The proportion of formal-sector employers sampled with non-discriminatory policies and non-discriminatory practices in recruitment, advancements and benefits for employees with HIV
This indicator measures one small but rather concrete aspect of HIV-related discrimination: discrimination in formal-sector employment. The indicator should be disaggregated to look separately at company policies and at practice.
Obviously, practices in formal-sector employment represent just a small fraction of all the situations in which HIV-related discrimination may take place. National AIDS programmes may work to reduce discrimination in different ways in different countries. However discrimination in the workplace will be a concern in virtually every country. National programmes may work directly with employers or workers' unions to reduce discrimination in the workplace, or they may choose to work through the regulatory and legislative environments. In either case, success in reducing the discrimination suffered in employment by HIVpositive individuals should be reflected in this indicator. This is because employer practices are influenced by many things, including the regulatory environment. Where legislation comes into force to protect the rights of people and workers with HIV, or where court rulings change the likelihood that this legislation will be enforced, changes in employer policies and practices are likely to follow. The summary indicator sums up both policy and practice. However it will often be the difference between the two which is of most interest to programme managers. If employer policies become more supportive of HIVpositive employees in response to legislation or other pressure but discriminatory practices do not in fact change, then a shift in emphasis may be needed to ensure enforcement rather than simply existence of non-discriminatory policies. Measurement of discriminatory practice is not straightforward, especially where it is illegal. Many companies will have reasons other than HIV status for the dismissal of an HIV-positive employee, and some of these reasons will be legitimate. Like Policy Indicator 1, this indicator of discrimination will be affected to an extent by the opinions of the individuals responding to the survey, hence the importance of ensuring a mix of respondents from within and outside management. It is worth noting that discrepancies between policy and practice may arise in either direction. A company may have no stated policy on HIV, but may nonetheless ensure that infected employees are not discriminated against in practice. The survey should ascertain whether employers have a policy on other terminal illnesses, and whether policies and practices relating to HIV differ from those relating to other terminal illnesses. The indicator will be affected by which employers and companies are included in the survey. The protocol will determine the broad mix of national and international employers, including those in the public sector. Informed consent from companies will be needed even where the survey takes the form of a selfcompleted anonymous questionnaire. There may be considerable refusal bias in the measurement of this indicator, with companies that have a poor record less likely to respond than those that do not. It is also possible that the response rate from union or workers’ representatives will differ significantly from that of management. It may be possible to negotiate a “blanket” informed consent for all members of the local chamber of commerce and industry, that would then allow data collectors to approach non-management employees directly. The refusal bias is especially worrying if it changes significantly over time. This may be the case when new legislation is introduced, but before compliance changes.
A targeted condom service outlet refers to fixed distribution points or mobile units with fixed schedules providing condoms for free or for sale. Other behavior change beyond abstinence and/or being faithful includes the targeting of behaviors that increase risk for HIV transmission such as engaging in casual sexual encounters, engaging in sex in exchange for money or favors, having sex with an HIV-positive partner or one whose status is unknown, using drugs or abusing alcohol in the context of sexual interactions, and using intravenous drugs.
This indicator provides a tangible measure of the potential reach of condom distribution to a given community as an important part of a comprehensive prevention message.
This indicator provides a relatively straightforward measure of potential reach in prevention activities that include the distribution of condoms.
Percentage of individuals who are still on treatment and who are still prescribed a standard first-line regimen after 6, 12 and 24 months from the initiation of treatment.
This indicator is important for tracking early warning signals of potential treatment failure. Unnecessary changes in regimen, treatment failure and intermittent ART are all associated with HIV drug resistance. The first year of treatment is most indicative of programme success in sustaining regimen continuity. Programmes in which > 80% of new patients are not on a first-line regimen after a year may be less likely to minimize the emergence of HIV drug resistance. This indicator measures the proportion of patients beginning first-line ART in a given cohort who are still on first-line therapy one year after ART begins.
Number of patients who are still on treatment and who are still prescribed a standard first-line regimen 12 months after initiating treatment.
Total number of individuals initiating treatment on a first-line regimen in the ART start-up group in the previous 6, 12 and 24 months.
Because this indicator does not measure temporary interruptions in ART it may overestimate the continuity of first-line ART. Where possible, information should also be collected on whether the drugs were picked up each month. The quality of this indicator depends on the quality of the medical records and the patient registry.
Percentage of ARV storage and delivery points meeting the minimum quality criteria. Storage points are usually warehouses (i.e. medicines are not dispensed to individuals). Service delivery points are pharmacies, health centres and clinics (including TB centres) where ARV drugs are dispensed to individual patients. In many countries the drug distribution system consists of a central level, a district level and service delivery points. In such cases the central and district nodes usually have the function of a warehouse, whereas the service delivery points do not.
This indicator measures a number of key components of the ART supply chain. An ART programme can be effective only if an uninterrupted flow and appropriate quality of ARV drugs is maintained.
This indicator builds on Core Indicator 3, Percentage of ARV storage and delivery points experiencing stock-outs in the preceding six months. It describes some key aspects of the quality of the distribution system. It can track improvements in quality. Disaggregation of the data by quality aspect provides an insight into where problems are occurring and can guide programmatic action on addressing them.
Number of storage and delivery points that meet the quality criteria.
Total number of storage and delivery points sampled (preferably the same number as sampled for Core Indicator 3, Percentage of ARV storage and delivery points experiencing stock-outs in the preceding six months.).
The strength of this indicator is that the information needed can be obtained from the national quality tracking system existing in many countries. If such a system is not available the indicator can easily be collected by observing a sample of storage and delivery points. This indicator can provide information allowing comparison between different regions within a country, particularly if there are notable rural-urban differences in the quality of the health system. However, it captures only the basic elements of quality (stock-outs, delivery and storage). Other important components of a drug supply system of satisfactory quality are not captured. This indicator is meant to provide an illustration of quality for national-level tracking and comparisons. For thorough programmatic action a drug-tracking and quality assurance system must be in place. This indicator is focused on public and not-for-profit systems of drug supply. In some countries, however, the private sector plays a significant role in supplying ARV drugs. In such cases, wherever possible, private drug supply systems should also be included in this assessment. Once the drug supply system is in place with the basic quality characteristics, the ART country programme is likely to shift to more comprehensive quality assurance management.
The number of HIV-infected women referred to FP services for postpartum contraception from ANC services offering the minimum package to prevent HIV in infants and young children.
The indicator measures the quantity of referral for postpartum contraceptive advice for HIV-positive and non-infected women. It is directly relevant to the second prong of the strategy for the prevention of HIV in infants and young children.
The referral of HIV-infected women to postpartum contraception services reduces the probability of unintended pregnancy in the future and thus reduces the overall risk of MTCT. The referral of HIV-negative women to such services reduces the probability of them becoming infected in the future assuming that dual protection is advised and adopted), while helping to reduce the incidence of unintended pregnancies.
The number of HIV-infected women, calculated on the basis of estimates of prevalence of HIV at each site, referred to FP services for postpartum contraception from ANC services offering the minimum package to prevent HIV in infants and young children.
All women referred to FP for postpartum contraception from ANC services offering the minimum package to prevent HIV in infants and young children.
The indicator suggests the extent to which women are referred to postpartum counselling on FP but does not attempt to ascertain either the different contraception options that are selected or the regularity with which they are used. Consequently, it cannot reveal anything about the effectiveness of the advice given.
Existence of national guidelines (either approved or in draft form) for the prevention of HIV infection in infants and youg children and the care of infants and young children in accordance with international or commonly agreed standards. Guidelines should be available for all four components of the comprehensive strategy for preventing HIV infection in infants and young children.
The indicator identifies whether guidelines exist that are in line with international or commonly agreed standards.
National guidelines are commonly based on existing international standards or on standards about which there is general agreement but which have not yet been formally presented as international guidance. Without guidelines, services of unknown quality and impact could be implemented on an ad hoc basis, making it difficult to monitor and evaluate efforts.
This indicator is not concerned with the quality of guidelines or that of their implementation. Furthermore, because it does not capture new developments in the field, the guidelines have to be reassessed periodically in order to guarantee that they remain consistent with changing standards.
Ratio of the proportion of OVC compared to non-OVC who are malnourished (underweight).
To assess progress in preventing relative disparity in malnutrition among orphaned and vulnerable children versus other children.
This indicator measures the level of malnutrition (underweight) among orphaned and vulnerable children versus other children. Weight-for-age reflects a combination of acute and chronic malnutrition for the child.
(1) Malnutrition rate among OVC (%) Numerator 1: Number of OVC aged 04 years who are malnourished (below -2 standard deviations from the median weight-for-age of WHO/NCHS reference population). Denominator 1: Number of OVC aged 04 years.
(2) Malnutrition rate among non-OVC (%) Numerator 2: Number of non-OVC aged 04 years who are malnourished (below -2 standard deviations from the median weight-for-age of WHO/NCHS reference population). Denominator 2: Number of non-OVC aged 04 years.
This indicator does not cover the majority of orphans who are older than age 5. Malnutrition rates have been reliably used globally; they will be useful to maintain for assessing malnutrition status among pre-school orphaned and vulnerable children living in households, and orphaned and vulnerable children living in institutional care arrangements. The data on underweight reflect a childs overall growth progression during his/her lifetime. The status of orphaned or vulnerable might be a recent change and might not yet have affected the childs nutrition status. Analysis of this indicator should consider the timing of these events.
National levels of child malnutrition are not expected to change markedly, except in situations of drought, famine or war. The situation of orphaned and vulnerable children may change more rapidly, however. The opportunity should be taken whenever there are national (or geographically representative) nutrition surveys to assess orphans and other children made vulnerable by HIV/AIDS. This core indicator can be accompanied by two additional indicators: (a) stunting (height-for-age) and (2) wasting (height-for-weight). Stunting reflects long-term malnutrition, whereas wasting reflects more recent or acute malnutrition. The Body Mass Index (BMI) can also be considered for adolescents, related to standard BMI-for-age curves; this is recommended by the U.S. Centers for Disease Control and Prevention as the only valid measure for adolescents.
The proportion of all children aged 0–17 living outside of family care.
To obtain estimates of children living on the streets and in institutions.
This indicator assesses the number of children living outside of traditional households, including homeless children and children living in institutions. There is little information available on children living outside of households because national surveys such as DHS and MICS normally exclude structures that are not considered households.
Number of children aged 0–17 living outside of family care.
All children aged 0–17.
Children in formal care in household settings (i.e. orphans placed in community homes with appointed guardians) are at risk of being counted as children in family care. In some places with high epidemic levels, this is becoming an increasingly common phenomenon, in particular, for children who have been orphaned by AIDS. To locate children living on the streets for surveys requires going to the sites where they congregate, visit frequently or sleep. In some instances this might be difficult because the sampling points might be insecure for interviewers.
In a country where many orphans are placed in community homes (households) with appointed guardians, such living arrangements should be included in the count for children living outside of family care. It is important to include the time spent on the streets or in institutions, mobility, etc., among the background variables for children living in institutions or on the streets. These surveys should be done in close collaboration with programmes and seen as an opportunity to collect information for planning and programming purposes.
National Policy and Planning Effort Index score for orphaned and vulnerable children
The purpose of the effort index is to measure the current response at the national level to the crisis facing orphaned and vulnerable children. It will identify specific strengths, weaknesses, and gaps in policy and planning efforts.
The index reflects the national OVC task forces opinion on how well the country is doing in eight areas of response to OVC. In other words, the index measures how the national OVC task force judges the national response when stakeholders are asked to rate the programme on a list of important items. The effort index is intended to measure policy and planning effort independent of programme outputs. For example, policy and planning efforts include items such as the degree of political support, whether laws have been reviewed, and the availability of resources, but do not include output measures such as the proportion of orphans attending school or showing evidence of malnutrition. The effort score can be used as a diagnostic tool to indicate the strength of various areas and to suggest corrective action. In this context, the term effort encompasses not only the activities of the national government but also includes those of non-governmental organizations, multilateral and bilateral organizations and others. It assesses if appropriate policies and strategies are in place and can be used to monitor year-to-year changes.
The OVC Policy and Planning Effort Index mainly builds on two tools recently developed in the area of HIV/AIDS. First, it is based on the experience of the AIDS Programme Effort Index (API) developed by UNAIDS, the United States Agency for International Development (USAID) and the Policy Project. The API was developed to measure political commitment and programme effort in areas of HIV prevention and care. Furthermore, it expands on the National Composite Policy Index recently implemented by UNAIDS to measure progress towards specific goals of the Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS). The tool and questions could be incorporated into the National Composite Policy Index. The major concern surrounding an effort index is its subjectivity and its reliability. The outcome depends entirely on the choice of informants, and informants will likely change from year to year. The indicator is simple to assess, however, and is designed to complement the existing National Composite Index. Its simple quantitative nature means that it does not give information on the effectiveness of national policies and strategies, only whether they exist or not.
Ratio of the proportion of OVC compared to non-OVC aged 1517 who had sex before age 15.
To assess progress in preventing early-age exposure to sexually transmitted infections/HIV/teenage pregnancies among orphans and other children made vulnerable by HIV/AIDS.
One way young people can be protected from infection is by delaying sexual activity. There is evidence to suggest that a later age at first sex reduces susceptibility to infection per act of sex, at least for women. This indicator provides information on the prevalence of early sexual activity among orphaned and vulnerable children and other children aged 1517. Adolescents form a high-risk group for HIV/AIDS because they are at a crucial stage of growth and might not be fully mature physically or emotionally. They may also be more likely to be bullied or exploited in sexual relationships. Teenage orphans and other vulnerable adolescents can be at especially high risk because of a lack of adult guidance to help them protect themselves. The ratio of early sex for OVC versus non-OVC will monitor whether the behaviour of OVC is different from that of non-OVC.
(1) Proportion (%) of OVC who had sex before age 15. Numerator 1: Number of OVC who report their age at first sex as under age 15. Denominator 1: Number of OVC aged 1517.
(2) Proportion (%) of non-OVC who had sex before age 15. Numerator 2: Number of non-OVC who report their age at first sex as under age 15. Denominator 2: Number of non-OVC aged 1517.
First sex is a significant event for most people and can probably be remembered in this age group without too much difficulty. But young people may be unsure of their exact age or may give a different age: one that is more socially acceptable. There is evidence that young people do not always tell the truth about the age at which they first had sex, and there is also evidence that they may deny that they have ever had sex. Young people of both sexes may alter their responses as a result of their societys views on young peoples sexuality. Analysis of the reporting of age at first sex has shown that the existence, extent and direction of the reporting or recall bias are not predictable. Furthermore, there is probably no difference in any potential bias between orphaned and vulnerable children and other children.
If sample sizes are sufficient, it might be useful to consider the standard UNGASS indicator on condom use at last high-risk sex by OVC status. This indicator assesses the proportion of sexually active young people who minimize their risk of HIV and other sexually transmitted infections through use of condoms. Condom use is one important component of HIV prevention. It is especially important for children who are having sex with non-regular partners; condom use provides an indication of life skills. Orphaned and vulnerable children may be at a disadvantage because they lack the opportunities for acquisition of life skills and may be more likely to be exposed to risky sexual encounters. For this reason it is important to compare the levels of protection between orphaned and vulnerable children and other children. For more details, see: Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators, UNAIDS, 2002.