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Frerichs, R.R. HIV numbers, surveillance and program strategies.

SEA-AIDS Network, October 27, 1998.

R.R. Frerichs Posting

Estimates of HIV infection and AIDS cases tend to vary widely in most developing countries, depending on who is doing the estimation and the techniques they use to estimate the large pool of undetected cases.

Yet while varying numbers in countries such as Thailand, India or Vietnam may generate headlines and cause concern, it is not clear that they lead to different policies. The intent of HIV surveillance programs which have been established in most Asian countries is to provide crude estimates of the prevalence of HIV infection for planning or evaluating control programs. If surveillance programs are not tied to control efforts, they are more appropriately termed monitoring programs.

In surveillance programs once HIV is found to be present, then it becomes easier for government officials to mobilize the public and various service organizations to commit resources and address the problem. But what policies should be established and what programs should be funded? Given the enormous competition for government funds, the HIV programs that get money should have been shown to be effective in preventing HIV infection at less cost than competing programs such as childhood immunization campaigns, nutrition programs for pregnant women, or tuberculosis treatment efforts. While some may not accept such funding competition within the health care sector, it certainly is a reality in most Asian countries, now more evident then ever due to the regional economic problems.

When surveillance systems show that HIV is becoming more common, should public funds be spent on case-finding and partner notification so that additional infections can be prevented? Is finding cases and notifying long term sexual partners cost-effective, when compared to other proposed intervention or prevention strategies? If this information is not known (as is the case in most Asian countries), then local experimentation should be encouraged to develop new detection strategies, supporting approaches that do what they are supposed to do and rejecting those that don t.

To conduct such experimentation, researchers interested in case-finding will likely want to use newer HIV tests that do not require sophisticated laboratory personnel or require waiting of up to several weeks for the results. Such simple or rapid tests are described in the October 16th Weekly Epidemiological Record of the World Health Organization (volume 73, number 42, pp. 321-326, 1998) which can be downloaded from the website (no longer linked):

The article correctly notes that for surveillance programs, rapid or simple tests may have considerable advantages when seeking information on hard-to-reach populations such as IV drug users (a major problem in Myanmar, Vietnam and Southern China) and commercial sex workers (hard to reach in countries were brothels are not the main mode of service delivery), or information about persons living in remote areas (i.e., most countries in Asia). While the WHO article presents the need for testing of pregnant women, no mention is made of setting up testing and partner notification programs, or of using testing in creative ways to avoid further viral transmission. Because of the general reluctance throughout Asia to address HIV in an open manner, many look to WHO and UNAIDS for leadership in encouraging such testing efforts, and to support demonstration projects and experimentation to determine both the cost and effectiveness of various detection strategies.

Showing leadership in this area is difficult but essential in these troubled times when money is short, donors are fatigued and field workers are seeking new programs or efforts that might lead to success.