H.I.V.

SENTINEL
SURVEILLANCE
Dr. Rajesh Kamath
Assistant Professor
Department of Public health
Manipal University

Introduction
According to the HIV Estimates for 2012, the
estimated number of people living with
HIV/AIDS in India was 20.89 lakh in 2011.
The adult (15-49 age-group) HIV prevalence
at national level has continued its steady
decline from an estimated level of 0.41% in
2001 to 0.27% in 2011.
But still, India is estimated to have the third
highest number of estimated people living
with HIV/AIDS, after South Africa and Nigeria
(UNAIDS Report on the Global AIDS epidemic
2010).

The top 20 People living with

HIV / AIDS
Rank Country People with HIV/AIDS
1 South Africa
5,600,000
2 Nigeria
3,300,000
3 India
2,400,000
4 Kenya
1,500,000
5 Mozambique
1,400,000
6 Tanzania
1,400,000
7 Uganda
1,200,000
8 United States
1,200,000
9 Zimbabwe
1,200,000
10 Russia
980,000

The top 20 People living with

HIV / AIDS
11 Zambia
980,000
12 Malawi
920,000
13 China
740,000
14 Cameroon
610,000
15 Thailand
530,000
16 Cote d'Ivoire 450,000
17 Ukraine
350,000
18 Botswana
320,000
19 Indonesia
310,000
20 Lesotho
290,000

The top 20 HIV/AIDS adult prevalence

rate
Rank

rate
1
2
3
4
5
6
7
8
9
10

Country
Swaziland
Botswana
Lesotho
South Africa
Zimbabwe
Zambia
Namibia
Mozambique
Malawi
Uganda

HIV/AIDS adult prevalence

25.9
24.8
23.6
17.8
14.3
13.5
13.1
11.5
11
6.5

The top 20 HIV/AIDS adult prevalence

rate
11 Kenya

6.3
12 Tanzania
5.6
13 Cameroon
5.3
14 Gabon
5.2
15 Equatorial Guinea
5
16 Central African Republic
4.7
17 Nigeria
3.6
18 Cote d'Ivoire
3.4
19 Congo, Republic of the
3.4
20 Chad
3.4
88 INDIA
0.3

Introduction

1. The annual national HIV Sentinel Surveillance

(HSS) is one of the components of second
generation HIV surveillance in India.
2. Indias HSS system is the largest HSS system
in the world.
3. The HSS system helps in understanding the
dynamics of the HIV epidemic and monitoring
the trends among different population groups
and geographical areas and, thus,
4. provides inputs to the programme for
strengthening prevention and control activities.

Introduction
5. The sentinel sites have been scaled up in a
phased manner from 180 in 1998 to 1359 in
2010-11.
6. 696 ANC sites, 184 STD sites and 479 sites
among high risk groups (Female Sex WorkersFSW, Men who have Sex with Men-MSM,
Transgenders-TG & Injecting Drug Users-IDU) and
bridge population(Single Male Migrants-SMM &
Long Distance Truckers-LDT).
7. A total of 4,27,559 samples were collected and
tested during HIV Sentinel Surveillance 2010-11.

Introduction
8.

Almost every district in the country is now

covered under surveillance.
9. Under HSS, an antenatal clinic in
government or private hospitals is designated
as an ANC sentinel site where 400 pregnant
women (ANC attendees) are recruited.
10. Similarly, the STD clinic and Gynaecology
(OBG) clinic in the same (or nearby)
government facility are together designated as
an STD sentinel site where 150 STD patients
attending the STD clinic and 100 female STD
patients attending the OBG clinic, are included
in surveillance.

Introduction
11.

Surveillance is carried out over a

period of three months.
12. Three staff-members at each facility
are given the responsibility to implement
the surveillance activities.
13. They include a doctor, who is
designated as the sentinel site in-charge,
14. a nurse or counselor who assists in
data collection and a
15. laboratory technician responsible for
collection of the blood specimens.

Introduction
HIV

prevalence among different population

groups in 2010-11 shows that HIV is
concentrated among High Risk Groups
Transgenders (8.82%), IDU (7.14%), MSM
(4.43%) and FSW (2.67%) while HIV
prevalence among ANC clinic attendees,
considered proxy for general population, is low
at 0.40%.
Bridge population groups have HIV prevalence of
0.99% among migrants and 2.59% among
truckers.

What is HIV Sentinel

Surveillance ?
HIV Sentinel Surveillance is defined as
a system of monitoring HIV epidemics
among specified population groups
by collecting information on HIV from
designated sites (sentinel sites) over years,
through a uniform and consistent
methodology that allows comparison of
findings across place and time,
to guide programme response.

What is HIV Sentinel

Surveillance ?
Sentinel

Site is defined as
a designated service point/facility,
where blood specimens & relevant
information are collected from a fixed
number of eligible individuals,
from a specified population group over a
fixed period of time, periodically, for the
purpose of monitoring the HIV
epidemic.

Objectives of HIV Sentinel

Surveillance (HSS)
1.

To monitor trends in prevalence of HIV

infection over time.
2. To monitor the distribution and spread
of HIV prevalence in different population
subgroups and in different geographical
areas.
3. To identify emerging pockets of HIV
epidemic in the country.

Groups covered under HSS

1. High Risk Groups: FSW, MSM, TG & IDU
2. Bridge Population: Migrants & Truckers
3. Low Risk Population: Pregnant women attending ANC Clinics

FSW
Female Sex Worker
MSM
Men who have Sex with Men
TG
TransGender
IDU
Injection Drug Users

Epidemiological basis of HIV Surveillance

Male
clients

MALES

FSW
MSM

Spouses/
Partners
FEMALES

CHILDREN

IDUs

Why surveillance among ANC

clinic attendees?

1. Pregnant women represent the sexually

active segment of general population, and
hence taken as proxy for monitoring HIV among
general population
2. Unlinked Anonymous Testing strategy is
possible only at those clinics where testing and
blood specimen collection is done routinely. At
ANC clinics, routine blood specimen collection is
done for Syphilis and Hemoglobin testing, a part
of which can be used for HIV testing
3. Pregnant women represent a more
homogeneous group than persons attending any
other clinic/ OPD.

Why surveillance among ANC

clinic attendees?
4.

Pregnancy, being physiological, does

not introduce any bias in HIV prevalence
which other illnesses/ diseases may
introduce due to underlying factors
common to HIV
5. Facilities for antenatal care are
available across the country at different
levels of health care system and hence
are feasible for implementation

Methodology of
HIV Sentinel
Surveillance at
ANC sites

Inclusion Criteria
1.

Inclusion Criteria for ANC sentinel

surveillance:
2. Age group 15-49 years.
3. Pregnant women attending the
antenatal clinic for the first time during
the current round of surveillance.

Inclusion Criteria

If the pregnant woman becomes eligible by the above

criteria, she should be included in surveillance,
irrespective of:
1. Date of antenatal registration.
2. HIV positivity status (if known to counsellor or
treating doctor).
3. Participation in previous rounds of surveillance.
4. Whether she is being tested for HIV under PPTCT
(or not).
5. A pregnant woman should be recruited only once
during a round of surveillance. To ensure this, verify
the date of her previous visit to ANC clinic.
6. If the date of her previous visit to ANC clinic falls
during the current round of surveillance, she should
be excluded from the sample.

Recruitment Process at
ANC Sentinel Site

Eligibility Criteria &

Consecutiveness
applied here

Case discussion 1
21 year old Geeta is studying in 2nd year BA.
She is 7 months pregnant and has come to the
ANC OPD on 12th March 2013.
This is her second visit and she had earlier
come to the ANC clinic on 19th December 2012.
Surveillance at your ANC clinic started from 1st
January 2013.
Her husband is a clerk in a local bank and they
live in the same town.
Is this woman eligible for surveillance?

Case discussion 2
A

14 year old tribal girl is brought to the

ANC OPD on 15th January 2013 by her
mother with 5 months amenorrhea.
She is unmarried, does not go to school
and helps her mother in the house.
This is her first pregnancy.
This is her first visit to the clinic.
Is this female eligible for surveillance?

Components of Sampling Methodology

For each sentinel site, the same approach must be
applied during every round of surveillance. 3
things need to be constant :
1. Sample size the number of people to be
recruited for HSS.
2. Sampling method - the approach adopted at the
sentinel site for recruiting eligible individuals in
HSS Consecutive sampling with Unlinked
anonymous testing.
3. Duration of sampling - how long to recruit for
HSS 3 months no more, no less.

Sample Size
1.

The recommended sample size for

ANC surveillance per site is 400.
2. This sample size is feasible to be
achieved in a period of three months.
3. This sample size is adequate for
monitoring HIV trends.

Consecutive Sampling
1. From the start of surveillance, all individuals
attending the sentinel site facility who are eligible for
inclusion in surveillance as per the defined criteria,
should be recruited in the order they attend the clinic.
2. Every successive individual should be recruited in
HSS till designated sample size of 400 is achieved or
the designated period of three months is over,
whichever is earlier.
3. This sampling method removes all chances of
selection or exclusion based on individual preferences
and other reasons, and hence reduces selection bias.
4. It is convenient and easy to follow.

Consecutive Sampling
5.

In clinics with large daily attendance, it is

recommended that not more than 20 consecutive
eligible attendees be recruited per day (to ensure
quality of surveillance data collection).
6. In such cases, the first 20 eligible attendees on
a given day should be recruited.
7. Sample collection should be stopped once the
target of 400 has been achieved, or
at the end of the three month period, even if the
target of 400 is not achieved.

Consecutive Sampling
8. In order to reach the target, sentinel
sites SHOULD NOT recruit pregnant women
admitted in the hospital/labour ward or
through special campaigns to increase OPD
attendance or by holding special camps or
by any other means.
9. Data from sentinel sites are much more
useful and reliable when the strategy of
consecutive sampling is strictly adhered to.

Implications of not doing

Consecutive Sampling
1.

There may be chances of selection bias in

enrolling the women by sentinel site staff.
2. There may be a chance of including or
excluding individuals with a specific
characteristic that may affect HIV
prevalence. (E.g. If women with known HIV
status get preferentially enrolled or
eliminated, the HIV prevalence in the
women sampled may be over-estimated or
under-estimated)

Case discussion 3
An

ANC surveillance site has not

managed to get the requisite sample
size at the end of three months of
surveillance period.
The site in-charge decides to continue
recruiting till they achieve the target
sample size of 400.
Is this the right approach?

Case discussion 4
The

site-in-charge at Jambhi CHC which

is a sentinel surveillance site, asks the
hospitals close to his facility to refer
pregnant women to the CHC as sentinel
surveillance is on-going.
Are these instructions correct?

Case discussion 5
In a district hospital with an average daily OPD
of 40 pregnant women at the ANC clinic,
surveillance was not initiated from the
designated date as doctor was on leave.
Towards the end of surveillance, when the
doctor joins duty, he asks the nurse to start
collecting samples from all pregnant women
who come to the clinic and completes the target
in 10 days, within the three month period.
Is this the right approach?

Testing
strategy for ANC
sentinel sites

Unlinked Anonymous Testing

1. HIV Testing is done on a portion of blood specimen

collected for routine diagnostic purposes (such as Syphilis,
Hepatitis B) after removing all personal identifiers.
2. The information collected in the data form, or the HIV test
result from the blood specimen should NEVER be linked to
the individual from whom the information/specimen is
collected.
3. Neither the staff collecting the blood specimen nor the
staff testing the blood specimen must be able to track the
results back to the individual.
4. Therefore personal identifiers such as name, address, OPD
registration number etc. should NOT be mentioned anywhere
on the data form, blood specimen, data form transportation
sheet or sample transportation sheet.

 5. Similarly,
Unlinked
Anonymous Testing
HSS sample

number or any mark

indicating inclusion in HSS should not be
mentioned in the ANC register or ANC patient
card/ OPD card.
6. Part of the blood specimen with identifiers is
used on site for conducting routine test for
which it has been collected. Part of the blood
specimen without identifiers is sent for HIV
testing under HSS.
7. Report of the prescribed diagnostic test (e.g.
syphilis test) MUST be communicated to the
participant.

Case discussion 6
The

laboratory technician after drawing

blood for syphilis testing and HSS, labels
both aliquots with the patient name and
ANC registration No./OPD No. and tests
required.
He then sends the HSS samples to the
HSS testing lab and retains the other for
syphilis testing at the local lab.
Is this the correct procedure?

Case discussion 7
The

laboratory technician draws blood specimens

from eligible pregnant women during the first week
of surveillance.
He sends the samples as per protocol to the HSS
testing lab.
He makes a note of the HSS sample number on the
ANC/lab register and calls up the HSS testing lab to
know which samples were positive.
He calls the positive women to let them know so
they can seek immediate medical help.
Is this the correct procedure?

Case discussion 8
In

an ANC clinic, the counsellor marks SS, in

the ANC registration card for all eligible
attendees to make a note for ANC attendees who
have been included for HSS, to avoid duplication.
As attendees come in, he first checks for this
mark on the registration card and includes only
those that do not have the SS mark, and who
meet the eligibility criteria.
Is this approach violating any principles of HSS
that you have learnt so far?

 References

http://www.naco.gov.in/NACO/National_A

IDS_Control_Program/10711/

THANK
YOU