A Guide on Indicators for Monitoring and Reporting on the Health Sector Response to HIV/AIDS. January 2011

Transcription

1 A Guide on Indicators for Monitoring and Reporting on the Health Sector Response to HIV/AIDS January 2011

2 Acronyms ANC ART ARV CTX EBF HIV IDU IDP IPT L&D M&E MARPs MDG MoH MSM MTCT NSP OST PCP PCR PEP PEPFAR PLHIV PITC PMTCT PWID STI SW TB UNAIDS UNGASS VCT Antenatal Care Antiretroviral Therapy Antiretroviral Drug Co-trimoxazole Exclusive Breastfeeding Human Immunodeficiency Virus Injecting Drug Users Internally Displaced Persons Isoniazid Preventive Therapy. Also can be termed TBPT (TB preventive therapy) Labour and Delivery Monitoring & Evaluation Most-at-Risk Populations Millennium Development Goal Ministry of Health Men who have Sex with Men Mother-to-Child Transmission Needle and Syringe Programme Opioid Substitution Therapy Pneumocystis carinni pneumonia Polymerase Chain Reaction Pre or Post-exposure Prophylaxis U.S. President's Emergency Plan for AIDS Relief People Living with HIV/AIDS Provider Initiated Testing and Counselling Prevention of Mother-to-Child Transmission People Who Inject Drugs Sexually Transmitted Infections Sex Workers Tuberculosis United Nations Joint Programme on AIDS United Nations General Assembly Special Session Voluntary Counselling and Testing 2

3 TABLE OF CONTENTS I. INTRODUCTION 4 Introduction 4 Monitoring Health Sector Progress Towards Universal Access to HIV/AIDS Prevention, Care, and Treatment 5 Programmatic Information 5 Indicator Descriptions in this Guide 6 Target Audiences and Capacity-Building 7 Planning for Global Reporting 7 Technical Support and Contact for Questions 8 Acknowledgements 8 II. INDICATOR DESCRIPTIONS 9 List of indicators 9 A. Testing and counselling 9 B. Prevention in health care settings C. Prevention of sexual transmission of HIV and prevention of transmission through injecting drug use 9 D. Care 9 E. HIV/TB 10 F. Sexually transmitted infections 10 G. Antiretroviral therapy 10 H. Health systems 10 I. Women and children 10 3

4 I. Introduction As countries scale up their national HIV/AIDS programmes towards the goal of universal access (UA) to prevention, treatment, care and support 1, it is increasingly important to strengthen strategic information on the epidemic and national responses to inform policies and programmes, improve the effectiveness of interventions and promote accountability. At the international level, WHO is committed since the 59 th World Health Assembly in 2006 to monitor and report annually on global progress in countries' health sector responses towards universal access to HIV prevention, treatment, care and support. 2 WHO is working with UNICEF and UNAIDS to monitor the health sector response to HIV/AIDS towards universal access. Progress in the health sector is a key measure of progress towards universal access, as well as broader Millennium Development Goals. WHO, UNICEF and UNAIDS will jointly publish a report in the second half of 2011 on progress in scaling up the health sector response to HIV/AIDS towards universal access, including HIV services for women and children. In order to collect data from countries, the three agencies have developed a joint Reporting Tool. The tool covers the health sector response to HIV/AIDS, with a module dedicated to interventions for women and children. This guidance document compiles descriptions for indicators for the 2011 round of Reporting Tool, which is used to collect data from countries to develop the annual global report Towards universal access: scaling up priority HIV/AIDS interventions in the health sector". It must also be considered for use to monitor the health sector response at the national level, in addition with other information, to review progress. Global Reporting: This guide is used to support and facilitate data collection using the "Joint Reporting Tool for Monitoring and Reporting on the Health Sector Response to HIV/AIDS". This data collection form, disseminated to all countries, is the main tool to enable annual global reporting on the health sector progress towards Universal Access to HIV prevention, care, and treatment through the annual publication Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. 3 National Monitoring: This guide can also be used for national monitoring of the health sector's response to HIV/AIDS. It can be adapted to the epidemic context of each country. For example, countries should select indicators that would support monitoring of their own nationally-set targets. They may also add or remove some of the indicators depending on the importance of intervention areas to their country epidemic. 1 United Nations General Assembly. Political Declaration on HIV/AIDS, New York, United Nations, HIV/AIDS. WHO's contribution to universal access to HIV/AIDS prevention, treatment and care: report by the Secretariat. Geneva, WHO, WHO, UNAIDS, UNICEF, "Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector. Progress report 2010" available at 4

5 Monitoring Health Sector Progress Towards Universal Access to HIV/AIDS Prevention, Care, and Treatment The UA health sector monitoring framework and corresponding reporting tool is organized around the following categories of key intervention areas: Testing and Counselling; Prevention in the Health Setting; Sexual Transmission and IDU; Care, HIV/TB, STI; ART; Health Systems; and Women and Children. For each area, indicators for the dimensions of availability, coverage, and impact, as well as basic programmatic information are suggested to monitor the scale-up of priority interventions. More and more importance is being placed on disaggregrating data by sex and by age groups. The latest global and country reported data and statistics are available through various platforms already, 4 and aligned with internationally recommended indicators (e.g. UNGASS, or other international M&E guides developed by WHO and partners). The indicators to be reported are encompassing the UNGASS ones related to the health sector, and include the additional key indicators useful to monitor the national and global response to HIV/AIDS in the health sector. Indicators Intervention Areas Availability Coverage Impact Testing and Health Sector Counselling Prevention in the Health Setting Sexual Transmission and IDU Physical Availability of Care, HIV/TB. STI interventions ART Health Systems Women and Children- PMTCT, paediatric care *Full definitions of availability, coverage, and impact can be found in the footnotes* 5 Proportion of Population Needing the Intervention Who Receive It Impact Related to the Key Intervention Area Increasing availability, coverage and impact of a key intervention alone can influence scale-up in other intervention areas, and the combined effect of scaling-up availability, coverage, and impact of all intervention areas together should demonstrate a synergized impact on the HIV epidemic. For example, increasing the availability and uptake of testing and counselling will increase the number of people who know their status, and this effect should be seen through increased uptake and coverage of PMTCT and ART subsequently. Proper infection control should reduce unnecessary transmission of HIV and TB, reducing incidence. The combined effect of reducing incidence and treating those in need will determine the impact on the HIV epidemic measured by HIV prevalence, incidence, and averted deaths. Programmatic Information Data on national policy and programmatic responses are also important to monitor a country s scale-up especially in new or evolving areas. A selection of policy and programmatic questions are included in the reporting tool, but are not discussed in this guide. 4 WHO, HIV/AIDS, "Data and statistics" available at UNAIDS Secr., "Country Factsheets" available at 5 Availability defined in terms of reach-ability (physical access), affordability (economic access) and acceptability (socio-cultural access) of services that meet a minimum standard of quality 5. To make services available, affordable and acceptable is an essential pre-condition for "universal access". Coverage defined as the proportion of the population who receive an intervention among those who need it. Coverage is influenced by supply (provision of services) and demand by people in need of services. Outcome/Impact defined in terms of behavioural change, reduced new infection rates or survival improvements; it is the result of coverage of services, modulated by the efficiency and effectiveness of the interventions and changes in other relevant factors. Impact goals have been set in the context of the MDGs and the UNGASS declaration on HIV/AIDS. While the impact goals reflect the ultimate purpose of interventions, impact indicators alone will not sufficiently monitor programs to inform the scaling up of access. Therefore, systematic monitoring of progress towards universal access needs to include availability and coverage as well. 5

6 Indicator Descriptions in this Guide The indicator descriptions follow this format: The indicator number is the number in the UA reporting tool Rationale What it measures Numerator Denominator How to Measure and Measurement Tools Disaggregation Strengths and weaknesses Additional considerations Data utilization Data Quality Control and Notes for the Reporting Tool Other References X. INDICATOR TITLE Why this indicator is important What the indicator measures Definition of the numerator Definition of the denominator (sources of information must be specified: for some indicators, estimates only are possible and/ or required) What is included in the numerator and denominator Method of measurement Tools used for measurement Recommended disaggregation. Even if not included for breakdown in the Reporting Tool, disaggregation is recommended to be collected for national monitoring and reporting as appropriate. Description of the strengths and weaknesses of the indicator Other points for countries to note How this indicator can be used and some implications Additional information on issues to consider when filling in the reporting tool. Includes elements of: Double Reporting: What to pay attention to in order to assess possible double reporting. National Representativeness: What to pay attention to in order to assess the national representativeness of the value reported. Denominator Issues: Issues to note about the denominator Triangulation Options: Other data sources that can be reviewed to assess the validity of the indicator value References related to the indicator, e.g.: UNGASS: UNGASS indicator requested for UNGASS 2008 reporting PMTCT: Indicator in the updated Monitoring and Evaluating the PMTCT of HIV A guide for national programmes (2010) HIV/TB: Indicators in the updated A guide to monitoring and evaluation for collaborative TB/HIV M&E activities (2009) IDU: Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users (2009) 6

7 Target Audiences This guide can be used as a reference for national program managers and UN staff completing the Annual Reporting Form for Global Monitoring and Reporting on the Health Sector Response Towards Universal Access; or for anyone working on monitoring and evaluation related to HIV, the health sector, or broader development goals, as a handbook of indicators for key HIV interventions in the health sector. Planning for Global Reporting The guide provide a comprehensive description of the definition of each of the indicators, including where possible, the numerators and denominators, how to measure and measure tools, disaggregation requirements, strength and limitations, as well as other additional considerations for collating and reporting as well as reporting and interpretation of the data. Data Collection and Validation Process at the Country Level In line with our commitment to the "3 ones", we strongly recommend that the country offices of WHO, UNICEF and the UNAIDS Secretariat jointly support national counterparts and partner agencies to collate and validate data and build consensus through a single collaborative consultation process. Such collaboration will enable greater completeness and homogeneity of data and allow more comprehensive global analysis. Country offices should work together to determine the most appropriate process and division of responsibilities for data collection, validation and reporting. As a first step, we propose that country offices of the three agencies organize a joint meeting with national authorities, identify focal points, and agree on a division of tasks to liaise with national partners to collect data for the different sections of the reporting tool. We recommend that a consensus meeting then be organized at country level to cross-validate data, which will then be relayed to regional offices and headquarters for global analysis. Data validation and assessment at the country level with partners and stakeholders, where people are most familiar with the data, is crucial; having a routine system to review and validate data is encouraged. Data Collection and Validation Process at Regional and Global level At the regional level, regional offices will liaise with country offices to answer any queries and provide other support as requested, and ask for any clarifications necessary. It would be ideal if WHO, UNICEF, and UNAIDS can discuss and agree on the logistical arrangements in the reporting process including: aligned messages to be sent from regional offices to country offices; the focal point(s) for data collection; data review and validation procedure and decisions; the focal point for managing and updating the database; and the process to share data. At the global level, agencies will work together to validate data with other data sources where possible and based on what we know of country monitoring systems, and ask for clarifications necessary. The responsibilities and processes and timeline need to be discussed with the common goal of jointly producing one set of data related to the HIV response in the health sector. This collaboration by the 3 agencies to collaborate on a joint reporting process should minimize the possibility of having many varying values for the same indicator among the agencies. Data Utilization at National, Regional and Global levels It is the hope that this process to monitor and report on the HIV response in the health sector also facilitates the review and analysis of data at the national level. Countries may use this opportunity to strengthen national capacity in monitoring and reporting. For example by supervision visits at collection sites, through data quality exercises, or carrying out a national workshop to build capacity around monitoring, collecting and 7

8 analysing data. 6 Data validation workshops in-country should generate discussions on areas where more data is desired or areas where a country s M&E systems is weak and needs attention; it is also a good opportunity to discuss among partners how to strengthen the monitoring and evaluation system to make it functional at the national level, as well as discuss the reporting process within the country. Countries may also review and analyze the final dataset to develop situational analyses of the health sector response to HIV in their country. At the regional level, data can also be stored, reviewed and analyzed to develop situational analyses of the health sector response to HIV in the region and discuss with countries on how M&E systems strengthening can be further supported. Data will also be presented in regional meetings. Globally, data collected through this process will be analyzed and presented in the next annual global report Towards universal access: scaling up priority HIV/AIDS interventions in the health sector as well as other regional and global reports. Where appropriate, some indicators will be aggregated or analyzed globally and regionally, whereas others will be used to describe country examples or as part of a country situational analysis. Technical Support and Contact for Questions WHO, UNICEF and UNAIDS are committed to support countries improve their strategic information system, including and not limited to the review of health sector M&E systems; data quality and validation; evaluating impact; surveillance; operational research; and training in various aspects of strategic information. Please do not hesitate to contact us at hivstrategicinfo@who.int for any questions or requests. Please send any comments and suggestions for improving this guidance document to: pervilhacc@who.int Acknowledgements We would like to especially thank staff from Government Ministries at all levels who collect, validate, and provide this information every year. We thank WHO, UNICEF, and UNAIDS staff who work at the country and regional levels to facilitate the process of data transfer and reporting. We appreciate the contribution of MACRO-DHS to provide us with the latest DHS (Demographic and Health Survey) results available. 6 ref. "Joint WHO-UNICEF- UNAIDS-PEPFAR Capacity-building Workshop: Strengthening Reporting and Monitoring in the Health Sector for the Africa Region, Johannesburg, S. Afr., Sept 2010", WHO, Final Report, Dec. 2010, available at: 8

9 II. INDICATOR DESCRIPTIONS List of indicators Page A Testing and counselling #A1 Number of health facilities that provide HIV testing and counselling services 12 #A2 Number of women and men aged 15 and older who received HIV Testing and Counselling (T&C) in the last 12 months and know their results 13 #A3 Percentage of women and men aged who received an HIV test in the last 12 months and who know their results 15 # A4 Percentage of most-at-risk populations (MARPs) who received an HIV test in the last 12 months and who know their results 16 B Prevention in health care settings #B1 Percentage of health care facilities where all therapeutic injections are given with new, disposable, single use injection equipment 17 #B2 Number of health facilities with post-exposure prophylaxis (PEP) services available on site 18 C Prevention of sexual transmission of HIV and prevention of transmission through injecting drug use #C1 Estimated Number of injecting drug users (IDUs) 20 #C2 Number of needle and syringe programme (NSP) sites 21 #C3 Number of people on opioid substitution therapy (OST) 22 #C4 Number of syringes/needles distributed by needle and syringe programmes (NSP) 23 #C5a Percentage of injecting drug users (IDUs) reporting the use of sterile injecting equipment the last time they injected 24 #C5b Percentage of injecting drug users (IDUs) reporting the use of a condom the last time they had sexual intercourse 25 #C5c Percentage of female and male sex workers (SWs) reporting the use of a condom with their #C5d most recent client 26 Percentage of men reporting the use of a condom the last time they had anal sex with a male partner 27 #C6abc Percentage of most-at-risk populations (IDUs-C6a, SWs-C6b, MSM-C6c) who are HIVinfected 28 D Care #D1 Percentage of adults and children enrolled in HIV care and eligible for co-trimoxazole (CTX) prophylaxis (according to national guidelines) currently receiving CTX prophylaxis 29 9

10 E HIV/TB #E1 Number of health-care facilities providing ART services for people living with HIV with demonstrable infection control practices that include TB control 30 #E2 Percentage of estimated HIV-positive incident TB cases that received treatment for TB and HIV 32 #E3 Percentage of adults and children newly enrolled in HIV care starting isoniazid preventive therapy (IPT) 34 #E4 Percentage of adults and children enrolled in HIV care who had TB status assessed and recorded during their last visit 36 F Sexually transmitted infections #F1 Percentage of women accessing antenatal care (ANC) services who were tested for syphilis at first ANC visit 38 #F2 Percentage of antenatal care attendees who were positive for syphilis 39 #F3 Percentage of antenatal care attendees positive for syphilis who received treatment 40 #F4 Percentage of sex workers (SWs) with active syphilis 41 #F5 Percentage of men who have sex with men with active syphilis 42 G Antiretroviral therapy #G1 Number of health facilities that offer antiretroviral therapy (ART) 43 #G2a Percentage of eligible adults and children currently receiving antiretroviral therapy (ART) 45 #G2b Number of eligible adults and children who newly initiated antiretroviral therapy (ART) during the reporting period (2010) 48 #G3a Percentage of adults and children with HIV still alive and known to be on antiretroviral therapy 12 months after initiating treatment among patients initiating antiretroviral therapy during 2009, 49 #G3b (b). 24 months after initiating treatment among patients initiating antiretroviral therapy during #G3c (c). 60 months after initiating treatment among patients initiating antiretroviral therapy during H Health systems #H1 Percentage of health facilities dispensing ARVs that experienced a stock-out of at least one required ARV in the last 12 months 51 #H2 Percentage of facilities providing ART using CD4 monitoring in line with national guidelines/policies, on site or through referral 53 I Women and children #I1 Number of pregnant women attending ANC at least once during the reporting period 55 #I2A Number of health facilities providing ANC services 56 #I2B. Number of health facilities providing ANC services that also provide HIV testing and counselling for pregnant women 57 # I2C. Number of health facilities providing ANC services that offer both HIV testing and antiretrovirals for the prevention of mother-to-child transmission on site 58 #12D Number of health facilities providing ANC services which also provide CD4 testing on site, or have a system for collecting and transporting blood samples for CD4 testing for HIV-infected pregnant women 60 10

11 #I3 Number of health facilities that offer paediatric antiretroviral therapy (ART) 61 #I4 Percentage of health facilities that provide virological testing services (e.g. PCR) for diagnosis of HIV in infants on site or from dried blood spots (DBS) 63 #I5 Percentage of pregnant women who were tested for HIV and received their results - during pregnancy, during labour and delivery, and during the post-partum period (<72 hours), including those with previously known HIV status 65 #I6 Percentage of pregnant women attending antenatal care (ANC) whose male partner was tested for HIV 68 # I7 Percentage of HIV-infected pregnant women assessed for ART eligibility through either clinical staging or CD4 testing 69 #I8a Percentage of HIV-infected pregnant women who received antiretroviral drugs to reduce the risk of mother-to-child transmission (MTCT) 71 #I9 Percentage of infants born to HIV-infected women receiving ARV for prophylaxis for the prevention of mother-to-child transmission (PMTCT) 74 #I10 Percentage of infants born to HIV-infected women started on co-trimoxazole (CTX) prophylaxis within two months of birth 76 #I11 Percentage of infants born to HIV-infected women receiving a virological test for HIV within 2 months of birth 78 #I12 Distribution of feeding practices (exclusive breastfeeding, replacement feeding, mixed feeding/other) for infants born to HIV-infected women at DPT3 visit 80 #I13 Percentage of HIV-infected children aged 0 14 years who are currently receiving ART 83 Note on General Country Information A frequently asked question is what we are defining as a health facility. For the purposes of this reporting process, we are excluding health facilities that provide specialized care which would never provide any HIV services (e.g. an eye clinic). If you have difficulties trying to define what is counted as a health facility for this exercise, please provide any comments you have in the Comment box or us. 11

12 A. Testing and Counselling A1 Number of health facilities that provide HIV testing and counselling services Rationale Knowledge of HIV status is critical to expand access to HIV treatment, care and support, and prevention. Availability of testing and counselling (TC) services is the pre-requisite for scaling up TC coverage so that more people know their HIV status, which can be expanded through voluntary counselling and testing (VCT) and provider initiated testing and counselling (PITC) models. What it measures Availability of TC services in health facilities. Numerator Number of health facilities that provide HIV testing and counselling services How to Measure and Numerator: Two possible sources of information, either: Measurement Tools 1. Central register of all T&C sites; 2. Central test kit procurement records for the number of facilities requesting kits. If both are available, then provide the information from both Please include data on all facilities providing services in the country, whether private, public, NGO, or other. Information on availability of certain services are usually summarized at the national or sub-national level. National TC programs should have a record of facilities that provide TC services. Effort should be made to include facilities providing services in the private and NGO sectors, especially where they are a significant provider of TC services. A recent health facility census can also provide this information as well as much more in-depth information on availability of services. All sites where TC is offered should be counted. Thus sites that offer testing and refer out samples to a lab elsewhere, get test results back, and relay results to the client, are included. All sites will be included in the numerator. Disaggregation If possible, by: 1. Type of health facility (e.g., government health facilities, NGOs, CBOs, mission hospitals, and private health facilities) 2. Type of services offered (e.g., TB clinic, STI clinic, etc) Strengths and weaknesses Data utilization Additional considerations Data Quality Control and Notes for the Reporting Tool This indicator is intended to monitor availability of TC services as countries continue to expand TC. It does not intend to capture quality of TC services provided. To look at progress in the number of health facilities which provide testing and counselling. Analyzing the data geographically and by type of health facilities, and triangulating it with population data, can provide insight into where there is a need to increase availability of TC services. It is recommended that every health facility has the capacity to offer testing and counselling in generalized epidemics 7. In low-level and concentrated epidemics, the goal may not be to have TC services available in every facility National Representativeness: Effort should be made to include all public, private and NGO-run health facilities The numerator matters in the comparison of trends in service availability over time. 7 Guidance of provider-initiated testing and counselling in health facilities, WHO/UNAIDS,

13 A2 Number of women and men aged 15 and older who received HIV Testing and Counselling (T&C) in the last 12 months and know their results Rationale Knowledge of HIV status is critical for access to HIV treatment, care and support, and prevention. There are different models for delivery of the testing and counselling services such as VCT and PITC. The essential elements of TC, however, are that those who are tested are appropriately counselled and know the results. What it measures Number of people aged 15 and older who received HIV T&C through any method or setting (excluding mandatory T&C) in the past 12 months and know their results (Note: Although not required for the purposes of this indicator the denominator may be gauged by using the general population as the denominator in generalized epidemics, and the most at-risk populations (MARPs) and other groups for low-level and concentrated epidemics) How to Measure and Measurement Tools Disaggregation Strengths and weaknesses Programmatic progress for testing and counselling.tracking the number of individuals who are tested and counselled and know their status provides an indication of uptake of T&C in the country. Program service statistics compiled from routine reports of the number of people tested and know the results from all service points, including VCT sites, clinics, hospitals, and NGO outreach points, etc., (excluding mandatory T&C) which are often aggregated at the district levels and subsequently at the national level. This indicator is not measured through population-based surveys (see next indicator). Sex: male, female Serostatus: HIV positive, HIV negative If possible : Age: 15-19, 20-24, 25+ Test: New test, Repeated test This indicator permits comparison of trends of the quantity of TC services delivered and the strength of scaling up TC services over time. This indicator will provide information on the number of times T&C occurred, and not necessarily the number of people who received T&C services unless countries have a mechanism to avoid double-counting of repeat testers. Data utilization Additional considerations for countries The indicator does not provide information on whether those who were tested were adequately referred to and receiving follow-up services to benefit from knowing their status. To know the number of tests conducted in the country, can compare with previous years to look at trends while considering the percentage of the population that may have already been tested recently. It can be useful to explore any patterns in testing, for example whether there were more tests conducted in a particular season or month when there were campaigns, or whether many more people are being tested in particular health facilities or in the communities. In some countries, a significant proportion of testing and counselling services are provided by community-based organizations or unregistered organizations, which often may not be included as part of national statistics. These organizations should be encouraged to register with national authorities so all data on testing 13

14 Data Quality Control and Notes for Reporting and counselling could be reflected in the national statistics. Double Reporting: Countries will need to estimate the extent of repeat testers in order to determine the true number of persons tested over the period. If countries have a mechanism to make such a meaningful assessment (e.g. record of the number of repeat testers), please do so and note how this was done. Otherwise, please report the total number of tests reported. National Representativeness: Try to ensure information from nongovernmental and private facilities is also available at the central level. If significant information is missing, note it down in the comments section. Denominator Issues: Although not required for the purposes of this indictor the validity of the numerator may be gauged by comparing the general population as the denominator in generalized epidemics, and the size of the most at-risk populations (MARPs) and other groups for low-level and concentrated epidemics. Triangulation Options: In generalized epidemics, data from population-based surveys asking for the number (and calculating the percentage) of people tested can be compared to with this indicator value to assess and discuss any major differences. Test Results: In the comments section, please report data by serostatus (number HIV+, HIV-) if available. 14

15 A3 Percentage of women and men aged who received an HIV test in the last 12 months and who know their results Rationale In order to protect themselves and to prevent infecting others, it is important for individuals to know their HIV status. Knowledge of one's status is also a critical factor in the decision to seek treatment. What it measures Estimate of the percentage of the population who were tested and counselled, and received results in the last 12 months Numerator Number of respondents aged who have been tested for HIV during the last 12 months and who know their results Denominator Number of all respondents aged How to Measure and Measurement Tools Population-based surveys (Demographic Health Survey, AIDS Indicator Survey, Multiple Indicator Cluster Survey or other representative survey) Disaggregation Strengths and weaknesses Additional considerations for countries Data utilization Data Quality Control and Note for Reporting Tool Respondents are asked: 1. I don't want to know the results, but have you been tested for HIV in the last 12 months? 2. If yes: I don't want to know the results, but did you get the results of that test? The denominator includes respondents who have never heard of HIV or AIDS. Sex: male, female Age: 15-19, 20-24, 25 plus In some settings, HIV prevalence is higher in populations that are mobile or difficult to reach who are often missed in national population-based surveys. Population-based surveys are usually conducted every few years and will not be able to provide annual progress especially in settings where scale-up of testing and counselling services is happening quickly. For further information on Demographic and Health Surveys, please consult the following website: To get an idea of the proportion of the population who had an HIV test in a given year. Countries conducting population-based surveys with HIV testing can review results based on serostatus. If AIS survey is done annually, annual trends can be reviewed. If data is only available every 3-5 years and if there has been scale-up of testing and counselling in recent years, review this population survey-based data with annual program statistics on the volume of testing to interpret the data. If a DHS or other population-based surveys have recently been conducted in your country and the results are unavailable now but may be available later this year, please let us know. 15

16 A4 Percentage of most-at-risk populations (MARPs) who received an HIV test in the last 12 months and who know their results Rationale In order to protect themselves and to prevent infecting others, it is important for most-at-risk populations to know their HIV status. Knowledge of one's status is also a critical factor in the decision to seek treatment. What it measures Coverage of testing and counselling among most-at-risk populations (MARPs). This indicator should be calculated separately for each population that is considered most-at-risk in a given country: sex workers, injecting drug users and men who have sex with men. Numerator Number of most-at-risk population respondents who have been tested for HIV during the last 12 months and who know the results. Denominator Number of most-at-risk population included in the sample. How to Measure and Behavioural surveillance or other special surveys, sampled for specific most-atrisk population groups can be used. Measurement Tools Respondents can be asked the following questions: 1. I don't want to know the results, but have you been tested for HIV in the last 12 months? If yes: 2.I don't want to know the results, but did you receive the results of that test? Disaggregation Strengths and weaknesses Additional considerations for countries Data utilization Data Quality Control and Notes for the Reporting Tool Sex: male, female Age: less than 25, 25+ MARPs: SWs, IDUs, MSM This indicator is useful when there is a functional behaviour surveillance system which regularly collects representative samples of data from MARPs. Sampling for a nationally-representative sample of MARPS is often not feasible and may be prone to selection biases. Even in countries with generalized epidemics, there may be groups of MARPS with concentrated sub-epidemics; these countries should also calculate and report for this indicator. Depending on the particular context, civil society organizations may be better placed to conduct data collection and analysis for MARPs and to feed back the results to the relevant groups. Access to survey respondents as well as the data collected from them must remain confidential. To get an idea of the proportion of sex workers, IDUs, and MSMs who have been tested in a given year. Data needs to be analyzed, interpreted and explored based on the sample of people interviewed and their particular context. Also consider groups that may not have been sampled (e.g. SWs, IDUs, and MSMs in other geographical areas or that may have different characteristics from those reached in the survey) and think about what proportion of them may be receiving HIV tests and how the situation can be improved. National Representativeness: It is always difficult to get information about the number of individuals in these groups (denominators) and hence it is probably impossible to obtain an accurately representative sample of MARPs in countries where the population is highly stigmatized and marginalized. Double counting: Double counting of individuals who receive multiple tests in a 12 month period is very likely, especially if they test in multiple sites. Please provide additional information on methods, analysis, and how the estimate was derived for the % MARPS tested in your country, to enable us to interpret the data. Some issues to consider are: regions of the country covered; sample size; data extrapolation assumptions; any significant data missing; uncertainty ranges where available. 16

17 B Prevention in health care settings B1 Percentage of health care facilities where all therapeutic injections are given with new, disposable, single use injection equipment Rationale Unsafe injections may transmit HIV What it measures Progress towards ending unsafe injections and infections caused by unsafe injections Numerator Number of health care facilities where all therapeutic injections are given with new, disposable, single use injection equipment Denominator How to Measure and Measurement Tools Disaggregation Strengths and weaknesses Additional considerations for countries Data utilization Data Quality Control and Notes for the Reporting Tool Other References Number of health facilities assessed for the survey How to measure: Determination of the indicator requires an assessment of health care facilities. Measurement tool: WHO Injection Safety Assessment Tool/Supervision By type of health care facility Strengths: When performed according to protocol, the injection safety assessment provides a statistically valid means of assessing injection safety in a geographic area. A full survey also provides considerable other information of use to a programme, e.g., an assessment of waste disposal, needle stick injuries among staff. A survey assesses potential modes of transmission other than injections, e.g., lancet use, phlebotomy, intravenous injections, intravenous cannula catheter use or multi-dose vial use. The assessment identifies multiple potential areas for improvement. Weaknesses: Formal surveys of injection safety are infrequently performed annually and, thus, measuring annual progress toward universal injection safety is seldom performed. "Injections" refers to skin-piercing procedures for immunization, diagnostic or therapeutic reasons and includes intramuscular, subcutaneous, intradermal, and intravenous injections, phlebotomies and lancet procedures. All these routes are included in the assessment tool. It does not, however, include indwelling intravenous devices for reasons other than therapeutic purposes. How frequently to perform a survey is a question that balances need and resources. Once a full assessment has been performed, progress could be measured via partial assessments or even via supervisory visits and checklists. If there is suspicion of considerable, or focal, unsafe injection practice, a country should conduct a survey to confirm if there is a problem and the magnitude and type of problem. Remedial action can then be taken, with a follow-up survey assessing the results of that action. Where value is low, assess reasons behind low coverage. Consider whether sample is representative, and whether the facilities assessed as not meeting the requirement have a common problem and propose solutions for improvement. Please provide confidence intervals in the Comments section if available. WHO Injection Safety Programme Indicator 17

18 B2 Number of health facilities with post-exposure prophylaxis (PEP) services available on site Rationale Health care workers and others who are exposed to HIV transmission through sharp injuries or sexual exposure should be protected. What it measures Number of health facilities offering PEP services on site for those who are at risk of HIV infection through occupational and/or non-occupational exposure to HIV. This indicator measures the availability of post-exposure prophylaxis (PEP) in health facilities. PEP reduces the probability of HIV infection after exposure to potentially HIVinfected blood or body fluids. For maximum effectiveness, PEP should be provided within hours after exposure. PEP may be provided following occupational exposure (for example, in healthcare facilities) or non-occupational exposure (such as after sexual exposure). Within the health sector, PEP should be provided as part of a comprehensive standard precautions package that reduces staff and patient exposure to infectious hazards in health care settings. PEP for non-occupational exposure should be considered for sexual assault survivors, particularly in high HIV prevalence countries. How to Measure and Measurement Tools The number is calculated by summing of the number of facilities offering PEP services. Information on the availability of specific services is usually kept at the national or sub-national level. National AIDS Programmes should have a record of all health facilities that offer PEP services. A health facility census or survey can also provide this information, along with more in-depth information on available services, provided the information is collected from a representative sample of health facilities in the country. One potential limitation to facility surveys or censuses is that they are usually only conducted once every few years. Countries should regularly update their programme records on the availability of PEP services in health facilities, and supplement these data with those obtained through a health facility survey or census every few years. "Offering" means the initiation of services, with at least risk evaluation, counselling, and provision of a starting package of ARVs for post-exposure prophylaxis. Disaggregation Strengths and weaknesses Measurement tools: Programme records; health facility survey/census are used. For health facility surveys or censuses, tools such as the Service Provision Assessment (SPA) or the Service Availability Mapping (SAM) can be used. Exposure: occupational, non-occupational Sector: public, private Strengths This indicator provides information about the availability of post-exposure prophylaxis (PEP) in health facilities, Weaknesses Does not capture the type and quality of PEP services provided, nor the impact of PEP. The full range of PEP services includes first aid, counselling, HIV testing prior and after providing PEP, provision of ARVs, and patient follow-up and support. Simple monitoring of PEP availability through programme records does not 18

19 Additional considerations for countries Data utilization Data Quality Control and Notes for the Reporting Tool ensure that all PEP-related services are adequately provided to those who need them. Even if monitoring included provision of PEP to those who need them, for PEP to be fully effective, it must be taken as directed and this indicator does not measure compliance with PEP that is administered. Countries may wish to monitor number of persons provided PEP and associated services, and adherence to medication. Setting up reporting forms/registers is recommended. Please refer to the guidelines at ( for more information. Use it as an opportunity to review other related data and discuss implementation of PEP. In case your data only reflects a proportion of districts or facilities in the country, please provide any comments that will help us interpret whether the data reported is nationally representative. 19

20 C Prevention of sexual transmission of HIV and prevention of transmission through injecting drug use C1 Estimated Number of injecting drug users (IDUs) Rationale Overall estimated number of people who inject drugs (PWID) What it Population size estimates of IDUs measures Data To be used as denominator for other IDU indicators. NOTE: The denominator for OST is the utilization estimated number of people dependent on opioids; but for countries which do not have those detailed data, please use the number of IDUs as a proxy for this. Other References - WHO/UNODC/UNAIDS Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users ( ) - Database of the Reference Group to the UN on HIV and injecting drug use, available through and in particular 2007 estimated number of people who inject drugs at: estimate+projection+tables.pdf 20

21 C2 Number of needle and syringe programme (NSP) sites Rationale Needle and syringe distribution programmes are among the most effective interventions for preventing transmission of HIV among people who inject drugs. Sufficient access to clean needles for the injecting population is measured with this indicator. What it measures Number of NSP sites (including pharmacy sites providing at no cost needles and syringes). Availability of sites that can provide clean needles and syringes to injection drug users. How to Measure and National program data Measurement Tools Disaggregation Administrative unit Urban, rural Strengths and Many NSPs are not "official" and therefore not counted among national program weaknesses data Additional Needle and syringe programmes (NSPs) are any programs that include access to considerations clean equipment and safe disposal through fixed or mobile exchange programmes and/or through pharmacies where equipment is available free of charge. In many countries pharmacy sales of injecting equipment are an important and sometimes the most significant source of clean injecting equipment accessible to drug users. However, pharmacies that sell needles and syringes are typically not counted in a retrievable data base as part of a public health or harm reduction program. If they are available, they should be counted and highlighted, if possible. Pharmacies that distribute needles and syringes free of cost typically do maintain records of needles distributed as part of the program and should be included. Please refer to the WHO/UNODC/UNAIDS Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users ( ) for a proposed complete set of globally agreed indicators for IDUs. Data utilization Get an idea of the availability of NSP sites, and trends over time. Also try to analyze data based on geographical location of the NSP sites and geographical distribution and population density of IDUs in the country. Try to assess whether sufficient NSPs are available for the number and distribution of IDUs in the country. Data Quality Control and Notes for the Reporting Tool National Representativeness: Many NSP sites are not "official" and may be run by NGOs, which the government may not have information on. Please try to assess the national representativeness of the number you are reporting. Other References WHO/UNODC/UNAIDS Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users ( ) 21

22 C3 Number of people on opioid substitution therapy (OST) Rationale Opioid substitution therapy represents a commitment to treat opioid dependence and to reduce the frequency of injecting, preferably to zero. OST is the most effective public health tool for reducing injecting drug use among opioid injectors. OST also provides a crucial support for the treatment of other health conditions, including HIV, TB and viral hepatitis. What it measures National commitment and progress towards the treatment of opioid dependence and reduction of HIV transmission probabilities among people who inject drugs. How to Measure and Program data Measurement Tools Disaggregation Administrative units; Urban, rural Strengths and Number of people on OST should be readily available and valid since they are weaknesses typically licensed by the relevant authorities. Additional Please refer to the WHO/UNODC/UNAIDS Technical Guide for countries to set considerations targets for universal access to HIV prevention, treatment and care for injecting drug users ( ) for a proposed complete set of globally agreed indicators for IDUs. Data utilization Other References Try to assess whether sufficient OSTs are available for the number and distribution of people who are dependent on opiods in the country. WHO/UNODC/UNAIDS Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users ( ) 22

23 C4 Number of syringes/needles distributed by needle and syringe programmes (NSP) Rationale Prevention of HIV transmission among IDUs requires sufficient clean needles and syringes to prevent re-use and sharing of such equipment. Program coverage therefore must include sufficient commodities to protect every injection by people who inject drugs. What it measures Number of syringes distributed by all NSPs in the last 12 months (including pharmacy sites providing no cost needles and syringes). Proxy for the coverage of injection acts by NSP How to Measure and Commodity procurement data or syringe dispensary data if available from NSPs. Measurement Tools (See Additional Considerations for explanation of NSPs) Disaggregation Strengths and weaknesses Additional considerations Data utilization Data Quality Control and Notes for the Reporting Tool Other References Urban/rural This covers syringes distributed through all NSPs.. Syringes obtained through pharmacy purchase and/or through secondary exchange (i.e. distribution among peers) are not captured by this indicator. Needle and syringe programmes (NSPs) are any programs that include access to clean equipment and safe disposal through fixed or mobile exchange programmes and/or through pharmacies where equipment is available free of charge. In many countries pharmacy sales of injecting equipment are an important and sometimes the most significant source of clean injecting equipment accessible to drug users. However, pharmacy sales are typically not collected in a retrievable data base as part of a public health or harm reduction program. If these data are available, they can be collected. Pharmacies that distribute needles and syringes free of cost typically do maintain records of needles distributed as part of the program and should be included. Please refer to the WHO/UNODC/UNAIDS Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users ( ) for a complete set of globally agreed indicators for IDUs as well as indicative targets for this indicator. Gives overall indication of availability of needles and syringes distributed by NSP programs. Try to explore based on a disaggregated situational analyses whether there are any inequities in the distribution of syringes and where this indicator value may be falling under the national value. Double Reporting: Efforts should be made to assure that double counting of syringes distributed does not occur. In particular, an NGO with multiple distribution sites but central purchasing may report from some sites and from the central purchasing mechanism. National Representativeness: If data are more readily available from some parts of a country than others, (not attributable to distribution of sites, though), representativeness should be questioned. If you have disaggregated data by administrative unit (e.g. by districts, oblasts), please include them in the comments section. UNODC and UN Reference Group on Drugs & Drug Injections Indicator 23