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Surveillance of acquired immunodeficiency syndrome in Africa: an analysis of evaluations of the World Health Organization and other clinical definitions.
EPIDEMIOLOGIC REVIEWS. 1994; 16(2):403-17.In order to improve public health efforts to combat the HIV pandemic, a system for surveillance of HIV and AIDS is needed. Definitions used for case reporting are at the heart of such a system. In many parts of Africa, however, facilities for diagnosing HIV infection and its subsequent complications are unavailable, and the definition developed by the US Centers for Diseases Control and Prevention (CDC) for use in developed countries is often impractical in Africa. The World Health Organization (WHO) in early 1985 therefore proposed using a provisional case definition of AIDS based principally upon clinical criteria. Developing a clinical definition of AIDS in Africa, however, is also complicated. The nonspecific nature of many of the signs and symptoms of HIV infection as well as the clinical redundancy between HIV and other epidemic health problems make definitive identification of any single disease problematic. Evaluation of the surveillance definition of AIDS in Africa is complicated by the lack of an accepted standard for comparison. Most studies in the field have used HIV serology as the standard, while others have employed the CDC definition for AIDS, giving the evaluations a certain relativity. This paper reviews available information on the WHO definition and other clinical definitions for AIDS in Africa in order to analyze their various field evaluations and explore the use of such definitions in the African context. Sections discuss surveillance clinical case definitions for African AIDS in adult and pediatric populations, clinical case definitions of African AIDS in adult and pediatric populations, sensitivity and specificity, the WHO clinical case definition for HIV epidemiologic survey, clinical definitions for AIDS in clinical practice, and working toward the improvement of the clinical definition of AIDS.
JOURNAL OF COMMUNICABLE DISEASES. 1994 Dec; 26(4):231-2.The World Health Organization (WHO) criteria for HIV clinical disease were tested among individuals with high-risk behavior in northern India. A questionnaire, based upon history and physical examination alone, standardized by the WHO to include both major and minor signs necessary for the clinical diagnosis of AIDS in adults was applied to 165 consecutive patients attending the STD clinic of Dr. R.M.L. Hospital, New Delhi. All patients were screened for the presence of STDs by the dermatologist in charge of the clinic, with patients fulfilling two major and at least two minor WHO criteria eventually classified as having clinical AIDS based upon the WHO case definition. Each of those patients was subjected to serological confirmation of the clinical suspicion using ELISA and Western blot commercial tests. Of the 165 patients screened, a definite diagnosis of STD was possible in 85. These patients were 20-45 years old (mean age, 30.59 years). All were male and chancroid was the most common STD in the cohort. Of the 85, only one satisfied the WHO clinical criteria for AIDS. Serological investigations, ELISA, and Western blot confirmed the subject's HIV-seropositive status. These results indicate that in northern India, clinical HIV disease remains rare even among individuals with high-risk behavior. The low prevalence of clinical HIV disease in that part of the country makes it difficult to assess the specificity and sensitivity of the WHO clinical criteria for AIDS.
Impact of the 1994 expanded World Health Organization AIDS case definition on AIDS surveillance in university hospitals and tuberculosis centers in Cote d'Ivoire.
AIDS. 1997 Dec; 11(15):1867-72.To assess the impact of the 1994 expanded World Health Organization (WHO) AIDS case definition upon AIDS surveillance in Cote d'Ivoire, passive AIDS case surveillance was conducted from March 1994 through December 1996 at the 3 university hospitals in Abidjan, while active AIDS case surveillance was conducted at the 8 large tuberculosis (TB) centers throughout Cote d'Ivoire. Standardized questionnaires were administered and blood samples for HIV testing were collected from patients evaluated. 3658 of the 8648 hospital patients met the clinical and/or expanded case definition: 744 HIV-seropositive individuals met only the expanded definition, 44 HIV-seropositive individuals met only the clinical definition, 2334 HIV-seropositive individuals met both definitions, and 536 HIV-seronegative persons met only the clinical definition. Of 18,661 TB center patients, 9664 met the clinical and/or expanded case definition: 5685 HIV-seropositive individuals met only the expanded definition, none of the HIV-seropositive individuals met only the clinical definition, 2625 HIV-seropositive individuals met both definitions, and 1354 HIV-seronegative persons met only the clinical definition. The use of the 1994 expanded definition for surveillance purposes should be encouraged in areas of the developing world where HIV serologic testing is available.
Meeting report on Fourth Regional Workshop on HIV / STD Surveillance, Cairo, Egypt, 7-10 October 1996.
Alexandria, Egypt, WHO, Regional Office for the Eastern Mediterranean, 1997. , 28 p. (WHO/EM/STD/2/E/L)The Eastern Mediterranean Regional Office of the World Health Organization is working to develop and strengthen surveillance for HIV, AIDS, and sexually transmitted diseases (STDs). Progress in the implementation of such strategies was discussed at the Fourth Regional Workshop on HIV/STD Surveillance held in Cairo, Egypt, in October 1996. The main objectives of HIV surveillance are 1) to monitor trends in HIV infection over time and place, and 2) provide information for program planning, advocacy, and program implementation. By the end of June 1996, a cumulative total of 3979 AIDS cases had been reported by 21 Member States in the region; however, the actual number is considered to be well over 12,000 and an estimated 220,000 persons are HIV-infected. HIV surveillance has focused primarily on STD patients. Obstacles to this approach include low attendance of STD patients (especially women) at public sector clinics, the unacceptability of unlinked anonymous testing in many countries, and insufficient coordination between sentinel sites and testing laboratories. Options for improving HIV surveillance include orientation of policy-makers on the importance of using unlinked anonymous testing to reduce participation bias, involvement of private doctors and nongovernmental organizations in surveillance of high-risk groups, introduction of tests for syphilis and hepatitis B in sentinel sites before surveillance begins, proper selection of sentinel sites to ensure adequate sample size, and preparation of an operations manual for staff at surveillance sites. The AIDS case definition needs to be reviewed and revised to suit the prevailing situation in the region. For STD surveillance, reports should be obtained from both private and public health facilities, with an etiology-based rather than syndromic approach to diagnosis.
Scaling up antiretroviral therapy in resource-limited settings: treatment guidelines for a public health approach. Rev. ed.
Geneva, Switzerland, WHO, 2003. 67 p.Currently, fewer than 5% of people in developing countries who need ART can access the medicines in question. WHO believes that at least 3 million people needing care should be able to get the medicines by 2005. This represents almost a tenfold increase. These treatment guidelines are intended to support and facilitate the proper management and scale-up of ART in the years to come by proposing a public health approach to achieve the goals. The key tenets of this approach are as follows. 1) Scaling-up of antiretroviral treatment programmes with a view to universal access, i.e. all persons requiring treatment as indicated by medical criteria should have access to it. 2) Standardization and simplification of ARV regimens so as to support the efficient implementation of treatment programmes in resource-limited settings. 3) Ensuring that ARV treatment programmes are based on scientific evidence in order to avoid the use of substandard protocols that compromise the outcomes of individual patients and create a potential for the emergence of drug-resistant virus. However, it is also important to consider the realities with respect to the availability of human resources, health system infrastructures and socioeconomic contexts so that clear and realistic recommendations can be made. (excerpt)
Development in Practice. 2004 Jun; 14(4):569-573.Monitoring and evaluation (M&E) are needed by all development interventions in order to document their output and outcomes. Once a set of goals has been established in response to a development ‘problem’, a corresponding set of indicators (i.e. variables or information) will also be identified in order to review progress towards those goals. In Africa, the so-called ‘expert’ evaluators—those who see M&E as their professional calling—have dominated the process of selecting social indicators. Unfortunately, this domination has given rise to sporadic and unreliable social data for M&E purposes facing every agency involved in development work in Africa. Zimbabwe is no exception. This Practical Note tells the story of UNICEF Zimbabwe’s search for relevant and reliable indicators based on solid data. The guiding philosophy in this effort is the belief that local communities themselves are among the many agencies involved in implementing development programmes—in the sense that they always seek ways of tackling whatever problems they face. These communities must therefore be active participants in the process of selecting indicators. The paper will first discuss the difficulty in establishing relevant data and indicators in the context of Zimbabwe, a task which is now an urgent priority given the dual problems of HIV/ AIDS and a declining economy. It is generally believed that these two problems have been responsible for the reversal of social gains made immediately after independence—hence the need to know exactly what is going on. The paper will then highlight recent attempts by UNICEF Zimbabwe—together with its partners—to establish good and reliable information sources so that not only can it monitor and evaluate the various impacts of its programmes but also the social environment of children. In part, the pressure for community-generated indicators has also been driven by the shift in UNICEF’s approach to its work—an approach underpinned by human rights principles. The final part of the paper discusses the challenges that UNICEF and its partners have faced and continue to struggle with. It draws some lessons learned and points to what more could be done to improve the qualities of social indicators. (excerpt)
IAEN: Current Issues in the Economics of HIV / AIDS. Prospects for support and development of monitoring and evaluation (M&E) of HIV / AIDS assistance programs, Thursday, April 24, 2003. Transcript.
[Palo Alto, California], Henry J. Kaiser Family Foundation, 2003. 50 p.Each of us who works in this field and who visits countries where HIV/AIDS is devastating society has their own tragic memories of people that we have met, of communities that we have visited, of parents, dying parents of children affected by HIV/AIDS, so I can't think of anything more important than this discussion on effective strategies for resource mobilization and resource allocation. This is and area that we are giving much greater attention at USAIDS as we have access to greater resources. We are now doing a specific strategic plan for each country, and of course those plans very much involve our relationship with our primary partner, the host country government (Unintelligible) in UNAIDS and we are constantly asking ourselves, what impact, what choices because we all know there are more good choices in which to invest HIV/AIDS and your money and so you really have to focus on what is the impact on human beings. Will you prevent an infection? Will you provide desperately needed care or treatment or will you help a family who sold all of its lands to those whose last resources. I guess two memories that keep me up at night are sitting with women in Uganda, part of that wonderful Ugandan women's group working against AIDS, who are making scrapbooks for their children that say, this is who your parents, as they are dying, this is who your father was, this is who your mother is. (excerpt)
WHO approach to track HIV drug resistance emergence and transmission in countries scaling up HIV treatment [letter]
AIDS. 2005; 19(12):1329-1330.Treatment access programmes are currently expanding in resource-limited settings. The potential barriers to long-term success (such as intermittent drug supply, drug stock-outs, poor patient monitoring, incorrect prescribing practices and low adherence) as well as the need to begin programmes quickly to treat millions of individuals, have raised fears that the aggressive plan to roll out antiretroviral therapy (ART), particularly in Africa, may generate an epidemic of drug-resistant strains of HIV. (excerpt)
Getting in line: Coordinating responses for children affected by HIV and AIDS in sub-Saharan Africa.
Vulnerable Children and Youth Studies. 2010 Jun; 5(Suppl 1):92-100.Only one in every eight households containing orphans and vulnerable children (OVC) in African countries received any support from an external source (UNICEF, 2008). This is a reflection of how governments, both rich and poor, have ignored obligations ratified in conventions to ensure the social protection of vulnerable children (United Nations, 1989). Consequently, a disproportionate proportion of the financial burden of care of vulnerable children is borne by affected families and communities. It is deplorable that vulnerable children are forced to rely on the charity of income poor relatives and community members (Wilkinson-Maposa et al., 2005; Foster, 2005b). This situation is likely to continue until governments adequately assume their responsibilities. In countries such as Botswana, governments have responded to the crisis of children and AIDS and consequently most households containing vulnerable children now receive external support (UNAIDS et al., 2006). The movement to establish national social protection schemes for vulnerable households is gaining momentum. If cash transfers become established nationally, they may alleviate suffering on a wide scale (JLICA, 2009). In that case, community groups and non-governmental organizations (NGOs) that are currently responsible for implementing responses to support children affected by HIV and AIDS will still be needed to administer psychosocial and other services that are complementary to those provided by these schemes. It is vital that governments develop a central role in coordinating civil society responses and ensure that resources for vulnerable children are used more effectively. But most African governments have limited capacity to coordinate responses and have only recently engaged in this area that involves a few well-resourced international organisations, many local NGOs and innumerable community initiatives. This article reviews the responses of different sectors responding to the impacts of HIV/AIDS on children, and discusses how these may be better funded, coordinated and monitored, utilizing the findings from a study of civil society OVC initiatives and evolving national responses.
Paris, France, United Nations Educational, Scientific and Cultural Organization [UNESCO], 2012. 158 p.The education sector has a significant role to play in the response to HIV and AIDS. The sector can help to prevent the spread of HIV through education, and, in countries that are highly affected by HIV, by taking steps to protect itself from the effects of the epidemic. It can also make a significant contribution by supporting health improvement more generally and by helping to improve the sexual and reproductive health of young people in particular.This framework is designed to help those working in the education sector at a national level to understand the need for a robust response to HIV and AIDS in order to achieve Education for All (EFA) and the education-related Millennium Development Goals (MDGs). The document also highlights the education sector’s role in contributing to universal access to HIV and AIDS prevention, treatment, care and support.