Illustrative Cluster Detection and Response Strategy This strategy describes the use of HIV surveillance data to detect and confirm HIV recent infection clusters and the subsequent public health response activities. ACTIVITIES TOOLS STEP 1. Identify and characterize suspected HIV recent infection clusters using surveillance data and routine programmatic data [regional/national] Review HIV new diagnoses and recency data (i.e., rapid test for recent infection (RTRI) and/or recent infection testing algorithm (RITA) classification) at least monthly by health facility to identify HIV recent infection clusters Use initial definition of criteria to identify suspected HIV recent infection clusters: The number of new HIV diagnoses in the most recent month at the health facility fall more than 2 standard deviations above the mean number of new diagnoses in the previous three months; or Low volume health facility reporting <10 newly HIV-positive persons per month where ≥2 recent case are identified in the most recent month; or High volume health facility reporting ≥10 newly HIV- positive persons per month where ≥5 recent cases are identified in the most recent month NOTE: For countries considering or using molecular sequence-based approaches, examine HIV sequence data to identify closely related pairs Map health facilities meeting the above definition and visually inspect potential geographical clustering across more than one health facility to determine the size of the potential cluster For all HIV recent infection clusters meeting criteria above, evaluate and characterize clusters (all recent infections vs. all newly diagnosed HIV positives) using available data by: Month of diagnosis Testing location type (e.g., ANC, VCT, PITC, community) Demographic information (age and sex) Index partner status (yes or no) Risk behaviors and key population groups Dashboard views tracking and monitoring key indicators to identify HIV recent infection clusters 1 month STEP 2. Confirm and prioritize HIV recent infection clusters for response [regional/national] Determine if alternative explanations exist for the increase in new diagnoses and/or recent infections through local consultations (e.g., increase in outreach testing, testing campaigns, increase in testing sites) Determine if increase in the number of new HIV diagnoses and recent infections is an artifact of data quality issues (e.g., transcription errors, duplicate entries) Review HIV testing data over a longer time period (e.g. from the prior 6 -12 months) to look for patterns suggestive of a cluster in which diagnoses were temporally spaced out When more than 1 clusters are confirmed in a given month in a district, a cluster prioritization approach is needed to effectively allocate resources on clusters where response activities will have the greatest impact on interrupting ongoing HIV transmission. Consider the following factors to prioritize HIV recent infection clusters: Size of the cluster (i.e., number of individuals with recent infection) Key population and priority population groups known to be stigmatized and/or vulnerable and with high potential for poor outcomes (e.g., injection drug users, commercial sex worker, migrants, MSM, pregnant women) Evidence of ongoing high risk behaviors (e.g., injection drug use, commercial sex work, partners not on PrEP) Shifts in demographic or risk profiles among cases in a given geographic unit (e.g. migrant populations coming in or out of an area) Dashboard views characterizing HIV recent infection clusters DQA SOP Guide for local consultations and cluster prioritization Based on review of data is this confirmed as a recent HIV infection cluster? □ Yes □ No (stop here and close investigation) If yes, what is the level of concern for onward transmission in this cluster? □ High: Response is needed (proceed to Step 3) □ Medium: Monitor closely and respond as needed based on available resources STEP 3. Respond to confirmed and prioritized HIV recent infection clusters [health facility/regional/ national] CLUSTER RESPONSE PROGRAM RESPONSE Conduct interviews, in particular with recently infected individuals, contacts, key informants, and service providers to identify risk networks (infected and uninfected high-risk persons) Initiate testing and re-testing activities for individuals in the risk network not known to be HIV infected (e.g., prioritization of partner services for indexes with recent infections, targeted community testing, social network testing in key populations) Refer HIV-negative persons in the network to PrEP services and other prevention (condom distribution / accessibility) and counseling services Ensure HIV-positive persons in the network are linked to care and initiated on ART Ensure HIV-positive persons in the network are virally suppressed (e.g., follow-up after ART initiation, retention on ART, adherence support, drug-resistance testing and/or switching treatment regimens) Cluster Response Data Abstraction Form Routine programs Address gaps identified in routine programming that are factors that contribute to on-going transmission (e.g., linkage to care, active tracing of clients lost to follow-up, testing coverage [3-12 months], PrEP coverage, partner notification services and index testing coverage) Conduct interviews with service providers, peers, other key informants to look for missed opportunities for earlier diagnosis and/or challenges related to linkage to care or adherence to ART Enhanced interventions Consider additional interventions depending on the characteristics of the cluster including but not limited to: Community level interventions (e.g., media campaigns) Strengthening partnerships (e.g. with HIV providers, STD clinics, local health departments, correctional services, NGOs, and CBOs etc.) Service availability assessments/mapping of resources Targeted outreach and testing at venues Policy changes/reallocation of resources (e.g., increase availability of PrEP services) Programmatic Data Review Worksheet Programmatic Response Interview Guide 1 month STEP 4. Document and communicate outcomes of HIV recent infection cluster investigation [regional/national] For each cluster for which response activities are initiated, track outcomes of activities to assess ongoing concern related to cluster Use the following key considerations to determine completion of cluster response activity: Whether persons in the recent infection cluster without evidence of viral suppression have been successfully linked to care Whether persons in the risk network have been tested/re-tested and referred for PrEP intervention as warranted Whether new diagnoses have been identified through active investigation Whether the rate of new diagnoses identified suggests that more testing is warranted Whether required follow-up activities can be transitioned to local service providers Communicate outcomes of HIV recent infection cluster investigation to stakeholders Cluster Investigation Worksheet Instructions for Completing the Cluster Investigation Worksheet DRAFT