IBBS Field operations and monitoring manual English

INTEGRATED BIOLOGICAL ANDBEHAVIORAL SURVEILLANCEFIELD OPERATIONS ANDMONITORING MANUALCANADA - PAKISTAN HIV/AIDS SURVEILLANCE PROJECTNATIONAL AIDS CONTROL PROGRAMPROVINCIAL AIDS CONTROL PROGRAMSCANADA - PAKISTAN

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualCONTENTS1. INTRODUCTION ................................................................................................... 51.1 Project Goal ........................................................................................................71.2 Project Objectives: ...............................................................................................72. INTEGRATED BIOLOGICAL & BEHAVIORAL SURVEILLANCE..................................................82.1. Case Definitions ..................................................................................................103. PLANNING THE FIELD WORK...................................................................................123.1 Involving Key Stake Holders ....................................................................................123.2 Identifying Human Resources ..................................................................................133.3 Data Collection Approaches.....................................................................................173.4 Non Human Resources Required ................................................................................184. SAMPLING METHODOLOGY .................................................................................... 194.1 Random or Systematic Random Sampling .....................................................................194.2 Snowball Sampling ..............................................................................................194.3 Respondent Driven Sampling ...................................................................................204.4 Multi Stage Cluster Sampling ...................................................................................224.5 Network Sampling ...............................................................................................235. THE BEHAVIORAL INTERVIEW ................................................................................. 245.1 Beginning the interview : .......................................................................................245.2 Concluding the interview : ......................................................................................255.3 Editing the Questionnaires : ....................................................................................255.4 Handling reluctant respondents:...............................................................................266. TAKING BIOLOGICAL SAMPLES ................................................................................ 276.1 The Do's............................................................................................................276.2 The Don'ts .........................................................................................................286.3 Waste Management ..............................................................................................287. ETHICAL CONSIDERATIONS .................................................................................... 297.1 Informed consent ................................................................................................297.2 Confidentiality ...................................................................................................297.3 Compensation ....................................................................................................307.4 Interview debriefing .............................................................................................308. MONITORING IBBS ............................................................................................... 318.1 Local IBBS Workshop ..........................................................................................318.2 Recruitment of Social Mobilizer ................................................................................328.3 Actual Data Collection...........................................................................................338.4 Monitoring of high-risk groups ..................................................................................33ANNEXURES.............................................................................................................35Annexure 1: Questionnaire ............................................................................................36Annexure 2: Monitoring Formats......................................................................................833

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualACRONYMS AND ABBREVIATIONSAIDSAcquired Immune Deficiency SyndromeCDCU Central Data Coordinating UnitCIDACanadian International Development AgencyDBSDried Blood SpotEIAEnzyme ImmunoassayFSWFemale Sex WorkerHASP HIV/AIDS Surveillance ProjectHIVHuman Immunodeficiency VirusHRAHigh Risk ActivityHRGHigh Risk GroupHSWHijra Sex WorkerIBBSIntegrated Behavioral and Biological SurveillanceIDUInjecting Drug UserKIKey InformantL1 Level 1L2 Level 2MSWMale Sex WorkerNACP National AIDS Control ProgramNGONon-Governmental OrganizationPACPProvincial AIDS Control ProgramPKRPakistani RupeeRDSRespondent Driven SamplingSDStandard DeviationSDPService Delivery Program/PackageSGSSecond Generation SurveillanceSIUT Sindh Institute of UrologySRSSystematic Random SamplingSTISexually Transmitted InfectionTATake AllUCUnion CouncilVCTVoluntary Counseling and Testing4

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual1. INTRODUCTION (WHO) the main features of SGS HIV infectionThis manual has been developed to assist surveillance include:organizations and program managers inplanning and implementation of secondgeneration surveillance system for humanimmunodeficiency virus (HIV) infection in lowlevel and concentrated HIV epidemics.Utilization of the lessons learnt andexperiences of the previous HIVsurveillance, improving efficiency andwidening the scope of the existing nationalsurveillance systems.The document primarily focuses on a keycomponent of Second Generation SurveillanceTailoring of a more flexible surveillance(SGS) which is integrated behavioral and system which is line with the needs andbiological surveillance (IBBS). The first partwill focus on field operations and the second onmonitoring of field work.The emerging threat of HIV and AcquiredImmunodeficiency Syndrome (AIDS) poses aserious challenge to the healthcare system inPakistan. This is compounded by factors suchas poverty, low educational levels,stigmatization, low status of women and lowcondom use.According to the World Health Organizationstate of the epidemic (such as low toconcentrated level of epidemic affectingprimarily some groups of population) to thereal epidemiological situation in ariouscountries and to the available resources.Improving the integration of HIV biologicalsurveillance (HIV and AIDS reporting andHIV surveillance) with behavioral risksurveillance (monitoring trends inbehaviors or using STI data as indicator ofbehavioral change).Key differences between conventional andsecond generation surveillance systemFirst Generation or Conventional SurveillanceHigh risk groups were not coveredSTI patients/donors who visited the sentinel sites themselves were includedOnly biological information collectedBiological data inadequate to develop appropriate preventive programmes or policiesSecond Generation SurveillanceTargets high risk groupsLinks HIV dataIdeal for countries with low or concentrated HIV epidemicsMore sensitive and flexibleCollects biological and behavioral information5

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSupporting continuous research into newepidemiological tools, improved methods prevalence. The low-level epidemics arefor building estimates and modeling the characterized by HIV prevalence that does notepidemic.exceed 5% in any defined subpopulation, and isBetter ways of using data for advocacy, less than 1% in pregnant women. Inplanning, monitoring and evaluationpurposes.concentrated epidemics, HIV prevalence isover 5% in at least one subpopulation and lessAccording to the WHO/UNAIDS classification, than 1% in pregnant women. In generalizedthere are three main states of the HIV and AIDS epidemics, HIV is firmly established in theepidemics: low-level, concentrated and general population, and exceeds 1% amonggeneralized. The box describes the pregnant women.classification system according to HIVWHO and UNAIDS classification of HIV/AIDS epidemicsLow-levelHIV prevalence has not consistently exceeded 5% in any defined subpopulation and is5% in at least one defined subpopulation and is 1% in pregnant womenProjections based on the WHO/UNAIDS model sex workers (including males, females andsuggest that approximately 70,000 to 80,000 hijra-transgender) who could spread thepersons are HIV positive in the country, i.e., 0.1 infection at a quick pace.percent of the adult population in Pakistan.Data analysis indicates that HIV/AIDs is most In 2000, the Government of Pakistan through aprevalent in adults between 25-44 years of age. broad consultative process developed aAlthough these numbers are significantly low in National Strategic Framework for HIV and AIDScomparison to other countries in the region, that set out broad strategies for effectivethere exist multiple risk factors which could control of the epidemic. Based on thelead to a rapid upsurge in these numbers. There recommendations provided by the Nationalare substantial numbers of high risk groups Strategic Framework, the Government ofincluding injection drug users and commercial Pakistan expanded its response to combat the6

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualHIV and AIDS epidemic through Enhanced policies and program at the local, regional,HIV/AIDS Control in 2003. As part of the provincial and national levels. The followingresponse, the Canadian InternationalDevelopment Agency (CIDA) providedassistance for the establishment of an effectivenational HIV/AIDS Surveillance Project2(HASP). To date, HASP has strengthened andexpanded the existing provincial surveillanceand monitoring system by involving theNational/Provincial AIDS Control Programs ando t h e r s t a k e h o l d e r s i n c l u d i n g n o n -governmental organizations, researchinstitutions and laboratories in thedevelopment and implementation of aneffective “second generation surveillance” HIVsurveillance system.The monitoring of trends in HIV prevalence isconducted through surveillance activities. Inlow-level epidemics, the risk of HIV infection islikely to be concentrated among those withhigher risk behaviors [e.g., female sex workers(FSWs), injection drug users (IDUs), men havingsex with men (MSM) etc.]. Surveillance effortsare mainly focused on these groups. Throughthis system, national; and to a certain extentregional and local; trends in HIV risk behaviorsamong these populations can also be assessed.The risk behavior trend data obtained throughthe system will provide important informationthat can be triangulated with other datasources to assess the effects of preventionare the goals and objectives of the project:1.1 Project Goal“To collect, analyze and disseminate accurateinformation on the prevalence of key riskbehaviors and of HIV in selected vulnerablegroups in order to guide the development ofprevention and care programs and policies inPakistan.”1.2 Project ObjectivesTo conduct geographic mapping of MSWs,Hijra, FSWs, IDUs in selected sites.To draw a representative sample of MSWs,Hijra, FSWs, IDUs in selected sites for theconduct of Integrated Behavioral andBiological Surveillance (IBBS).To collect socio-demographic andbehavioral information and Dried BloodSpot specimens from selected samples ofMSWs, Hijra, FSWs, and IDUs in selectedsites.To analyze integrated behavioral and biologicaldata and disseminate it to inform policymakersand stakeholders for program development.2HASP is a CIDA project, implemented by a consortium of Agriteam Canada Consulting Ltd., the University of Manitoba andProAction: Partners for Community Health, Inc., with technical assistance from the Public Health Agency of Canada.7

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual2. INTEGRATED BEHAVIORAL ANDBIOLOGICAL SURVEILLANCEIntegrated behavioral and biologicalsurveillance (IBBS) is the second mostimportant component of SGS in Pakistan aftermapping.Geographical mapping providesinformation about the estimates of differenthigh risk groups and lists the hot spots wherethese groups congregate.In addition to taking blood samples for HIVtesting, information is also collected through astructured questionnaire to understand the HIVrisky behaviors and practices.The wordintegrated indicates that HIV data is linked tothe individual; however, it is anonymousunlinked.Both behavioral and biologicalinformation is collected from the sameindividual.The results of mapping are used in IBBS to:1. Derive a sampling strategy for recruitmentof high risk groups (HRGs), and to2. Identify spots where HRGs are to berecruitedThere are four HRGs and their sub-types whichare targeted in IBBS:1. Injection drug-users (IDUs),2. Male sex workers (MSWs),3. Hijra sex workers (HSWs),4. Female sex workers,a. Brothel-based,b. Street-based, andc. Home and kothikhana (KK) based8

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualFig 1: A graphical representation of the overall processof the research study conducted to collect IBBS dataMAPPING EXERCISEDATA ANALYSIS REPORT ON MAPPINGUTILIZATION OF RESULTS FOR SAMPLINGINTEGRATED BIOLOGICAL & BEHAVIOURALSURVEILLANCE (IBBS)BIOLOGICAL DATACOLLECTION(DRIED BLOOD SPOT)BEHAVIOURALDATACOLLECTION (EDITING)LAB ANALYSIS &DATA ENTRYDATA ENTRYDATA MERGING & ANALYSISREPORT WRITINGUTILIZATION OF RESULTS FOR FINALIZING SURVEILLANCE ACTIVITIES9

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual2.1 Case DefinitionsThe following are the case definitions of highrisk groups which are to be recruited in IBBS:1 Female Sex workersInclusion CriteriaAny female who undertakes sexual activity inreturn for money or other financial benefits,irrespective of site of operation, i.e., street,brothel or home.The following women cannot be included in thestudy:Less than 15 years of age,Over 45 years old,Not willing to participate in the study, andNot willing to provide informed consent.Based on these criteria, the study subjects canbe defined as:” Any female aged 15 to 45 years whoundertakes sexual activity in return formoney or other financial benefits,irrespective of site of operation, i.e.,street, brothel or home, and is willing toparticipate in the study.”2 Male Sex workersInclusion CriteriaAny male who undertakes sexual activity with aman in return for money or other financialbenefits.Less than 15 years of age,Over 45 years,Not willing to participate in the study, andNot willing to provide informed consent.Based on these criteria, the study subjects canbe defined as:“Any male aged 15 to 45 years whoundertakes sexual activity with a man inreturn for money or other financial benefitsand is willing to participate in the study.”3 Hijra Sex Worker (Transgender)Inclusion CriteriaAny person who identifies him/herself as ahijra and undertakes sexual activity with a manin return for money or other financial benefits.The following hijras cannot be included in thestudy:Less than 15 years old,Over 45 years,Not willing to participate in the study, anNot willing to provide informed consent.Based on these criteria, the study subjects canbe defined as:“Any hijra aged 15 to 45 years who undertakesexual activity with a man in return for moneyor other financial benefits and is willing toparticipate in the study.”The following men cannot be included in thestudy:10

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual4 Injection Drug UsersInclusion CriteriaA person who has injected drugs for nontherapeuticpurposes in the past six months.The following IDUs cannot be included in thestudy:Under 18 years of age,A person who appears to be, in theinterviewer's judgment, incapable ofunderstanding the information providedabout the survey (e.g., due to intoxication,dope sickness, the person is cognitivelyimpaired, etc.),Not willing to participate in the study,Not unwilling to provide informed consent.Based on these criteria, the study subjects canbe defined as:“Any person 18 years or above who hasinjected drugs for non-therapeutic purposesin the past six months and is willing toparticipate in the study”11

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual3. PLANNING THE FIELD WORKterms of reference finalized with them,As IBBS is the second component of SGS inPakistan, the field teams have gained someexperience of working with HRGs. However,the dynamics of IBBS are quite different frommapping and require hard work along withdedication and commitment.While planning IBBS please keep in mind the:Security of the interviewer,Security of the respondent, andQuality of dataDetermining what human resources arerequired, e.g., female interviewers insome cities for FSWs or experienced fieldworkers.Determining what non-human resourcesare required, e.g., stationary, DBS ortransportation for field teams.3.1 Involving key stakeholdersBefore the IBBS activities start in the field, it isimportant to consider the following fourpoints:Involvement of key stake holders, e.g.,keeping the National/Provincial AIDSControl Programs updated about IBBSschedule,Adequate number of social mobilizers foreach high risk group identified and theIt is absolutely critical both politically andtechnically to involve key stakeholders andgain support from various partners includingmembers of the communities involved in IBBS.These include Provincial and National AIDSControl Programs, Non-GovernmentalOrganizations (NGOs) and the HRGsthemselves. The partners should be providedclear-cut answers on the following issues:Check list for involving key stakeholders Field activity discussed with PACP - Manager All key local stakeholders identified Letters of support/identification cards for staff available (preferably from PACPs) Local government (City government/ DCO/Police etc.,) are informed of the process Which organization is working with target groups Field activity discussed with the local NGO/CBOs and their participation ensured12

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualWhat are the goals of the activity? Discussspecific objectives of the study and alsodetermine how much time is needed forconducting the activity.Target communities (high-risk groups)should be made to clearly understandhow they would benefit from the researchand how their cooperation is needed.Coordinate among government agenciesand various donor agencies on plans fordata collection, seeking input from all therelevant players on decisions about howfield activity should be organized.Ensure that the local NGOs and CBOsworking with HRGs are involved in theoverall process of field activity. Waysshould be established to utilize theirhigh risk groups and local experience inconducting biological and behavioral datacollection.3.2 Identifying Human ResourcesHuman resource will include persons who willbe conducting field work. The following keypersons with their responsibilities must beidentified prior to IBBS data collection:1. Site CoordinatorIn each site where data is collected, a sitecoordinator will be appointed. The sitecoordinator is responsible for supervising allfield activities taking place in the target cityincluding briefing and dispatching of fieldteams, supervision and quality assurance offield work, data collation, data editing anddata management.available contacts with members of theResponsibilities of Study CoordinatorMaintain liaison between the field team and technical teamPlanning of all field activities and ensuring logistic and communication support in coordinationwith the Finance and Admin Officer.Briefing each team about the data collection process, providing them with a list of places whichneed to be visited on that day and the type of KIs to be interviewed.Supervise and monitor the data collection process in the field by visiting field teams randomly ona daily basisTo ensure the data collection process according to given protocol and assure the quality of databy random checking of the questionnaires for skip pattern, completeness, appropriateness of theresponses etc on daily basis.Get all forms edited and signed by team supervisors on a daily basis.Provided all forms to the respective data entry teamConduct regular meetings with the teams to highlight field problems and propose solutions.Conduct all delegated work assigned by PSSO.Provide regular updates to HASP provincial and National offices on weekly basis.13

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual2. Team Supervisors as per requirement. The field team is providedwith adequate stationary, transportation andAt least one supervisor for each high risk group mobile phone cards for communication. Bloodis required. Each supervisor is responsible for samples and biological waste are to be handledhis/her team's performance. The supervisor as per universal precaution.will ensure that the interviewes are conductedResponsibilities of SupervisorTo conduct daily meetings and brief the team about the day's work in the morning meetingPlan field activity along with the site coordinator in and ensure that it is completed in the requiredtime frameDebrief the team during evening meeting, discuss field issues and suggest solutionsApply codes/serial number and issue questionnaires in the morningTo edit the forms daily and appraise the team about mistakesMaintenance of record and dispatch of filled questionnaireTo arrange for social mobilizers.Maintain close contact with team members in order to closely monitor and support datacollection at each stage including sampling specifications (sampling points, selection ofrespondents), and interviewing specifications. This is necessary to ensure quality andconsistency throughout the data collection processAct as a resource person for the field team members thereby providing them with answers andclarification to questions that may or may not have been covered in the guidelinesIntroduce your team members to the various social mobilizers in order to facilitate the fieldwork/interviewing processMonitor the work-in-progress, prepare and submit weekly reports to the Project ManagerReview and edit each completed questionnaire in order to ensure that all questionnaires filled bythe team members are complete and according to guidelinesAct as a motivator to the team members3. Interviewers (Male and Female) questionnaire, cordially interacting with therespondent and proper biological sampleThe interviewer is responsible for properly collection. The number of interviewers willadministering the consent form and vary in each city.14

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualResponsibilities of InterviewerTo conduct IBBS interviews according to the provided training and guidelinesTo be prepared, and have all the necessary supplies: e.g. questionnaires, guidelines, a pen orpencil, required administrative forms (such as log books which may vary from one setting toanother)To ensure confidentiality of information, and eliminate any apprehensions and fears from themind of the study subjectsTo make the subjects comfortable and at ease before conducting the interview.To read each question aloud exactly as it is written in the questionnaire. However theinterviewer should also be capable of rephrasing the questions albeit not changing its contextTo listen carefully and without judgment to the respondent's answers and commentsTo accurately record the respondent's answers on the questionnaire according to instructions inthis manualTo probe for additional information when necessaryTo ask the supervisor for assistance whenever there is a question which is not covered in thismanualNot to give advice to respondents but to refer them to local resources or the supervisor4. Social Mobilizers'Social mobilizer' is a term derived for the keycontact for HRG. Generally, he/she belongs tothat particular group; however, this may notalways be the case. A useful SM facilitates thefield team in approaching theHRG. The importance of having socialmobilizers cannot be emphasized; withouttheir presence and support, it will not bepossible to approach and recruit any one of thehigh risk groups.Their primary responsibility is to help the fieldteam in recruiting genuine high risk groupsfrom different spots in each city. Their numberwill depend on the size of the city.5. MonitorsThe monitors may be internal or external.Their primary responsibility is to ensure thateach high risk group interviewed is within thecase definition, recruited from the correct spotand there is no duplication of interviews. Thenumber of interviewers will vary in each city.15

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualResponsibilities of MonitorTo ensure that the research study is being conducted as per designed and there are nodeviations from the research protocol.To ensure that all ethical guidelines are followedTo ensure the accuracy of information collectedTo ensure that all study subjects recruited strictly follow the case definitions,To ensure that there is no duplication (both in interview and blood sample collection)amongst the high risk groupTo ensure that IBBS interviews are conducted in privacy however, the monitor does nothave to sit for the complete interviewThe Do'sBe a part of the teamProvide maximum support to the field teamBe polite, however firm with the field teamEnsure confidentiality of the interview processIf it is established that the study participant (CSW or IDU) do not belong to the requiredhigh risk group do not let that interview take placeIf the study subjects don't follow case definitions, close down the interviewMaintain documentation of different monitoring formatsKeep the site coordinator updatedThe Don'tsDon't act as you are apart from the teamDon't be rude, or arrogant even if the field team are making mistakesDo not be part of any argument either with the field worker or anyone elseDon't intrude into interviewsDon't critique in front of people.6. Receptionist brought for interviews. The receptionist canalso hand out questionnaires and otherA receptionist is needed in the office to settle relevant material to the field teams.respondents who come to the office or are16

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual7. Administration/Accounts Person 3.3 Data Collection ApproachesThe administration and accounts persons are 3.3.1 Central Data Collectionresponsible for providing support to field teamsby arranging timely transportation, stationary,folders, mobile cards and compensation forThe following figure (Fig 2.) provides aconceptual framework for a central datarespondents. They may also have other collection place and highlights the number ofresponsibilities assigned by their respectiveorganizationstaff required at each site.This proposed format may work best when data8. Office Assistant (may notnecessary be everywhere)is collected at a central place. Central datacollection makes monitoring of field activitieseasier, ensures security of field staff andimproves the quality of data collected. WhileThis person may or may not be required in eachcity. However, this kind of support will be veryuseful in running day-to-day errands.this approach has its benefits, it may not bepracticable for some of the high risk groups,e.g., home-based female sex workers and Hijrasex workers.Fig 2.Proposed framework for central data collectionStudy CoordinatorReceptionist / Reg. OffMonitoring TeamFSW Team IDU Team MSW + Hijra TeamSameAs IDUteamTeam LeaderSameAs IDUteamPhysicianSocial Mobilizers(2-3)Dispenser/NurseInterviewers(2-4)17

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual3.3.2 Field Data CollectionWherever central data collection is notpracticable, field teams may be deployed tocollect data at various sites. The same staff asmentioned in the central approach is required;however, more emphasis needs to be placed onthe monitoring of field activities. Additionalmedical staff will be required which willaccompany each field team.One of the most critical issues regardingselection of field staff is the inclusion of socialmobilizers as part of the main field team.Social mobilizers serve as the backbone of allfield teams and prepare inroads into the highrisk groups. They will also help in selection ofstudy subjects as per the samplingmethodology and can act as ambassadors of thestudy in their respective groups.3.4 Non-human resources requiredNon-human resources are also important insupporitng overall data collection. Thefollowing is a check list for the key non-humanresources required to conduct the study in anefficient manner:Check list for Non Material ResourcesAdequate office space ready and operational prior to data collectionNecessary furniture and fixtures availableNecessary displays prepared e.g., instructions for interviewers, DBS instructions etc.,Vehicles hired along with drivers as per needBasic medicines including analgesics, multivitamins, etc procured.ASD supplies procuredMaterial for DBS procured … includes lancets, DBS cards, Sterilization,Log books maintained… registration book, DBS book, Monitoring/Supervisors team book,Interviewers book,All team members have mobile phones for communicationBasic stationary available in sufficient amountAdequate amount of Questionnaires and data collection formats availableBefore starting the field work it is desired thatall logistic arrangements should be thoroughlyarranged by the project management so thatthe technical team has to deal with minimalmanagement issues.Somebody from the team (admin/logisticofficer) should be given responsibility toupdate this check list regularly.18

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual4. SAMPLING METHODOLOGYpreferably be performed by a statisticalsoftware such as SPSS.The essential requirement of any sample is thatSystematic random sampling is selection ofit should be representative of the populationthevery K sampling unit of the population afterfrom which it is drawn and can producethe first sampling unit is selected at random.sufficient statistical inferences. A sample isFor example, if a sample of 100 persons needsconsidered to be representative if the analysesto be selected from a population of 1,000, onemade using the researcher's sampling units might take every tenth individual (K = N/n =produce results similar to those that would be 1,000/100 = 10). The first selection isobtained had the researcher analyzed the determined by a random process. Anotherentire population.example is if the 4th person was selected; thesample would then consist of individualsThe sampling strategy should be discussed numbered 4, 14, 24, 34, 44, and so on.only with the technical team and the field staffshould only be provided information on howand where the recruitment of study subjectswill be performed.For the purpose of our study, we are only usingprobability sampling for recruitment of variousHRG members. The following techniques areproposed:Random or systematic random sampling,Multi-stage cluster sampling (CS) or timelocation cluster sampling (TLCS),Respondent-driven sampling (RDS),Snowball technique.4.2 Snowball SamplingThis is a technique for developing a researchsample where existing study subjects recruitfuture subjects from among theiracquaintances. Thus, the sample groupappears to grow like a rolling snowball. Thissampling technique is often used in hiddenpopulations such as male sex workers. Becausesample members are not selected from asampling frame, snowball samples are subjectto numerous biases. One of the key biases isany person who has many friends is likely to berecruited into the sample.4.1 Random or Systematic RandomSamplingRandomization means, tossing a coin to decideon selection of a study participant. The criticale l e m e n t o f r a n d o m i z a t i o n i s t h eunpredictability of the next selection which isalso its strength. It usually requires a list of allsampling units and randomization mayIt was widely believed that it was impossible tomake unbiased estimates from snowballsamples, but a variation of snowball samplingcalled respondent-driven sampling has beenshown to allow researchers to make unbiasedestimates from snowball samples under certainconditions.19

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual4.3 Respondent-Driven SamplingThe following guidelines are provided for thedriven sampling:3. Four identification tickets should be givento each seed. Each ticket should have atracking number. Thus, seed one gets hispractical implementation of respondentidentificationticket as well as three moreidentification tickets for the subjects he1. The first stage involves determining the will recruit. We are sending you a sample of3number of seeds required to reach theproposed sample size, as we discussed inour training workshops. Thus, if the sampleof 200 is to be achieved and four waves ofrecruitment are followed, five seeds willbe required. As we also discussed, thenumber of seeds should be slightly morethan what is actually required to adjust thedropouts. To achieve the required sampleof 200, six seeds should be recruited.the identification ticket. It is advisable toprint contact information (contact name,number, and address of the ticket wherethe person has to reach) at the back of theticket. When the first referred subjectcomes to the center, he is identifiedthrough the ticket and is provided threemore tickets to recruit three moresubjects.2. The recruitment of initial seeds should be4done from different zones.NACP - GoPTRACKING NO. A01To be used before 31 st Dec 2005NACP - GoPTRACKING NO. A01To be used before 31 st Dec 2005NACP - GoPNACP - GoPTRACKING NO. A02 TRACKING NO. A03To be used before 31 st Dec 2005 To be used before 31 st Dec 20053 Seed is the first person implanted to start a chain in RDS.4 Each city is divided into different zones which is different from UCs.20

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual4. A tracking number should be provided to The subjects they recruit should beeach study subject. This tracking number isnumbered as A00. Kindly note that theseOTHER THAN the registration number of numbers can continue up to 12; e.g., A12,the subject and is only required to trackB12, C12; as each seed will recruit athe subject in his respective chain. I wouldmaximum of 12 study subjects.suggest that each seed should be given acode (A, B, C, D) and the subjects heA01 B01 C01recruits should follow this pattern.A02 B02 C02A03…. A12 B03…B12 C03…C12Seed 1 Seed 2 Seed 3A00 B00 C005. A tracking register should be maintained at the center. A sample register is given below :IDNetworkSizeCouponReceived#1CouponGiven#2CouponGiven#3CouponGiven#1Payment#2Payment#3Payment1 124 0 30001 30002 30003 No Yes Yes2 90 30002 30004 30005 30006 Pending No No3 143 30004 30007 30008 30009 No Pending No4 64 30003 30010 30011 30012 No No No5 342 30008 30013 30014 30015 No No No6. Since RDS has dual incentives, the given when the subject recruited reachescompensation to the subject will bethe office).provided for the subject's own interview 7. Ask each subject about the networkand blood sample as well as for recruitingsize,i.e., the number of subjects in hisother study subjects. The compensation ofnetwork.Rs. 400 can be distributed under:Rs. 175 for his own interview + DBS.8. Remember that RDS CANNOT beimplemented through multiple datacollection centers and a central dataRs. 75 for each subject referred (which iscollection center is a must.21

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual4.4 Multistage Cluster Sampling Once the sampling frame has been developed,a sample of sites can be chosen either withMultistage cluster sampling is an appropriateprobability proportional to size (PPS) or withtechnique that can be used for HRGs which areequal probability. PPS selection should be usedassociated with various sites in a fixed manner.when establishments vary significantly in termsFor example, in case of street based FSWs, theof numbers of sex workers associated withfollowing procedure can be adopted:them (e.g., when there are larger sites with 3-5The first step involves development of thetimes as many sex workers as smallersampling frame. As part of the sampling frameestablishments) and when it is possible todevelopment, it is useful to list all the sitesobtain measures of size prior to samplewhere street-based FSWs can be located, andselection. Where the numbers of sex workersto gather information on the number of sexassociated with establishments are roughlyworkers associated with each site. Thiscomparable (i.e., vary in size by a factor of lessinformation is useful for 1) selecting clustersthan three), sampling with equal probabilitywith probability-proportional-to-size (PPS)will suffice.should this option be chosen, 2) determiningthe appropriate number of sex workers to beFinally, a list of sites along with number of FSWsampled from each cluster, and 3) determiningto be selected from each site is provided to thehow many sample sites must be chosen.survey team, for recruitment into the study.22

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual4.5 Network Sampling Lahore. In addition, a guru who is directlyrelated to hijras may also be a NWO.Network sampling requires directly workingwith network operators/madams/pimps andNetwork sampling is applicable to threeutilizing their services for recruitment of highhome-baseddifferent typologies including kothikhana andrisk groups. It has been previously used forFSWs and hijras. A list of allrecruiting FSWs and hijras. Network samplingNWOs should be developed and ready prior tois connected with mapping but not completedIBBS data collection. This list should berestricted to it. Network operators nowadaysrepresentative of the whole city. If mappingplay a pivotal role in commercial sex. They areresults suggest that the area has a high numberusually persons (both male and female) who doof FSWs or is geographically large, recruitingnot have their own setup such as a kothikhanamore than one NWO is recommended.where an auntie or a pimp has a place and girlsFor example, if a network operator has agreedare available for commercial sex, but theyto help recruit 10 FSWs from a medium-sizefacilitate the process of providing FSWs toarea, it must be attempted that during thisclient(s) anywhere in the city. In the end, theyprocess and time additional network operatorscharge a fee for this purpose either from themay be enlisted from that area in order togirl or madam/pimp. This category is rapidlyensure maximum recruitmentincreasing in urban cities like Karachi and23

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual5 The Behavioral Interview Answer the respondent's questions: Somerespondents may question you about theThe behavioral interview is the foundation of purpose of the survey before agreeing toIBBS which aims to collect information on participate. Answer the respondent's questionsrespondent's knowledge, attitudes, beliefs, as directly as possible referring to theand practices regarding HIV and AIDS and other introduction paragraph on the front of eachSTIs. The information obtained from the questionnaire. However, if a respondent hasbehavioral interview forms the basic structure questions about AIDS or other interviewonwhich the epidemic is defined and related topics at any time during the interview,prevention activities designed. Therefore, politely explain that you prefer to completethe interview plays a key role in conducting the interview first and discuss his/herIBBS; and the interviewer has the major role at questions after the interview.this stage of the study.Listen to the respondent: Listening carefully5.1 Beginning the Interviewto what your respondents say is as important asasking the questions on the questionnaire.A respondent's first impression of you willSome questions in the questionnaire requirestrongly affect his/her willingness toyou to listen to what the respondent says andcooperate with the survey. Therefore, it isrecord it by simply drawing a circle around thevery important that you approach eachnumber next to a printed response category.interview in a friendly and professionalSometimes, you must write down the exactmanner. Guidelines for good interviewinganswer given by the respondent if the answerinclude the following:does not fit in any of the listed categories. InBreaking the ice: You should always greet theeither case, be a good listener. Do not rush intorespondent first and thank him or her and thencircling the code category before you havemove on to a casual chit chat.completely heard the respondent. That may betaken as a sign of disrespect or not payingAlways remain neutral: Your job as an attention. More importantly, people who rushinterviewer is to collect facts. An interviewer into coding a response are often in danger ofshould be friendly but firm, neutral but attributing their own biases, preferences andinterested. Your tone of voice, facial favorite response categories to theirexpressions and even body postures all respondents.combine to establish the rapport you createwith your respondent. Do not express surprise,Probing: Occasionally, a respondent maypleasure or disapproval at any response oranswer a question incompletely, or seem tocomment made by the respondent.have misunderstood the question. The first24

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualThing to do is simply to repeat the question aswritten a second time. If this does not help, youwill have to probe to obtain theresponse.Probing is a way of asking for furtherinformation without influencing the response.For example, “Could you explain that a littlemore?” or “Could you be more specific aboutthat?” You must never interpret a respondent'sanswer and then ask the respondent if yourinterpretation is correct.If the respondent gives an ambiguous answer,try to probe in a neutral way, asking questionssuch as:“Can you explain a little more?”“I did not quite hear you; could you please tellme again?”“There is no hurry. Take a moment to thinkabout it.”Answer all queries and questions of therespondent.Direct the respondent to the nearestHIV/AIDS information resource (could be anNGO, a VCT centre, or a service program forHRG) for services and more information.It is important to remember that your job isnot to educate respondents, but only tocollect information from them and referthem to the appropriate facilities.Tips in Conducting the Interview1 Understand the Survey Questionnaire.1. Be neutral throughout the interview.2. Never suggest answers to the respondent.3. Handle hesitant respondents tactfully.Read every question exactly as written and in4. Do not form expectations.sequence: The wording of each question has5. Do not hurry the interview.been carefully chosen and for that reason it is6. Do not “read” questions from theessential that you read each question to thequestionnaire.respondent exactly as it is written. It is veryimportant for this survey that each question is7. Ask all the questions.asked to each respondent in exactly the same 8. Do not leave a question unanswered.manner. Certain sections of the questionnairealso have an introductory paragraph that must5.3 Editing the Questionnaires:be read to the respondent in its entirety.All interviews are required to be checked and5.2 Concluding the Interview:the interviewers should edit the questionnaireonce the interview has been completed.Once the interview is complete, theinterviewer should:Questionnaire editing will be done by theinterviewer followed by editing by thesupervisor as well. Interviewers will be25

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manualrequired to edit their questionnaires before that particular time or may haveconsidering an interview complete. All misunderstood the purpose of your visit. Onequestionnaires should be reviewed from of the reasons for reluctance may be researchbeginning to end for the following:fatigue. This will be a challenging situation aseven the incentive for compensation may notVerify that an interview code has been convince them to participate. Try to find outrecorded in the interviewer box on the why the respondent is unwilling to participatecover page of the questionnaire.and respond accordingly. Some arguments youcan use to persuade a respondent toVerify that the interviewer has signed theparticipate are:witnessed verbal consent.Verify that all skip and filter instructionshave been respected.Verify that the responses are legible.Verify that only one response code iscircled for each question unlessinstructions allow for more than oneresponse.Verify that any corrections made by theinterviewer are done legibly and accordingto the instructions.5.4 Handling Reluctant Respondents:Occasionally, a potential respondent willrefuse to participate in the survey. Do not takethe initial unwillingness of a respondent to beinterviewed as a final refusal. Try to putyourself in their position and think of factorsthat might have brought about this reaction.The respondent may not be in the right mood atThe respondent cannot be replaced byanyone else.The information they provide will helpdevelop programs which assist people likethemselves.If confidentiality is an issue, assure therespondent that his or her name will not goon the questionnaire. Questionnaires willonly be identified by a number. Everyoneworking on the survey has pledged tomaintain confidentiality. Never ask therespondent's name.However, in some circumstances a respondentmay continue to refuse. In this situation,respect the respondent's right to refuse andthank the respondent for his/her time. Do nottake these refusals personally. Remember tofill the refusal form that has been provided toyou and keep track of the refusal number.26

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualWear gloves, and then peel off the alcoholswab packet.Choose the client's finger for prick,disinfect the fingertip with alcohol and letthe finger dry for 30 seconds.The sample is taken from the middle fingerof the left hand.Prick the tip of the finger with the lancet.Hold the client's finger pointing downtowards the floor to develop the blood-flow process. Do not act in haste.Collect blood drop on DBS card by the dropmethod (blood should drop on card bygravitational force).Fill the five spots on the card with one dropof blood dropped in the center of thecircle.Once the circles on the card are filled, holdthe client's hand with fingers pointingtowards the ceiling and then fix Saniplaston the client's pricked finger.Place filled DBS card on the stand and let itdry for 3-8 hours, after which cover it withflying paper and in Ziploc bags fortransportation to testing labs.Dispose of all used material (gloves, swabcovers, swabs, lancet, etc.) in the redbiohazard bag for disposal in incinerators.Preserve samples in the ziplock bag on a6. Taking Biological SamplesThe capillary “dried blood specimen” (DBS)methodology for collection of biologicalspecimen Is selected for the second generationsurveillance because of its relative ease ofcollection; there are no special requirementsfor storage and shipping; the methodology hasbeen successfully used elsewhere in similarstudies; there is potential for the use of thedetuned assay with DBS samples to helpidentify recent HIV infection (incidence); andthe potential to identify different strains ofHIV.The collection of the DBS will involve the use ofa lancet device that automatically retracts sothat accidental skin punctures are virtuallyimpossible. After the participant washeshis/her hands with an alcohol-based handsanitizer, the area to be punctured is sterilizedwith an alcohol pad and allowed to dry. Thelancet device is placed on the selected area(the pad of the finger from which the DBS willbe collected), then depressed. This results in apuncture of the skin and the subsequentformation of drops of blood that are thencollected on a specially prepared filter paper.It is important that an adequate sample becollected by completely saturating each of thefive inscribed circles with blood.6.1 The Do'sFirst (write) fill out the DBS card withcorrect client code and date.27

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manualdaily basis (after they are thoroughly dried).Thirty samples per bag can be stored.Thread should be used to hold the cardstogether.Samples need to be transported to therespective lab on a weekly basis.6.2 The Don'tsDon't prick the client's finger pulp becauseblood flow will be restricted.Don't let client's finger touch the cardwhile dropping blood.Do not spill the blood drop outside thecircle.Handle the card carefully by not touchingor holding the card near the blood spots.Do not place filled cards on the table.Do not fold the cards.Do not prick the bag.Do not use tape to hold cards together.6.3 Waste ManagementAll waste material produced during taking ofblood samples including the sheets, lancets,cotton, gloves, etc., should be carefullycollected and disposed of. All this materialshould be collected in the red bags provided tothe field teams and should be incinerated. Thefield coordinator should look for the facility ofan incinerator available in the local site, wherethis material is transported on a daily basis andis incinerated.At sites where an incinerator is not available, adeep pit should be excavated and the wastematerial should be buried.28

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual7 Ethical ConsiderationsThe following ethical issues should befollowed:Participation will be voluntary and no coercionshould be used in the recruitment process.Anyone wishing to find out about the surveyshould be allowed to contact the studycoordinator or members of the local researchteam. All participants should be given athorough briefing on the behavioralsurveillance survey and an explanation of theprocedures, including data collection andstorage and dried blood spot collection,transport and storage. All participants will beinformed of the procedures that would ensuretheir confidentiality.7.1 Informed ConsentInformed verbal consent should beobtained prior to entry into the survey.Use the standard consent form at thebeginning of the questionnaire.The interviewer before starting theinterview should read out loud the consentform to the participant.Kindly make sure that the respondent hasunderstood every part of informedconsent.Kindly emphasize the purpose of the riskbehavior survey (i.e., the objectives), thepotential risks involved (i.e., duringcollection of the blood spots), andwillingness to complete the interview andprovide a finger-prick blood sample.All participants should be informed of theirright to refuse to answer any questionswith which they do not feel comfortable;withdraw from the survey at any timeduring the interview or blood spotcollection.All participants should be informed thatwithdrawal from the survey would notaffect their care or access to services intheir community.The interviewer subsequently signs theappropriate place on the questionnaire toindicate that consent was obtained beforeproceeding with data collection.7.2 ConfidentialityThe following measures should be taken toe n s u r e a n d m a i n t a i n p a r t i c i p a n t s 'confidentiality.Do not take any identification information,i.e., name, address, contact information,etc., from the respondent at any stage ofthe study.Do not ask for written consent.All survey-related material (e.g.,completed questionnaires) should be keptin a secure and locked cabinet at thesurvey field offices and should be29

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manualaccessible only to the study coordinatorand other study staff (e.g., Interviewers).At the Data Management Unit,questionnaires should be kept in a secureand locked cabinet and only authorizedpersonnel should have access to them.Electronic data files with questionnaire andlaboratory data should be passwordprotectedand accessible only to authorizedpersonnel.7.3 CompensationAll participants will be provided cashcompensation.This compensation is provided to all studysubjects irrespective of their grouptypology and is meant to compensate fortheir time and travel.Kindly make sure that the social mobilizersand recruitment staff is not using thisamount for inducement or coercion.Do not ask the participants to sign in aregister on taking compensation. The teamleader can sign on behalf of the studysubject.7.4 Interview DebriefingOnce the interview process is completed, theinterviewer should:Answer all queries and questions of therespondent.Direct the respondent to the nearestHIV/AIDS information resource (could be anNGO, a VCT center, or a service program forHRG) for services and more information.It is important to remember that your job isnot to educate respondents, but only tocollect information from them and referthem to the appropriate facilities30

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual8. MONITORING IBBSMonitoring is an intermittent (regular orirregular) series of observations in time carriedout to show the extent of compliance withformulated benchmarks and indicators bothquantitative and qualitative.All IBBS activities must be regularly monitoredfor authenticity and quality of informationcollected from high-risk groups. While therewill be external monitors such asrepresentatives of NACP/PACPs, there mustalso be internal monitors designated by theorganization implementing the IBBS in eachcity. These monitors should be availablethroughout the IBBS process starting from thelocal IBBS workshop till the completion of datacollection.should be aware ofSessions:the entire planningprocess. It should be understood that steppingin the field without planning the entire activityand having a mitigation plan would be not veryeffective. MF-1 should be used for monitoringpurposes.The local IBBS workshop is also evaluated bythe participants. However, MF2 should be usedfor all local workshops. Generally, the areasthat need to be assessed are:1.The quality of informationpassed on in the plenary sessions has to becorrect, and the session should beinteractive so that the participantsunderstand the concepts properly.The5IBBS training manual should be usedextensively for the purpose.There are four key areas that should beregularly monitored:1. Local IBBS workshop for overall quality oftraining and contents.2. Planning of IBBS field work.3. Recruitment of social mobilizers.4. Actual data collection.8.1 Local IBBS WorkshopThe planning of IBBS workshop should ideallytake place after all the other details of fieldwork have been finalized. However, it may alsobe organized earlier. The designated monitor2.Role plays: The second crucial componentof the local workshop which should bemonitored and evaluated is the role playsin which administering of consent form andquestionnaire is practiced by theparticipants. If this area is not givenadequate attention, that can compromisethe quality of interviews and the overallindicators for various high-risk groups maynot reflect the actual situation. Followingthe interview, there should also be adebriefing session in which the interviewerwill try to answer the respondent'squestions.5The IBBS training manual has been developed to provide a format for training of field staff on how to train field teams on how to collectauthentic data. This document is available from HASP-NACP offices.31

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual3. DBS: Collecting the biological sample byDBS method is the final part of the IBBSprocess. The local workshop should coverit step-by-step from preparation of thefinger to disposing of waste.8.2 Recruitment of social mobilizersfor each high-risk groupThe IBBS activity cannot be implementedsuccessfully if the organization does have goodcontacts with social mobilizers. They are thekey persons who play a pivotal role in improvingthe quality and authenticity of data. Each high-risk group requires a separate social mobilizerand, depending on the size of the city, theirnumber may vary.The monitor should keep in mind that in citieslike Larkana (Sindh) or Sargodha (Punjab), oneor two social mobilizer for IDUs and hijras maybe sufficient. However, in large cities likeKarachi and Lahore, the number will have to beincreased to get to all the relevant spots. Thetwo categories which require a lot of focus andAttention are FSWs and MSWs. Therefore, asufficient number of efficient social mobilizersis necessary.The following criteria should be kept in mindwhile recruiting social mobilizers:FSW social mobilizers: The monitor andothers should know that social mobilizers,especially for FSWs, have a habit of boastingabout the number of their contacts andconnections. However, when it will come toactual data collection, the field team will oftenhear comments like, “There was a police raid;therefore, the kothikhana is shut,” or, “The girlis out for a program and won't be back for manyhours,” or, “She is not responding; her mobilenumber must have recently changed.”Things to be kept in mind while recruiting asocial mobilizer:1. While finalizing the deal with any FSWsocial mobilizer, he/she must beassessed critically regarding theirconnections with madams/pimps ornetwork operators (NWOs) as well asFSWs.2. In reality, a social mobilizer does nothave more than 8-10 contacts andsometimes even fewer.3. All terms and conditions; particularly,f i n a n c e s , t r a n s p o r t a t i o n a n dcommunication; should be fixed prior tostarting data collection as any ambiguitycan potentially delay the process.4. Social mobilizers should always beprovided mobile cards for bettercommunication.5. Transportation for social mobilizersshould be provided throughout the datacollection process.6. An effective social mobilizer should bevalued.32

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualMSW social mobilizers:1. An effective social mobilizer for thisgroup would preferably be an MSWhimself.2. He should be assessed in the beginning ofIBBS for authenticity and connections.1. An IDU will have visible marks on theforearms due to multiple injection shots.2. Many times an IDU will be carrying a syringebut this may not be the case every time.3. IDUs usually inject drugs in groups.3. One social mobilizer will not besufficient to cover the whole city.However, the sampling methodology alsoplays a role in this regard.4. In case of snowball or respondent-drivensampling, many social mobilizers maynot be required.8.3 Actual data collection:If the actual data collection process is notplanned well, the exercise will fail. Monitoringthe data collection has to be very alert.Ideally, there should be separate monitors foreach high-risk group. The monitor(s) for FSWsshould preferably be female. Please alsorefer to MF-M3 for the “interviewerevaluation form”.8.4 Monitoring of high-risk groups:IDUsRefer to the case definition for IDUs.While monitoring IDUs, the following should beobserved closely:4. It is the duty of the monitor to ensure thatno duplication takes place.5. The list of spots which were produced aftermapping should be with the team whilegoing in the field.6. The monitor should ensure that IDUs arerecruited from the designated spots. Asthis group is mobile, it is possible that theymay have moved from the actual spot. Forexample, if the spot's name is “kuchrakundi at the corner of the post office” andby the time the team gets there they havemoved to another close by spot within 100yards, that should be considered as thesame spot.7. If there are any doubts regarding theauthenticity of the high-risk group, themonitor should reject the respondent.However, no argument should take place inthe field.Hijras:Refer to the case definition for IDUs.While monitoring hijras, the following shouldbe observed closely:33

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual1. The respondent is a transgender with theFSWs:body language and movement of a hijra.The monitor for FSWs should preferably be afemale.2. The respondent is recruited from a genuinedera.Refer to the case definition for FSWs.3. It is the duty of the monitor to ensure that FSWs are one of the most difficult groups tono duplication takes place.monitor because of social and culturalsensitivities. That is why emphasis is placed on4. If there are any doubts regarding the designating a female monitor for this group.authenticity of the high-risk group, themonitor should reject the respondent.While monitoring FSW, the following should beobserved closely:1. If the monitor is a female, she shouldMSWs:directly ask (in privacy) the respondent afew questions about her sexual practices.Refer to the case definition for MSWs.While monitoring MSW, the following should beobserved closely:For example, time elapsed in commercialsex, the number of clients, how she seeksclients, and whether she belongs to akothikhana, is home-based or comes from1. The respondent has come through a a street-based network.sampling strategy such as snowball orrespondent-driven. 2. In case the monitor is a male, a few basicquestions such as whether the respondent2. Many a time, an IDU will turn up as an MSW is an FSW and indulges in commercial sexto earn compensation. It should be may be asked.ensured that only MSWs are interviewed.3. The body language of MSW is often like If there are any doubts regarding thehijras or even females; they may alsohave cosmetic eyebrows or facials (butthis will not always be the case).authenticity of the high-risk group, the monitorshould reject the respondent.4. If there are any doubts regarding theauthenticity of the high-risk group, themonitor should reject the respondent.34

ANNEXURES

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualANNEXURE 1QUESTIONNAIRESBEHAVIORAL SURVEILLANCE SURVEYCANADA-PAKISTAN HIV/AIDS SURVEILLANCE PROJECTWITH NATIONAL/PROVINCIAL AIDS CONTROL PROGRAMMEQUESTIONNAIRE FOR IDU’sName of the city:HRA Typology:Zone # :Sampling Mode:Name of the spotTime:Interviewer Name:nterviewer Code:Date of Interview:- -DD/MM/YYWas the Interview completed? Y N Signature:Checked by:Supervisor Name:Supervisor Code:Editor Name:Editor Code :Date of Checking:Signature:Date of Checking:Signature:- -DD/MM/YY- -DD/MM/YYDate Entry: 1st Entry Name: Date:Code- -DD/MM/YY2nd Entry Name:CodeDate:- -DD/MM/YY36

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 1: Socio-Demographic CharacteristicsNo. QuestionsCoding categories Skip to Code101 What is your age? (In completed years) Years ___________102 How many years of education have youcompleted?IlliteratePrimaryMiddleMetricIntermediateGraduateNo response12345698103 What is your current marital status? UnmarriedCurrently marriedSeparatedDivorcedWidowed104 What is your mother tongue? UrduPunjabiSindhiPashto105 Do you belong to this city? YesNo106 What is the reason for your coming to_______ (City name)?(Mark one only)107 How long do you plan to live in thiscity?(All three boxes of days, mths andyrs can be filled where applicable)BalochiBrahaviSiraikiHindkoOthers ______________DrugsTo meet relativesBusinessOthers __________No ResponseDAYS |____|____|MONTHS |____|____|YEARS |____|_____|PermanentlyDon’t know1234512345678121239810837

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualIn the last 12 months have you been awayfrom this city?If yes, name the last five cities traveled inthe past one year and how much time wasspent in each city:( most recent travel first)What is your Profession?What is your average monthly income?What is your current living arrangement?Currently, with whom you are living?Yes 1No 2No Response 98ABCDECityProfession_______________Rs. _______Don’t have anyNo responseFamily HomeDeraShrine/DarbarStreet/ LaneHostelGuest house/ HotelOthers_________________AloneWith relatives/familyWith friendsSexual partnersOthers ______________If No,skip toQ110Time in months9698123456123438

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 2: Drug and injection related questionsNo. QuestionsCoding categories Skip to Code201 How long have you been injectingdrugs?202 During the past one month, whichdrugs did you usually inject?Do not read the optionsMultiple responses are allowed203 During past one month, how manytimes did you usually inject in a day?(Read list. Only one response isallowed)204 When you injected in the past onemonth, how often did you use a needleor syringe that no one else besides youhad ever used?(Read out options 1-5)Years ______Less than one yearNo ResponseTamgesicAvilDiazepamBupronHeroinSosegonPentazogonPentonilPhenerganCap. RestorilTab. MarzineOther ____________9698Y / N1 21 21 21 21 21 21 21 21 21 21 21 21 2Once a day12-3 times a day24 times or more a day 3No Response 98 98Always 1Most of the time 2Sometimes 3Never 4Did not inject in the pastmonth55Don’t Know 97 97No Response 98 98205 When you injected in the past onemonth, how often was the injectiongiven by a professional injector?(Read out options 1-4)206 How many times did you injectyesterday?AlwaysMost of the timeSometimesNeverDon’t KnowNo ResponseNumber ______ZeroNo Response12349798969839

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualQuestion 207 to 218 are about LAST INJECTIONNo. QuestionsCoding categories Skip to Code207 Where did you have your last injection? Park/ground/open1spaces/streetsOwn House /friendsMazars/darbarHotel/shopDon’t KnowNo Response2349698208 With whom did you inject your lastinjection?209 The last time you injected did you injectwith a used syringe/needle?210 If an old syringe was used, why didn’tyou use a new syringe/needle the lasttime you injected?(Do not read responses)211 If an old syringe was used, did you tryto clean the syringe/needle?212 How did you attempt to clean thesyringe/needle?213 Last time you injected, did you passyour needle or syringe on to someoneelse?Some family membersFriendsPeople I know wellPeople I don’t know atallNo oneNo ResponseYes with oldsyringe/needleNoDon’t KnowNo ResponseNew syringe notavailableToo expensiveInjection partnerinsistedDidn’t think it wasnecessaryDidn’t think of itOthers__________YesNoWaterDisinfectant(detol/spirit)Cloth/PaperBlow/suckBleachNo ResponseOther ___________YesNoDon’t KnowNo Response12345981296981234512123459812979821321340

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual214 Last time you injected, how manypeople used the same needles or syringeeither before or after you?215 When you injected drugs did you useother injection equipment e.g.(Cooker, cotton, spoon, filters. Etc.)216 Was this equipment used by someoneelse?217 Last time you injected, was the injectiongiven by a professional injector?218 Last time that you injected with a newsyringe/needle how did you get/obtainnew syringe/needle?(Do not read responses)(If respondent gives more than oneanswer, ask where he has bought them orgotten them more often and circle onlythat response (CHECK ONE ONLY)Number ______ZeroDon’t KnowNo ResponseYesNoNo ResponseYesNoNo ResponseYesNoNo Responsea) _____BOUGHTTHEM Where?969798129812981298General Store 1Pharmacy 2Clinic/ Dispensary 3Fellow Drug UserFriends45Drug seller6NGO worker 7b) ___GIVEN /OBTAINED Where?at a Clinic/ Dispensary 8by a Friend 9by a NGO worker 10by a Guest House/HotelGarbageNo responseOther____________129821741

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual301 At what age did you first have sexualintercourse?Section 3: Sexual BehaviorFEMALE SEXUAL PARTNERS – “Now I am go ing to ask you some questions aboutdifferent types of sexual partners and condom use with them. I’d like to first ask youabout the time you have sex with your spouse or regular female partner who you livewith”No. QuestionsCoding categories Skip to CodeAge in years _______Never had vaginal or analIntercourseDon’t knowNo response969798309302 In the past 6 months, have you hadsexual intercourse with spouse orregular female partner that you arecurrently living with?303 The last time you had sexualintercourse with your regular femalepartner, did you use a condom?YesNoNo responseYesNoNo response12981298304304 In the past 6 months, have you paidany female to have sexual intercourse(vaginal or anal) with you?305 In the past 6 months, how manydifferent female partners did you pay tohave sexual intercourse with you?306 The last time you paid a female to havesexual intercourse with you, did you usea condom?307 Of all times you had sexual intercoursewith a female partner in the past 6months, how often did you use acondom?308 Why didn’t you use a condom at thattime?Do not read responsesYesNoNumber`______Don’t KnowNo responseYesNoNo response.AlwaysSometimesNeverNo responseNot availableToo expensiveDon't like themDidn’t think it wasnecessaryDidn’t think of itOthers_____________1297981298123981234530730930942

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual“ Now I’d like to ask about buying sex from men or hijras .” And “ I’d like to ask aboutthe times you were given money or drugs in exchange for sex”.No. QuestionsCoding categories Skip to Code309 In the past 6 months , have you ever Yes1 314paid a man or hijra to have sexual No2intercourse with you?No response98310 In the past 6 months, of all the timesyou had sexual intercourse with thosepartners, how often did you use acondom?Read out options 1-4311 Why didn’t you use a condom duringthat time?(Do not read responses)312 The last time you had sexualintercourse with man or Hijra did youuse a condom?313 The last time you had sexualintercourse with a man or Hijra didyou use a lubricant (gel/ cream/ oil)?AlwaysMost of the timeSometimesNeverNo responseNot availableToo expensivePartner objectedDon't like themDidn’t think it wasnecessaryDidn’t think of itOthers___________YesNoNo responseYesNoNo response12349812345612981298312312314 Have you ever had exchange sex formoney or drugs?YesNoNo Response1298315 Have you ever discussed HIV/AIDS orSTIs with any of your clients?YesNoNo response129843

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 4: AIDS knowledge, risk and avoidanceNo. QuestionsCoding categories Skip to Code501401 Have you ever heard of HIV or the diseasecalled AIDS?402 Can a healthy looking person be carryingHIV/AIDS?403 How do you think HIV/AIDS can betransmitted from one person to anotherperson?(Multiple responses are allowed)Do not read the listYesNoNo responseYesNoDon’t knowNo responseSexual intercourseSharp instruments /syringeInsect bitesKissing, Touching, HuggingEating & drinking withpatientsMother to childBlood transfusionStaying filthyThrough AnimalsDon’t knowNo responseOthers ____________1298129798Y/ N1 21 21 21 21 21 21 29798404 What method(s) do you kn ow of which canbe used to prevent HIV/AIDS?(Multiple responses are allowed. Do notread the list)405 Do you know where people can go, if theywant to do an HIV/AIDS test?Using CondomRefraining from sexStaying Away from patientsStaying cleanNo Blood transfusionUsing clean syringesDon’t knowNo responseOther_____________YesNoNo response406 If yes, where? Place ___________407 Do you think that you are at risk of gettingHIV?YesNoDon’t knowNo response408 Have you ever been tested for HIV/AIDS? YesNoDon’t KnowNo Response409 If Yes, what was the result of HIV/AIDStest?HIV +iveHIV ?iveDon’t KnowNo ResponseY/ N1 21 21 21 21 21 29798129812979812979812979840750144

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 5: knowledge about STI’sNo. QuestionsCoding categories Skip to Code501 Do you know that certain diseases can Yes1 505be transmitted through sexual act? No2502 What do you do to protect yourself fromsuch diseases?DO NOT READ RESPONSESMULTIPLE RESPONSES ARE ALLOWED503 In the past 6 months, have you sufferedfrom any sexually transmittable disease?504 From whom did you take treatment?(Do not read the responses. Note the lasttreatment received)505 Did you stop having sex when you hadthe symptoms?506 Did you use a condom when having sexduring the time you had the symptoms?507 During the past 6 months, have youbeen arrested?508 Have you ever taken alcohol during thecourse of a sexual act in the past 6months?509 Have you ever sold blood in exchangeof money in the last 6 months?510 Government of Pakistan has startedprograms for the health of drug users.Have you ever heard of these programsin your city?511 If yes, are you a part of any of theseprograms.No responseUse condoms UrinateWash with dettolTake medicineDon’t doNo responseOther _____________YesNoDon’t KnowNo responseDoctor /HospitalSelf MedicationDispensary/TBAHakim/ HomeopathicPharmacyTook no treatmentNo responseOthers _______YesNoNo responseYesNoNo responseYesNoNo responseYesNoNo responseYesNoNo responseYesNoYesNo9812345981297981234569812981298129812981298121250751451445

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual512 If yes, how long have you been a part ofit.513 How many times do you avail theservices of these programs?514 Do you know of any place/program/DICwhere you can obtain new needles andsyringes?515 If yes, can you please name that place/program?Do not read responsesMultiple responses are allowed516 What are some of the services that youhave ever used in these offices in thepast 6 months?Do not read the responsesMultiple response are allowed517 Have you been provided new needlesand syringes, free of cost in the past onemonth?518 If yes, who provided the new needlesand syringes?Duration_________More than once in a week 1Once in a week 2After two weeks 3Once in a month 4Less than once in a month 5YesNoNo ResponseNai ZindgiFHI for TruckersSurveillance CenterMarie Stope SocietyAl NijatPakistan SocietyMarie AdelaideCDNFDOST Welfare SocietyThe legend SocietyOthers(specify):___________Servicesa- Medicinesb- STI treatmentc- Counselingd- Social servicese- Condomsf- HIV testg- New Needle /Syringesh- Anti-SepticDressing (ASD)i-DetoxificationOthersYesNoOutreach workerA peer educatorFrom a needle exchangeprogramClinicothersspecify)____________129812345678910121234Ever516endtheinterview46

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualNote the Inter view end time:am / pmThank you very much for your kind cooperation and spending your valuable time with me.Debriefing:Ask participant if s/he has any questions. Provide risk reduction counseling as appropriate. Give referrals/information re nearby HIV testing and counseling services. Provide information on local health social serviceagencies if appropriate.Taking the finger prick blood sample“Now I am going to prick your finger to obtain a blood sample which I will blot onto a piece of paper. Are youokay with this?The DBS was taken correctlyYesNo (specify reason)Time taken for DBS: _________________________minutesInterviewer comments:47

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualBEHAVIORAL SURVEILLANCE SURVEYCANADA-PAKISTAN HIV/AIDS SURVEILLANCE PROJECTWITH NATIONAL/PROVINCIAL AIDS CONTROL PROGRAMMEQUESTIONNAIRE FOR FSW’sName of the city:HRA Typology:Zone # :Sampling Mode:Name of the spotTime:Interviewer Name:nterviewer Code:Date of Interview:- -DD/MM/YYWas the Interview completed? Y N Signature:Checked by:Supervisor Name:Supervisor Code:Editor Name:Editor Code :Date of Checking:Signature:Date of Checking:Signature:- -DD/MM/YY- -DD/MM/YYDate Entry: 1st Entry Name: Date:Code- -DD/MM/YY2nd Entry Name:CodeDate:- -DD/MM/YY48

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 1: Socio-Demographic CharacteristicsNo. QuestionsCoding categories Skip to Code101 What is your age? (In completed years) Years ______102 How many years of education have youCompleted?Illiterate/ uneducatedPrimaryMiddleMetricIntermediateGraduateNo response103 What is your current marital status? UnmarriedCurrently marriedSeparatedDivorced104 How many children do you have? ZeroWidowed105 What is your mother tongue? UrduNumber______No response.PunjabiSindhiPashtoBalochiBrahviSiraikiHindkoOthers__________123456981234509812345678If 1skip to105106 Which city do you belong to? This cityName of the city_______107 How long have you lived in this City? Number Of Years _____Less than 1 year 88108 Which religion do you belong to? IslamChristianityHinduismOther ______________12396 If 96skip to10849

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual109 What else do you do other than SexWork?110 What is your average monthly incomefrom your other work/ job?111 What is your current livingarrangement?Profession __________Only FSW 0Rs. _______No response 98Home1hostel2Hotel / Guest House 3Kothi Khana4Others _______If onlyFSWskip to111112 Currently, with whom you are livingwith?AloneWith relatives/familyWith friendsWith sexual partnerOther _____________123450

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 2: Information about Sex WorkNo. QuestionsCoding categories Skip to Code201 How long you have been in sex work? Years___________Less than 1 yearNo response202 What is your average monthly incomefrom sex work?203 At what age you had your first sexualintercourse?Rs. _______No responseDon’t Know88989899Age in years_______No response 98204 From where do you get your clientsmost of the time?205 How many clients on an average doyou entertain in one day?206 In the past one week, approximatelyhow many clients did you have?207 How many days in a week do you dosex work?Anti/Baji/madamPimpCall girl/ mobile phoneRoaming aroundOld Clients referOthers _______No of clients _______Don’t KnowNo ResponseNo of Clients _______Don’t KnowNo ResponseNo of days ________Don’t KnowNo Response1234599799899799899799851

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 3: Sexual behavior with paying clients“Now I am going to ask you about your clients who pay you some money for havingany sort of sexual activity301 In the past one-month, approximately howmany paying clients have you had?302 In the last month you had sexual contactwith paying client, how often did you use acondom?303 How many paying clients did you havevaginal sex with in the last month?“No. QuestionsCoding categories Skip to CodeNumber_______Don’t KnowNo responseAlwaysSometimesNeverNo responseNumber_______Don’t KnowNo response99799812398997998304 The last time you had vaginal sex with apaying client, did you use a condom?305 How many paying clients did you have analsex with in the last month?306 The last time you had anal sex with apaying client, did you use a condom?307 The last time you had anal sex with a payingclient, did you use a lubricant (Gel, oil,Cream)308 How many paying clients did you have oralsex with in the last week?YesNoNo responseDon’t do itNumber _______No responseYesNoNo responseYesNoNo responseDon’t do itNumber_______Don’t KnowNo response12980998129812980997998308310309 The last time you had oral sex with a payingclient, did you use a condom?YesNoNo response1298310 Whom do you have to give that money?Do not readKeep my selfPimp/Aunty/madam/ bajiPoliceHusbandOthers ______123452

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 4: Sexual behavior with non-paying partners“Now I am going to ask you about your clients who don’t pay you money for havingany sort of sexual activity (Your husband, boyfriend or a lover)”No. QuestionsCoding categories Skip to Code401 In the past one month, approximately withhow many non-paying partners you hadsex?Number _______ZeroNo response0998If 0skip to501402 In the last month you had sexual contactwith non-paying client, how often did youuse a condom?AlwaysSometimesNever123No response98403 How many non- paying partners did youhave vaginal sex with in the last month?Don’t do itNumber _______Don’t knowNo response0997998If 0skip to405404 The last time you had vaginal sex with anon-paying partner, did you use a condom?YesNo12Don’t know97No response98405 How many non- paying partners did youhave anal sex with in the last month?Don’t do itNumber _______No responseDon’t know0998997If 0skip to407406 The last time you voluntarily had anal sexwith a non-paying partner, did you use acondom?YesNoDon’t know1297No response98407 How many non-paying partners did youhave oral sex with in the last month?Don’t do itNumber ________Don’t knowNo response0997998If 0skip to501408 The last time you had oral sex with a nonpayingpartner, did you use a condom?YesNoNo response129853

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 5: Condom UseNo. QuestionsCoding categoriesSkip to Code501 Do you have a condom with younow? Please show me502 Which places or persons have youobtained condoms from in the lastone month?Do not read out. Multipleresponses are allowed503 Last time where did you obtaincondom from?Do not read out504 Last time, you paid for or gotcondom for free?Can show a condomCannot show a condomNo responseShopPharmacyClinic/ dispensaryGuest House/HotelFriendsPimpsNGO workerClient brought himselfNo responseOther__________General storeMedical storeClinic/dispensaryGuest House/HotelFriendPimpNGO workerClient brought himselfNo responseOther_______PaidFreeNo response129812345678981234567898129854

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection Section 6: Knowledge 5: Condom about Use HIV/AIDSNo. QuestionsCoding categoriesSkip to Code601 Have you ever heard of HIV or thedisease called AIDS?602 Can a healthy looking person becarrying HIV/AIDS?603 How do you think HIV/AIDS canbe transmitted from one person toanother person?Do not read out. Multipleresponses are allowed604 What method(s) you know of whichcan be used to prevent HIV/AIDS?Do not read out.605 Do you believe that if usedproperly, condoms protect fromHIV/AIDS?YesNoDon’t knowNo responseYesNoDon’t knowNo responseSexual intercourseSharp instruments/syringeInsect bitesKissing, Touching, HuggingEating& drinking withpatientsMother to childBlood transfusionStaying filthyThrough AnimalsDon’t knowNo responseOther___________CondomRefraining from sexStaying Away from patientsUsing clean syringesOthersDon’t knowNo responseYesNo606 Do you know where can people cango,if they want to get an HIV/AIDStest?YesNoDon’ t KnowNo response607 If yes, from where Name of the place________608 Do you think that you are at risk ofgetting HIV?129798129798Y/N1 21 21 21 21 21 21 21 21 21 29798Y/N1 21 21 21 2979812Don’t Know 97No response 98129798YesNoDon’t knowNo response129798If 2 skipto 70160855

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual609 Have you ever been tested for HIV? YesNoDon’t knowNo response610 What was the Result? HIV+veHIV –veDon’t KnowNo response129798129798If 2, 97,98 skipto 70156

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 6: 7: Knowledge knowledge about HIV/AIDS STI’sNo. QuestionsCoding categoriesSkip to Code701 Are you aware of any diseaseswhich are transmitted sexually?702 Do you do anything to avoid gettingdiseases, which are transmitted bysex?YesNoDon’t knowNo responseYesNoNo response703 What do you do to avoid STI’s? Always use condomsUrinateWash with dettolTake medicineNo responseOther______________704 In the past 6 months, have yousuffered from any sexuallytransmittable disease?705 If yes, did you get treatment forthat?706 From whom did you get thetreatment?Do not read out707 Is there any doctor or health workerwho treats STI’s?708 In the past 6 months, were youever beaten or otherwise physicallyforced to make you have sex withsomeone even though you did notwant to?709 During the past 6 months, haveyou been arrested?YesNoDon’t knowNo responseYesNoDon’t knowNo responseDoctor /HospitalSelf MedicationDispensary/TBAHakim/ HomeopathicPharmacyNo responseOthers _______YesNoNo responseYesNoNo responseYesNoNo response12979812981234981297981297981234598129812981298If noskip to704If noskip to704If noskip to707If noskip to70757

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual711 Have you injected drugs in the last6 months?712 During past 6 months, have youever had sex with injecting druguser?713 Have you sold blood for money inlast six months?714 Government of Pakistan has startedprograms for the health of sexworkers. Have you ever heard ofthese programs in your city?YesNoNo ResponseYesNoNo ResponseYesNoNo ResponseYesNo12981298129812if noend theinterview715 If yes, are you a part of any of theseprograms.YesNo12if noend theinterview716 If yes, how long have you been apart of it?717 How many times do you avail theservices of these programs?Duration______________More than once in a weekOnce in a weekAfter two weeksOnce in a monthLess than once in a month1234558

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualNote the Interview end time:am / pmThank you very much for your kind cooperation and spending your valuable time withme.Debriefing:Ask participant if s/he has any questions. Provide risk reduction counseling as appropriate. Givereferrals/ information re nearby HIV testing and counseling services. Provide information on localhealth and social service agencies if appropriate.Taking the finger prick blood sample –“Now I am going to prick your finger to obtain a blood sample which I will blot onto a piece of paper.Are you okay with this?The DBS was taken correctlyFor Lahore and Karachi:“Now I am going to take your blood sample through Syringe/Injection. Are you okay with this?1 Yes 2 NoYesNo (specify reason)Time taken for DBS: _________________________minutesInterviewer comments:59

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualBEHAVIORAL SURVEILLANCE SURVEYCANADA-PAKISTAN HIV/AIDS SURVEILLANCE PROJECTWITH NATIONAL/PROVINCIAL AIDS CONTROL PROGRAMMEQUESTIONNAIRE FOR MSW’sName of the city:HRA Typology:Zone # :Sampling Mode:Name of the spotTime:Interviewer Name:nterviewer Code:Date of Interview:- -DD/MM/YYWas the Interview completed? Y N Signature:Checked by:Supervisor Name:Supervisor Code:Editor Name:Editor Code :Date of Checking:Signature:Date of Checking:Signature:- -DD/MM/YY- -DD/MM/YYDate Entry: 1st Entry Name: Date:Code- -DD/MM/YY2nd Entry Name:CodeDate:- -DD/MM/YY60

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 6: 7: Knowledge knowledge about HIV/AIDS STI’sNo. QuestionsCoding categoriesSkip to Code101 What is your age? (In completed Years _________years)102 Your educational level? UneducatedPrimaryMiddleMetricIntermediateGraduateNo response103 What is your current marital status? UnmarriedCurrently marriedSeparatedDivorcedWidowed104 What is your mother tongue? UrduPunjabiSindhiPashtoBalochiBarahviSiraikiHindko123456981234512345678105 Do you belong to this city YesNo106 Have you come to this cityspecifically for sex workOthers __________YesNoNo Response121298108107 How long do you plan to live in thiscity?DAYS|____|____|MONTHS |____|____|YEARS |____|_____|PermanentlyDon’t know969761

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual108 In the last 12 months have you beenaway from this city for sex work?YesNoNo Response1298If No,skip toQ 110109 If yes, name the last five citiestraveled in the past one year andhow much time was spent in eachcity( most recent travel first)ABCDECityTime in months110 What do you do besides being insex work?Other Profession___________Only sex work 96111 What is your total monthly income? Rs. _______Don’t knowNo response112 What is your current livingarrangement?113 With whom you are currentlyliving?Family HomeDeraShrine/DarbarStreet/ LaneHostelGuest house/ HotelOthers______________AloneWith Family/ RelativesWith FriendsSex PartnerOther __________________9798123456123462

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 2: 6: Information Knowledge about HIV/AIDS Sex WorkNo. QuestionsCoding categoriesSkip to Code201 How long you have been in sexwork?202 What is your approximate monthlyincome from sex work?203 At what age you had your firstsexual intercourse?Years ________Less than 1 yearDon’t knowNo responseRs ______________Don’t knowNo responseAge in Years ________Don’t knowNo Response96979897989798204 How do clients usually contact you? Pimp/GuruMobile phoneBy roaming aroundThrough old clientsOthers____________205 How many clients on an average doyou entertain in one day?Please take time to think about your answerto this question. Remember thisinformation is strictly confidential206 In the past one week, approximatelyhow many clients did you have?Please take time to think about your answerto this question. Remember this informationis strictly confidentialNo of clients ________Don’t knowNo responseNo of Clients _______Don’t KnowNo Response12349798979863

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection Section 3: Sexual 6: Knowledge behavior about with paying HIV/AIDS clients“Now I am going to ask you about your CLIENTS who PAY you some money forhaving any sort of sexual activity and condom use with themNo. QuestionsCoding categoriesSkip to Code301 How many paying clients have youhad last month?Please take time to think about your answerto this question. Remember thisinformation is strictly confidential302 Of all these clients you had sex within the last month, how often didyou use a condom?(Read out options 1-3)303 Why didn’t you use a condom atthat time?Do not read responsesMark one onlyNumber_______Don’t KnowNo responseAlwaysSometimesNeverNo responseNot availableToo expensivePartner objectedDon't like themDidn’t think it wasnecessaryDidn’t think of it999812398123456304304 How many paying clients did youhave anal sex with in the lastmonth?305 The last time you had anal sex witha paying client, did you use acondom?Others_________________Number________ZeroDon’t KnowNo responseYesNoNo Response9969979981298307306 The last time you had anal sex witha client; did you use any Lubricant(Gel, Cream and Oil)?307 Whom do you have to give thatmoney?308 Have you ever discussed HIV,AIDS or STIs with any of yourclients?YesNoNo responseNobody, keep myselfPimp/GuruPoliceFamilyHusband/WifeOthers ______________YesNoNo response129812345129864

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection Section 4: Sexual 6: behavior Knowledge with about NON-PAYING HIV/AIDSpartners“Now I am going to ask you about your clients who don’t pay you money for havingany sort of sexual activity (Your wife, boyfriend or a lover)No. QuestionsCoding categoriesSkip to Code401 In the past one month,approximately with how many nonpayingmale partners you had sex?Please take time to think about your answerto this question. Remember thisinformation is strictly confidential402 Of all the times you had sex with anon-paying male partner in the lastmonth, how often did you use acondom?Number _______ZeroDon’t KnowNo responseAlwaysSometimesNeverNo response99699799812398405403 How many non- paying malepartners did you have anal sex within the last month?404 The last time you had anal sex witha non-paying male partner, did youuse a condom?405 In the last month did you pay anymale to have anal sex with you?406 Last month when you paid a malepartner to have anal sex with youdid you use a condom?407 How many female partners did youhave sex with in the last month?408 The last time you had sex with afemale partner, did you use acondom?409 If sometimes /never, Why didn’tyou use a condom at that time?Do not read responsesMark one onlyNumber _______ZeroDon’t KnowNo responseYesNoDon’t KnowNo responseNumber _______ZeroDon’t KnowNo responseYesNoNo responseNumber _______ZeroDon’t KnowNo response998AlwaysSometimesNeverNo responseNot availableToo expensivePartner objectedDon't like themDidn’t think it was necessaryDidn’t think ofitOthers_______________99699799812979899699799812989969971239812345640540750165

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection Section 6: Knowledge 5: Condom about Use HIV/AIDS“Now I am going to ask you about your clients who don’t pay you money for havingany sort of sexual activity (Your wife, boyfriend or a lover)No. QuestionsCoding categoriesSkip to Code501 Do you have a condom with younow? Please show me502 Last time when you used a condom,where did you get it from?showed a condomNo condomNo responsea) ______ BOUGHTTHEM Where?1298Do not read responses(If respondent gives more than oneanswer, ask where he has boughtthem or gotten them more often andcircle only that response .MARKONE ONLY)General StorePharmacyClinic/ DispensaryGuest House/HotelFriendsPimpsNGO workerb) ____GIVEN/OBTAINEDWhere?at a Clinic/ Dispensaryby a Friendsby a Pimpsby a NGO workerby a Guest House/HotelClient bought himselfresponseOther_____________1234567891011121366

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual601 Have you ever heard of HIV or thedisease called AIDS?602 Can healthy looking persons becarrying HIV/AIDS?603 How do you think HIV/AIDS canbe transmitted from one person toanother person?Do not read out(multiple responses are allowed)604 What method(s) you know whichcan be used to prevent HIV/AIDS?Do not read outMultiple responses are allowed605 Do you know where people can go,if they want to get an HIV/AIDStest?YesNoNo responseYesNoDon’t knowNo response1298129798Y/NSexual intercourse 1 2Sharp instruments/syringe 1 2Insect bites 1 2Kissing, Touching,1 2HuggingEating& drinking with 1 2patients1 2Mother to child1 2Blood transfusion 1 2Staying filthy 1 2Through Animals97Don’t Know98No responseOthers _____________Using condomRefraining from sexStaying Away from patientsUsing clean syringesDon’ t KnowNo responseOthers___________YesNoNo response606 If yes, where? Name of theplace________607 Do you think that you are at risk ofgetting HIV?608 Have you ever been tested forHIV?609 If Yes, what was the result ofHIV/AIDS test?Section 6: Knowledge about HIV/AIDSNo. QuestionsCoding categoriesSkip to CodeYesNoDon’t knowNo responseYesNoDon’t knowNo responseHIV+ veHIV - veDon’t knowNo responseY/N1 21 21 21 29798129812979812979812979870160770167

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 6: Knowledge Section 7: STIs about HIV/AIDSNo. QuestionsCoding categoriesSkip to Code701 Do you know that certain diseasescan be transmitted through sexualact?702 What do you do to protect yourselffrom such diseases?Do not read responsesMultiple responses are allowed703 In the past 6 months, have yousuffered from any sexuallytransmittable disease?704 From whom did you taketreatment?(Do not read the responses. Note thelast treatment received)705 Did you stop having sex when youhad the symptoms?706 Did you use a condom when havingsex during the time you had thesymptoms?YesNoNo responseUse condomsUrinateWash with dettolTake medicineDon’t do anythingNo responseOther ________________YesNoDon’t knowNo responseDoctor /HospitalSelf MedicationDispensary/TBAHakim/ HomeopathicPharmacyTook no treatmentNo responseOthers _______YesNoNo responseYesNoNo response129812345981297981234569812981298707707707 During the past 6 months, have youbeen arrested?708 Have you ever taken alcohol duringthe course of a sexual act in thepast 6 months?709 Have you taken any drugs throughinjection in the last 6 months?(Do Not Count drugs injected formedical purposes or treatment of anIllness)710 During past 6 months, have youever had sex with an injecting druguser?YesNoNo responseYesNoNo responseYesNoNo responseYesNoNo response129812981298129868

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual711 Have you sold blood for money inthe past 6 months?712 Government of Pakistan has startedprograms for sex workers. Haveyou ever heard of these programs inyour city?713 If yes, are you a part of any of theseprograms.714 If yes, how long have you been apart of it?715 How many times do you avail theservices of these programs?\716 Do you know of anyplace/program/DIC where you canobtain condoms?717 If yes, can you please name it.Do not read responsesMultiple responses are allowedYesNoNo responseYesNoYesNoDuration_________More than once in a weekOnce in a weekAfter two weeksOnce in a monthLess than once in a monthNeverYesNoNo ResponseMSM Contech InternationalContech InternationalTahafuz Sehat by InfectionControl SocietyBehtar Kal ProgrammeGazi Welfare Tr ustORA InternationalOthers(specify):___________129812121234561298123456716716719718 What are some of the services thatyou have ever used in these officesin the past 6 months?Do not read the responsesMultiple response are allowedServicesEver719 Have you been given free condomsin the past one monthYesNo720 If yes, who provided these condoms Outreach workerA peer educatorFrom programsClinicothers(specify)_________________12123469

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualNote the Inter view end time:am / pmThank you very much for your kind cooperation and spending your valuable time with me.Debriefing:Ask participant if s/he has any questions. Provide risk reduction counseling as appropriate. Give referrals/information re nearby HIV testing and counseling services. Provide information on local health social serviceagencies if appropriate.Taking the finger prick blood sample“Now I am going to prick your finger to obtain a blood sample which I will blot onto a piece of paper. Are youokay with this?The DBS was taken correctlyYesNo (specify reason)Time taken for DBS: _________________________minutesInterviewer comments:70

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualBEHAVIORAL SURVEILLANCE SURVEYCANADA-PAKISTAN HIV/AIDS SURVEILLANCE PROJECTWITH NATIONAL/PROVINCIAL AIDS CONTROL PROGRAMMEQUESTIONNAIRE FOR HSW’sName of the city:HRA Typology:Zone # :Sampling Mode:Name of the spotTime:Interviewer Name:nterviewer Code:Date of Interview:- -DD/MM/YYWas the Interview completed? Y N Signature:Checked by:Supervisor Name:Supervisor Code:Editor Name:Editor Code :Date of Checking:Signature:Date of Checking:Signature:- -DD/MM/YY- -DD/MM/YYDate Entry: 1st Entry Name: Date:Code- -DD/MM/YY2nd Entry Name:CodeDate:- -DD/MM/YY71

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 1: Socio-Demographic CharacteristicsNo. QuestionsCoding categoriesSkip to Code101 What is your age? (In completed Years ________years)102 Your educational level? Uneducated / IlliteratePrimaryMiddleMetricIntermediateGraduateNo response103 What is your current marital status? UnmarriedCurrently marriedSeparatedDivorcedWidowed1234569812345104 What is your mother tongue? UrduPunjabiSindhiPashtoBalochiBrahviSiraikiHindko105 Do you belong to this city? YesNo106 Have you come to this cityspecifically for sex work?107 How long do you plan to live in thiscity?(All three boxes of days, mthsand yrs can be filled whereapplicable)Others _____________ 0YesNoNo ResponseDAYS |____|____|MONTHS |____|____|YEARS |____|_____|PermanentlyDon’t know12345678121298969710872

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual108 In the last 12 months have you beenaway from this city for sex work?YesNoNo Response1298If No,skip toQ 110109 If yes, name the last five citiestraveled in the past one year andhow much time was spent in eachcity(most recent travel first)ABCDECityTime in months110 What do you do other then being insex work?OtherProfession_____________Only sex work 96111 What is your approximate totalmonthly income?112 What is your current livingarrangement?Rs. _______Don’t knowNo responseFamily HomeDeraShrine/DarbarStreet/ LaneHostelGuest house/ HotelOthers_________________9798123456113 With whom you are currentlyliving?AloneWith Family/ RelativesWith FriendsSex PartnerOther __________________123473

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual201 How long you have been in sex work? Years ________Less than 1 yearDon’t knowNo response202 What is your approximate monthly incomefrom sex work?203 At what age you had your first sexualintercourse?Section 2: Information about Sex WorkNo. QuestionsCoding categories Skip to CodeRs. ____________Don’t knowNo ResponseAge In Years________Don’t knowNo Response204 How do clients usually contact you? GuruMobile phoneBy roaming aroundThrough old clientsOthers ____________205 How many clients on an average do youentertain in a day?(Please take time to think about your answer to thisquestion. Remember this information is strictlyconfidential)206 In the past one week, approximately howmany clients did you have?(Please take time to think about your answer to thisquestion. Remember this information is strictlyconfidential)No of clients ________Don’t knowNo responseNo of Clients _______Don’t KnowNo Response9697989798979812349798979874

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual301Section 3: Sexual behavior with paying clients“Now I am going to ask you about your CLIENTS who PAY you some money forhaving any sort of sexual activity and condom use with them”No. QuestionsCoding categoriesSkip to CodeHow many paying clientshave you had during last onemonth?Number_______Don’t KnowNo response997998(Please take time to think aboutyour answer to this question.Remember this information isstrictly confidential)302 Of all these clients you hadsex with in the last onemonth, how often did youuse a condom?(Read out options 1-3)303 Why didn’t you use acondom at that time?Do not read responsesMark one onlyAlwaysSometimesNeverNo responseNot availableToo expensivePartner objectedDon't like themDidn’t think it was necessaryDidn’t think of it12398123456304304304 How many paying clients didyou have anal sex with in thelast month?305 The last time you had analsex with a paying client, didyou use a condom?306 The last time you had analsex with a client, did you useany Lubricant (Gel, Cream,Oil)?307 Whom do you have to givethat money you earn fromsex work?(Multiple Reponses areallowed)308 Have you ever discussedHIV/AIDS or STIs with anyof your clients?Others_________________Number________ZeroDon’t KnowNo responseYesNoNo responseYesNoNo responsekeep myselfGuruPoliceFamilyHusband/WifeOthers____________YesNoNo response9969979981298129812345129830775

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 4: Sexual behavior with NON-PAYING partners“Now I am going to ask you about your clients who don’t pay you money for havingany sort of sexual activity (Your husband, boyfriend or a lover)”No. QuestionsCoding categoriesSkip to Code401 In the past one month,approximately with how many nonpayingpartners you had sex?(Please take time to think about your answerto this question. Remember this informationis strictly confidential)402 Of all the times you had sex with anon-paying partner in the lastmonth, how often did you use acondom?Number _______ZeroDon’t KnowNo responseAlwaysSometimesNeverNo response99699799812398501403 How many non- paying malepartners did you have anal sex within the last month?Number _______ZeroDon’t Know996997501No response998404 The last time you had anal sex witha non-paying partner, did you use acondom?YesNoNo response129876

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 5: Condom UseNo. QuestionsCoding categoriesSkip to Code501 Do you have a condom with younow? Please show me502 Last time when you used acondom, where did you get itfrom?Do not read responses(If respondent gives more than oneanswer, ask where he has boughtthem or gotten them more often andcircle only that response .MARKONE ONLY)Can show a condomCannot show a condomNo responsea) ______ BOUGHTTHEM Where?General StorePharmacyClinic/ DispensaryGuest House/HotelFriendsPimpsNGO workerb) ____GIVEN/OBTAINEDWhere?12981234567at a Clinic/ Dispensaryby a Friendsby a Pimpsby a NGO workerby a Guest House/HotelClient bought himselfNo responseOther_____________89101112139877

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 6: Knowledge about HIV/AIDSNo.Questions601 Have you ever heard of HIV or thedisease called AIDS?602 Can healthy looking persons becarrying HIV/AIDS?603 How do you think HIV/AIDS can betransmitted from one person toanother person?Do not read outMultiple Responses are allowed.604 What method(s) you know of whichcan be used to prevent HIV/AIDS?Do not read outMultiple Responses are allowed.605 Do you know where can people go,if they want to get an HIV/AIDStest?Coding categoriesYesNoNo responseYesNoDon’t knowNo responseSexual intercourseSharp instruments/syringeInsect bitesKissing, Touching, HuggingEating& drinking with patientsMother to childBlood transfusionStaying filthyThrough AnimalsDon’ t KnowNo responseOther _________Using CondomRefraining from sexStaying Away from patientsUsing clean syringesDon’ t KnowNo responseOthers___________YesNoNo response1298129798Y/N1 21 21 21 21 21 21 21 21 29798Y/N1 21 21 21 297981298Skip to Code701607606 If yes, where? Name of theplace:___________607 Do you think that you are at risk ofgetting HIV?YesNoNo response608 Have you ever been tested forHIV/AIDS?609 If Yes, what was the result ofHIV/AIDS test?YesNoDon’t KnowNo ResponseHIV+veHIV-veDon’t knowNo Response129812979812979870178

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualSection 7: STIsNo.QuestionsCoding categoriesSkip to Code701 Do you know that certain diseasescan be transmitted through sexualact?YesNoNo response1298707702 What do you do to protect yourselffrom such diseases?Do not read responsesMultiple responses are allowedUse condomsUrinateWash with dettolTake medicineDon’t do anythingNo responseOther ________________1234598707703 In the past 6 months, have yousuffered from any sexuallytransmittable disease?YesNoDon’t knowNo response129798707704 From whom did you take treatment?(Do not read the responses. Note thelast treatment received)Doctor /HospitalSelf MedicationDispensary/TBAHakim/ HomeopathicPharmacyTook no treatmentNo responseOthers _______12345698705 Did you stop having sex when youhad the symptoms?YesNoNo response1298706 Did you use a condom when havingsex during the time you had thesymptoms?YesNoNo response1298707 During the past 6 months, have youbeen arrested?YesNoNo response1298708 Have you ever taken alcohol duringthe course of a sexual act in the past6 months?YesNoNo response1298709 Have you taken any other drugsthrough injection in the last 6months?YesNoNo Response1298(Do Not Count drugs injected for medicalpurposes or treatment of an Illness)79

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual710 During the past 6 months have youever had sex with injecting druguser?YesNoDon’t Know1297711 Have you sold blood for money inthe past 6 months?712 Government of Pakistan has startedprograms for the sex workers. Haveyou ever heard of these programs inyour city?713 If yes, are you a part of any of theseprograms?714 If yes, how long have you been apart of it.715 How many times do you avail theservices of these programs?716 Do you know of anyplace/program/DIC where you canobtain condoms?717 If yes, can you please name it.Do not read outMultiple Responses are allowed.YesNoNo ResponseYesNoYesNoDuration_________More than once in a weekOnce in a weekAfter two weeksOnce in a monthLess than once in a monthNeverYesNoNo ResponseMSM Contech InternationalContech InternationalTahafuz Sehat by InfectionControl SocietyBehtar Kal ProgrammeGazi Welfare TrustORA InternationalOthers(specify):__________________1298121212345612981234567716716719718 What are some of the services thatyou have ever used in these officesin the past 6 months?Do not read the responsesMultiple response are allowedServicesMedicinesSTI treatmentCounselingSocial servicesHIV testCondomsLubricantsPhysical examinationOthersEver80

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring Manual719 Have you been given free condoms Yesin the past one monthNo720 If yes, who provided these condoms Outreach workerA peer educatorFrom programsClinicothers(specify)________________12123481

Integrated Behavioral and Biological SurveillanceField Operations and Monitoring ManualNote the Inter view end time:am / pmThank you very much for your kind cooperation and spending your valuable time with me.Debriefing:Ask participant if s/he has any questions. Provide risk reduction counseling as appropriate. Give referrals/information re nearby HIV testing and counseling services. Provide information on local health social serviceagencies if appropriate.Taking the finger prick blood sample“Now I am going to prick your finger to obtain a blood sample which I will blot onto a piece of paper. Are youokay with this?The DBS was taken correctlyYesNo (specify reason)Time taken for DBS: _________________________minutesInterviewer comments:82

ANNEXURE 2MF-IBBS-01: PLAN OF IBBS DATA COLLECTIONHIV AIDS SURVEILLANCE PROJECT - NACPDate : City : Filled by:S.NoHRGSampleSizeNo ofteamsSampling strategy Collection Site Team SupervisorNo of TeammembersStartingdateEndingdate1IDUsstreet2IDUshome3 MSWs4 Hijras567BrothelFSWStreetFSWHomeFSW8 KK FSW9101112

MF-IBBS-02: OVERVIEW OF IBBS DATA COLLECTIONHIV AIDS SURVEILLANCE PROJECT - NACPCity:Form filled by:IDUs MSW FSW HijrasDateFormscompletedDBSobtainedNo ofteamsFormscompletedDBSobtainedNo ofteamsFormscompletedDBSobtainedNo ofteamsFormscompletedDBSobtainedNo ofteams

MF/IBBS-03:DATA COLLECTION OVERVIEWHIV AIDS SURVEILLANCE PROJECT - NACPHRA typology & Sampling techniqueDate:Team Composition Zone Spots Names to be visited InterviewsTeam LeaderInterviewer/sSocial MobilizerPhlebotomistDr/NurseIBBS forms to be completedNo of DBS to be collectedIBBS completedDBS completedrefusalsNo of refusal forms completedForms coded by Interviewer.Forms edited by SupervisorForms SubmittedDBS SubmittedDBS waste submitted

MF-IBBS-04: DATA MANAGEMENT FLOWHIV AIDS SURVEILLANCE PROJECT - NACPCity:Form filled by:DateFormsfilledINTERVIEWER SUPERVISOR DATA MANAGEMENTFormseditedNo ofFormssubmittedBack LogNo offormsreceivedFormsCheckedNo of Formssubmittedfor entryBackLogNo offormsreceivedDataentry 1Dataentry 2BackLogCheckedby DataManager

MF-IBBS-05: TRAINING EVALUATION FORMHIV AIDS SURVEILLANCE PROJECT - NACPDate:Form Filled by:No of Days: City :No of Participants:No. of Resource Persons:Training Objectives:Names & Qualifications of the Master trainers:S. No. Name of Master trainer Qualification & organizationTopics covered:S. NO Topics12345678910Duration ofsessionAdequately CoveredGood (10) to (1) Poor

What problems were faced in reading questionnaires?How these problems were removed/explained by facilitators?Sessions which needed more input?Observations/comments:

MF-IBBS-06: INTERVIEW EVALUATION FORMHIV AIDS SURVEILLANCE PROJECT - NACPDate:City:Form Filled by:HRGName of Field worker:1- Duration of Interview : _____ min2- Please rate the interviewer on following on a scale of 1 to 5. Please tick ()Very Poor Poor Satisfactory Good Very Good2.1 Informed Consent 1 2 3 4 52.2 Rapport building 1 2 3 4 52.3 Clarity in questioning 1 2 3 4 52.4 Probing by interviewer 1 2 3 4 52.5 Writing Eligibility 1 2 3 4 52.6 Quality of Information 1 2 3 4 52.7 Ability to answerinterviewees questions1 2 3 4 52.8 Overall Interviewing 1 2 3 4 53- Interviewer explained the data confidentiality to respondent properly: Yes No4- Interviewer took notice of the respondents’ body language: Yes No5- Interviewer kept ethical considerations in view while interviewing: Yes No6- The subjects were properly referred to SDP / VCT Yes NoComments/Observations:

MF-IBBS-07: DBS EVALUATION FORMHIV AIDS SURVEILLANCE PROJECT - NACPDate:City:Form Filled by:HRGName of Field worker:Please observe and note whether following steps were taken or not:Please tick ()Where was the DBS taken Field centreClient seated comfortably? Yes NoSample Taker wearing gloves? Yes NoFinger cleaned with alcohol swab? Yes NoHand of client placed on the table: Yes NoPrick with lancet: Single More# of drops colleted on card:Drops collected with: Ease DifficultyFinger cleaned with Alcohol swab: Yes NoBandage tape applied: Yes NoCondition of client: In pain RelaxedWaste disposed properly in Bio hazard bag: Yes NoAverage time taken for DBS collection:Observations/comments: