Working Group on Global HIV/AIDS/STI Surveillance
UNAIDS/WHO Working Group on Global
HIV/AIDS and STI Surveillance
UNAIDS/WHO
Guidelines for STI
surveillance
Working Group on Global HIV/AIDS/STI Surveillance
major causes of acute illness
 may lead to infertility
 can impose long term disability
 have psychological consequences
 may result in death
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UNAIDS/WHO
STIs: 333 million curable
cases/year
North America
14 million
Western Europe
16 million
North Africa & Middle East
10 million
Latin America &
The Caribbean
36 million
Sub-Saharan Africa
65 million
Global total: 333 million
* gonorrhoea, chlamydial infection, syphilis and trichomoniasis
East Asia & Pacific
23 million
South & South-East Asia
150 million
Australasia
1 million
UNAIDS/WHO
Eastern Europe and Central Asia
18 million
Working Group on Global HIV/AIDS/STI Surveillance
Estimated new cases of curable STD* among
adults, 1995
Working Group on Global HIV/AIDS/STI Surveillance
1 - Case reporting
2 - Prevalence assessment and monitoring
3 - Assessment of STI syndrome etiologies
4 - Antimicrobial resistance monitoring
5 - Special STI surveillance-related studies
6 - Evaluation
UNAIDS/WHO
STI Surveillance Components
Types and formats of case reporting:
 Syndromic vs. Etiologic
 Universal vs. Sentinel
UNAIDS/WHO
The type of case reporting used depends
on the availability of laboratory tests in
clinical care.
Working Group on Global HIV/AIDS/STI Surveillance
Case Reporting
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asses disease burden
monitor trends in incidence
provide information useful in programme
planning and management
provides info required for patient and
partner management
provide data necessary for managing
health services
UNAIDS/WHO
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Working Group on Global HIV/AIDS/STI Surveillance
Objectives of case-reporting
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Practical to establish
No need of laboratory facilities
Can be performed at any level
Provides information to
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Assess disease burden,
monitor trends in incidence,
assist in programme planning and management
plan and manage delivery of health services
LIMITATIONS
Only urethral discharge and genital ulcer disease (nonvesicular) are potentially useful for monitoring trends in STD
incidence
Provides poor assessment of disease burden and trends in
women
Syndromes are not pathogen specific
UNAIDS/WHO
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Working Group on Global HIV/AIDS/STI Surveillance
Syndromic case-Reporting
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uses no laboratory diagnostic tests
uses flow charts as a basis for diagnosis
and treatment
provides treatment for diagnosis with
multiple causative agents
syndromic reporting fits in the context of
management
UNAIDS/WHO
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Working Group on Global HIV/AIDS/STI Surveillance
Syndromic Management
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requires well-developed systems of
laboratory diagnosis incorporated into
routine STD clinical care
requires diagnosis based on laboratory
testing
LIMITATIONS
Many STIs are not useful for monitoring
trends in incidence
More useful for monitoring trends in STI
incidence in men as compared to women
Availability of diagnostic tests does not
assure quality
UNAIDS/WHO
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Working Group on Global HIV/AIDS/STI Surveillance
Etiologic Case-Reporting
Provides a minimum estimate of
population based STI incidence
Advantage:
 Good for reporting ongoing information
on the capacity of health care providers to
report STIs
UNAIDS/WHO
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Working Group on Global HIV/AIDS/STI Surveillance
Universal Case-Reporting
UNAIDS/WHO
Purposes include:
 assessment proportion of clinic attendees
with STI compared with other conditions
 determination of STI distribution seen at
clinics
 assessment of trends in numbers of cases at
sentinel sites, as a possible indication of
trends in disease burden in the community
Working Group on Global HIV/AIDS/STI Surveillance
Sentinel Case-Reporting
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Disadvantages
cannot be used to
provide minimum
population-based
rates of disease
not representative of
other clinics
integration of quality
STD care into primary
care may suffer
UNAIDS/WHO
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Advantages
obtain higher quality
data
more detailed data on
patients
Working Group on Global HIV/AIDS/STI Surveillance
Sentinel-Case Reporting
Working Group on Global HIV/AIDS/STI Surveillance
Can be difficult to co-ordinate but may be
improved through:
 site visits
 training courses
 provision of written updates on STI
diagnosis and treatment
UNAIDS/WHO
Case-Reporting in the Private
Sector
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Annually
annual case reports
annual trend in overall
population-based
rates of reported
cases, using available
census data and
stratified by basic
demographic
categories
UNAIDS/WHO
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Quarterly
comparison of
quarterly number of
case-reports with the
same quarter from
previous year
examination of
quarterly trends in
number of cases and
prevalence from past
1-2 years
Working Group on Global HIV/AIDS/STI Surveillance
Analysis of Case-Reports
UNAIDS/WHO
Primary purposes:
 identify population subgroups with high
STI prevalence
 monitor trends in STI prevalence among
defined populations
Primary limitation:
 no role in the management of individual
patients and their partners
Working Group on Global HIV/AIDS/STI Surveillance
Prevalence Assessment and
Monitoring
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syphilis (m,f)
gonorrhoea (m,f)
chlamydia (m,f)
trichomoniasis (f)
genital ulcer disease (m,f)
urethral discharge (m)
Working Group on Global HIV/AIDS/STI Surveillance
In settings where patients are seen
without relation to symptoms
UNAIDS/WHO
Useful STIs for prevalence
assessment and monitoring
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best done among high risk populations
which are likely to have high prevalence
minimally, assessment of prevalence must
be done in major cities
assessment of STI prevalence among
women should include: syphilis,
chlamydia, and genital ulcers.
Working Group on Global HIV/AIDS/STI Surveillance
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UNAIDS/WHO
Prevalence Assessment
Studies
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sample size
data elements and reporting formats
measuring test positivity vs.
prevalence
linkages with HIV seroprevalence
surveys
analysis and interpretation
Working Group on Global HIV/AIDS/STI Surveillance
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UNAIDS/WHO
Elements of Prevalence
Studies
UNAIDS/WHO
Objectives:
 Provide data for guiding STI syndromic
management
 Assist in the interpretation of syndromic
case-reports
 Assist in the assessment of disease
burden due to specific pathogens
Working Group on Global HIV/AIDS/STI Surveillance
Assessing Syndrome Etiologies
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microscopy; chlamydia testing in selected settings
For genital ulcer disease:
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syphilis serologic testing
chancroid culture, HSV culture or antigen detection test
available in selected settings
For vaginal discharge syndrome:
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Gram stain, wet mount, KOH prep
diagnostic test for chlamydia and gonorrhea
Working Group on Global HIV/AIDS/STI Surveillance
For urethral discharge:
UNAIDS/WHO
Laboratory Requirements for
Assessing Syndrome Etiologies
Antimicrobial Resistance Monitoring
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OBJECTIVES
To obtain data necessary for developing
guidelines for treatment
Demographic and risk information obtained may
also be used to further characterize risk factors
for resistance
Determine the local epidemiology of a disease
UNAIDS/WHO
As a core component of STI surveillance and because of the
extensive use of antibiotics to treat gonococcal infections, it is
important for all countries to monitor microbial resistance in N.
gonorrhoeae. If chancroid is high, periodic assessment of
resistance in H. ducreyi is also recommended.
Working Group on Global HIV/AIDS/STI Surveillance
Neisseria gonorrhoeae/Haemophilus ducreyi
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ability to culture organisms
perform biochemical and serologic
confirmatory tests
testing for the minimum inhibitory
concentration on antimicrobial
agents
Working Group on Global HIV/AIDS/STI Surveillance
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UNAIDS/WHO
Laboratory requirements
for resistance monitoring
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Examples
outbreak investigations
prevalence of viral STIs
estimation of economic costs of STIs
Working Group on Global HIV/AIDS/STI Surveillance
Used to address STI surveillance issues
which are not part of routine case
reporting or prevalence assessments.
UNAIDS/WHO
Special STI Surveillance -related
Studies
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identification of all STI surveillance activities,
characterized by components, and syndrome or
disease
initially evaluate each component separately, separate
attention should be paid to each syndrome or disease
overall assessment identifying gaps, duplication, and
areas in need of strengthening
Working Group on Global HIV/AIDS/STI Surveillance
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UNAIDS/WHO
Evaluation of Surveillance
Systems
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disseminate to health centers and
clinicians
national STI programme managers
In communicating consider using...
 annual reports
 newsletters
 press releases
 fact sheets
UNAIDS/WHO
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Working Group on Global HIV/AIDS/STI Surveillance
Disseminating, communicating,
and using STI surveillance data