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HIV/STI Surveillance for CAREC Member Countries

Participant Manual

October 2007

Acknowledgements

This pilot manual was prepared by the Caribbean Epidemiology Centre (CAREC) in collaboration with:

the United State Department of Health and Human Services, Centers for Disease Control and Prevention (HHS-CDC), Global AIDS Program (GAP) Surveillance Team
the University of California at San Francisco (UCSF), Institute for Global Health, AIDS Research Institute through the University Technical Assistance Program (UTAP) with CDC/GAP.

This workshop is sponsored by the following partners of the CAREC Special Programme on Sexually Transmitted Infections:

the United State Department of Health and Human Services, Centers for Disease Control and Prevention (HHS-CDC)
PANCAP—Global Fund and World Bank Projects

CAREC thanks the workshop participants, national epidemiologists, surveillance officers and other public health professionals from the following countries: Trinidad & Tobago, Guyana, Turks & Caicos, Anguilla, Antigua & Barbuda, Barbados, British Virgin Islands, Dominica, Grenada, Montserrat, St. Lucia, St. Kitts & Nevis.

Funding for the initial creation of this manual was provided in part by the United States Agency for International Development and PANCAP.

Unit 1, The Global HIV/AIDS Situation and the HIV/AIDS Epidemic in the Caribbean	8
Overview	8
Introduction	9
Trends (CAREC Surveillance data, 1982-2003)	14
Summary	17
Unit 1 Exercises	18
Unit 2, Biology, Transmission, Natural History, Prevention and Treatment of HIV Infection and AIDS	20
Overview	20
Introduction	22
Biology of HIV	22
HIV Transmission and Natural History	24
Spectrum of Disease Following HIV Infection	33
Prevention Transmission of HIV/AIDS	33
HIV/AIDS Treatment	36
Summary	38
Unit 2 Exercises	39
Unit 3, Overview of Public Health Surveillance	42
Overview	42
Introduction	43
Public Health Surveillance	43
Surveillance Terms	46
Past Approaches to Communicable Disease Surveillance	48
CAREC Regional Communicable Disease Surveillance System	49
Major Changes in the Regional Communicable Disease Surveillance System	50
Legal Basis	50
Strategic and Operational Plans	51
Reporting Chain	51
Data Transfer	53
Analysis and Interpretation	53
Dissemination of Information	54
Use of Data and Information	55
Monitoring and Evaluation	56
Summary	57
Annex 3.1. Syndromes and Communicable Diseases under Regional Surveillance	58
Unit 4, HIV Case Surveillance	60
Introduction	60
What is Third Generation Surveillance?	60
Section 4.1: HIV Case Surveillance	65
Table of Contents, continued
Introduction to HIV Case Surveillance	66
The Relationship Between the Natural History of HIV and Surveillance	66
History of HIV/AIDS Case Surveillance	69
Sources of HIV Case Surveillance Reports	73
Section 4.1 Exercises	74
Section 4.2: Clinical Staging and Surveillance Case Definitions for HIV Infection	76
Introduction to Clinical Staging and Surveillance Case Definitions for HIV infection	78
History of Clinical Staging and HIV/AIDS Case Surveillance Definitions	78
Linking HIV Clinical Staging, ART Use, and HIV Case Surveillance	83
Section 4.2 Exercises	85
Section 4.3: Components of an HIV Case Surveillance System	86
Introduction to an HIV Case Surveillance System	86
Defining Reportable Events	87
Case Finding	87
Case Report Form	92
Unit 4 Summary	96
Unit 4 Case Study	97
Annex 4.1. WHO clinical staging of HIV/AIDS for adults and adolescents with confirmed HIV infection	109
Annex 4.2. Revised WHO clinical staging of HIV/AIDS for infants and children with confirmed HIV Infection	110
Annex 4.3. Presumptive and definitive criteria for recognising HIV/AIDS-related clinical events in HIV-infected adults and adolescents (older than 15 years)	112
Annex 4.4. Presumptive and definitive criteria for recognising HIV/AIDS-related clinical events in HIV-infected children	122
Unit 5, Monitoring Surveillance System Quality	134
Overview	134
Introduction	135
What Surveillance Systems Describe	135
Evaluating Surveillance Systems	138
Evaluation Process	139
Data Flow in the Caribbean Region	143
Measuring Completeness	143
Measuring Timeliness	147
Measuring Validity	149
Planning for Future Evaluations	152
Summary	153
Table of Contents, continued
Unit 5 Exercises	154
Unit 6, Surveillance for Sexually Transmitted Infections (other than HIV)	156
Section 6.1: Overview of STI Surveillance	156
Introduction	158
STI Surveillance and HIV Epidemic State	159
STI Aetiologies versus STI Syndromes	160
Symptomatic and Asymptomatic STIs	161
Case Definitions	163
Components of STI Surveillance Systems	164
Levels of STI Surveillance - Basic, Intermediate and Advanced	164
Components of STI Surveillance Systems – In Detail	167
Universal STI Reporting	167
Prevalence Assessment and Monitoring	169
Assessing STI Syndrome Aetiologies	171
Behavioural and Biological Surveillance Surveys	174
Monitoring of Anti-Microbial Resistance of STI Pathogens	176
Section 6.2: Case Reporting, Data Management and Analysis	178
Planning Your Data Collection	179
Collecting Data	180
Entering and Analysing Data	182
Summary	185
Annex 6.1. Caribbean Epidemiology Centre Quarterly STI Reporting Form	189
Annex 6.2. CAREC Surveillance Case Definitions for Sexually Transmitted Infections (STIs)	190
Definition of STI, by Syndromes	190
Definitions of STI, by Aetiology	191
Unit 7, Confidentiality and Data Security	196
Overview	196
Introduction	198
Addressing Ethical Issues	198
Unique Identifiers—Name versus Codes: Balancing Risks and Benefits	199
Confidentiality	204
Guidelines for Confidentiality and Data Security	204
Guiding Principles	205
Policies	206
Responsibilities	211
Training	212
Physical Security	213
Table of Contents, continued
Data Security	216
Data Movement	217
Access Control	221
Summary	231
Unit 7 Exercises	232
Annex 7.1. Additional Laptop Security Considerations	234
Annex 7.2. Additional Security and Policy Considerations	238
Annex 7.3. Sample Employee Confidentiality Agreement/Oath	243
Annex 7.4. Attachment G: Using Surveillance Data to Document Need and Initiate Referrals	244
Unit 8, Analysis, Interpretation, and Dissemination of HIV Surveillance Data	256
Overview	258
Introduction	258
Communicating HIV Data	265
Formats for Disseminating HIV Data	266
Types of Analyses	267
HIV Surveillance Report	270
Annual HIV Epidemiologic Profile	272
Recommended Analyses	273
Programme Monitoring Data	275
Unit 8 Exercises	278
Appendix A, References	A-1
Appendix B, Abbreviations and Glossary	B-1
Appendix C, Useful Links	C-1
Appendix D, Answers to Warm-Up Questions and Case Studies	D-1
Appendix E, Action Plan for Strengthening Surveillance in Caribbean Countries	E-1
Appendix F, Regional Surveillance Indicators and Data	F-1
Appendix G, Regional Reporting Requirements HIV/AIDS and STI	G-1

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