(WP)/OCD/STD(4)/97
ENGLISH ONLY
Report series no.: RS/97/GE/28(PHL)
REPORT
WORKSHOP ON HIV, AIDS AND STD EPIDEMIOLOGY IN THE WESTERN PACIFIC REGION Convened by the REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION Manila, Philippines 8-10 September 1997
Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines November 1997
NOTE
The views expressed in this report are those of the participants of the Workshop on HIV. AIDS and STD Epidemiology in the Western Pacific Region and do not necessarily reflect the policies of the World Health Organization
This report has been prepared by the Regional Office for the Western Pacific Region of the World Health Organization for governments of Member States in the Region and for the participants of the Workshop on HIV, AIDS and STD Epidemiology in the Western Pacific Region, which was held in Manila, Philippines from 8 to 10 September 1997.
CONTENTS
SUMMARY 1. INTRODUCTION ................................................................................... . 1. 1 1. 2 1.3 1.4 2. Objectives ......................... ' ................................................................ 1 Participants and resource persons ............................................................. I Organization of the workshop ................................................................. , 1 Opening Ceremony ............................................................................... 1
PROCEEDINGS ........................................................................................ 2 2.1 2.2 2.3 2.4 Summary of the first day ........................................................................ 2 Summary of the second day .................................................................... 2 Summary of the third day ....................................................................... 3 Evaluation ................................................................. , ........................ 3
3.
CONCLUSIONS ........................................................................................ 4 ANNEXES: ANNEX I ANNEX 2 ANNEX 3 LIST OF PARTICIPANTS ........................................................ 7 WORKSHOP SCHEDULE .................................................... 11 WORKSHOP EVALUATION FORMS ...................................... 13
SUMMARY
In order to enhance the surveillance of HIY I AIDS and STDs in the Western Pacific Region, Joint United Nations Programme on HlY/AIDS (UNAIDS) and WHO Regional Office for the Western Pacific jointly hosted a three-day workshop with representatives from nine countries and areas of the Region. The workshop participants reviewed available information on HIV, AIDS and curable STDs and compiled fact sheets containing key epidemiological information for the Region. In addition, recommendations were made to improve the collection, analysis and use of epidemiological information. This workshop was the first on STD, HIY and AIDS epidemiology in the Western Pacific Region and is perceived as an initial step towards the development of a regional network of professionals involved in epidemiological surveillance. This workshop also provided a better understanding of the relations between Ministries of Health, WHO and UNAIDS. The majority of participants found that the workshop had focused on their needs, that the objectives of the workshop had been achieved and it had been worthwhile.
1. INTRODUCTION
1.1
Objectives
The general objective of the workshop was 10 compile and review key epidemiological information on HIV, AIDS and curable STDs by country, in order to improve understanding of the dynamics and to provide a better basis for decision-making and effective programme implementation at national, regional and global levels. Specifically, the workshop objectives were: (1) to collaborate in finalizing country-specific epidemiological fact sheets which will include at least three sections: statistics and indicators, a summary of prevalence studies, and discussion of the data; and (2) to prepare a report to include observations on the strengths and weaknesses of existing surveillance systems, and recommendations/proposals to improve the flow of epidemiological information about the current epidemiological situation in the Western Pacific Region. 1. 2 Participants and resource persons There were eleven participants representing eight Member States. The secretariat from the Western Pacific Regional Office provided technical and operational support for the training course. The list of participants is attached as Annex I. 1.3 Organization of the workshop
The workshop was held at the Western Pacific Regional Office from 8 to 10 September 1997. A range of methods was used during the workshop including: presentations, small group discussion sessions with five to six participants, plenary sessions and country-specific working sessions. 1.4 Opening Ceremony
Dr S.T. Han, Regional Director, WHO Regional Office for the Western Pacific, opened the meeting. Dr Han highlighted the crucial role of surveillance systems in constructing estimates and projections of HIV infection, for building national and international awareness and advocacy, for designing appropriate interventions, and for planning the health care resources needed for the care of AIDS patients. Professor Zheng Xiwen was designated as chairman of the meeting, and Dr Nguyen Thi Thanh Thuy as rapporteur.
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2. PROCEEDINGS
2.1
Summary of the first day
2.1.1 Presentation: Overview of HIV / AIDS/STDs status and surveillance activities developed in the West Pacific Region The Regional Adviser in Sexually Transmitted Diseases and AIDS delivered the presentation. He stated that the HIV/AIDS epidemic is spreading in the Western Pacific Region although it is currently at a low level. Most countries now have an established system of both HIV / AIDS case reponing and surveillance in selected groups of population. Curable STDs are highly prevalent in the Region, chlamydial infections in panicular. WHO has estimated that the prevalence of all curable STDs in the Western Pacific Region is 35 million. The extent of this epidemic needs funher exploration. Monitoring of antibiotic resistance shows that this is also a growing problem, panicularly the resistance to penicillin. 2.1.2 Presentation: Update on methods for HIV / AIDS surveillance The Senior Epidemiulogist from UNAIDS Headquaners in Geneva, explained that HIV sentinel surveillance was set up to indicate the magnitude of the epidemic, its geographic distribution and trends over time. Preliminary plans which have been drawn up for expanding surveillance were presented. The new generation of surveillance will focus on younger age groups and will integrate behavioural data. 2. 1.3 cases Presentation: Overview of the methods for estimation and projection of HIV / AIDS
The Deputy Director of the National Centre in HIV Epidemiology and Clinical Research, Australia, made a presentation on HIV / AIDS key indicators (HIV incidence, HIV prevalence and AIDS incidence) and the methods for their direct and indirect measurement.
2.1.4
Presentation: Demonstration of Epimodel
The WHO Consultant, gave a computer-assisted presentation of the software developed by WHO. 2. 1.5 Country-specific working session
Participants were introduced to the two formats for epidemiological data that had been prepared by UNAIDS and WPRO. Every participant had then a chance to review and complete the data sheets before their discussion during a plenary session. 2.2 2.2.1 Summary of the second day Sheet format discussion
As requested by the participants, the agenda was changed slightly and the second day staned with a plenary discussion about the proposed structure of the STD summary sheet format. It was felt that more structured sub-headings would help in completing and reading the forms. A consensus for modifying some of the sub-headings was reached.
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2.2.2
Presentation: Overview of methods for STO surveillance
The main issues and limitations for curable STOs surveillance systems was highlighted by the Regional Adviser. He emphasized the importance of curable STD as a public health problem not only because of the high morbidity and potential sequela, but also because of their role in HIV transmission. 2.2.31 Country-specific working session
The next session was introduced by the Consultant with a presentation of the Regional STO database developed by WHO Regional Office for the Western Pacific. The participants were then convened to another working session to revise and complement the section of the epidemiological sheets related to curable STOs. The session was followed by a discussion. It was pointed out that estimates for curable STOs were difficult to calculate because of the lack of standardized methodology for data collection and interpretation and also because of the relative scarcity of data. The WHO Regional Office for the Western Pacific emphasized that figures contained in the data sheets should be seen as rough estimates. The need for enhanced programmes for STO prevention and control was stressed. It was agreed that Member States would try to refine STO estimates despite their current limitations, while developing surveillance on curable STOs at the same time. 2.2.4 Presentation: Health care and other indicators; Prevention indicators
The Senior Epidemiologist from UNAIDS presented the methodology for collection of the indicators and their potential use and limitations. It was noted that few countries in the Western Pacific Region have been collecting data related to these indicators. 2.3. 2.3.1 Summary of the third day Country-specific working session:
The session began with a brief introductory presentation delivered by the Statistician from WHO Headquarters, Geneva. She presented the format and the use of the surveillance questionnaire prepared by WHO. Each participant was then asked to revise and complete the form corresponding to their country. 2.3.2 Working session: Strengthening surveillance systems at the country level
The participants broke into two groups to discuss the strengths and weaknesses of epidemiological surveillance systems in the Region as well as articulate future directions of work. Both groups presented their conclusions. A common text highlighting the main features was then drawn up and revised by all participants in a plenary session. 2.4 Evaluation
An evaluation questionnaire with 18 questions was distributed to all participants at the end of the meeting. The majority of participants found that the workshop had focused on their needs, that the objectives of the workshop had been achieved and that it had been worthwhile. About half of the participants thought that the meeting had been well conducted. The complete set of answers is given in Annex 3.
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3. CONCLUSIONS
There is growing evidence that STDs (including HIV I AIDS) are a major public health issue. In the last few years, Member States have gained experience in HIV I AIDS surveillance methodology and in formulating estimates for HIV I AIDS. The participants appreciated the workshop, which gave them the opportunity to update their knowledge as well as exchange ideas with colleagues from WHO, UNAIDS and other Member States in the Region. This workshop was the first on STD, HIV and AIDS epidemiology in the Western Pacific Region and is perceived as an initial step towards the development of a regional network of professionals involved in epidemiological surveillance. This workshop also provided a better understanding of the relations between Ministries of Health, WHO and UNAIDS. Based on discussions during the workshop, strengths and weaknesses of STD, HIV and AIDS epidemiological surveillance as well as priorities for future directions were identified: Identified existing strengths: • HIV / AIDS case reporting and HIV surveillance in selected population groups are already in place; common reporting procedures (including HIV reporting) are in place throughout the Western Pacific Region; public health infrastructures are involved in HIV I AIDS surveillance; data are used for public health action; and data are used to build HIV/AIDS estimates and projections.
•
• • •
Identified existing weaknesses: (a) General issues: • • it is difficult to reach groups with high risk behaviour; there is a lack of standardized procedures for all types of surveillance, both at planning and implementation levels; there is a need to complement STD, HIV I AIDS with behavioural data and with information regarding the provision of health services; data collection in rural areas remains insufficient; and there is no systematic collection of identified programme indicators.
•
• •
(b) STD surveillance: • surveillance is insufficiently developed and supported;
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•
it is still based on case reporting subject to large under-diagnosis and underreporting; ad hoc surveys are implemented without a comprehensive and structured approach; and links with Health Ministry surveillance structures and with policy-making bodies remain insufficient. HIV sentinel surveillance;
• •
©
•
population groups surveyed remain limited.
(d) HIV I AIDS estimates and projections; • • updated national consensus are not regularly held; and there is generally a lack of standardized methods and procedures.
Future directions for work were also specified (a) • Country level: a review of HIV sentinel surveillance strategies and procedures should take place regarding: • • • • • • • (b) • • • • sample size number and distribution of sites target groups testing procedures (unlinked anonymous, voluntary confidential, etc.) implementation and management
behavioural surveillance should complement existing surveillance activities; STD surveillance should be strengthen. WHO and UNAIDS to continue advocacy and support to increase resources for surveillance; to facilitate the development of a regional network of experts; to develop guidelines for STD and behavioural surveillance; to revise existing guidelines for HIV I AIDS surveillance and in particular the second generation in order to adapt it to regional needs (e.g. HIV reporting and use of surveillance methods other than unlinked anonymous while preserving patient confidentiality); to disseminate experience with new technologies (saliva HIV testing, STD diagnostics) ;
•
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• •
to insure technical support for implementation; and to sustain and strengthen collection, analysis and dissemination of HIV / AIDS and STD data at the regional level.
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ANNEX 1
LIST OF PARTICIPANTS. CONSULTANT AND SECRETARIAT 1. PARTICIPANTS
AUSTRALIA
Dr John Kaldor Deputy Director National Centre in HIV Epidemiology and Clinical Research 2/376 Victoria Street Darlinghurst NSW 1010 Tel: +61 293324648 Fax: +61 29332 1837 E-mail: jkaldor@nchecr.unsw.edu.au Dr Tia Phalla Programme Manager National AIDS Committee Ministry of Health Phnom Penh Tel: 85523722515 Fax: 85523722515 E-mail: Dr Gong Xiang-Dong Assistant Fellow National Center for STD and Leprosy Control Institute of Dermatology Chinese Academy of Medical Sciences 12 J iangwangmiao Road Nanjing 210042 Tel:86 10 63186655 Fax: 8625 5414479 E-mail: Professor Zheng Xiwen Director Center for AIDS Surveillance Chinese Academy of Preventive Medicine 27 Nanwei Road Beijing 100050 Tel: 00 86 1- 6317 9516 Fax: 00 8610 63179516 E-mail:
CAMBODIA
CHINA
-8Annex 1
HONG KONG
Dr S.S. Lee Consultant Special Preventive Programme Office Department of Health Hong Kong Government 5/F, Yaumatei Jockey Club Clinic 145 Battery Street Kowloon Tel: 85227804390 Fax: 852 27809580 E-Mail: microssl@hkucc.hku.hk Dr Mohd Nasir bin Abdul Aziz Assistant Director (AIDSISTD) Division of Disease Control Public Health Department Ministry of Health Kuala Lumpur Tel: Fax~
MALAYSIA
E-mail: NEW ZEALAND Dr Nigel Dickson AIDS Epidemiology Group Department of Preventive and Social Medicine University of Otago Medical School P.O. Box 913 Dunedin Tel: 00 643 479 Fax: 00 643 479 7298 E-mail: ndickson@gandalf.otago.ac.nz Dr James Wangi Senior Specialist Medical Officer Department of Health P.O. Box 3991 Boroko. NCD Tel: 675 3236290 Fax: 675 301 3604 Dr Maria Consorcia Lim-Quizon Resident Epidemiologist HIV I AIDS Surveillance/FETP Department of Health San Lazaro CompoundSta Cruz Manila Tel: (632) 743 8301 Fax: (63 2) 743 6076 E-mail: hssfetp@portalink.com
PAPUA NEW GUINEA
PHILIPPINES
-9Annex 1 VIET NAM Dr Nguyen Tran Hien Programme Coordinator National AIDS Committee Sub-Committee of HIV Surveillance National Institute of Hygiene and Epidemiology 1 Yersin Street Hanoi Tel: 844 8524 1421 Dr Nguyen Thi Thanh Thuy Adjoin-chief of Public Health Department Pasteur Institute Ho Chi Minh City Tel: 848202815 Fax: 848823 1419
2. CONSULTANT
Dr Denis Pigot 3 Ave Sur #8 Antigua Guatemala Tel: (502) 832 0269 Fax: (502) 832 2887 E-mail: dpigot@pronet.net.gt
3 . SECRETARIAT
Dr Gilles Poumerol Regional Adviser in Sexually Transmitted Diseases and AIDS WHO Regional Office for the Western Pacific Manila Tel: (63 2) 528 9866 Fax: (63 2) 521 1036 E-mail: poumerolg@who.org.ph Mrs A. Ghee Short-term Professional WHO Regional Office for the Western Pacific Manila Tel: (63 2) 528 9866 Fax: (632) 521 1036 E-mail: gheea@who.org.ph
-1OAnnex 1 Dr B, Schwartlander Senior Epidemiologist Surveillance and Epidemiology Department of Country Support UNAIDS/Headquarters Geneva Switzerland Tel: (+4122) 791 3666 Fax: (+4122) 791 4187 E-mail: schwartlanderb@unaids.org
Ms M. Anker Statistician Division of Emerging and Re-emerging Communicable Diseases World Health Organization Geneva Switzerland Tel: (+4122) 7914564 Fax: (+4122) 791 E-mail: ankerm@who.ch
Workshop on HIV/AIDS/STD Epidemiology in Asia and Pacific Manila, Philippines, 8-10 September 1997 TENT ATIVE TIMET ABLE Time 0800-0830 0830-0900 0900-0910 0910-0930 0930-1000
WPR/OCD/STD/(4)/97.1-A
3 September 1997
Monday, 8 September Registration 1. Opening Ceremony 2. Introduction and objectives of the meeting 3. Overview of HIV / AIDS/STD status and surveillance activities developed in WPR 4. Update on methods for HIV / AIDS surveillance
Time 0800-0930
Tuesday, 9 September 8. Curable STD case reports and estimates - Overview of methods for STD survei llance - Country work: revision of curable STD case reports and estimates
Time 0800-0900
Wednesday, 10 September Item 11 (continued) - Country work: revision of available data for prevention indicators for the country level
0900-1030
- Presentation and interpretation of the prevention indicators
COFFEE 1030-1100 1100-1130 1130-1200 5. Overview of the methods for estimation and projection of HIV / AIDS cases 6. Demonstration of Epimodel 7. HIV / AIDS case reports and estimates - Presentation of country data sheets 1130-1200 100-1130
BREAK 1100-1200 12. Strengthening surveillance for HIV / AIDS and curable STDs at country level - Group work
Item 8 (continued) - Presentation and discussion of STD figures 9. WPRO computer database - Presentation LUNCH BREAK
..... .....
1330-1530
Item 7 (Continued) - Country work: revision of HIV / AIDS case reports and estimates - Presentation and discussion of HIV / AIDS data
1330-1430
Item 9 (continued) - Discussion on the database and its use at country and regional level 10. Demographic, socio-economic and health care indicators - Revision of country data II. Prevention indicators and their significance
1300-1400
Item 12 (continued) - Presentation and discussion of surveillance systems: accomplishments, strengths and weaknesses
1400-1515 1515-1530
13. Concl usions 14. Closing ceremony I
1600
Regional Director's Informal Get-together
- Introduction I
!'V
~
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ANNEX 3
WORKSHOP EVALUATION SUMMARY
General views: I personally found the workshop: (please tick boxes) Stimulating Useless Relevant Plenty of discussion Rigid Well conducted Demanding Patronizing Too spread out Coherent Focused on my needs Objectives achieved Little activity Worth time spent 4 1 1
4
4
2
1
Boring 1 Useful Irrelevant Too little discussion
4
5 5
3
1 1
5 2
2
2
5
Flexible Poorly conducted Undemanding
5 2
1
5 5 3 6
4
5 3 2
3
Challenging Too condensed Fragmented Focused on facilitator's opinion Objectives not achieved
5 4 4
3 2
5 1
2
5 3 1
4
1
Plenty of activity Not worth time spent
1