An Introduction to HIV Case Surveillance

1. An Introduction to HIV Case Surveillance Irum Zaidi Epidemiologist Global AIDS Program Centers for Disease Control

2. Have you ever laid awake at night wondering…. How many people know their HIV status (diagnosed) in my country?

3. Have you ever laid awake at night wondering…. I wonder what their CD4 count was at time of diagnosis – are they eligible for HIV treatment? How many people know their HIV status (diagnosed) in my country?

4. Have you ever laid awake at night wondering…. How many of the ones diagnosed with HIV have died – was the death due to the an HIV-related illness? I wonder what their CD4 count was at time of diagnosis – are they eligible for HIV treatment? How many people know their HIV status (diagnosed) in my country?

5. Have you ever laid awake at night wondering…. What are the behaviors associated with HIV infection…heterosexual, MSM, IDU, mobile populations? How many of the ones diagnosed with HIV have died – was the death due to the an HIV-related illness? I wonder what their CD4 count was at time of diagnosis – are they eligible for HIV treatment? How many people know their HIV status (diagnosed) in my country?

6. Evolution of data needs • Need for epidemiologic data in countries has evolved over the past 5 years • 2004 - few national level HIV care and treatment programs • surveillance need at that time was to monitor HIV in general population. • 2009 – many national large scale prevention, care and treatment programs • people are living with HIV for many years, need epidemiologic information about people who are diagnosed with HIV.

7. Background information • Countries had variable coverage of AIDS case surveillance • With the revised WHO HIV case definitions, recommendation is to transition from AIDS surveillance to HIV or advance HIV case surveillance • Monitoring only AIDS will not inform us on the direction of the HIV epidemic

8. Components of a surveillance system are like pieces of a puzzle High-Risk Pop Surveillance ARV drug resistance and subtyping HIV Incidence Surveillance STI TB/HIV General Pop Surveys HIV Case Reporting ANC Surveillance

9. Monitor HIV disease HIV disease sentinel events HIV exposure (exposed infants or sexual transmission) HIV infection 1st positive HIV test 1st CD4 count 1st CD4count <350 1st viral load 1st CD4 <200 AIDS-related Opportunistic Infection Death

10. Monitor HIV disease HIV disease sentinel events HIV exposure (exposed infants or sexual transmission) HIV infection 1st positive HIV test 1st CD4 count 1st CD4count <350 AIDS reporting 1st viral load 1st CD4 <200 AIDS-related Opportunistic Infection Death

11. Monitor HIV disease HIV disease sentinel events HIV exposure (exposed infants or sexual transmission) HIV infection 1st positive HIV test 1st CD4 count 1st CD4count <350 HIV case reporting 1st viral load 1st CD4 <200 AIDS-related Opportunistic Infection Death

12. What type of data do we have? • Have aggregate information on the • Estimated # of PLWHA, among general population, sub-pops like high-risk groups • Behavioral data about different groups • Number of tests done for HCT (not unique individuals) • Number of HIV positive tests from HCT (not unique individuals) • Number of people in care and treatment (unique individuals)

13. Data from HIV case reporting • Provides in-depth information about people diagnosed with HIV • Individual level data on people diagnosed with HIV • Date of HIV diagnosis • HIV transmission risk • CD4 closest or at diagnosis • Date started care and treatment • Date of death • As HIV case reporting becomes complete then need for prevalence surveys decreases

14. Reporting sources • Counseling and testing • Care registers • ART registers/patient cards • TB registers • Hospitals • Labs • Vital registration

15. Data flow for case surveillance

16. What will the data tell us? • Assist to monitor the incidence and prevalence of HIV infection including AIDS, and HIV-related morbidity and mortality in the population • Identify changes in trends of HIV transmission and identify populations at risk • Target prevention interventions and evaluate their effectiveness • Where there is a high-level of completeness of reporting, the BED assay can be applied to estimate incidence rates • More accurately determines need for care and treatment • Provide denominator data to evaluate reach of programs

17. Country X Example • Estimated 990,000 PLWHA 2007, (UNAIDS 2008) • Ever enrolled into care 209,790 (Country level PMS, December 2008) • Ever started on ART 122,243 (Country level PMS, December 2008) • Currently on treatment 90,212 (Country level PMS, December 2008)

18. 990,000 estimated PLWHA (modeled data)

19. 990,000 estimated PLWHA 320,000 estimated # of people need of ART

20. 980,000 estimated PLWHA 310,000 estimated need of ART 90,212 currently on ART

21. Estimated number of people infected with HIV How many people diagnosed with HIV? number of people receiving ART

22. In closing • Data from case surveillance system will provide demographic, clinical and behavioral information on persons diagnosed with HIV • Data can focus areas needed for further research/surveillance such as behavioral surveillance • Case reporting system can also be used as a platform for drug resistance and incidence surveillance

23. Thank you for your attention