1. Module 1: Final Case Study #1-CS-1

2. Case Study: Instructions v Try this case study individually. v We’ll discuss the answers in class. # 1-CS-2

3. Answers to final case study Question 1 1.You are the HIV sero-prevalence officer for Inyo province. Inyo is a large province in the Mono Republic, a country with a concentrated HIV epidemic. Sero- prevalence surveys are conducted annually in Inyo in antenatal clinics. You examine data from the past five year and observe the following: # 1-CS-3

4. Answers to final case study Question 1, continued 20012002200320042005 Number of subjects 61206790694266717662 Overall Prevalence 29%32%30%24%21% Prevalence by age (years) : 15 - 19 25%20%19%14%12% 20 - 24 32%29% 24%23% 25 - 29 37% 38%31%29% 30 - 34 42%40%37%30% 35 - 39 30%31%36%28%25% 40 - 44 15%22%24%18%15% Sero-prevalence of HIV among pregnant women attending ANCs in Inyo Province 1999- 2005. # 1-CS-4

5. Answers to final case study Question 1, continued a.Using the above data, create a figure to show HIV prevalence by age group and year. # 1-CS-5

6. Answers to final case study Question 1, continued b.What trends do you see regarding HIV prevalence in relation to age and year? Overall, HIV prevalence was highest in 2002 and decreased between 2002 and 2005. HIV prevalence was highest among pregnant women ages 25 to 34, while lowest among pregnant women ages 15 to 19 and 40 to 44. Among pregnant women 15 to 24 and 30 to 34 years old, HIV prevalence peaked in 2001 and decreased from 2001 through 2005. Among pregnant women ages 25 to 29 and 35 to 44 years, HIV prevalence was highest in 2003 and decreased between 2003 and 2005. # 1-CS-6

7. Answers to final case study Question 2 2.Inyo province has recently been given funds to begin second-generation HIV surveillance. Until now, HIV/AIDS surveillance has been limited to HIV and AIDS case reporting and sentinel sero- surveillance at antenatal and STI clinics. # 1-CS-7

8. Answers to final case study Question 2, continued a.What components of second-generation HIV surveillance would you implement to strengthen the province’s surveillance system? When possible, components of second generation surveillance that would strengthen the province’s surveillance system would include: © behavioural surveillance, which involves asking a sample of people about their sexual and, sometimes, their drug-injecting behaviour © improving and using HIV/AIDS case reporting © improving and using death registries © sexually transmitted infection (STI) surveillance # 1-CS-8

9. Answers to final case study Question 2, continued b.What measures would you include? Biological measures could include: HIV prevalence, STI incidence and prevalence, TB prevalence, the number of adult AIDS cases and the number of pediatric AIDS cases. Behavioural indicators could include: sex with a non-regular partner in last 12 months, condom use at last sex with a non-regular partner, age at first sex, use of unclean injecting equipment reported by drug injectors and reported number of clients in the last week by sex workers. Sociodemographic indicators could include: age, gender, socio-economic and educational status, geographic residency (urban vs. rural) or migration status, marital status and parity (for antenatal sites). # 1-CS-9

10. Answers to final case study Question 3 3.Inyo province provides free antiretroviral therapy (ART) to HIV-infected pregnant women. What ethical issues must you consider when conducting HIV surveillance among pregnant women in a setting where ART is available? Because ART is available in Inyo province, conducting HIV surveillance through anonymous unlinked sero-surveillance presents ethical issues. If anonymous unlinked surveillance surveys are used women must have access to voluntary HIV counselling and testing with referrals for care for HIV-infected women. Case reporting and surveys conducted in conjunction with voluntary counselling and testing would diagnose individuals with HIV infection and give them their results so that if needed, they could begin ART and must present the same ethical concerns as anonymous unlinked surveys. # 1-CS-10

11. Answers to final case study Question 4 4.Annual sero-prevalence surveys have been conducted at five antenatal clinics in the district for the past four years. The survey is conducted between June and September of each year. Evaluation of the sero-prevalence surveys is one of your responsibilities. This entails assessing the data for quality and completeness. After the first two months of the current annual survey you examine the database and observe the following: # 1-CS-11

12. Answers to final case study Question 4, continued Missing data during sero-surveillance by site, Inyo Province Site 1Site 2Site 3Site 4Site 5 Number of subjects 158165208287189 Percent missing data: Age 6%5%2%4%5% Date specimen collected 2%1% 2%3% Residence 4%5%2%3%5% Parity 3%2%1%2%3% Live births 1%2% 1%3% HIV serology 1% 0%20%1% # 1-CS-12

13. Answers to final case study, continued a.What are your thoughts regarding the data in this table? Is there anything of concern? 20% of HIV serologic results are missing from site 4. # 1-CS-13

14. Answers to final case study Question 4, continued b.What are some possible explanations for this finding? How would you investigate these? What steps would you take to correct the problem(s)? There are many possible explanations, including: © A problem with data entry. This could be investigated by examining the hard copies of the data. © Laboratory error: testing was not done. © Laboratory error: testing was done but not recorded. # 1-CS-14

15. Answers to final case study Question 4, continued v You conduct your investigation and find that the HIV serologic results are missing on the hard copies. You then visit the laboratory and meet with the director. v In your discussions, you discover that reagents for HIV testing were not available for a period of time. The laboratory director indicates that there is now an ample supply of HIV reagents and that the survey can be completed without any interruptions. # 1-CS-15

16. Answers to final case study Question 4, continued c.Having identified the problem, how do you address it in the short term and what are some steps you can take to ensure that such a problem does not recur? Additional training session might be needed. At a minimum, the sero-prevalence coordinator should meet first with the laboratory director and then with laboratory staff to review the protocol. © In addition, since one lapse in protocol was found, the coordinator should keep a close watch on the data from this site and should make frequent visits there to assess adherence to protocol, answer questions and stress the importance of sero-prevalence surveys. © Improving communication between the sero-prevalence coordinator and the laboratory director regarding the adequacy of supplies should also be discussed. # 1-CS-16

17. Questions, Process Check v Do you have any questions on the information we just covered? v Are you happy with how we worked on the final case study? v Do you want to try something different that will help the group? # 1-CS-17

18. Small Group Discussion Get into small groups to discuss these questions.  Does your country have a functional HIV case reporting system?  If your country is not conducting HIV case reporting, discuss why it is not.  If your country does not have an HIV case reporting system, discuss current limitations to HIV case reporting. What are some possible solutions for these limitations?  Working alone or with others from your country, region or district, complete the following tables and then discuss your responses in your small group.

19. Case Study 1. You are the regional surveillance officer for Ethiopia. The national AIDS control programme is interested in expanding and improving its surveillance programme and the national surveillance officer is conducting site visits to various districts to discuss ways of improving surveillance. During your meeting with the national surveillance officer, you are asked to suggest additional surveillance activities in your region that you believe could be implemented successfully. Describe what these activities would be.

20. Case Study, Cont. 2. The national surveillance officer has indicated that there is interest in using data collected from HIV and other care programmes for reporting of persons with advanced HIV disease. Review the worksheet you completed in your small group discussion and use this to determine the necessary steps to expand current surveillance activities. List these activities.