1. 1 HIV/AIDS Indicators HIV/AIDS and Malaria Impact Evaluation Workshop Asmara 18-22 February 2008 Elizabeth Ninan Damien De Walque

2. 2 Source: UNAIDS, 2000 HIV Impact Measures Reduction in the number of persons infected by HIV Improved survival of persons with HIV infection Improved quality of life and productivity of citizens directly/indirectly affected by HIV

3. 3 Periodic Surveys AISAIDS Indicators’ Survey BSSBehavioural Surveillance Survey (MARPs) DHSDemographic Health Survey HSS HIV Sentinel Surveillance MICSMultiple Indicators Cluster Survey SPPSSTI Periodic Prevalence Survey (MARPs) UNGASSUnited Nations General Assembly Special Session on HIV/AIDS

4. 4 Common Themes 1.Vulnerability 2.Risk Behaviours 3.HIV Prevalence 4.National Response – prevention; treatment; care and support 5.Socio-economic Impact

5. 5 Vulnerability Knowledge, attitudes, practices, gender, stigma and discrimination -% of young people aged 15-24 who both correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission -% of young people aged 15-24 that are HIV infected -% of respondents who believe that, if her husband has an STI, a wife can either refuse to have sex with him or propose condom use -% of respondents expressing accepting attitudes towards people with HIV

6. 6 Risk Behaviours- Most At Risk Populations (MARPs): % of sex workers who report using a condom with their most recent client % of IDUs who have adopted behaviours that reduce the transmission of HIV in the last 12 months, sterile needles, condoms % of men who reported the use of a condom the last time they had sex with a male partner General Population: % of women and men (15-49) who had sex with non-marital, non- cohabiting sexual partner in the last year % of young women and men (15-24) who has multiple sex partners in the last year % of young women and men (15-24) who had sex before the age of 15 % of young women and men (15-24) who report using a condom last time they had sex

7. 7 Measuring trends in HIV Prevalence UNAIDS/WHO recommend: Generalised epidemic countries, monitor HIV prevalence trends through Antenatal Clinic (ANC) surveillance Low or concentrated epidemic countries, monitor HIV prevalence trends through special surveys among populations at higher risk to HIV

8. 8 HIV Prevalence. -Estimated number of adults and children living with HIV (15-49) -Estimated number of children (0-14) living with HIV -% of young people aged 15-24 living with HIV -Median prevalence amongst pregnant women -HIV prevalence amongst STI patients (% median) -HIV prevalence amongst TB patients (% median) -Reported annual number of AIDS cases, cumulative AIDS cases and the estimated number of deaths due to AIDS -% of members of a defined sub-population at higher risk of contracting or spreading HIV (IDUs, MSM, sexworkers) in the capital city who are living with HIV

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11. 11 A note on HIV prevalence indicators Models have improved dramatically because of population based surveys and research –UNAIDS Reference Group on Estimates and Projections meets regularly to improve and refine models to reflect latest understanding –Male to female ratio originally based on a few research sites –Found that ANC sites were too ‘urban’ –Recent adjustments to reflect research showing average time from infection to need for treatment is 11 years instead of 9 years –Household surveys informed male-female ratio, urban-rural ratio, other biases in ANC surveillance SADC Leadership Conference on HIV and AIDS, Dr. Mary Mahy, Nov 2007 Source: SADC Leadership Conference on HIV and AIDS, Dr. Mary Mahy, Nov 2007

12. 12 Drop in Number Living with HIV Due to Change in Model, not Programmes As the models evolve, we can not compare results from one year to the next –Can not compare 2004 Report estimates to 2006 Estimates Models can however estimate prevalence for prior years SADC Leadership Conference on HIV and AIDS, Dr. Mary Mahy, Nov 2007 Source: SADC Leadership Conference on HIV and AIDS, Dr. Mary Mahy, Nov 2007

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15. 15 National Response Successful features include (from DCP2, 2006) : high-level political leadership active engagement of civil society and religious leaders in a multisectoral approach population-based programs designed to change social norms increased open communication about sexual activities and HIV/AIDS

16. 16 National Response Successful features include (from DCP2, 2006) : contd programs to combat stigma and discrimination condom promotion STI surveillance and control interventions targeting key “bridge” populations — populations that transmit the virus from high- risk to low-risk groups.

17. 17 National Response The amount of money allocated in national accounts for spending on HIV prevention and care programmes, per adult aged 15-49. % of schools with teachers who have been trained in life skills based HIV education and who taught it during the last year % transfused blood screened for HIV Number women and men with advanced HIV infection receiving antiretroviral combination therapy % of infants born to HIV infected mothers who are infected Number of children under the age of 5 receiving antiretroviral combination therapy % of respondents who have ever voluntarily requested an HIV test, received the test and received their results % of HIV positive pregnant women receiving a complete course of antiretroviral prophylaxis to reduce mother-to-child transmission

18. 18 Socio-economic Impact Households and families - Estimated 12 million children under the age of 18 orphaned in SSA (% of children under 18 who are orphans, or vulnerable) - Weakened family networks - lost earnings and increased costs for medical care and funerals - Generations that do not benefit from their elders' knowledge Education - Shortage of qualified teachers - Decreased enrollment and productivity among children from AIDS-affected HHs - More HIV positive children who do not survive the years of schooling

19. 19 Socio-economic Impact Labour

20. 20 Socio-economic Impact Health care - The strain on the healthcare system - Health care workers who are themselves infected with HIV/AIDS Agriculture and food security - Food insecurity because of loss of labor - Malnutrition cause of decreased food availability Overall economic growth - AIDS affects men and women during the prime working years of their lives - depletion the nations' workforce can have damaging effects on businesses and institutions

21. 21 Challenges of Measuring HIV Specific Impacts Incidence and prevalence rates Mortality rates Orphans averted

22. 22 Is prevalence the best measure of impact? ‘The number of individuals in a population infected with the virus at a certain time point’ Lack of decline in HIV prevalence can be due to multiple factors such as increased survival (through treatment); immigration Population based surveys with HIV testing are important Need to collect data on ART in these surveys

23. 23 Incidence Data ‘The number of people who are newly infected with HIV over time’ Reliable age-specific incidence data make it possible to accurately forecast the course of the epidemic, identify risk groups and assess the impact of interventions Measuring incidence: prospective cohort (expensive, time-consuming, do not reflect true pop incidence) Others possible measures: p24, Two tests, BED assay, PCR

24. 24 Mortality rates Among HIV infected population: - Counting ‘lives saved’ not the best measure since ART may only delay death by a year or two - Patients from ART clinics lost to follow-ups Years of life added, aggressively seek info on patients lost to follow-up

25. 25 Mortality rates Among general population: - Cause of death difficult to ascertain - Lives saved due to infections averted (persons may die of other causes or become infected at a later time) - Years of life added among HIV infected (does this decrease other mortality e.g. survival of children, does it increase chance of transmission thus increasing mortality to others) Verbal autopsies, accept certain level of uncertainty in cause of death, concentrate on trends in young adults, take account of multiple factors, examine difference in overall number of deaths in time period with and without ART

26. 26 Averting Orphans Definition of orphans: single/double Community vs policymakers definitions Though extending the life of an HIV infected orphan through ART is a desired outcome, this adds to years of orphanhood Examine difference in the overall number of orphans in time period with and without ART

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