1. A Basic Understanding of HIV SurveillanceReferenceSOURCEUNAIDS/WHO Dr Rajeev Kashyap B.Sc., B.D.S ., M.Sc. (DPH)U.K C.C.R.A., P.M.I., C.R.A.A(Canada)

2. Impact of the HIV/AIDS worldwide epidemic Every day, over 6,800 persons become infected with HIV. Every day, over 5,700 persons die from AIDS, mostly because of lack of access to HIV prevention and treatment services. (Source: UNAIDS/WHO 2007)

3. Prevalence of the Epidemic

5. Macrophages As the number of these cells is depleted because of the virus, patients become immunodeficient, meaning their immune systems are insufficient to ward off infections. They develop opportunistic infections and certain cancers.

6. Biology: HIV Types

7. How HIV Is Transmitted Both HIV-1 and HIV-2 are transmitted in the same ways: The predominant route of transmission is through Unprotected heterosexual intercourse or Homosexual intercourse between men. HIV is also transmitted through blood, blood products, and donated organs (also referred to as parenteral transmission). HIV may be transmitted from an infected mother to her fetus or infant during pregnancy, delivery or when breastfeeding (also referred to as perinatal transmission).

12. Factors that Affect HIV/AIDS Prevalence High prevalence of sexually transmitted infections (STIs) Limited access to STI management Limited access to, or social non-acceptance of, condoms War and civil disturbance Cultural/ethnic practices Women’s low status Low literacy rates Increasing urbanization, migration, and mobilization Low level of political commitment Exposure to blood from unsafe medical practices and/or traditional practices

13. The two main factors driving the HIV/AIDS epidemic in Asia are injection drug use and commercial sex.

15. Prevention of Mother-To-Child Transmission A short-course antiretroviral regimen given to the mother and the newborn baby can substantially reduce the risk of perinatal transmission of HIV during pregnancy and childbirth.

16. HIV-Positive Mothers HIV-positive mothers can avoid the risk of transmission through infected breast milk by using breast milk substitutes. However, significant health risks are associated with this practice: Malnutrition Exposure to other infections For this reason, WHO/UNICEF/UNAIDS have developed several documents that address HIV and breastfeeding.

17. Antiretroviral Drugs Treatment

18. Antiretroviral drugs are used to treat HIV infection. In the past, the high cost of these drugs made them rarely used in most developing countries. Several agencies are now making funds available for antiretroviral and other therapies. These organizations includeThe Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank Multi-sectoral AIDS Plan (MAP) and The United States President’s Emergency Plan for AIDS Relief (PEPFAR).

19. ARV Therapy ARV therapy has reduced the rate of progressing to AIDS in areas where these drugs are accessible. It has also been associated with changes in the types of opportunistic infections that appear with AIDS.

20. Classes of antiretroviral drugs There are three classes of antiretroviral drugs: Nucleoside reverse transcriptase inhibitors (NRTIs) Non-nucleoside reverse transcriptase inhibitors (nNRTIs) Protease inhibitors (Pis)

21. WHO recommends the following antiretroviral therapy strategy First line drugs: 2 NRTI + 1 NNRTI Second line drugs: 2 NRTI + PI Surveillance is an important tool to monitor drug resistance in populations on treatment.

22. Preventing & Treating Opportunistic Infections In addition to antiretroviral drugs, the treatment of HIV infection includes diagnosis, prophylaxis, andtreatment of selected opportunistic infections. Anti-tuberculosis (TB) drugs extend the lives of patients with both HIV and TB. Cotrimoxazoleprophylaxis has been used successfully to prevent the onset of opportunistic infections in HIV-positive patients in sub-Saharan Africa. Vaccines are available for some potential opportunistic infections, such as pneumococcal disease

23. Main Components of Public Health Surveillance The main components of surveillance include: The systematic collection, analysis, and evaluation of morbidity and mortality reports and other relevant data Timely and regular distribution of information about the trends and patterns of disease to those who need to know Use of the information for disease prevention and control measures An important part of the definition is that surveillance systems involve ongoing collection and use of health data

24. SomeProblems -disease surveillance systems Duplication of effort Delay in reporting Inadequate data collection, analysis, use and dissemination Lack of integrated training Lack of evaluation Lack of laboratory involvement and coordination Lack of supervision

26. Public health agencies

28. Sentinel surveillance

29. Laboratory-based reporting

30. Case definition

31. Prevalence

32. Incidence

33. Passive surveillance

35. Relationship between Disease and Case Definition

36. Relationship between disease and case definition is described in definitions below Sensitivity - The ability of a case definition or laboratory test to predict true disease (a/(a+c)). Specificity - The ability of a case definition or laboratory test to predict absence of true disease (d/(b+d)). Positive predictive value - The proportion of persons meeting a case definition, having a positive laboratory test that have true disease (a/(a+b)). Negative predictive value - The proportion of persons not meeting a case definition, having a negative laboratory test that do not have true disease (d/(c+d)).

37. Purpose of HIV/AIDS Surveillance Epidemiologic surveillance is to detect trends in disease incidence and prevalenceover time Providing an accurate assessment of the distribution of disease by person, place and time Providing information on changes or trends in disease distribution by geographic, socio-demographic or exposure parameters Identifying groups or geographical areas for targeted intervention efforts Providing information to evaluate effectiveness of intervention efforts Providing data for prevention program management (such as for voluntary counselling and testing, prevention of mother-to-child transmission and sexually transmitted infection management) Providing data for development and implementation of research efforts

38. Prevalence and Incidence Prevalence measures the level of HIV infection in a population. It is measured as a unitless proportion, such as the percent infected or the number of infections per thousand persons tested. Prevalence is influenced by both the rate of new infections (incidence) and the rate that infected people leave the population by death, cure or migration. Incidence is the rate at which new HIV infections occur in a population in a given period of time. Because it is a rate, its unit of measurement always has time in the denominator

39. Core Elements HIV case reporting involves routinely reporting all cases of HIV infection to accurately monitor the HIV epidemic, assess how the epidemic is changing, and create programs for HIV prevention and medical care that best serve affected people and communities. AIDS case reporting involves routine reporting of specific data elements for persons diagnosed with AIDS in all or selected health facilities in the country to monitor AIDS morbidity in the general population. HIV sero-surveillance seeks to estimate the prevalence of HIV infection in selected populations such as antenatal clinic (ANC) attendees, STI patients and blood donors by conducting sero-prevalence surveys in these populations on an ongoing basis.

40. Advantages and Disadvantages

41. Summary( Recap) The purpose of HIV/AIDS surveillance is to provide an accurate picture of the epidemic, which will then help to guide prevention and treatment programs. It helps to identify population sub-groups that are at higher risk for infection. Also, more information is provided on the distribution of disease over time and space. Now think of what the situation is like in your country. What is the approximate HIV prevalence in your district or province? Which sub-populations are most affected by the HIV/AIDS epidemic in your region?

42. The HIV/AIDS epidemic is becoming larger and more complex. Surveillance efforts must become more sophisticated if they are to be effective.

43. Today, we use second-generation HIV surveillance, which is designed to collect and integrate data reported from a variety of other sources:Behavioural surveillanceHIV/AIDS case reportingDeath registrationSexually transmitted infection (STI) surveillanceAdditional data provide a more comprehensive understanding of trends in the epidemic as well as the effectiveness of control and prevention measures.

45. Today, we use second-generation HIV surveillance, which is designed to collect and integrate data reported from a variety of other sources:Behavioural surveillanceHIV/AIDS case reportingDeath registrationSexually transmitted infection (STI) surveillanceAdditional data provide a more comprehensive understanding of trends in the epidemic as well as the effectiveness of control and prevention measures.

46. Goals The goals of second-generation HIV surveillance are: Better understanding of trends over time Better understanding of the behaviours driving the epidemic in a country Increased focus on sub-populations at highest risk for infection Flexibility to change with the state of the epidemic

50. Concentrated epidemic

52. Concentrated Epidemic Characteristics of a concentrated epidemic include: HIV has spread rapidly in a defined sub-population, but is not well-established in the general population. HIV prevalence is consistently over 5% in at least one defined sub-population. HIV prevalence is below 1% in pregnant women in urban areas. This epidemic state suggests active networks of risk within the sub-population.

53. Generalized Epidemic Characteristics of a generalized epidemic include: HIV is firmly established in the general population. HIV prevalence consistently over 1% in pregnant women. Sexual networking in the general population is sufficient to sustain an epidemic independent of sub-populations at higher risk for infection.

54. Summary( Recap) The three epidemic classifications explain the extent of the impact and transmission of the HIV/AIDS epidemic. Each relates to specific characteristics of the epidemic. The three types are listed below: Low-Level Concentrated Generalized

55. Prevention SavesMoney &Lives