|Guidelines for HIV Interventions in Emergency Settings (UNAIDS - UNHCR - WHO - OMS, 1996, 59 p.)|
Disease, or syndrome-specific, data should be collected by the health information system (HIS) for HIV/AIDS/STD surveillance purposes for new cases of the following conditions:
1. HIV/AIDS-associated diseases:
· clinically diagnosed new cases of active tuberculosis, with or without radiological confirmation.
2. Newly diagnosed cases of STD-associated clinical signs:
· male urethral discharge;
· vaginal discharge;
· genital ulcers.
3. HIV and/or VDRL/RPR sero-reactivity in selected populations:
· VDRL/RPR sero-reactivity in pregnant women, and blood donated for transfusion;
· HIV sero-reactivity in blood donated for transfusion.
4. Denominator data:
· number of persons consulting, or admitted to, clinics/health facilities/hospitals each month.
Laboratory facilities for smear microscopy (for acid-fast bacilli (AFB), suggestive of M. tuberculosis) should be available. Where possible, surveillance data on tuberculosis cases reported should be stratified by: (a) pulmonary tuberculosis, AFB smear positive; (b) pulmonary tuberculosis, AFB smear negative; (c) extrapulmonary tuberculosis.
Surveillance data should be analysed separately for each camp/emergency area (i.e., all new cases reported by a health facility in a camp/emergency area are counted, even if the person is not from the camp). Rates should be calculated on the basis of all newly diagnosed cases reported of the above conditions in a camp/area (the numerator), divided by the reported number of attendances for all clinics/health facilities/hospitals in the camp/area (the denominator). The data should be analysed as two-monthly moving averages.
Using moving averages helps to obtain trends that are more easily interpretable as changes in disease frequency, and not due to other phenomena such as changes in clinic attendance.
EXAMPLE. Surveillance of new cases of active tuberculosis is started in January. For January, a rate for the month alone is calculated, and graphed; in February, the average (mean) of the February and January rates is calculated, and graphed; for March, the average rate for February - March is plotted; for April the moving average rate for March - April; for May, the moving average will be the mean of the April and May monthly rates, and so on.
Laboratory testing for HIV should use kits that detect both HIV-1 and HIV-2. For emergency needs assessment purposes, distinguishing HIV-1 infection from HIV-2 is not a priority, as prevention measures against both HIV serotypes will be the same.
Continuous (routine) monitoring of data separately by camp/emergency area is important, since these data are to be used for rational targeting and selection of priority areas/camps in which to take public health action. For example, a rise in the apparent HIV sero-prevalence in blood donated for transfusion in one camp/area may lead to the following actions: (a) site visits to both blood donation site and laboratory, to determine whether or not clerical, procedural, and/or technical errors have occurred; (b) reinforcement of blood donor motivation, recruitment, and deferral procedures; (c) review and/or 3 months) reinforcement of the donor screening questionnaire; (d) intensified HIV/AIDS/STD prevention efforts in the camp/area. If these measures are effective, HIV/syphilis sero-prevalence in donated blood should remain low, decrease, or rise more slowly than in the population as a whole.
1. An estimate of the age/sex profile of the camp/emergency area, should be obtained when a census of the camp/emergency area is conducted; the repetition of such surveys depends on the duration of the emergency, or stability of the camp/emergency; generally they should be repeated as often as once a year (or less frequently). As a minimum, age may simply be collected as: newborn/toddler; child; prepubertal adolescent; postpubertal adolescent/young adult; adult; elderly.
Age/sex data help to define supply/logistics needs, by providing a crude estimate of the of the number of persons at risk of HIV/AIDS/STD (i.e. the total of postpubertal adolescents/young adults, plus adults)
2. The overall coordinator for the emergency should compile an annual census of: (a) all agencies or groups (health ministry; national NGOs; bilateral aid agencies; international NGOs; multilateral agencies) providing health services to the population/area affected by the emergency. These data should be shared with the STD/AIDS coordinator, and the HIS coordinator. Such data should include the name of the chief-of-party of each agency, and the types of health-related activities in which they are involved.
The HIS coordinator, or HIS staff, should make regular supervisory tours (at least every 3 months) of the camps/areas affected by the emergency. From the first of such visits, the HIS team should develop a profile of the different camps, including its location/accessibility (on main road, near large town, etc.). Such qualitative data will also help make a preliminary assessment of the HIV/STD risk profile of the populations.
The data will also help in assessing the distribution and spread of diseases; for example, if two camps, 10 km apart, are on the same road whereas the other camps are not, then if for example, an epidemic affects one of these two camps, then the other camp on the same road may be next to be affected, even if other camps are closer by distance as the crow flies.
On supervisory tours by either the HIS team, or the STD/AIDS coordinator, the clinics/health facilities/hospitals should be checked to see if they have adequate supplies of: condoms; HIV test kits; and VDRL or RPR test kits. The simplest way would be to ensure that local stores have enough stocks of such items to cover at least the previous months utilization rate.
EXAMPLE. Records indicated that 5,000 condoms were requested/supplied to local clinics last month. The local storehouse had 10,000 condoms remaining in-stock. The STD/AIDS coordinator concluded that local stocks were adequate to meet expected demands.
3. Once a year, the HIS team should coordinate an unlinked anonymous survey of HIV seroprevalence in pregnant women coming to selected health facilities for antenatal care, who have blood taken for VDRL/RPR testing. In this unlinked anonymous testing, residual blood originally taken for VDRL/RPR are tested for HIV after all data which identify the source person are removed. This method, recommended by WHO for HIV surveillance purposes, makes it possible to obtain the best possible data on HIV penetration into the population (here, of pregnant women), while protecting the anonymity of the person.
4. The central warehouse should be monitored by the HIS team, or STD/AIDS coordinator, to ensure that there remains in-stock at the central warehouse supplies of: (a) condoms; (b) HIV or RPR/VDRL test kits; (c) disposable needles; (d) ciproflaxin, sufficient to cover three times the demand for the above-mentioned items in the preceding month.
Stocks of all other items should also be monitored, but by a logistics, or stock control, officer, whose duty it would be to ensure an uninterrupted and adequate supply of all equipment and supplies. The above-mentioned items are proposed as indicator items, to be monitored in addition by the STD/AIDS coordinator, and/or the HIS team, to monitor the adequacy of supplies.
5. Once the first round of the previously-mentioned needs assessments have been completed, and/or the routine collection and analysis of continuous data are in-place and functional, consideration should be given to conducting a baseline prevention indicator (PI) round of surveys within the first 12 months following the start of the needs assessments. This is especially so if the camp is likely to exist for some time (as a rule of thumb, 2 years or more), and/or the emergency will remain unresolved for some time (2 years or more). The PI are a series of indicators developed by GPA to help assess the effectiveness of public health HIV/AIDS/STD prevention and control programmes against heterosexually transmitted HIV/STD. Such PI surveys should be repeated every 2-3 years, to look at trends in these indicators of HIV/AIDS/STD prevention.