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Background Globally, men who have sex with other men (MSM) increasingly use virtual platforms for networking and soliciting sexual partners due to unrelenting stigma and discrimination. However, most studies estimating the MSM population for HIV prevention coverage in sub-Saharan Africa focus on physical sites, failing to account for MSM using virtual platforms. This study aimed to examine the feasibility of estimating the MSM population using virtual spaces in Tanzania. Methods MSM recruited from civil society organisations collected data on two levels: First, a participatory ranking method involving key informants was used to identify virtual sites, and on each site, they listed all profiles used by MSM in selected towns. Secondly, research assistants logged in to those platforms three times a day (morning, afternoon, and evening) and counted all those who were active online at every time point for seven days. Those online were invited to participate in a voluntary short survey. The number of profiles recorded was generated by aggregating the virtual site profiles for MSM registered daily. Data collected in the short survey were then applied as correction factors to adjust for MSM counted twice or more on different days of the week and for those who may have been missed in the survey. Results A total of 4,480 active profiles were observed. Of the 4,480 unadjusted profiles, only 2,429 were unique. 598 male virtual site users aged 18 + years were interviewed to collect data on correction factors. Approximately 91% of participants on virtual sites also visited physical venues. Nearly 90% of participants in the short survey used virtual sites for socialising and sexual networking several times a week. Conclusion This study shows that virtual mapping is a feasible strategy to capture estimates of MSM who cannot be counted through venue-based approaches, especially in contexts where MSM face legal and societal stigmatisation and discrimination.

Background India plans elimination of HIV-Mother-to-Child-Transmission in 2020. Targets include >95% coverage of Antenatal-care (ANC) and HIV-testing. In 2015-16, while 43% of the estimated Indian pregnant-women (PW) received HIV-tests, one state reported >95% testing. Indian public-health-care is a three-tiered system from primary-level sub-centres (population-5000) to tertiary-level hospitals. ANC involves multiple-visits per pregnancy at different care-levels and data are aggregated in the Health-Management-Information-System (HMIS) at all levels. We validated (public and private-sector data from this state, for duplication in ANC registration and HIV-testing using mixed methods. Methods In the absence of guidelines for assessing aggregate-data duplication, we used mixed-methods, including surveys among 9845 PW and providers from 240 facilities in 10/36 representative districts; in-depth-interviews; case-studies and analysis of HMIS and HIV-program data (April 2015-Mar 2017). Interviews and case-studies highlighted inadvertent duplicate data-capture. Surveys quantified levels of duplication and adjustment factors (public and private-sector) were developed. Results Twenty-four% PW, visited multiple facilities for ANC, while 81% providers reported all the PW coming to their facilities as new ANC registrations (irrespective of lower-tier registration); identifying a minimum duplication of 19% (24%*81%) in ANC coverage. Twenty-nine% and 28% PW from public and private-facilities reported >1 HIV-test; while 75% and 36% reported visiting another public-facility where HIV test was likely to be reported again. Minimum duplication of 22% and 10% in HIV testing was noted in public and private-sectors respectively. Conclusions We report methods to quantify repeat HIV-testing and duplicate-reporting, due to inherent processes in ANC in public-healthcare in India. Modification of data-capture was recommended and adopted across India. Key messages Assessing duplication in aggregate health data is key to developing robust datasets for disease elimination

Introduction A programmatic mapping and size estimation study was conducted in 24 districts in 5 regions of Tanzania to estimate the size and locations of female sex workers (FSW) and men who have sex with men (MSM) to inform the HIV programming for Key Populations. Methodology Data were collected at two levels: first, interviews were conducted with informants to identify venues where FSWs and MSM frequent. Secondly, the size of MSM and FSWs were estimated through interviews with FSWs, MSM and other informants at the venue. The venue estimates were aggregated to generate the ward level estimates. Correction factors were then applied to adjust for MSM/FSW counted twice or more, absent from the venues on the mapping day or remain online and hidden. The ward size estimates for mapped wards were extrapolated to non-mapped wards and aggregated to generate district and regional level estimates. Results A total of 4,557 level I interviews were conducted. Further, 3,098 FSWs and 1,074 other informants at the FSWs venues and 558 MSM and 210 other informants at the MSM venues were interviewed during level II. The mapping survey identified 6,658 FSW, 1,099 FSW and MSM and 50 MSM venues in 75 wards. A total of 118,057 (range: 108,269 to 127,845) FSWs and 23,771 (range: 22,087 to 25,454) MSM were estimated in the study regions after extrapolation and accounting for correction factors. It was estimated that 5.6% and 1.3% of the female and male population of reproductive age (15–49 years old) could be FSWs and MSM in the study regions, respectively. Conclusion This study provides the baseline figures for planning, target setting and monitoring of the HIV intervention services in the study areas and geographic prioritisation of the response by allocating more resources to areas with a large number of FSWs and MSM.

BACKGROUND Most low-income settings experiencing concentrated HIV epidemic lack information about key populations (KPs), including people who inject drugs (PWID), men who have sex with men (MSM), male sex workers (MSW), transgender (TG) and female sex workers (FSW) because they are hidden and marginalised in society and frequently undocumented. Out of several approaches to size estimation, mapping and size estimation is particularly useful when local estimates are needed for planning and monitoring of prevention programmes. OBJECTIVE To locate hot spots related to sex work, cruising spots, and injecting drug use, and to estimate the number of sex workers, PWID, MSM, MSW and TG at the district level (adjusting for double-counting, frequency of visiting spots, and low visibility), and at the national level using extrapolation algorithms . METHODS The mapping exercise among MSM, MSW, TG, PWID and FSW was carried out in 44 districts of Nepal between July and November 2016 by collecting relevant information directly from hotspots where KPs members congregate. Districts to be mapped were selected purposively, to both provide data to local programmes in areas with high concentrations of KPs, and inform extrapolation to unmapped districts as part of national estimation procedures. RESULTS Altogether 11056 KPs and 10977 non- KPs informants were interviewed from across the 44 mapped districts to identify the hotspots. District level adjustment factors (mobility adjustment, frequency adjustment and invisibility adjustment) were sequentially applied. The final estimates used all three adjustment factors. We found that the national estimate of FSW in Nepal ranges between 43,829 to 54,207. The national estimate of MSM/TG lies between 88,009 and 112,150, of which a minimum of 18,704 and maximum 24,216 are TG, and a minimum 53,373 and maximum 67,292 are MSM. And finally the national estimate of PWID ranges between 27,248 to 34,487. Among them, a minimum 24,572 and a maximum 30,561 are men, and minimum 2,676 and maximum 3,926 are women. CONCLUSIONS The size of KPs provided through mapping exercise can be utilised for setting benchmarks and measuring program coverage. The major limitation is that mapping may count the majority of KPs who visit hotspots on a very regular basis, while missing the subset who are not “hotspot based” or who visit hotspots less frequently. However, the strength of mapping is that it reflects hands-on knowledge and experience of people who have access to communities that outside researchers may not have, thereby accounting for people who might otherwise be invisible.

Background Female sex workers (FSWs) in India are provided a standardised package of clinical interventions for management of sexually transmitted infections (STIs). A study was conducted among FSWs at known high STI prevalence sites to determine the effectiveness of the service package. Methods A cohort of FSW clinic attendees in two cities, Hyderabad and Mumbai, were enrolled and followed up from October 2008 to November 2009. At each visit, behavioural and clinical data were obtained and vaginal swabs collected for laboratory testing of cervical infections (gonorrhoea and chlamydia). Results 417 participants were enrolled, of whom 360 attended at least a follow-up visit. Prevalence of cervical infections did not change between the baseline and final visits (27.7% and 21.3% respectively, p=0.08) in spite of presumptive treatment at baseline and syndromic management at all visits. The proportion of asymptomatic cervical infections increased from 36% at baseline to 77% at the final visit. Incidence rate of cervical infections was high (85.6/100 person years) and associated with a prevalent cervical infection at baseline (HR=2.7, p

We explore the magnitude of and current trends in HIV infection among people who inject drugs and estimate the reach of harm reduction interventions among them in seven high-burden countries of the South-East Asia Region. Our data are drawn from the published and unpublished literature, routine national HIV serological and behavioural surveillance surveys and information from key informants. Six countries (Thailand, Myanmar, Nepal, Indonesia, India, and Bangladesh) had significant epidemics of HIV among people who inject drugs. In Thailand, Indonesia, Bangladesh, Myanmar and India, there is no significant decline in the prevalence of HIV epidemics in this population. In Nepal, north-east India, and some cities in Myanmar, there is some evidence of decline in risk behaviours and a concomitant decline in HIV prevalence. This is countered by the rapid emergence of epidemics in new geographical pockets. Available programme data suggest that less than 12 000 of the estimated 800 000 (1.5%) people who inject drugs have access to opioid substitution therapy, and 20-25% were reached by needle-syringe programmes at least once during the past 12 months. A mapping of harm reduction interventions suggests a lack of congruence between the location of established and emerging epidemics and the availability of scaled-up prevention services. Harm reduction interventions in closed settings are almost nonexistent. To achieve significant impact on the HIV epidemics among this population, governments, specifically national AIDS programmes, urgently need to scale up needle-syringe programmes and opioid substitution therapy and make these widely available both in community and closed settings.

Background: Closing the HIV prevention gap to prevent HIV infections requires rapid, worldwide rollout of large-scale national programmes. Evaluating such programmes is challenging and complex, requiring clarity of evaluation purpose and evidential approaches substantively different to those employed for pilots and small programmes. Objectives: This paper describes the evaluation design for the implementation phase of Avahan, the India AIDS initiative, a large HIV prevention programme funded by the Bill and Melinda Gates Foundation. Avahan, which began in December 2003, has a 10-year charter to impact the Indian epidemic and its response by implementing an HIV prevention programme targeting core and bridge groups in 83 districts of six Indian states, transferring the programme to the Government of India, and disseminating programme learning. Methods: The foundation commissioned an external process to design Avahan's evaluation framework. An independent advisory group oversees and guides course corrections in the execution of this framework. Results: Avahan's evaluation framework comprises: trend and synthetic analysis of data from core, bridge and household biobehavioural surveys in a subset of intervention districts, denominator estimates and programme monitoring from all intervention districts, and government's antenatal surveillance (two sites per district in all districts); bespoke transmission dynamics modelling to estimate infections averted (subset of districts); cost effectiveness studies (subset of districts). In addition, there are other knowledge-building and quality-monitoring activities. Conclusion: Rather than a small set of monofocal Outcome measures, scaled programmes require nuanced evaluations that approximate programmatic scale by collecting data with different levels of geographical scope, synthesize multiple data and methods to arrive at a composite picture, and can cope with continuous environmental and programme evolution. (C) 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

A wide range of methods is now available for assessing the nature and characteristics of drug injecting populations, and for evaluating the effectiveness of interventions developed to reduce injecting related harms. The public health surveillance tasks in relation to injecting drug use populations and associated health problems are the same, in principle, as for the surveillance of other health problems. These are: to describe the patterns of the condition, the nature of the problem and the environment (context) in which it occurs; to determine the scale of interventions needed and estimated coverage required, to forecast future health care needs; to mobilise resources and target prevention; and to evaluate interventions. Countries vary in their existing levels of information as well as resources for surveillance systems, research and evaluation. We propose three levels of assessment: basic assessment, which is suitable in situations of low awareness and information, routine surveillance, and enhanced surveillance, which requires more complex research and/or analyses of data collected from routine surveillance.

Adequate surveillance of hard-to-reach and 'hidden' subpopulations is crucial to containing the HIV epidemic in low prevalence settings and in slowing the rate of transmission in high prevalence settings. For a variety of reasons, however, conventional facility and survey-based surveillance data collection strategies are ineffective for a number of key subpopulations, particularly those whose behaviors are illegal or illicit. This paper critically reviews alternative sampling strategies for undertaking behavioral or biological surveillance surveys of such groups. Non-probability sampling approaches such as facility-based sentinel surveillance and snowball sampling are the simplest to carry out, but are subject to a high risk of sampling/selection bias. Most of the probability sampling methods considered are limited in that they are adequate only under certain circumstances and for some groups. One relatively new method, respondent-driven sampling, an adaptation of chain-referral sampling, appears to be the most promising for general applications. However, as its applicability to HIV surveillance in resource-poor settings has yet to be established, further field trials are needed before a firm conclusion can be reached.

A probability sample of 206 men who have sex with men from 16 sites in Phnom Penh were surveyed about sexual behaviors and tested for HIV and sexually transmitted infections (STIs). HIV and syphilis prevalence was 14.4% and 5.5%, respectively. Out of the total sample, 81% reported anal sex with any male partners in the past 6 months, and 61.2% reported having had vaginal sex. In the past 6 months, 82.8% of the sample reported having male partners who paid them to have sex. Self-reported sexual orientation did not match well with self-reported sexual behavior. Significant risk factors for HIV infection were anal sex with multiple partners, unprotected vaginal sex with commercial female partners in the past month, and any STI. Complex sexual networks indicate that men who have sex with men act as a bridge between higher and lower HIV prevalence populations. Better prevention efforts structured around behaviors rather than sexual identities are needed.

HIV prevalence among sex workers in Ho Chi Minh City has increased rapidly from 6.5% in 1999 to 18.1% in 2000. This study examined whether injecting drug use among street-based sex workers (SSWs) in Ho Chi Minh City is a high-risk factor for HIV infection. The goal of this study was to determine the correlates and prevalence of intravenous drug users among SSWs in Ho Chi Minh City. A cross-sectional study was conducted among SSWs in Ho Chi Minh City during December 2000. The SSWs were interviewed and tested for HIV-1. HIV-1 seroprevalence was 16.3%. Regression analysis indicated that injecting drugs and being younger than 25 years of age were independently associated with HIV seropositivity. Young SSWs who inject drugs are at the greatest risk of contracting HIV and acting as a bridge for HIV to the sexually active population. (authors)

Introduction : An important public health question is the degree to which HIV epidemics among injecting drug users (IDUs) can contribute to more generalised spread of the virus heterosexually among non-IDUs. Mathematical models can be of use in understanding the complexities of such epidemiological problems. Methods: In this paper, the Asian Epidemic Model (AEM) is used to explore different scenarios for potential HIV transmission by IDUs to non-injecting sexual partners and beyond. The model is applied to a ‘general Asian' setting, in which (1) there is the potential for sex work to drive a self-sustaining heterosexual epidemic, and (2) the vast majority of IDUs are male and do not engage in sex work themselves, but a substantial minority of the IDUs do purchase sexual services from sex workers. Within such a setting, three different scenarios are modeled, and within each scenario, the level of HIV prevalence among IDUs is varied, to see the impact of preventing HIV among IDUs at different stages. Results: The number of HIV infections attributable to IDUs over a 15-year period was greatest when the epidemic among IDUs started in advance of a generalised heterosexual epidemic, with a 171% increase in infections if the IDU prevalence was not kept under control. Once a heterosexual epidemic was underway, controlling HIV prevalence among IDUs still resulted in a meaningful reduction in infections (23%), including among non-IDUs. Once the heterosexual epidemic started to decline, the relative proportion of infections attributable to IDUs increased, creating a situation for IDUs to feed into new epidemics. Discussion: In the early stages of a heterosexual epidemic, maintaining HIV prevalence at low levels among IDUs can buy critical time to address the potential for rapid heterosexual transmission. In more advanced heterosexual epidemics, preventing HIV among IDUs can still avert a substantial number of infections.

Background The purpose of this study was to evaluate whether HIV-1 prevalence among antenatal clinic (ANC) attendees in Cambodia provided a reasonable estimate of HIV-1 prevalence among all women 15‐49 years. Methods Antenatal clinic attendees in five HIV sentinel surveillance sites (five provinces) were selected by consecutive sampling (n = 1695). The population survey of females by household was carried out in the same five areas. Household females aged 15‐49 years were selected using a three-stage cluster sampling design (n = 3066). Serum-based HIV ELISA testing was done for both ANC attendees and household females. The HIV prevalence for ANC attendees and household females were compared by age group and urban versus rural location. Results The overall prevalence of HIV-1 infection among ANC attendees (1.62%, 95% CI : 1.26‐1.98) was similar to the overall prevalence obtained from the general population of household females (1.24%, 95% CI : 0.92‐1.55) in the same catchment areas in Cambodia. In the rural areas, the overall HIV prevalence among ANC attendees (2.18%, 95% CI : 1.59‐2.77) was significantly higher than among the household females (0.86%, 95% CI : 0.49‐1.23) after adjustment for age distribution and education level. In the 15‐24 age group in rural areas, the HIV prevalence of ANC women was 2.71% (95% CI : 0.96‐4.46) compared with 0.77% (95% CI : 0.02‐1.53) in household females. Conclusions Although ANC data can be used to estimate trends over time, it should be realized that ANC data may overestimate the actual prevalence in the younger age group in rural areas in Cambodia.

Strategic information is fundamental to the formulation and delivery of effective HIV programmes, but generating that information is a complex process, for which most countries in south and south-east Asia lack capacity and supporting structures. Although most countries in this region have made tremendous strides in collecting relevant data, advances in the ability to translate that data into strategic information and evidence for action, have not kept pace. To overcome these shortcomings, this paper presents a comprehensive approach to collecting strategic information and building the capacity to use it effectively, which is based on experience in the successful use of data in different countries in south and south-east Asia. The system recommended here requires that staff and resources carry out four major functions: implement an early alert and response system allowing for the timely collection, synthesis and use of information to respond quickly to emerging epidemics; carefully analyze data to develop policy scenarios and resource projections to guide decision-making; periodically evaluate the impact of the current response and make recommendations to improve it; and engage policy-makers in ways that proactively promote improvements to current programmes based on evidence. At present, countries in this region are carrying out these functions in an ad-hoc and uncoordinated manner, if at all. The establishment and resourcing of structures dedicated to fulfilling these functions in an organized and coordinated manner are required to counteract the formidable barriers and challenges that inhibit the use of Asia's wealth of data for maximum benefit.

Bangladesh is a low HIV prevalence country, with buprenorphine injectors having the highest prevalence of HIV at 2.5% as of 1999. Using National HIV Behavioral Surveillance data, the impact of a needle exchange program (NEP) on sharing behavior among injecting drug users in two cities was measured. Results showed positive changes that varied with the different settings. Those who reported utilizing the NEP were compared with those who did not. Differences in Dhaka were significant for the average proportion of needles shared but not for the proportion of men who ever shared in the last week. In Rajshahi, where professional injectors were the norm, the impact of an NEP was greater and affected both the proportion of needles shared as well as the proportion of men never sharing. Behavioral surveillance methods have the potential to measure intervention impact through comparative analysis in certain settings.

Objective: This article summarizes issues and recommendations for conducting HIV risk behavioral surveillance surveys (BSS) based on experiences from ten BSS projects in eight countries in Asia and Africa. Background: BSS consists of systematic and repeated cross-sectional surveys of HIV and sexually transmitted disease-related behaviors, with other knowledge and attitudinal variables added where appropriate. Its major purpose and utility is in detecting trends among selected vulnerable and high-risk population groups whose behavioral change can have the most impact on the epidemic. BSS is also useful for tracking trends in behaviors over time in regions exposed to HIV prevention activities, as a contributing component to the comprehensive monitoring and evaluation of interventions. Recommendations: (i) implement BSS as an essential adjunct to HIV/STD epidemiological surveillance; (ii) use BSS for evaluation purposes in combination with process data and triangulate results with qualitative research; (iii) choose sentinel groups based on epidemiological considerations, evaluation and monitoring needs, representative sampling frames, and political and cultural considerations; (iv) maintain 1-year intervals between survey waves for most groups in order to provide yearly updates on behavioral trends for programmatic adjustments; (v) use internationally standardized indicators and question wording; (vi) maintain strict quality control standards to enhance data validity and reliability; and (vii) develop a clear dissemination strategy during BSS design to increase the likelihood of utilization of BSS results. Conclusion: BSS represents a cost-effective way to determine whether programmatic behavioral targets and goals are being met, to identify persisting risk behaviors over time, and to indicate whether new intervention approaches are necessary.

The authors have conducted an analysis to validate a computer model that uses age-specific human immunodeficiency virus (HIV) prevalence data to estimate age-specific HIV incidence rates. Data for the analysis are from a cohort study of volunteer male workers in Bujumbura, the capital city of Burundi. Testing for HIV prevalence was conducted at baseline, and HIV-negative subjects were retested annually from 1990 to 1993 to determine rates of seroconversion. Input parameters required for the model include age-specific HIV prevalence and estimates of age-specific mortality rates for HIV-negative and HIV-positive subjects. Incidence rate estimates from the model were 2.0, 2.7, 1.0, 1.5, and 1.8 per 100 person-years for age groups 20-24, 25-29, 30-34, 35-39, and 40-44 years, respectively. Corresponding observed incidence rates for the same age groups were 1.6, 1.8, 2.2, 2.3, and 1.5 per 100 person-years, respectively. Most observed incidence rates fell within the 95% confidence limits of the model estimates. Expected numbers of cases within age intervals did not differ significantly from observed number of cases. The authors conclude that the model proved to be successful in approximating observed incidence rates and that it is a useful tool, particularly in countries where prevalence data are available and where HIV prevalence has stabilized, which is when the underlying assumptions in the model are best met. The model provides crucial information about incidence rates that might not be evident from prevalence data alone.The authors conducted an analysis to validate a computer model which uses age-specific HIV prevalence data to estimate age-specific HIV incidence rates. Data for the analysis are from a cohort study of volunteer male workers in Bujumbura, Burundi. Subjects were tested at baseline for infection with HIV, with the HIV-negative subjects retested annually from 1990 to 1993 to determine rates of seroconversion. The computer model requires the input of age-specific HIV prevalence and estimates of age-specific mortality rates for HIV-negative and HIV-positive subjects. The model produced incidence rate estimates of 2.0, 2.7, 1.0, 1.5, and 1.8 per 100 person-years for age groups 20-24, 25-29, 30-34, 35-39, and 40-44 years, respectively. Corresponding observed incidence rates for the same age groups were 1.6, 1.8, 2.2, 2.3, and 1.5 per 100 person-years, respectively. Most observed incidence rates fell within the 95% confidence limits of the model's estimates such that the expected numbers of cases within age intervals failed to differ significantly from the observed numbers of cases. The authors believe that the model successfully approximated the observed incidence rates. It may therefore be highly useful in countries where prevalence data are available and where HIV prevalence has stabilized.

This paper presents key methodological approaches and challenges in implementing and analysing the first round of the integrated biobehavioural assessment of most-at-risk populations, conducted in conjunction with evaluation of Avahan, the India AIDS initiative.The survey collected data on HIV risk behaviours, sexually transmitted infections and HIV prevalence in 29 districts in six high-prevalence states of India. Groups included female sex workers and clients, men who have sex with men, injecting drug users and truck drivers. Strategies for overcoming some challenges of the large-scale surveys among vulnerable populations, including sampling hidden populations, involvement of the communities targeted by the survey, laboratory and quality control in remote, non-clinic field settings, and data analysis and data use are presented.Satisfying the need for protocols, guidelines and tools that allowed for sufficient standardization, while being tailored enough to fit diverse local situations on such a large scale, with so many implementing partners, emerged as a major management challenge. A major lesson from the first round is the vital importance of investing upfront time in tailoring the sampling methods, data collection instruments, and analysis plan to match measurement objectives.Despite the challenges, the integrated biobehavioural assessment was a huge achievement, and was largely successful in providing previously unavailable information about the HIV situation among populations that are critical to the curtailment of HIV spread in India. Lessons from the first round will be used to evolve the second round into an exercise with increased evaluative capability for Avahan.