STI/HIV/AIDS Surveillance Systems Evaluations: Central America, Panama and the Dominican Republic August 2004-Octuber 20

1. Edgar R. Monterroso, MD, MPH Centers for Disease Control and Prevention (CDC) Global Program on AIDS (GAP) STI/HIV/AIDS Surveillance Systems Evaluations: Central America, Panama and the Dominican Republic August 2004-Octuber 2007

2. Background • 2nd. Generation HIV Surveillance trainings • Regional HIV Surveillance Strategic Plan, 2004 • Need for evaluation of surveillance systems to strengthen them

3. Why evaluate? • Definition: • “ongoing and systematic collection, analysis, and interpretation of health data in the process of describing and monitoring a health event.” • Information is used for: • planning, implementing, and evaluating public health interventions and programs. • Surveillance data are used • to determine the need for public health action • to assess the effectiveness of programs. • Recommendations for improving quality and efficiency, e.g., eliminating unnecessary duplication. • The countries evaluated were Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica, Panama and the Dominican Republic.

4. Objetives • Evaluate or describe the Epidemiological Surveillance Systems (ESS) in the context of 2nd. Generation surveillance • Produce a report that would underline the results of the evaluation and to provide concrete recommendations. • Identify priorities for STI/HIV/AIDS surveillance in each country • Establish a national plan for Second Generation HIV Surveillance

5. Updated Guidelines for Evaluating Public Health Surveillance Systems • Recommendations from the Guidelines Working Group • MMWR Recommendations and Reports • July 27, 2001;50(RR-13):1–35 • This article can be found at: • http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm

6. Goals of second generation surveillance systems • Better understanding of trends over time • Better understanding of the behaviors driving the epidemic • Surveillance more focused on sub-populations at highest risk • Flexible surveillance that moves with the needs and state of the epidemic • Better use of surveillance data to increase understanding and to plan prevention and care

7. HIV/AIDS Surveillance Behavioral Surveillance Laboratory Investment STI Surveillance Other Sources Tuberculosis ART Surveillance Mortality Data use/ management Monitor and evaluation Evaluation Components 2nd. Generation surveillance

8. Approaches • Qualitative Focus: • Document review • Group/focus group interviews • Individual Interview • Direct observation • Quantitative Focus • Characteristics and trends in the epidemic • ESS components • Laboratories • Information management/use • Monitor and evaluation

9. General population HIV/AIDS Prevalence • HIV Incidence in MARPs • Epidemic Tendencies • National AIDS Program • ART Services Centers • NGOs working on AIDS • Laboratory (HIV tests) • Reporting System (passive surveillance) • Sentinel Surveillance • Epidemiologic data analysis Selection of areas to visit Epidemic Indicators Response Indicators ESS Indicators

10. Analysis Methodology Qualitative Areas Quantitative Areas • Laboratory data • ESS data • ESS Staff • Data Users Interviews, Observation Questionnaries Thematic Guide Analysis Plan Epi info 3.2.2 SWOT

11. Countries evaluated Countries evaluated from 2004 - 2006 Country evaluated in 2007 STI surveillance only

12. HIV/AIDS Case Reporting • Strengths • Standard case definition and national reporting forms • Sentinel surveillance in pregnant women • A legal framework exists --HIV/AIDS reporting is normed • There are appropriately trained individuals working in the surveillance system (FETP) • Opportunities • NGO are being supported • HIV testing for pregnant women is a national priority

13. HIV/AIDS Case Reporting • Strengths • Reporting systems – parallel, informal • Considerable delays, limited analysis and communication of findings. • Centralized data entry in many systems • Epidemiologists working many areas • No real supervision that would be considered “on site” training nor systematic • No HIV Surveillance Plans • Private sector doesn’t report

14. Behavioral surveillance for HIV infection risk • Strengths and opportunities • Health personnel with some behavioral surveillance research experience (some of the countries, DR) • Behavioral surveys in some at risk groups • Support to NGOs • There is interest at the central level to do behavioral surveys

15. Behavioral surveillance for HIV infection risk • Weaknesses • Survey results not systematically guided towards ESS • No social (ethnographic surveys) to describe different groups at risk • No recent BSS • There are some behavioral indicators but are not systematically reported on nor across the board (in-country)

16. Laboratory • Strengths • Rapid tests used in some countries as part of their algorhythm • Results given with post-test counseling • Periodic trainings for their staff • Human Resources of high caliber (technical and operatives) • Many of the labs have standardized operational manuals for HIV • Labs notify positive results to the national surveillance system

17. Laboratory • Weaknesses • Lead role not necessarily taken up by National Central Lab • Not all lab systems have a standarized diagnostic algorhythm • Infrastructure is inadequate and personnel is limited • No standarized quality control in place • Biosafety measures achieved to a certain degree • Quality standards are not in place • Some blood banks are using rapid tests to test their bloods despite the existence of norms against it.

18. LQA to assess reporting

19. How did our evaluations make an impact on surveillance in the countries? R/ National Strategic Plans for STI/HIV/AIDS Surveillance

20. National Strategic Plans for STI/HIV/AIDS Surveillance, Agosto 2004-Octubre 2007

21. Integrated Epidemiologic Profile (IEP) • “integrated perspective on the status of the HIV/AIDS epidemic through accessing multiple data sources” • It includes sociodemographic and clinical characteristics • It allows for focusing on specific groups at risk to • develop specific interventions • It allows the identification of “unmet needs” (i.e., ARVS) • It strengths the validity of the results • It relys on data triangulation

22. Conceptual framework AIDS Education and Prevention, 17, Supplement B, 3-16, 2005

23. Types of data sources and process Routine Surveillance Evaluation Surveys Improved Public Health Surveillance Epidemiologic Surveys Care and treatment Validated Data Analysis ..... Triangulation Decision Making

24. Questions an Integrated Epidemic Profile must address • What are the socio-demographics of the affected • population? • What is the perspective of the HIV/AIDS epidemic? • What are the risks indicators for HIV infection risk • in the population being serviced? • What are the service utilization patterns for PLH? • What is the number of individuals not being • serviced/covered by ART and their characteristics?

25. Thanks/Gracias