|Year : 2020 | Volume
| Issue : 5 | Page : 4-7
Site preparedness and quality of HIV sentinel surveillance at antenatal care clinic sites in India, 2019
Shashi Kant1, Sanjay Kumar Rai2, Shreya Jha3, Nishakar Thakur4, Puneet Misra2, Kiran Goswami2
1 Professor and Head of Department, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
3 Consultant, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
4 Statistician, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||04-Dec-2019|
|Date of Decision||24-Jan-2020|
|Date of Acceptance||10-Feb-2020|
|Date of Web Publication||14-Apr-2020|
Dr. Shreya Jha
Room No. 26, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Quality of HIV sentinel surveillance (HSS) depends on preparedness of the site and adherence to the standard operating procedures (SOPs) for HSS. A designated sentinel site is considered prepared for the round of sentinel surveillance based on the availability of infrastructure, human resource, and consumables. Objectives: The study objectives were to describe the site level preparedness and adherence to SOP of antenatal care clinic (ANC) sites during the 16th round of HSS in India. Methods: This was a cross-sectional study based on the findings of the supervisory visits conducted by public health specialists in ANC sites during the 16th round of HSS from January to March 2019. Semi-structured checklists were used to assess site-preparedness and adherence to the SOP for HSS. All supervisors were expected to upload the filled pro forma to the HSS management information system (MIS). We present here a descriptive analysis of the uploaded visit reports. Results: Of 870 HSS sites, 783 (90%) were visited, and 479 (61.2%) reports were uploaded to MIS. Preround HSS training was not attended by one-fifth (22.6%) of the site in-charges; 35.8% of them had never received any HSS training. SOP was followed at most (94%) of the sites. The most frequently reported problem at the sites was inadequate or delayed availability of consumables. Conclusion: The overall quality of site-level preparedness at antenatal clinic sites in India was good. Attention needs to be given to timely and adequate availability of consumables at sentinel sites along with proper administrative support and preround training of site in-charges.
Keywords: HIV sentinel surveillance, site preparedness, supportive supervision
|How to cite this article:|
Kant S, Rai SK, Jha S, Thakur N, Misra P, Goswami K. Site preparedness and quality of HIV sentinel surveillance at antenatal care clinic sites in India, 2019. Indian J Public Health 2020;64, Suppl S1:4-7
|How to cite this URL:|
Kant S, Rai SK, Jha S, Thakur N, Misra P, Goswami K. Site preparedness and quality of HIV sentinel surveillance at antenatal care clinic sites in India, 2019. Indian J Public Health [serial online] 2020 [cited 2020 Jul 4];64, Suppl S1:4-7. Available from: http://www.ijph.in/text.asp?2020/64/5/4/282414
| Introduction|| |
The prevalence of HIV among adults in India was 0.22% (95% confidence interval 0.16–0.30), with 21.4 million people living with HIV as per 2018 data. A laboratory-based surveillance was started in 1995 at 52 sites to monitor the geographic spread of the disease. To monitor the spread of disease in different population subgroups, a facility-based HIV sentinel surveillance (HSS) was started in 1998 at a total of 176 sites. These included antenatal care clinics (ANCs) (92 sites), sexually transmitted diseases clinics (76 sites), injecting drug users (5 sites), female sex workers (1 site), and tuberculosis clinic (2 sites). The HSS among pregnant women is currently carried out biennially. The numbers of ANC sites for HSS were periodically scaled up to better understand the level and trend of the disease epidemic in general population, particularly in low HIV prevalence states.
The 16th round of HSS among pregnant women visiting ANC was scheduled from January to March 2019. HSS in India was conducted as per the national guidelines. The evaluation of surveillance activities is an integral step to determine the quality of the current system and also to adjust the design and approach for future activities. Concurrent supervision and monitoring is the best way to determine the quality of surveillance. A key strength of HSS in India in the past was the quality of supportive supervision provided during the surveillance period. The supervisory team was a multitier system consisting of central team members, state surveillance teams (SSTs), regional institute (RI), and State AIDS Control Society (SACS).
Preparedness of a site is a prerequisite for good quality sentinel surveillance. Adherence to standard operating procedure (SOP), as described in the national guidelines, is essential to ensure good quality data. During the HSS period, supervisors undertook site visits to assess the preparedness of the sites, as well as to verify the adherence to SOP. The main objective of this paper was to describe the site level preparedness and adherence to SOPs of ANC sites during the 16th round of HSS.
| Materials and Methods|| |
This was a cross-sectional study. The supervisors were public health specialists with experience in HIV epidemiology and surveillance. The supervisors visited the ANC sites to provide supportive supervision. Supportive supervision for HSS was provided by the central team members (CTMs) at national level (who could visit any sentinel site in India), by the members of six RIs at regional level (who would visit any of the states in that region), and by members of the SST and SACS at the state level (who would visit to their respective state).
This round of HSS was scheduled from January to March 2019. However, some sites started at a later date due to logistic reasons.
All HIV sentinel sites that received at least one supervisory visit during this round were included for analysis. We excluded the sites visited by the SACS representatives only to avoid a potential conflict of interest.
Schedule of visits
Efforts were made so that the maximum number of the sites could be visited by one of the supervisory team members within the first 15 days of initiation of HSS activities. However, those sites where problems were reported in the previous HSS-round were prioritized for a supervisory visit. Priority was also accorded to the sites that were newly established in 2019.
Site-preparedness was assessed based on the availability of human resources, consumables and equipment, and biomedical waste (BMW) management practices. Adherence to SOP was assessed using a checklist, and observance of actual practice at the time of supervisory visits. Supervisors also enquired from site personnel regarding any difficulty faced by them in following the SOP.
A semi-structured checklist was used to assess the components of site preparedness and adherence to the SOP. Quality assurance: All tiers of supervisors as well as personnel at site level were provided appropriate training prior to the start of HSS. The CTMs were trained at national level. At the regional level, the SST members, and representatives of the SACS were trained. The site personnel, including site in-charge (medical officers [MO]), counselor, and laboratory technician (LT), was trained by SACS with support from the CTMs, SSTs, and RI.
Data were collected from January to March 2019 using the checklist. The data were then uploaded into the web-based management and information system (MIS). This MIS was specially designed for this round of HSS by the National Institute for HSS, All India Institute of Medical Sciences (AIIMS), New Delhi. The link of the MIS was shared with all the supervisors along with their username and password. Different modules were available in the MIS for different tier of the user as applicable. Supervisors uploaded the information in the MIS which was downloaded in the excel sheet and used for analysis. Inclusion and exclusion criteria: All complete entries in the web portal were included in this analysis. For sites that were visited more than once, only the first supervisory visit report was included in the analysis. Statistical analysis: the descriptive analysis was done using Microsoft Excel and STATA-12 software (StataCorp. 2011. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP) and reported as numbers and percentage. The responses to the open-ended questions were read and most commonly reported areas were identified. AIIMS is the National and Regional Institute for HIV surveillance and as national and Regional Institute, it was mandated to carry out epidemiological investigations periodically as part of maintaining the highest quality of surveillance data and to help optimal interpretation of the findings of surveillance. HSS is a part of an ongoing program which is conducted biennially. This was a secondary data analysis based on information collected during the HSS period and one of the authors (SR) is the custodian of the data. Hence, ethical clearance was not required.
| Results|| |
A total of 870 ANC sites participated in the 16th round of HSS of which 783 (90%) sites were visited by the supervisors. However, information was uploaded to the MIS for 479 (61.2%) sites. The total numbers of priority sites were 114 (including 97 problem sites from the previous round and 17 new sites) out of which information was uploaded to the MIS for 67 (58.8%) sites.
Most of the supervisory visits (60.5%) were made by the SST members, followed by CTM (31.3%). Most of the sites (80.8%) were well-established sites that had been carrying out HSS activities for more than 5 years. The start of HSS activity was delayed for more than a month in 19.4% of the sites. The most common reason cited for the delayed start of HSS was lack of administrative approval or nonavailability of consumables. Nineteen percent of site visits were made within the 1st month of the start of HSS [Table 1].
|Table 1: Characteristics of the HIV sentinel surveillance sites visited (n=479)|
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About two-thirds of sites (67%) had blood collection facility available at the clinic site itself. In the remaining one-third sites where blood collection sites were at a place other than the clinic; in about 75% of these sites, it was located in the same building, whereas for the rest of the sites (25%) it was in a different building. Majority of sites (89%) had a Prevention of Parent to Child Transmission Centre or Integrated Counseling and Testing Center available at the HSS site.
Of 479 sites, 17 sites (0.03%) reported the rejection of sera samples by their respective State Reference Laboratories (SRL). Supervisors recommended that 111 of the 479 (22.7%) sites should be revisited to assess if their recommendations had been complied.
Details about the personnel at site
A total of 108 (22.6%) MO had not received any training prior to the start of this round of HSS. Of these 39 (35.8%), MO had never received any training in HSS in the past either. The proportion of untrained counselors and LTs was low (about 6% each) [Table 2]. Approximately one quarter (23.2%) of the MO, 13.8% of counselors and 14% of LTs were participating in the HSS activity for the first time [Table 2].
|Table 2: Characteristics of personnel at antenatal care clinic sites (n=479)|
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SOP being followed at the site
SOP was being followed at most of the sites. Out of 479 sites, 342 sites (71.4%) were following all the SOPs. This showed that, in general, the quality of data collection was good. The only issue of concern was improper BMW management in 12% of the sites [Table 3].
|Table 3: Practices regarding components of standard operating procedure followed at HIV sentinel surveillance sites|
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Most of the sites (85%) dispatched the blood samples to SRL once in a week.
Gaps identified at the sites
Some open-ended questions were also included in the checklist so that the supervisors could share their overall experience and insight regarding the sentinel sites as well as list the issues raised by the site personnel. The most frequently reported problem by the site personnel was inadequate or delayed consumables required for the conduct of HSS. The most common recommendation from the supervisors was to adhere to the SOPs.
| Discussion|| |
HSS was conducted in 870 ANC sites spread over all the states and Union Territories in India from January to March 2019. Information was supposed to be uploaded to the MIS by the supervisors. All the sites for with information were uploaded on the website were included in the analysis.
Most of the sites were functional for more than the past 5 years. The utility of the site depends on repeat measurement at the consistent sites which helps in delineating the trend of the disease. However, the surveillance mechanism should remain alert to newer emerging HIV hotspots. Therefore, after due deliberations, 17 new HSS sites were added during the 2019 round of HSS. Half of the sites reported delay in the start of HSS activity by more than 7 days. The reasons cited were untrained site in-charges, nonavailability of logistics and supplies, and administrative approval. HSS activity started more than 1-month late in about one-fifth of the sites. Majority of these sites were in Bihar, Telangana, Mizoram, and Manipur and the delay was mainly because of state-related administrative issues. Thus, the site preparedness to carry out the HSS activities was suboptimal in these states. This issue should be addressed during future rounds of HSS.
MO was the designated site in-charge and was expected to lead the HSS team at their respective sites. Since MO occupies a crucial position, all of them were invited to attend the training program prior to the start of HSS round. We found that about one-quarter of MO had not received preround training. What was more alarming was that one-third of these MO (approximately 8% overall) had never attended any HSS training in the past either. Such a situation could result in poor quality of HSS activities. As a remedial measure, the supervisors attempted to impart onsite training on the important aspects of HSS activities.
Notwithstanding the fact that some of the MO had not received any training in HSS, we observed that proper methodology was followed at most of the sites. Thus, in general, the quality of the data collection was good. It was possible that the untrained MO had, on their own initiative, apprised themselves about the HSS. They may have been aided in this effort by local laboratory technicians and counselors, most of whom were trained repeatedly during the past rounds of HSS.
BMW segregation should be a continuous process and not merely restricted to the HSS period. Lacunae in this area suggested the need to strengthen the hospital policy and practice. As an interim measure, this aspect may be given more emphasis during the preround training of LTs.
There were a total of 17 new sites during HSS 2019, of which 15 (88.2%) sites were visited. Priority was given to the supervision of new sites to ensure that they complied with the SOPs. Nonetheless, information was not available for two new sites. It is possible that these sites were also visited, but the supervisor did not upload their finding on MIS. To the best of our knowledge, this is the first report to assess the preparedness of HSS in India. The supervisors themselves entered the information from the checklist to the MIS thus minimizing the chances of error.
| Conclusion|| |
The preparedness of the site to start the HSS activities on the scheduled date was low. However, the overall quality of HSS at antenatal clinic sites in India was good. More attention is required so that the site in-charge receives preround training. Attention needs to be given to the availability of adequate consumables at the sentinel sites along with proper administrative support. In addition, the emphasis on BMW segregation during preround training would further improve the quality of HSS in ANC in India.
We would like to acknowledge the contribution of the National AIDS Control Organization and our supervisors, including the CTMs, SST members, RI officials, and SACS members for their valuable inputs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]