Guidelines on surveillance among populations most at risk for HIV

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In indirect sharing, one syringe is used to prepare the drug solution, which is then divided into one or moresyringes for injection. The solution is transferred between syringes with the needle removed (frontloading)or plunger removed (backloading). This allows virus transmission if the preparation syringe is not clean.The importance of each of these methods of sharing may depend on local behaviour. For example, ifdirect sharing has been virtually eliminated due to intervention programmes and behaviour change, thensurveillance should monitor indirect sharing.Surveillance should also monitor sharing that involves many different “sharing partners” within a shortperiod (“rapid partner-change” behaviour), since this behaviour is associated with rapid transmission of HIVamong persons who inject drugs. Technical guidelines that provide specific guidance on monitoring andevaluating interventions for injecting drug use are available. (http://www.who.int/hiv/pub/idu/idu_target_setting_guide.pdf)Finally, collect information on access to sterile injecting equipment. Easy access to sterile injection equipmentis critical for HIV prevention among persons who inject drugs.In summary, surveillance among persons who inject drugs should incorporate: data on drug injection risk behaviour sexual risk behaviour size and growth of the population patterns of drug use access to sterile injecting equipment participation in prevention activities, including screening for hepatitis access to antiretroviral therapy.Men who have sex with menHIV among men who have sex with men is increasing in many countries of the world (22,23,24). Surveillancein this population has often underestimated the magnitude of infection and risk among this population.Many countries do not include men who have sex with men in their regular surveillance activities becausehomosexuality is illegal and highly stigmatized (25).The impact of risk among men who have sex with men varies, depending on the level of the epidemic.Even in some regions with a generalized epidemic, men who have sex with men may have a higher HIVprevalence than among the general population (26).Use formative research to enlist the cooperation of the community.Behavioural questions that should be included in surveys with men who have sex with men include: thenumber of partners, sexual behaviour and frequency of sex with female partners, time since initiation ofmale-to-male sex, frequency of condom use, participation in HIV prevention or care programmes and otherrelevant variables.Other populationsIn some countries, access to populations most at risk for HIV may be limited. As a result, surveillanceactivities may be planned among proxy populations. In some cases, regular and consistent HIV testing andcounselling will be available from proxy populations (for example, prisoners), providing an opportunity toanalyse potential trends. It is important to ensure that ethical processes were followed to generate thesedata before using them.Surveillance systems based on proxy populations might not be adequate. Although they can be useful forsupplementing surveillance, they will typically not provide full and representative information on the actualgroup of interest. As a result, they suffer from the same problems and weaknesses of such sampling orselection biases (sampling biases and weaknesses are described later in this document). Additional variablesthat should be asked of these populations depend on the behaviour that puts the group at increased risk.12
Incarcerated populationsPersons in prison might be more likely to engage in behaviours that increase their risk for acquiring HIVthrough injecting drugs, engaging in anal sex with fellow prisoners (27,28) or tattooing (29). While thesebehaviours occur in many prison settings, incarcerated populations are not a proxy population for allinjecting drug users or men who have sex with men.Prison populations are often used as proxy populations. Surveillance among prisoners should include thereason for each prisoner’s incarceration (this can provide potential information to determine if they wereinfected before imprisonment).Keep in mind that incarcerated persons may have been infected before they were incarcerated.Military recruitsIn some countries, military recruits are more likely to visit sex workers. This makes them a useful proxypopulation for clients of sex workers. In addition, this population is often routinely tested for sexuallytransmitted infection (including HIV) through existing medical systems.<strong>Guidelines</strong> on surveillance among populations most at risk for HIVHowever, being in the military is not on its own a risk factor for HIV infection so interpret results with caution.2.1.7 Integrate with existing surveillance and monitoring plansAfter conducting all of these preliminary activities, including the formative assessment and size estimation,revise and review the HIV surveillance protocol. Ensure that the protocol documents the decisions madeand plans future surveillance activities on a timeline. Make sure that the surveillance protocol is incorporatedinto the national monitoring and evaluation plan to avoid overburdening staff and duplicating efforts. Usethe surveillance protocol to develop funding requests for surveillance activities.2.2 Step 2: Decide on the surveillance designSurveillance results will help determine: how many people are infected with HIV among the population most at risk, and the factors that might be associated with their HIV status.Therefore, surveillance activities must collect biological and behavioural data.There are a few ways to collect biological data. Options include: HIV case reporting using programme data for surveillance sentinel surveillance.Regardless of the biological surveillance design, behavioural data should also be collected. Tracking HIVprevalence or incidence may show the progress in implementing prevention programmes. However,these data alone will not indicate why the programmes succeeded or failed. Behavioural data can showassociations with particular aspects of risk.Historically, surveillance activities for biomarkers and for behavioural indicators were conducted as separateactivities. When planning surveillance activities that collect information on biomarkers, it is currentlyrecommended to also collect data on risk and preventive behaviours.2.2.1 HIV case reportingMany developed countries rely on HIV case reporting (and the self-reported transmission route) forsurveillance among most-at-risk populations. However, this method has several limitations: Many individuals are not diagnosed until long after they have been infected, or not at all, leading tounderreporting. The self-reported mode of transmission is potentially biased, as individuals may not want to disclosehigh-risk behaviours to health-care providers. HIV case reporting generally provides only limited data on the risks of HIV transmission or behaviour.13
Page 1 and 2: UNAIDS/WHO Working Groupon Global H
Page 3 and 4: UNAIDS/WHO Working Groupon Global H
Page 5 and 6: ContentsAcknowledgements1 Introduct
Page 7 and 8: 1. IntroductionThe overall goal of
Page 9 and 10: Generalized The epidemic has mature
Page 12 and 13: Table 2.1. Potential stakeholders t
Page 14 and 15: Decide on a clear and specific defi
Page 19 and 20: Sampling of subgroups of interest m
Page 21 and 22: 2.3.3 Cluster or targeted samplingD
Page 23 and 24: Figure 2.2. Respondent-driven sampl
Page 25 and 26: Time-location sampling in Harare, Z
Page 27 and 28: Surveillance among men who have sex
Page 29 and 30: 3. Conduct surveillance of populati
Page 31 and 32: When constructing a questionnaire,
Page 33 and 34: 3.2.5 Maintain confidentiality and
Page 35 and 36: HIV incidence (recent infection) is
Page 37 and 38: 4.1.4 Use the results to improve pr
Page 39 and 40: Appendix A: List of additionalsurve
Page 41 and 42: Humanimmunodeficiencyvirus (HIV)HIV
Page 43 and 44: Appendix C: LinksUNAIDS/WHO Working
Page 45 and 46: 18 Topp L et al. Representativeness
Page 47 and 48: 59 Brookmeyer R, Stroup DF (eds). M
Page 49: For more information, contact:World

Guidelines on surveillance among populations most at risk for HIV

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