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Surveillance to measure impact of ART Theresa Diaz, MD MPH CDC Global AIDS Program.

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Presentation on theme: "Surveillance to measure impact of ART Theresa Diaz, MD MPH CDC Global AIDS Program."— Presentation transcript:

1 Surveillance to measure impact of ART Theresa Diaz, MD MPH CDC Global AIDS Program

2 Presentation Background Background AIDS Surveillance Strategies AIDS Surveillance Strategies Potential directions for AIDS surveillance Potential directions for AIDS surveillance Mortality Surveillance Mortality Surveillance Examples of use of AIDS surveillance Examples of use of AIDS surveillance

3 Objectives and Types of HIV/AIDS surveillance ObjectiveTypes Estimate national/local HIV prevalence ANC surveillance ANC surveillance General population survey with HIV testing General population survey with HIV testing Surveys of high risk populations with HIV testing. Surveys of high risk populations with HIV testing. Describe risk behaviors Behavioral surveys Behavioral surveys Risk group classification of reported cases of HIV or AIDS Risk group classification of reported cases of HIV or AIDS Bio/behavioral surveys Bio/behavioral surveys AIDS incidence AIDS surveillance AIDS surveillance Opportunistic Disease surveillance Opportunistic Disease surveillance Estimate AIDS mortality Death registries Death registries

4 Purpose of AIDS Surveillance in Relation to ART To measure burden To measure burden How many persons have AIDS? (How much medication, care services do we need?)How many persons have AIDS? (How much medication, care services do we need?) To monitor trends To monitor trends Are the number of persons with AIDS decreasing over time?Are the number of persons with AIDS decreasing over time? To assess access to care To assess access to care Did they know they were HIV positive before developing symptoms?Did they know they were HIV positive before developing symptoms? Were they offered ART or had access to ART?Were they offered ART or had access to ART? Did they receive care or prophylaxis for O.Is?Did they receive care or prophylaxis for O.Is?

5 Potential strategies by which to do AIDS surveillance StrategyStrengthsWeaknesses Universal AIDS reporting (passive) MOST COMMON Includes those not in ART programs Includes those not in ART programs Measures burden Measures burden Monitors trends Monitors trends Could measure access to care Could measure access to care Underreporting Underreporting Little data/incomplete Little data/incomplete Large Delays Large Delays Universal AIDS reporting (active) Includes those not in ART programs Includes those not in ART programs Measures burden Measures burden Monitors trends Monitors trends Could measure access to care Could measure access to care Limits underreporting and incompleteness Limits underreporting and incompleteness Additional resources Additional resources Will still have some delay Will still have some delay Opportunistic Infection Reporting (report certain O.I. Usually based on Lab dx) Additional information on diseases causing symptoms Additional information on diseases causing symptoms Could be easier to classify than using AIDS case definition Could be easier to classify than using AIDS case definition Dependent on diagnostic capabilities Dependent on diagnostic capabilities Must link to HIV test Must link to HIV test Additional resources Additional resources

6 Potential strategies by which to do AIDS surveillance StrategyStrengthsWeaknesses Sentinel AIDS reporting (Passive) – health care staff report all year around May get complete information May get complete information Can monitor trends in select outcomes Can monitor trends in select outcomes Could measure access to care depending on site selection Could measure access to care depending on site selection Can not measure burden or overall trends Can not measure burden or overall trends Bias depends on sites chosen Bias depends on sites chosen Delays Delays Additional resources Additional resources Sentinel AIDS reporting (Active) – Data collectors go to clinics two to three months in a year to collect data on all patients seen in the past 12 months. Should be able to collect complete and extensive information Should be able to collect complete and extensive information Can monitor trends in select outcomes Can monitor trends in select outcomes Could measure access to care depending on site selection Could measure access to care depending on site selection Less burdensome on health staff Less burdensome on health staff Can not measure burden or overall trends Can not measure burden or overall trends Bias depends on sites chosen Bias depends on sites chosen Additional resources Additional resources Use ART program data Uses existing info Uses existing info Less resources Less resources Only represents persons in ART programs

7 Possible approach for AIDS surveillance (Once ART programs are in place) Concentrated/low level epidemics– Do active universal AIDS reporting. Concentrated/low level epidemics– Do active universal AIDS reporting. Staff seek cases through lab, mortality data, visiting select facilities in combination with passive reporting.Staff seek cases through lab, mortality data, visiting select facilities in combination with passive reporting. Review all reported cases for completeness and follow-up on incomplete cases.Review all reported cases for completeness and follow-up on incomplete cases. Generalized epidemics - Do active sentinel reporting. Generalized epidemics - Do active sentinel reporting. Select a variety of types health care facilitiesSelect a variety of types health care facilities Send staff to collect data at same time period each yearSend staff to collect data at same time period each year Use all sources of data including medical records, physician/nurse interviews, patient interviews, proxy interviews.Use all sources of data including medical records, physician/nurse interviews, patient interviews, proxy interviews. Will need protocols, data collection templates and suggested data analysis Will need protocols, data collection templates and suggested data analysis

8 Sampling for Sentinel Sites Should include primary and tertiary facilities. Should include primary and tertiary facilities. Should include facilities that are and are not part of ART program Should include facilities that are and are not part of ART program Should have rural/urban proportional distribution similar to country population Should have rural/urban proportional distribution similar to country population Should try to include some private health facilities. Should try to include some private health facilities. Ideally should have listing and information on all public health facilities in country to make selection. Ideally should have listing and information on all public health facilities in country to make selection.

9 Data Elements that could be Collected on AIDS Report Form Demographics (sex, age, residence) Demographics (sex, age, residence) Place of care Place of care First known positive HIV test First known positive HIV test Risk? Risk? Types of O.Is Types of O.Is Whether receiving ART, date started Whether receiving ART, date started Whether receiving preventive therapy for O.I.s, medication type and date started Whether receiving preventive therapy for O.I.s, medication type and date started Whether receiving therapy for O.I.s, medication type and date started by O.I. Whether receiving therapy for O.I.s, medication type and date started by O.I. First t cell count and viral load closest to diagnosis of AIDS. First t cell count and viral load closest to diagnosis of AIDS.

10 Suggested Basic Analysis for AIDS Reporting Data Overall number and number of AIDS cases by year– If doing universal Overall number and number of AIDS cases by year– If doing universal Who has AIDS and where (sex, age, risk?, geography) Who has AIDS and where (sex, age, risk?, geography) How long before AIDS diagnosis did they know they were HIV positive (by sex, age, risk, geography). How long before AIDS diagnosis did they know they were HIV positive (by sex, age, risk, geography). Which O.Is are most common? Which O.Is are most common? Did they get lab monitoring? Did they get lab monitoring? Did they start ART? Did they start ART? Did they receive prophylasix for O.I.s? (if should) Did they receive prophylasix for O.I.s? (if should) Did they receive treatment for O.Is. they have? Did they receive treatment for O.Is. they have? Proportion knowing HIV status before AIDS dx, receiving ART and /or prophylaxis by year. Proportion knowing HIV status before AIDS dx, receiving ART and /or prophylaxis by year.

11 Mortality Data weaknesses No death registry in country No death registry in country Death registry information not adequate enough to know who died from an AIDS related illness Death registry information not adequate enough to know who died from an AIDS related illness Underreporting Underreporting Not timely Not timely

12 Mortality Surveillance – Potential Solutions Improve national death registries Improve national death registries Do special studies - To determine if persons who died received ART, if so was ART adequate, if not, why not. Do special studies - To determine if persons who died received ART, if so was ART adequate, if not, why not. Cohort studiesCohort studies Retrospective chart review or interview of proxies of persons known to have died of AIDS (verbal autopsies)Retrospective chart review or interview of proxies of persons known to have died of AIDS (verbal autopsies)

13 *Adjusted for reporting delays Estimated Incidence of AIDS and Deaths of Adults and Adolescents with AIDS*, 1985 - 2001, United States 0 90 Deaths AIDS 1993 case definition Year of Diagnosis or Death 19851986198719881989199019911992199319941995199619971998199920002001 10 20 30 40 50 60 70 80 No. of Cases and Deaths (in thousands)

14 Year Proportion of AIDS Patients Surviving at Least One Year After Diagnosis of Their First AIDS-Defining Opportunistic Illness, by Year of Diagnosis, 1984 – 2000 (HIV/AIDS Surveillance Supplement Report 2002; 8(1):4)

15 Casos de aids (notificados e estimados) e taxa de incidência por ano de diagnóstico. Brasil, 1991 a 2002*. *Casos notificados até 31/12/02. 919293949596979899000102 0 5000 10000 15000 20000 25000 30000 0 5 10 15 20 25 casos notificadosIncidência HAART

16 Coeficiente de mortalidade por aids. Brasil, 1990-2000. 0,00 2,00 4,00 6,00 8,00 10,00 12,00 9091929394959697989900 Ano do óbito (por 100.000 hab) Fonte: SIM/DATASUS HAART

17 Conclusion AIDS surveillance could AIDS surveillance could Measure burden (if universal)Measure burden (if universal) Could assess coverage of ART programsCould assess coverage of ART programs Could identify areas in need of improvementCould identify areas in need of improvement Could monitor trends in relation to start of ART programsCould monitor trends in relation to start of ART programs Different strategies to collect data should be recommended based on epidemic type and extent of ART programs. Different strategies to collect data should be recommended based on epidemic type and extent of ART programs. Recommended data collection forms, analysis and sampling of health facilities need to be developed. Recommended data collection forms, analysis and sampling of health facilities need to be developed. Improvements of measuring AIDS related mortality are needed. Improvements of measuring AIDS related mortality are needed.


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