Progress Since Addis Surveillance Meeting 2004

1. Progress Since Addis Surveillance Meeting 2004 Theresa Diaz, MD MPH Global AIDS Program CDC 2008 Bangkok, Thailand

2. 2004 Conference Objectives Provide updates on emerging strategies for HIV and AIDS surveillance Present and discuss six consensus and research topics

3. 2004 HIV Statistics Compared to More Recent 38 million estimated persons living with HIV (overestimate). End 2007 about 33 million 400,000 persons on ARV. End 2007 about 3 million PEPFAR and GF distribution of funds had just begun.

4. 2004 HIV Surveillance Compared to Most Recent ANC sentinel surveillance in Africa 1000 sites in 32 countries (2003-2004) by 2005-2006 there were 2,500 sites in 31 countries By 2004 only 6 population based surveys with HIV testing in African countries, 7 globally. As of end of 2008, 25 countries in African have conducted such surveys, 30 globally. 2004 there were few MARPS surveys overall and few that used RDS. Between January 2003 and Oct 1, 2007, at least 122 MARPS surveys have used RDS. Other location based sampling MARPS surveys have also increased. In 2004, multiple AIDS case definitions, little HIV/AIDS case reporting, no HIVDR surveillance strategy, no ART outcome surveys, little data synthesis

5. Agenda for 2004 Conference Measuring recent infections Improving laboratory quality for surveillance Ethical aspects of surveillance Improving technical capacity in informatics Logistics of general population based surveys Linking biological and behavioral data Sampling high risk populations Use of PMTCT and VCT data for surveillance Surveillance in the context of care and treatment Using surveillance data (estimates and beyond)

6. Recent Infections Recommendations Do operational research of assays to assess appropriate population groups and issues regarding implementation Build capacity of national and international surveillance programs to select appropriate populations and interpret results Progress: Operational research done with BED but overestimation is problem Adjustment formula developed Multiple trainings provided on use of BED International Working Group now exists Multiple assays being considered However, still don’t have ideal method

7. National Population Based Surveys with HIV testing Recommendations: Use these surveys to fill gaps in HIV surveillance data Do not conduct on a regular basis but could do every five years. Do only in countries with relatively high HIV prevalence rates. Have protocols reviewed by a national ethical review board. Progress: Since 2000, 25 countries in Africa conducted these surveys Data used to fill gaps and improve estimation process Some countries conducted more that one survey Countries with HIV prevalence <5% conducted surveys Surveys reviewed by ethics board, new ethical challenges on returning HIV test results

8. Use of PMTCT and VCT data Recommendations Evaluate the utility of VCT data for surveillance and standardize protocols for analysis Expand use of PMTCT service data to complement ANC based SS Develop longitudinal record keeping be developed for better linkages to care Progress Several evaluations of PMTCT and ANC sentinel surveillance data but problem lies in quality of PMTCT data Longitudinal record keeping developed in some clinics Service data still problematic for surveillance use

9. Linking Biological and Behavioral data Recommendations Ensure surveillance can contribute to understanding of epidemic dynamics Encourage data linkage for triangulation and integrated analysis Progress Greater linkage of behaviors to HIV status through increased population based surveys and MARP surveys with HIV testing Several countries have done triangulation and more are planned Data use still limited

10. AIDS reporting and measuring impact of ART Recommendations Develop one AIDS case definition Improve AIDS case reporting system Expand existing TB surveillance system to capture data on HIV infection Capture data from individual patient records at point of entry into care with determination of outcome Improve overall and HIV-specific national-level mortality data in high-burden countries Progress One HIV case definition developed Little HIV, advanced HIV or AIDS reporting done TB surveillance captures HIV status in some countries ART outcomes being assessed using patient records in some facilities Better tools to measure causes of death by verbal autopsy but little improvement in overall mortality systems (e.g. vital statistics)

11. Other Progress Since 2004 Improved quality and analyses of ANC sentinel surveillance data. Developed strategy for HIVDR and implemented in a variety of countries

12. Key HIV Surveillance Data Points and the Course of HIV Infection, 2004 Advanced HIV Death HIV infection • Prevalence, behaviors, • morbidity • ANC sentinel surveillance* • Behavioral and • STI • Most at risk • group surveys • STI surveillance *Epidemics where infection is driven by the general population

13. Key HIV Surveillance Data Points and the Course of HIV Infection, 2009 Advanced HIV Death HIV infection • Prevalence, behaviors, • morbidity • ANC sentinel surveillance* • Population-based • Surveys with HIV testing* • Most at risk group • sero-surveys • HIV drug resistance • Behavioral and • STI • Population-based • Surveys* • Most at risk • group surveys • STI surveillance *Epidemics where infection is driven by the general population

14. Key HIV Surveillance Data Points and the Course of HIV Infection, the Future Advanced HIV Death HIV infection • Prevalence, behaviors, • morbidity • HIV case reporting or • advanced HIV • case reporting • ANC sentinel surveillance* • Population-based • Surveys with HIV testing* • Most at risk group • sero-surveys • ART outcomes • HIV drug resistance • Mortality • Vital registration • Behavioral and • STI • Population-based • Surveys* • Most at risk • group surveys • STI surveillance • Incidence • Report early • infant • diagnosis *Epidemics where infection is driven by the general population