongoing data collection possible) • Sentinel surveillance likely best • MSM • Gonorrhea (noninvasive testing) and syphilis testing, possibly via periodic surveys (etiologic) • CSW • Gonorrhea and chlamydia (noninvasive testing) and syphilis testing, possibly via periodic surveys (etiologic) • IDU • Gonorrhea (noninvasive testing) and syphilis testing, possibly via periodic surveys (etiologic)

  31. Clients Using Condoms andSTI Cases Reported - Thailand % using condoms STI cases reported ( thousands) 100 90 80 70 60 50 40 30 20 10 0 100 90 80 70 60 50 Clients using condom 40 30 STI cases reported 20 10 0 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Source: Sentinel Serosurveillance, Division of Epidemiology, Ministry of Public Health.

  32. If We Collect the Information, How Do We Use It? • There is little point and wasted resources if we collect information and do not use it. • What interventions do we make (or not make) if we collect the data?

  33. Summary • The concept of STI data for Second Generation Surveillance is appealing and appears straightforward. In reality, it is far more complex: What STIs to monitor, how to monitor them, in whom and how often? • "We" have given poor guidance. If we expect STI data to be used for SGS, we must provide guidance. • A review of the experiences with using STI data for SGS would identify good and bad experiences, and inform the development of guidance.

  34. It's been 9 years since 2000 Second Generation Surveillance for HIV: The Next Decade How're we doing with the STI part?

  35. STI Surveillance for SGS: Feasibility and added value--fact or fiction? Mostly fiction at this moment, but with promise to become fact

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