Transcript AIDS Surveillance

Module 1: Final Case Study
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Case Study: Instructions
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Try this case study individually.
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We’ll discuss the answers in class.
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Question 1
1. You are the HIV sero-prevalence officer for
Inyo province. Inyo is a large province in the
Mono Republic, a country with a
concentrated HIV epidemic. Seroprevalence surveys are conducted annually
in Inyo in antenatal clinics. You examine
data from the past five year and observe the
following:
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Question 1, continued
Sero-prevalence of HIV among pregnant women attending
ANCs in Inyo Province 1999- 2005.
2001
2002
2003
2004
2005
Number of subjects
6120
6790
6942
6671
7662
Overall Prevalence
29%
32%
30%
24%
21%
Prevalence by age (years) :
15 - 19
25%
20%
19%
14%
12%
20 - 24
32%
29%
29%
24%
23%
25 - 29
37%
37%
38%
31%
29%
30 - 34
42%
40%
37%
30%
30%
35 - 39
30%
31%
36%
28%
25%
40 - 44
15%
22%
24%
18%
15%
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Question 1, continued
a. Using the above data, create a figure to
show HIV prevalence by age group and
year.
HIV prevalence by age and year, Inyo Province, 2001-2005
45
40
35
15 - 19
Prevalence
30
20 - 24
25
25 - 29
20
30 - 34
35 - 39
15
40 - 44
10
5
0
2001
2002
2003
2004
2005
Year
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Question 1, continued
b. What trends do you see regarding HIV
prevalence in relation to age and year?
Overall, HIV prevalence was highest in 2002 and
decreased between 2002 and 2005. HIV prevalence
was highest among pregnant women ages 25 to 34,
while lowest among pregnant women ages 15 to 19
and 40 to 44. Among pregnant women 15 to 24 and
30 to 34 years old, HIV prevalence peaked in 2001
and decreased from 2001 through 2005. Among
pregnant women ages 25 to 29 and 35 to 44 years,
HIV prevalence was highest in 2003 and decreased
between 2003 and 2005.
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Question 2
2. Inyo province has recently been given funds to
begin second-generation HIV surveillance. Until
now, HIV/AIDS surveillance has been limited to HIV
and AIDS case reporting and sentinel serosurveillance at antenatal and STI clinics.
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Question 2, continued
a. What components of second-generation HIV
surveillance would you implement to strengthen the
province’s surveillance system?
When possible, components of second generation
surveillance that would strengthen the province’s
surveillance system would include:
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behavioural surveillance, which involves asking
a sample of people about their sexual and,
sometimes, their drug-injecting behaviour
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improving and using HIV/AIDS case reporting
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improving and using death registries
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sexually transmitted infection (STI) surveillance
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Question 2, continued
b. What measures would you include?
Biological measures could include: HIV prevalence,
STI incidence and prevalence, TB prevalence, the
number of adult AIDS cases and the number of
pediatric AIDS cases. Behavioural indicators could
include: sex with a non-regular partner in last 12
months, condom use at last sex with a non-regular
partner, age at first sex, use of unclean injecting
equipment reported by drug injectors and reported
number of clients in the last week by sex workers.
Sociodemographic indicators could include: age,
gender, socio-economic and educational status,
geographic residency (urban vs. rural) or migration
status, marital status and parity (for antenatal sites).
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Question 3
3.
Inyo province provides free antiretroviral therapy (ART)
to HIV-infected pregnant women. What ethical issues
must you consider when conducting HIV surveillance
among pregnant women in a setting where ART is
available?
Because ART is available in Inyo province, conducting HIV
surveillance through anonymous unlinked sero-surveillance
presents ethical issues. If anonymous unlinked surveillance
surveys are used women must have access to voluntary HIV
counselling and testing with referrals for care for HIV-infected
women. Case reporting and surveys conducted in
conjunction with voluntary counselling and testing would
diagnose individuals with HIV infection and give them their
results so that if needed, they could begin ART and must
present the same ethical concerns as anonymous unlinked
surveys.
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Question 4
4. Annual sero-prevalence surveys have been
conducted at five antenatal clinics in the district for
the past four years. The survey is conducted
between June and September of each year.
Evaluation of the sero-prevalence surveys is one
of your responsibilities. This entails assessing the
data for quality and completeness. After the first
two months of the current annual survey you
examine the database and observe the following:
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Question 4, continued
Missing data during sero-surveillance by site, Inyo Province
Number of subjects
Site 1
Site 2
Site 3
Site 4
Site 5
158
165
208
287
189
Percent missing data:
Age
6%
5%
2%
4%
5%
2%
1%
1%
2%
3%
Residence
4%
5%
2%
3%
5%
Parity
3%
2%
1%
2%
3%
Live births
1%
2%
2%
1%
3%
HIV serology
1%
1%
0%
20%
1%
Date specimen
collected
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Answers to final case study, continued
a. What are your thoughts regarding the data in this
table? Is there anything of concern?
20% of HIV serologic results are missing from site
4.
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Question 4, continued
b. What are some possible explanations for this
finding? How would you investigate these? What
steps would you take to correct the problem(s)?
There are many possible explanations, including:
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A problem with data entry. This could be
investigated by examining the hard copies of
the data.
Laboratory error: testing was not done.
Laboratory error: testing was done but not
recorded.
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Question 4, continued
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You conduct your investigation and find that
the HIV serologic results are missing on the
hard copies. You then visit the laboratory and
meet with the director.
In your discussions, you discover that
reagents for HIV testing were not available for
a period of time. The laboratory director
indicates that there is now an ample supply of
HIV reagents and that the survey can be
completed without any interruptions.
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Question 4, continued
c. Having identified the problem, how do you address
it in the short term and what are some steps you
can take to ensure that such a problem does not
recur?
Additional training session might be needed. At a minimum,
the sero-prevalence coordinator should meet first with the
laboratory director and then with laboratory staff to review the
protocol.
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In addition, since one lapse in protocol was found, the
coordinator should keep a close watch on the data from
this site and should make frequent visits there to assess
adherence to protocol, answer questions and stress the
importance of sero-prevalence surveys.
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Improving communication between the sero-prevalence
coordinator and the laboratory director regarding the
adequacy of supplies should also be discussed.
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Questions, Process Check
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Do you have any questions on the information
we just covered?
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Are you happy with how we worked on the
final case study?
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Do you want to try something different that will
help the group?
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Small Group Discussion
Get into small groups to discuss these questions.
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Does your country have a functional HIV case
reporting system?
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If your country is not conducting HIV case
reporting, discuss why it is not.
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If your country does not have an HIV case reporting
system, discuss current limitations to HIV case
reporting. What are some possible solutions for
these limitations?
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Working alone or with others from your country,
region or district, complete the following tables and
then discuss your responses in your small group.
Case Study
1. You
are the regional surveillance officer for
Ethiopia. The national AIDS control programme
is interested in expanding and improving its
surveillance programme and the national
surveillance officer is conducting site visits to
various districts to discuss ways of improving
surveillance. During your meeting with the
national surveillance officer, you are asked to
suggest additional surveillance activities in your
region that you believe could be implemented
successfully. Describe what these activities
would be.
Case Study, Cont.
2. The
national surveillance officer has
indicated that there is interest in using
data collected from HIV and other care
programmes for reporting of persons with
advanced HIV disease. Review the
worksheet you completed in your small
group discussion and use this to
determine the necessary steps to expand
current surveillance activities. List these
activities.