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Scale-up of human immunodeficiency virus (HIV) testing and antiretroviral therapy (ART) for people living with HIV has been increasing in sub-Saharan Africa. As a result, areas with high HIV prevalence are finding a declining proportion of people testing positive in their national testing programmes. In eastern and southern Africa, where there are settings with adult HIV prevalence of 12% and above, the positivity from national HIV testing services has dropped to below 5%. Identifying those in need of ART is therefore becoming more costly for national HIV programmes. Annual target-setting assumes that national testing positivity rates approximate that of population prevalence. This assumption has generated an increased focus on testing approaches which achieve higher rates of HIV positivity. This trend is a departure from the provider-initiated testing and counselling strategy used early in the global HIV response. We discuss a new indicator, treatment-adjusted prevalence, that countries can use as a practical benchmark for estimating the expected adult positivity in a testing programme when accounting for both national HIV prevalence and ART coverage. The indicator is calculated by removing those people receiving ART from the numerator and denominator of HIV prevalence. Treatment-adjusted prevalence can be readily estimated from existing programme data and population estimates, and in 2019, was added to the World Health Organization guidelines for HIV testing and strategic information. Using country examples from Kenya, Malawi, South Sudan and Zimbabwe we illustrate how to apply this indicator and we discuss the potential public health implications of its use from the national to facility level.Le dépistage du virus de l'immunodéficience humaine (VIH) et le traitement antirétroviral (TAR) pour les personnes vivant avec le VIH ont connu un véritable essor en Afrique subsaharienne. Par conséquent, les régions touchées par une forte prévalence du VIH détectent un pourcentage moins élevé de personnes testées positives dans leurs programmes de dépistage nationaux. En Afrique orientale et australe, là où certains endroits affichent une prévalence du VIH chez l'adulte égale ou supérieure à 12%, le taux de positivité des services de dépistage nationaux est passé sous la barre des 5%. Identifier les personnes nécessitant un TAR devient donc plus coûteux pour les programmes nationaux consacrés au VIH. Pour définir les objectifs annuels, on part du principe que les taux de positivité nationaux se rapprochent du taux de prévalence au sein de la population. Cette supposition a orienté les démarches vers des méthodes de dépistage permettant d'obtenir des taux de positivité plus élevés; une tendance qui s'écarte de la stratégie des services de dépistage et de conseil à l'initiative des prestataires, utilisée à l'aube de la lutte mondiale contre le VIH. Dans le présent document, nous nous intéressons à un nouvel indicateur, la prévalence ajustée sur le traitement. Cet indicateur peut servir de référence concrète pour les pays qui souhaitent évaluer le taux de positivité attendu chez l'adulte dans un programme de dépistage, en tenant compte de la prévalence du VIH au niveau national ainsi que de la portée du TAR. Le calcul consiste à enlever les personnes recevant un TAR du numérateur et du dénominateur de la prévalence du VIH. La prévalence ajustée sur le traitement peut aisément être déterminée en fonction des données de programme et estimations de population existantes. En 2019, elle a également été ajoutée aux lignes directrices de l'Organisation mondiale de la Santé pour l'information stratégique et le dépistage du VIH. En nous inspirant d'exemples issus du Kenya, du Malawi, du Soudan du Sud et du Zimbabwe, nous expliquons comment employer cet indicateur et abordons les potentielles implications liées à son utilisation en matière de santé publique, en partant du niveau national jusqu'aux établissements.La ampliación de las pruebas de detección del virus de la inmunodeficiencia humana (VIH) y del tratamiento antirretrovírico (TAR) para las personas infectadas por el VIH ha aumentado en el África subsahariana. En consecuencia, el porcentaje de personas que dan positivo en las pruebas de detección del VIH en los programas nacionales está disminuyendo en las zonas con alta prevalencia del virus. En África meridional y oriental, donde hay entornos con una prevalencia del VIH en adultos del 12 % o superior, la tasa de positividad de los servicios nacionales de pruebas de detección del VIH ha descendido a menos del 5 %. Por lo tanto, la identificación de las personas que necesitan TAR es cada vez más costosa para los programas nacionales de VIH. El establecimiento de objetivos anuales supone que las tasas de positividad de las pruebas nacionales se aproximan a las de la prevalencia de la población. Esta suposición ha generado una mayor atención a los enfoques de las pruebas que logran tasas más altas de positividad del VIH. Esta tendencia se aleja de la estrategia del asesoramiento y las pruebas que iniciaron los proveedores y que se utilizó al principio de la respuesta mundial al VIH. Se analiza un nuevo indicador, la prevalencia ajustada según el tratamiento, que los países pueden emplear como punto de referencia práctico para estimar la tasa de positividad esperada en adultos en un programa de pruebas de detección cuando se tiene en cuenta tanto la prevalencia nacional del VIH como la cobertura del TAR. El indicador se calcula eliminando del numerador y el denominador de la prevalencia del VIH a las personas que reciben TAR. La prevalencia ajustada según el tratamiento se puede estimar con facilidad a partir de los datos de los programas existentes y de las estimaciones de población, además, en 2019, se incluyó en las directrices de la Organización Mundial de la Salud para las pruebas de detección del VIH y en la información estratégica. A través de ejemplos de países como Kenia, Malaui, Sudán meridional y Zimbabue, se demuestra cómo aplicar este indicador y se discuten las posibles implicaciones para la salud pública de su uso desde el nivel nacional hasta el de los centros.لقد تزايد نطاق اختبار فيروس نقص المناعة البشرية (HIV) والعلاج المضاد للفيروسات القهقرية (ART) للأشخاص المتعايشين مع فيروس نقص المناعة البشرية في جنوب الصحراء الكبرى بأفريقيا. نتيجة لذلك، فإن المناطق التي يزيد فيها انتشار فيروس نقص المناعة البشرية لديها نسبة متناقصة من الأشخاص الذين ثبتت إصابتهم بالفيروس في برامج الاختبار الوطنية لديهم. في شرق وجنوب إفريقيا، حيث توجد بيئات يصل فيها انتشار فيروس نقص المناعة البشرية بين البالغين إلى نسبة 12% وما فوق، انخفضت الإيجابية من الخدمات الوطنية لاختبار فيروس نقص المناعة البشرية إلى أقل من 5%. ولذلك أصبح تحديد من هم بحاجة إلى العلاج المضاد للفيروسات القهقرية (ART) أكثر تكلفة بالنسبة للبرامج الوطنية لفيروس نقص المناعة البشرية. يفترض تحديد الهدف السنوي أن معدلات إيجابية الاختبار الوطنية تقارب معدلات الانتشار السكاني. أدى هذا الافتراض إلى زيادة التركيز على أساليب الاختبار التي تحقق معدلات أعلى من إيجابية فيروس نقص المناعة البشرية. هذا الاتجاه هو خروج عن استراتيجية الاختبار والاستشارة التي بدأها مقدم الخدمة، والمستخدمة مبكرًا في الاستجابة العالمية لفيروس نقص المناعة البشرية. نحن نناقش مؤشرًا جديدًا، وهو الانتشار القائم على ضبط العلاج، والذي يمكن للدول استخدامه كمعيار عملي لتقدير الإيجابية المتوقعة للبالغين في برنامج الاختبار عند التعبير عن انتشار فيروس نقص المناعة البشرية على المستوى الوطني، والتغطية المضادة للفيروسات القهقرية. يتم حساب المؤشر عن طريق حذف الأشخاص الذين يتلقون العلاج المضاد للفيروسات القهقرية من بسط ومقام انتشار فيروس نقص المناعة البشرية. يمكن تقدير الانتشار القائم على ضبط العلاج بسهولة من بيانات البرنامج الحالية وتقديرات السكان، وفي عام 2019، تمت إضافته إلى إرشادات منظمة الصحة العالمية لاختبار فيروس نقص المناعة البشرية والمعلومات الاستراتيجية. وباستخدام أمثلة من الدول من كينيا وملاوي وجنوب السودان وزيمبابوي، نوضح كيفية تطبيق هذا المؤشر، ونناقش الآثار المحتملة على الصحة العامة لاستخدامه من المستوى الوطني إلى مستوى المرفق.在非洲撒哈拉沙漠以南地区,对艾滋病毒感染者进行人体免疫缺陷病毒 (HIV) 检测和抗逆转录病毒治疗 (ART) 的规模正在不断扩大。结果发现,国家检测计划实施期间,在艾滋病患病率高发的地区,检测呈阳性的人数比例正在下降。在东非和北非,成人艾滋病患病率超过 12% 的地方,国家艾滋病检测计划中的阳性率下降了 5%。对于国家艾滋病毒计划来说,确定那些需要抗逆转录病毒疗法的人的所需成本正变得越来越高。制定的年度目标通常假定国家检测计划中的阳性率接近该地区的患病率。这一假设促使人们更加重视能够提高艾滋病毒阳性率的检测方法。这一趋势背离了全球艾滋病毒应对早期使用的由提供者发起的检测和咨询策略。我们讨论一种新的指标,即调整治疗后的患病率,在考虑全国艾滋病患病率和 ART 覆盖率时,各国可将其作为评估检测计划中成人阳性率的实用基准。该指标的计算方法是将接受抗逆转录病毒治疗的人数从艾滋病毒患病率的分子和分母中去除。调整治疗后的患病率可以很容易地从现有计划数据和人口估计数中估计出来,且在 2019 年已被添加到世界卫生组织艾滋病毒检测和战略信息指南中。我们以津巴布韦、肯尼亚、马拉维和南苏丹的国家为例,说明如何应用这一指标,并讨论从国家到设施层面使用该指标的潜在公共卫生影响。.Расширение масштабов тестирования на вирус иммунодефицита человека (ВИЧ) и антиретровирусной терапии (АРТ) для людей, живущих с ВИЧ, увеличивается в странах Африки к югу от Сахары. В результате в регионах с высокими показателями распространения ВИЧ наблюдается снижение доли населения с положительным результатом теста в рамках национальных программ тестирования. В восточной и южной частях Африки, где распространенность ВИЧ среди взрослого населения составляет 12% и выше, положительные результаты теста на ВИЧ в рамках национальных программ тестирования опустились ниже 5%. Таким образом, выявление лиц, нуждающихся в АРТ, становится более дорогостоящим для национальных программ по борьбе с ВИЧ. Ежегодная постановка целей предполагает, что процент лиц с положительным результатом теста в рамках национальных программ тестирования приблизительно соответствует проценту распространенности среди населения в целом. Это предположение вызвало повышенное внимание к методам тестирования, которые достигают более высоких показателей распространенности ВИЧ-инфекции. Эта тенденция является отступлением от стратегии тестирования и консультирования по инициативе поставщиков услуг, которая использовалась на раннем этапе глобальных мер борьбы с ВИЧ. Авторы обсуждают новый показатель распространенности с поправкой на лечение, который страны могут использовать в качестве практического ориентира для оценки ожидаемого процента взрослого населения с положительным результатом теста в рамках программы тестирования с учетом как распространенности ВИЧ на национальном уровне, так и охвата АРТ. Показатель рассчитывается путем исключения лиц, получающих АРТ, из числителя и знаменателя доли ВИЧ-инфицированного населения. Долю ВИЧ-инфицированного населения с поправкой на лечение можно легко оценить на основе существующих данных по программе и демографических оценок, которые в 2019 году были добавлены в рекомендации Всемирной организации здравоохранения по тестированию на ВИЧ и стратегической информации. Используя примеры из Зимбабве, Кении, Малави и Южного Судана, авторы проиллюстрируют применение этого показателя, а также обсудят возможные последствия его использования для общественного здравоохранения на национальном уровне и уровне учреждения.

IntroductionThe Global Fund to Fight AIDS, TB, and Malaria (the Global Fund) pivoted investments to support countries in their response to the COVID-19 pandemic. Recently, the Global Fund’s Board approved global pandemic preparedness and response as part of their new six-year strategy from 2023-2028.MethodsPrior research estimated that US$124 billion is required, globally, to build sufficient country-level capacity for health security, with US$76 billion needed over an initial three-year period. Action-based cost estimates generated from that research were coded as directly, indirectly, or unrelated to systems strengthening efforts applicable to HIV, TB, and/or malaria.ResultsOf approximately US$76 billion needed for country level capacity-building over the next three-year allocation period, we estimate that US$66 billion is needed in Global Fund-eligible countries, and over one-third relates directly or indirectly (US$6 billion and US$21 billion, respectively) to health systems strengthening efforts applicable to HIV, TB, and/or malaria disease programs currently supported by the Global Fund. Among these investments, cost drivers include financing for surveillance and laboratory systems, to combat antimicrobial resistance, and for training, capacity-building, and ongoing support for the healthcare and public health workforce.ConclusionThis work highlights a potential strategic role for the Global Fund to contribute to health security while remaining aligned with its core mission. It demonstrates the value of action-based costing estimates to inform strategic investment planning in pandemic preparedness.What is already known on this topicThe costs, globally, to build country-level public health capacity to address these gaps over the next five years has been previously estimated as US$96-$204 billion, with an estimated US$63-131 billion in investments required over the next three years.Research conducted prior to the COVID-19 pandemic indicated that over one-third of Global Fund’s budgets in 10 case-study countries aligned with health security priorities articulated by the Joint External Evaluation, particularly in the areas of laboratory systems, antimicrobial resistance, and workforce development.What this study addsWe estimate that over 85% of investments needed to build national capacities in health security, globally, over the next three years are in countries eligible for Global Fund support.Areas of investment opportunity aligned with the Global Fund’s core mandate include financing for surveillance and laboratory systems, combating antimicrobial resistance, and developing and supporting robust healthcare and public health workforces.How this study might affect research, practice or policyIn aggregate, global-level data highlight areas of opportunity for the Global Fund to expand and further develop its support of global health security in areas aligned with its mandate and programmatic scope.Such investment opportunities have implications not only for existing budgeting and allocation processes, but also for implementation models, partners, programming, and governance structures, should these areas of potential expansion be prioritized.This work emphasizes a role for targeted, action-based cost estimation to identify gaps and to inform strategic investment decisions in global health.

BACKGROUND HIV assays designed to detect recent infection, also known as “recency assays,” are often used to estimate HIV incidence in a specific country, region, or subpopulation, alone or as part of recent infection testing algorithms (RITAs). Recently, many countries and organizations have become interested in using recency assays within case surveillance systems and routine HIV testing services to measure other indicators beyond incidence, generally referred to as “non-incidence surveillance use cases.” OBJECTIVE This review aims to identify published evidence that can be used to validate methodological approaches to recency-based incidence estimation and non-incidence use cases. The evidence identified through this review will be used in the forthcoming technical guidance by the World Health Organization (WHO) and United Nations Programme on HIV/AIDS (UNAIDS) on the use of HIV recency assays for identification of epidemic trends, whether for HIV incidence estimation or non-incidence indicators of recency. METHODS To identify the best methodological and field implementation practices for the use of recency assays to estimate HIV incidence and trends in recent infections for specific populations or geographic areas, we conducted a systematic review of the literature to (1) understand the use of recency testing for surveillance in programmatic and laboratory settings, (2) review methodologies for implementing recency testing for both incidence estimation and non-incidence use cases, and (3) assess the field performance characteristics of commercially available recency assays. RESULTS Among the 167 documents included in the final review, 91 (54.5%) focused on assay or algorithm performance or methodological descriptions, with high-quality evidence of accurate age- and sex-disaggregated HIV incidence estimation at national or regional levels in general population settings, but not at finer geographic levels for prevention prioritization. The remaining 76 (45.5%) described the field use of incidence assays including field-derived incidence (n=45), non-incidence (n=25), and both incidence and non-incidence use cases (n=6). The field use of incidence assays included integrating RITAs into routine surveillance and assisting with molecular genetic analyses, but evidence was generally weaker or only reported on what was done, without validation data or findings related to effectiveness of using non-incidence indicators calculated through the use of recency assays as a proxy for HIV incidence. CONCLUSIONS HIV recency assays have been widely validated for estimating HIV incidence in age- and sex-specific populations at national and subnational regional levels; however, there is a lack of evidence validating the accuracy and effectiveness of using recency assays to identify epidemic trends in non-incidence surveillance use cases. More research is needed to validate the use of recency assays within HIV testing services, to ensure findings can be accurately interpreted to guide prioritization of public health programming.

IntroductionHIV assays designed to detect recent infection, also known as “recency assays,” are often used to estimate HIV incidence in a specific country, region, or subpopulation, alone or as part of recent infection testing algorithms (RITAs). Recently, many countries and organizations have become interested in using recency assays within case surveillance systems and routine HIV testing services, and in measuring other indicators beyond incidence, generally referred to as “non-incidence surveillance use cases.”MethodsTo identify best methodological and field implementation practices for the use of recency assays to estimate HIV incidence and trends in recent infections for key populations or specific geographic areas, we undertook: 1) a global Call for Information released from WHO/UNAIDS; and 2) a systematic review of the literature to: (a) assess the field performance characteristics of commercially available recency assays, (b) understand the use of recency testing for surveillance in programmatic and laboratory settings, and (c) review methodologies for implementing recency testing for both incidence estimation and non-incidence use cases.Results and discussionAmong the 90 documents ultimately reviewed, 65 (88%) focused on assay/algorithm performance or methodological descriptions, with high-quality evidence of accurate age- and sex- disaggregated HIV incidence estimation at national or regional levels in general population settings, but not at finer geographic levels for prevention prioritization. The remaining 25 documents described field-derived incidence (n=14) and non-incidence (n=11) use cases, including integrating RITAs into routine surveillance and assisting with molecular genetic analyses, but evidence was generally weaker or only reported on what was done, without validation data or findings related to effectiveness of recency assays when used for these purposes.ConclusionsHIV recency assays have been widely validated for estimating HIV incidence in age- and sex-specific populations at national and sub-national regional levels; however, there was a lack of evidence validating the accuracy and effectiveness of using recency assays for non-incidence surveillance use cases. The evidence identified through this review will be used in forthcoming technical guidance on the use of HIV recency assays for surveillance use cases by WHO and UNAIDS; further evidence on methodologies and effectiveness of non-incidence use cases is needed.

The World Health Organization (WHO) recommends providing tuberculosis preventive treatment (TPT) to all persons living with HIV and to all household contacts of persons with bacteriologically confirmed pulmonary tuberculosis disease. Regrettably, the absence of a harmonized data collection and management approach to TPT indicators has contributed to programmatic challenges at local, national, and global levels. However, in April 2020, the WHO launched the Consolidated HIV Strategic Information Guidelines, with an updated set of priority indicators. These guidelines recommend that Ministries of Health collect, report, and use data on TPT completion in addition to TPT initiation. Both indicators are reflected in the WHO’s list of 15 core indicators for program management and are also required by the US President’s Emergency Plan for AIDS Relief’s Monitoring, Evaluation, and Reporting (MER) guidance. Although not perfectly harmonized, both frameworks now share essential indicator characteristics. Aligned indicators are necessary for robust strategic and operational planning, resource allocation, and data communication. “Collect once, use many times” is a best practice for strategic information management. Building harmonized and sustainable health systems will enable countries to successfully maintain essential HIV, tuberculosis, and other health services while combatting new health threats.

UNSTRUCTURED The World Health Organization (WHO) recommends providing tuberculosis preventive treatment (TPT) to all persons living with HIV and to all household contacts of persons with bacteriologically confirmed pulmonary tuberculosis disease. Regrettably, the absence of a harmonized data collection and management approach to TPT indicators has contributed to programmatic challenges at local, national, and global levels. However, in April 2020, the WHO launched the Consolidated HIV Strategic Information Guidelines, with an updated set of priority indicators. These guidelines recommend that Ministries of Health collect, report, and use data on TPT completion in addition to TPT initiation. Both indicators are reflected in the WHO’s list of 15 core indicators for program management and are also required by the US President’s Emergency Plan for AIDS Relief’s Monitoring, Evaluation, and Reporting (MER) guidance. Although not perfectly harmonized, both frameworks now share essential indicator characteristics. Aligned indicators are necessary for robust strategic and operational planning, resource allocation, and data communication. “Collect once, use many times” is a best practice for strategic information management. Building harmonized and sustainable health systems will enable countries to successfully maintain essential HIV, tuberculosis, and other health services while combatting new health threats.

INTRODUCTION: Zimbabwe has a high burden of HIV (i.e., estimated 1.3 million HIV-infected and 13.8% HIV incidence in 2017). In 2017 the country developed and implemented a pilot of HIV case surveillance (CS) based on the 2017 World Health Organisation (WHO) person-centred HIV patient monitoring (PM) and case surveillance guidelines. At the end of the pilot phase an evaluation was conducted to inform further steps. METHODS: The pilot was conducted in two districts (i.e., Umzingwane in Matabeleland South Province and Mutare in Manicaland Province) from August 2017 to December 2018. A mixed-methods cross-sectional study of stakeholders and health facility staff was used to assess the design and operations, performance, usefulness, sustainability, and scalability of the CS system. A total of 13 stakeholders responded to an online questionnaire, while 33 health facility respondents were interviewed in 11 health facilities in the two districts. RESULTS: The HIV CS system was adequately designed for Zimbabwe´s context, integrated within existing health information systems at the facility level. However, the training was minimal, and an opportunity to train the data entry clerks in data analysis was missed. The system performed well in terms of surveillance and informatics attributes. However, viral load test results return was a significant problem. CONCLUSION: The HIV CS system was found useful at the health facility level and should be rolled out in a phased manner, beginning in Manicaland and Matabeleland South provinces. An electronic link needs to be made between the health facilities and the laboratory to reduce viral load test results delays.

BACKGROUND In 2019, 62% of new HIV infections occurred among key populations (KPs) and their sexual partners. The World Health Organization (WHO) recommends implementation of bio-behavioral surveys every 2-3 years to obtain HIV prevalence data for all KPs. However, the collection of these data is often less frequent and geographically limited. OBJECTIVE This study intended to assess the availability and quality of HIV prevalence data among sex workers (SWs), men who have sex with men (MSM), people who inject drugs, and transgender women (transwomen) in low- and middle-income countries. METHODS Data were obtained from survey reports, national reports, journal articles, and other grey literature available to the Global Fund, Joint United Nations Programme on HIV/AIDS, and WHO or from other open sources. Elements reviewed included names of subnational units, HIV prevalence, sampling method, and size. Based on geographical coverage, availability of trends over time, and recency of estimates, data were categorized by country and grouped as follows: nationally adequate, locally adequate but nationally inadequate, no recent data, no trends available, and no data. RESULTS Among the 123 countries assessed, 91.9% (113/123) presented at least 1 HIV prevalence data point for any KP; 78.0% (96/123) presented data for at least 2 groups; and 51.2% (63/123), for at least 3 groups. Data on all 4 groups were available for only 14.6% (18/123) of the countries. HIV prevalence data for SWs, MSM, people who inject drugs, and transwomen were available in 86.2% (106/123), 80.5% (99/123), 45.5% (56/123), and 23.6% (29/123) of the countries, respectively. Only 10.6% (13/123) of the countries presented nationally adequate data for any KP between 2001 and 2017; 6 for SWs; 2 for MSM; and 5 for people who inject drugs. Moreover, 26.8% (33/123) of the countries were categorized as locally adequate but nationally inadequate, mostly for SWs and MSM. No trend data on SWs and MSM were available for 38.2% (47/123) and 43.9% (54/123) of the countries, respectively, while no data on people who inject drugs and transwomen were available for 76.4% (94/123) and 54.5% (67/123) of the countries, respectively. An increase in the number of data points was observed for MSM and transwomen. Overall increases were noted in the number and proportions of data points, especially for MSM, people who inject drugs, and transwomen, with sample sizes exceeding 100. CONCLUSIONS Despite general improvements in health data availability and quality, the availability of HIV prevalence data among the most vulnerable populations in low- and middle-income countries remains insufficient. Data collection should be expanded to include behavioral, clinical, and epidemiologic data through context-specific differentiated survey approaches while emphasizing data use for program improvements. Ending the HIV epidemic by 2030 is possible only if the epidemic is controlled among KPs.

BACKGROUND Zimbabwe has a high burden of HIV, with an estimated 1.3 million people living with the virus and an HIV prevalence and incidence of 13.8% and 0.48%, respectively (2017 Spectrum estimates). In 2017, the Zimbabwe Ministry of Health and Child Care (MOHCC) developed and implemented a pilot of HIV case surveillance (CS) based on the 2017 World Health Organisation (WHO) Person-centred HIV patient monitoring (PM) and case surveillance guidelines. As the case surveillance guidelines were new, lessons learned from field implementation experiences were intended to inform the development of HIV case surveillance implementation guidance and tools. OBJECTIVE At the end of the pilot phase, the Ministry of Health and Child Care (MOHCC) commissioned an evaluation to inform further steps. METHODS Two districts, Umzingwane in Matabeleland South Province and Mutare in Manicaland Province were commissioned to run the CS pilot from August 2017 to December 2018. During this period, 1602 people living with HIV (PLHIV) newly diagnosed with HIV were reported in the CS system, while other HIV sentinel events, including ART initiation and first viral load test, were routinely reported. A mixed-methods cross-sectional study of stakeholders and health facility staff was used to assess the following CS system features: design and operations, performance, usefulness, sustainability and scalability. A total of 13 stakeholders responded to an online questionnaire, while 33 health facility respondents were interviewed in 11 health facilities in the two pilot districts. RESULTS The HIV CS system was adequately designed for Zimbabwe’s context, integrated within existing health information systems at the facility level. However, the training was minimal, and an opportunity to train the data entry clerks in data analysis was missed. The system performed well in terms of surveillance and informatics attributes. However, viral load test results return was a significant problem. The system was used at the health facility level to track the HIV positive clients in their catchment area; all facilities that were visited were aware of what is happening to their clients. Almost all respondents believed that the country can roll out the HIV CS system to all facilities with partner support. CONCLUSIONS The HIV CS system was found useful at the health facility level and should be rolled out in a phased manner, beginning with all facilities in Manicaland and Matabeleland South provinces. An electronic link needs to be made between the health facilities and the laboratory to reduce viral load test results delays. Lessons learned from the provincial roll out can be used for a nationwide scale-up.

The transition from paper to digital systems requires quality assurance of the underlying content and application of data standards for interoperability. The World Health Organization (WHO) developed digital adaptation kits (DAKs) as an operational and software-neutral mechanism to translate WHO guidelines into a standardized format that can be more easily incorporated into digital systems.WHO convened health program area and digital leads, reviewed existing approaches for requirements gathering, mapped to established standards, and incorporated research findings to define DAK components.For each health domain area, the DAKs distill WHO guidelines to specify the health interventions, personas, user scenarios, business process workflows, core data elements mapped to terminology codes, decision-support logic, program indicators, and functional and nonfunctional requirements.DAKs aim to catalyze quality of care and facilitate data use and interoperability as part of WHO's vision of SMART (Standards-based, Machine-readable, Adaptive, Requirements-based, and Testable) guidelines. Efforts will be needed to strengthen a collaborative approach for the uptake of DAKs within the local digital ecosystem and national health policies.

Background In 2019, 62% of new HIV infections occurred among key populations (KPs) and their sexual partners. The World Health Organization (WHO) recommends implementation of bio-behavioral surveys every 2-3 years to obtain HIV prevalence data for all KPs. However, the collection of these data is often less frequent and geographically limited. Objective This study intended to assess the availability and quality of HIV prevalence data among sex workers (SWs), men who have sex with men (MSM), people who inject drugs, and transgender women (transwomen) in low- and middle-income countries. Methods Data were obtained from survey reports, national reports, journal articles, and other grey literature available to the Global Fund, Joint United Nations Programme on HIV/AIDS, and WHO or from other open sources. Elements reviewed included names of subnational units, HIV prevalence, sampling method, and size. Based on geographical coverage, availability of trends over time, and recency of estimates, data were categorized by country and grouped as follows: nationally adequate, locally adequate but nationally inadequate, no recent data, no trends available, and no data. Results Among the 123 countries assessed, 91.9% (113/123) presented at least 1 HIV prevalence data point for any KP; 78.0% (96/123) presented data for at least 2 groups; and 51.2% (63/123), for at least 3 groups. Data on all 4 groups were available for only 14.6% (18/123) of the countries. HIV prevalence data for SWs, MSM, people who inject drugs, and transwomen were available in 86.2% (106/123), 80.5% (99/123), 45.5% (56/123), and 23.6% (29/123) of the countries, respectively. Only 10.6% (13/123) of the countries presented nationally adequate data for any KP between 2001 and 2017; 6 for SWs; 2 for MSM; and 5 for people who inject drugs. Moreover, 26.8% (33/123) of the countries were categorized as locally adequate but nationally inadequate, mostly for SWs and MSM. No trend data on SWs and MSM were available for 38.2% (47/123) and 43.9% (54/123) of the countries, respectively, while no data on people who inject drugs and transwomen were available for 76.4% (94/123) and 54.5% (67/123) of the countries, respectively. An increase in the number of data points was observed for MSM and transwomen. Overall increases were noted in the number and proportions of data points, especially for MSM, people who inject drugs, and transwomen, with sample sizes exceeding 100. Conclusions Despite general improvements in health data availability and quality, the availability of HIV prevalence data among the most vulnerable populations in low- and middle-income countries remains insufficient. Data collection should be expanded to include behavioral, clinical, and epidemiologic data through context-specific differentiated survey approaches while emphasizing data use for program improvements. Ending the HIV epidemic by 2030 is possible only if the epidemic is controlled among KPs.

There was no global guidance or agreement regarding when a country has an adequate system to report on the service packages among human immunodeficiency virus (HIV) key populations. This article describes an approach to categorizing the system in a country for reporting the service package among HIV key populations. The approach consists of four dimensions, namely the epidemiological significance, comprehensiveness of the service packages, geographic coverage of services, and adequacy of the monitoring system. The proposed categorization approach utilizes available information and can inform the improvement of the service delivery and monitoring systems among HIV key populations. Electronic supplementary material The online version of this article (10.1186/s40249-019-0570-4) contains supplementary material, which is available to authorized users.

BACKGROUND Key populations, including female sex workers (FSWs), are at a disproportionately high risk for HIV infection. Estimates of the size of these populations serve as denominator data to inform HIV prevention and treatment programming and are necessary for the equitable allocation of limited public health resources. OBJECTIVE This study aimed to present the respondent-driven sampling (RDS) adjusted reverse tracking method (RTM; RadR), a novel population size estimation approach that combines venue mapping data with RDS data to estimate the population size, adjusted for double counting and nonattendance biases. METHODS We used data from a 2014 RDS survey of FSWs in Windhoek and Katima Mulilo, Namibia, to demonstrate the RadR method. Information from venue mapping and enumeration from the survey formative assessment phase were combined with survey-based venue-inquiry questions to estimate population size, adjusting for double counting, and FSWs who do not attend venues. RadR estimates were compared with the official population size estimates, published by the Namibian Ministry of Health and Social Services (MoHSS), and with the unadjusted RTM. RESULTS Using the RadR method, we estimated 1552 (95% simulation interval, SI, 1101-2387) FSWs in Windhoek and 453 (95% SI: 336-656) FSWs in Katima Mulilo. These estimates were slightly more conservative than the MoHSS estimates—Windhoek: 3000 (1800-3400); Katima Mulilo: 800 (380-2000)—though not statistically different. We also found 75 additional venues in Windhoek and 59 additional venues in Katima Mulilo identified by RDS participants’ responses that were not detected during the initial mapping exercise. CONCLUSIONS The RadR estimates were comparable with official estimates from the MoHSS. The RadR method is easily integrated into RDS studies, producing plausible population size estimates, and can also validate and update key population maps for outreach and venue-based sampling.

To determine whether Malawi antiretroviral treatment (ART) clinics providing cotrimoxazole (CTX) prophylaxis had lower early mortality rates compared with clinics not providing CTX.Retrospective cohort study of eleven ART clinics in Malawi that were or were not providing CTX. Medical record abstraction was performed for all patients (N = 1295) initiating ART between July 1 and December 15, 2005. At 5 ART sites, CTX was given to patients dosed at 960 mg daily or 480 mg twice a day (according to national guidelines).When all defaults (patients lost to follow-up for90 days) were excluded from the analysis, the 6-month mortality rate was 10.7% in patients receiving ART at CTX clinics compared with 18.0% in those not at CTX clinics (6-month mortality risk reduction = 40.7%; P = 0.0013). Kaplan-Meier survival curves for patients receiving CTX and patients not receiving CTX were significantly different; survival differences were apparent as early as 40 to 45 days after initiation of ART.Patients receiving ART in Malawi at clinics offering CTX prophylaxis had significantly reduced mortality during the first 6 months of ART. This additional intervention may have the potential to improve the lives of patients on ART, because CTX is readily available and relatively inexpensive and can, in principle, be easily introduced into ART delivery programs.

Monitoring and evaluation of national antiretroviral therapy (ART) programs is vital, but routine, standardized assessment of national ART patient monitoring systems has not been established. Malawi has undertaken an ambitious ART scale-up effort, with over 57,000 patients initiated on ART by June 2006. We assessed the national ART monitoring and evaluation system in Malawi to ensure that the response to the epidemic was being monitored efficiently and effectively, and that data collected were useful.The evaluation, performed in August 2005, generally followed the Updated Guidelines for Evaluating Public Health Surveillance Systems (CDC) and Interim Patient Monitoring Guidelines for HIV Care and ART (WHO). Assessment was conducted with qualitative methods, including twelve ART site visits, with standardized key informant interviews with ART clinic coordinators, clinical staff, and data managers, at each site. Meetings were also held with key governmental stakeholders, including Ministry of Health and National AIDS Commission.The national monitoring and evaluation system devised by the Ministry of Health HIV/AIDS Unit is successful in achieving its objectives, and facilitates important aspects of the national response to HIV. Several basic changes in the data collection tools and system would facilitate more effective long-term assessment of the ART program and support improved patient care. As the number of ART sites and patients continues to expand, the current manual paper-based system may be overwhelmed. Identification and implementation of a feasible electronic data system that would maintain and improve data quality and the efficiency of data recording and reporting and enhance patient care is a priority.The assessment of ART monitoring and evaluation systems can optimize the effectiveness of national ART programs, and should be considered in other resource-constrained countries rapidly scaling up ART.