Proportion of the poorest households who received external economic support in the last 3 months
It measures progress in providing external economic support to poorest households affected by HIV and AIDS.
Economic support (with a focus on social assistance and livelihoods assistance) to poor and HIV-affected households remains a high priority in many comprehensive care and support programs. This indicator reflects the growing international commitment to HIV-sensitive social protection. It recognizes that the household should be the primary unit of analysis since many of the care and support services are directed to the household level. However, household data should be disaggregated to track whether or not households have orphans or an HIV-positive person. Tracking coverage of households with orphans and within the poorest quintile remains a developmental priority.
Number of the poorest households that received any form of external economic support in the last 3 months.
External economic support is defined as free economic help (Cash grants, assistance for school fees, material support for education, income generation support in cash or kind, food assistance provided at the household level, or material or financial support for shelter) that comes from a source other than friends, family or neighbours unless they are working for a community-based group or organization. This source is most likely to be the national government or a civil society organization.
Total number of poorest households.
Poorest households are defined as a household in the bottom wealth quintile. Countries should use the exact indicator definition and method of measurement for standardized progress monitoring and reporting at national and global levels. This will allow monitoring of changes over time and comparisons across different countries. However, countries can add or exclude other categories locally (for example, other wealth quintiles) depending on the country needs with respect to national program planning and implementation.
This indicator reflects new evidence of the need for a greater focus on wealth dimensions of vulnerability and the fact that that targeting on the basis of extreme poverty in high prevalence contexts ensures good coverage of poor households affected by HIV and AIDS . Proxy indicators of AIDS affectedness (such as “chronic illness’) have often been poorly associated with HIV, have weak associations with adverse developmental outcomes, and have proven difficult to define in household questionnaires.
This indicator demonstrates changing levels of economic support for the poorest households. In high prevalence contexts, in particular, the majority are likely to be HIV affected. The indicator also demonstrates changes in the composition of external support (e.g. cash, food, livelihoods) received by poor households.
The indicator does not measure directly economic support to HIV infected and affected households, which is difficult to establish during a survey, but implicitly suggests that households living in the bottom wealth quintile in high prevalence contexts are more likely to be negatively impacted by HIV and AIDS and in need of economic assistance. In order to keep measurement as simple as possible, the indicator does not attempt to identify the different sources of support to households but this should be partly captured in National AIDS Spending Assessments (NASA).
The collection of data through population-based surveys, particularly DHS and MICS, means that the indicator does not capture the status of people living outside of households such as street children, children in institutions and internally displaced populations. Separate surveys are needed to track coverage for such vulnerable populations.
For further information, please consult the following website:
Current school attendance among orphans and non-orphans (10-14 years old, primary school age, secondary school age)
It measures progress towards preventing relative disadvantage in school attendance among orphans versus non-orphans.
The indicator is split up in two parts so comparisons can be made between orphans and non orphans:
Part A: current school attendance rate of orphans aged 10-14 primary school age, secondary school age
Part B: current school attendance rate of children aged 10–14 primary school age, secondary school age both of whose parents are alive and who live with at least one parent
AIDS deaths in adults occur just at the time in their lives when they are forming families and bringing up children. Orphanhood is frequently accompanied by prejudice and increased poverty, factors that can jeopardize children’s chances of completing school education and may lead to the adoption of survival strategies that increase vulnerability to HIV. It is important therefore to monitor the extent to which AIDS support programmes succeed in securing the educational opportunities of orphaned children.
Part A: Number of children who have lost both parents and who attend school aged 10-14, primary school age, secondary school age
Part B: Number of children both of whose parents are alive, who are living with at least one parent and who attend school aged 10-14, primary school age, secondary school age
Explanation of Numerator
The definition of primary school age and secondary school age should be consistent with the UNESCO definition and as currently used for calculating other education-specific indicators such as net primary school enrolment/attendance rate and net secondary school enrolment/attendance rate for each country. The primary school age and secondary school age populations may vary slightly from country to country. Therefore this indicator uses the terms ‘primary school age’ and ‘secondary school age’ as currently applied in standard international measurements including in major survey programmes such as DHS or MICS to allow each country to apply its own national age ranges for primary and secondary school. The important point is to compare current school attendance of orphans and non-orphans across primary school and secondary school rather than by specific ages.
Part A: Number of children who have lost both parents
Part B: Number of children both of whose parents are alive who are living with at least one parent
The definitions of orphan/non-orphan used here—i.e., child aged 10–14 years as of the last birthday both of whose parents have died/are still alive—are chosen so that the maximum effect of disadvantage resulting from orphanhood can be identified and tracked over time. The age-range 10–14 years is used because younger orphans are more likely to have lost their parents recently so any detrimental effect on their education will have had little time to materialize. However, orphaned children are typically older than non-orphaned children (because the parents of younger children have often been HIV-infected for less time) and older children are more likely to have left school.
Typically, the data used to measure this indicator are taken from household-based surveys. Children not recorded in such surveys—e.g., those living in institutions or on the street—generally, are more disadvantaged and are more likely to be orphans. Thus, the indicator will tend to understate the relative disadvantage in educational attendance experienced by orphaned children.
This indicator does not distinguish children who lost their parents due to AIDS from those whose parents died of other causes. In countries with smaller epidemics or in the early stages of epidemics, most orphans will have lost their parents due to non-HIV-related causes. Any differences in the treatment of orphans according to the known or suspected cause of death of their parents could influence trends in the indicator. However, to date there is little evidence that such differences in treatment are common.
The indicator provides no information on actual numbers of orphaned children. The restrictions to double orphans and to 10–14 year-olds mean that estimates may be based on small numbers in countries with small or nascent epidemics.
For further information, please consult the following website:
Proportion of ever-married or partnered women aged 15-49 who experienced physical or sexual violence from a male intimate partner in the past 12 months
It measures progress in reducing prevalence of intimate partner violence against women (as an outcome itself and as a proxy for gender inequality).
An intimate partner is defined as a cohabiting partner, whether or not they had been married at the time. The violence could have occurred after they had separated.
Globally, and particularly in sub-Saharan Africa, the observed high rates of HIV infection in women have brought into sharp focus the problem of violence against women. There is growing recognition that women and girls’ risk of, and vulnerability to, HIV infection is shaped by deep-rooted and pervasive gender inequalities - violence against them in particular. Studies conducted in many countries indicate that a substantial proportion of women have experienced violence in some form or another at some point in their life. Studies from Rwanda, Tanzania, and South Africa show up to three-fold increases in risk of HIV among women who have experienced violence compared to those who have not.
Women aged 15-49 who currently have or ever had an intimate partner, who report experiencing physical or sexual violence by at least one of these partners in the past 12 months.
Explanation of Numerator
Ever married or partnered women aged 15-49 include women who have ever been married or had an intimate partner. An intimate partner is defined as a cohabiting partner, whether or not they had been married at the time. These women are asked if they experienced physical or sexual violence from a male intimate partner in the past 12 months. Physical or sexual violence is determined by asking women if their partner did any of the following:
o Slapped her or threw something at her that could hurt her
o Pushed her or shoved her
o Hit her with a fist or something else that could hurt
o Kicked, dragged, or beat her up
o Choked or burnt her
o Threatened her with, or actually used a gun, knife or other weapon against her
o Physical forced her to have sexual intercourse against her will
o Forced her to do something she found degrading or humiliating
o Made her afraid of what he would do if she did not have sexual intercourse with him
Those reporting at least one incident corresponding to any one of these items the last 12 months are included in the numerator.
Total women surveyed aged 15-49 who currently have or had an intimate partner.
Explanation of Denominator
Total women surveyed aged 15-49 who currently have or had an intimate partner.
This indicator assesses progress in reducing the proportion of women who have experienced recent (intimate partner violence) IPV, as an outcome in of itself. Further, the indicator should also be interpreted as a proxy for gender equality. A change in the prevalence level of recent violence over time will indicate a change in the level of gender equality—which is one of the structural factors driving the HIV epidemic. Gender equality has a clear, inverse relationship with IPV: In countries where IPV is high, gender equality, women’s rates of education, and women’s reproductive health and rights are low.
The indicator focuses on recent IPV, rather than ever experience of IPV, in order to enable monitoring and evaluating progress over time. Ever experience of IPV would show little change over time, no matter what the level of programming, since the numerator would include the same women for as long as they fell into the target age group. Sustained reductions in IPV are not possible without fundamental changes in unequal gender norms, gender relations at the household and community level, women’s legal and customary rights, gender inequalities in access to health care, education, and economic and social resources, and male involvement in reproductive and child health. Thus, changes in this one IPV indicator will be a bellwether for changes in the status and treatment of women in all the different societal domains, which in turn directly and indirectly contributes to reduced risk of HIV.
Even after adhering to the WHO ethical and safety guidelines and providing a good setting in which to conduct interviews, there will always be some women who will not disclose this information. This means that estimates will likely be more conservative than the actual level of violence which has taken place in the surveyed population
The complex relationship between violence against women and HIV has been conceptually illustrated in a comprehensive review of the current state of evidence and practice in developing and implementing interventions and strategies to address the intersection of violence against women and HIV. For over a decade, research world-wide has documented the undeniable link between violence against women (VAW) and HIV. Studies have demonstrated an association between VAW and HIV as both a contributing factor for infection as well as a consequence of infection. This relationship operates through a variety of direct and indirect mechanisms. For example:
o fear of violence may keep women from insisting on condom use by a male partner whom they suspect is HIV infected;
o fear of IPV may keep women from disclosing their HIV status or seeking treatment;
o forced vaginal penetration increases the likelihood of HIV transmission;
o rape is one manifestation of gender inequality and can result in HIV infection, although this represents a minority of cases
o Rape, other sexual and physical abuse can result in psychological distress that is manifested in risky sexual behaviour, with the result of becoming infected with HIV.
o Program on International Health and Human Rights at Harvard School of Public Health (2009). Gender-Based Violence and HIV, final draft report.
o Maman, Suzanne, Jacquelyn Campbell, Michael D. Sweat, Andrea C. Gielen. (2000)
o The intersections of HIV and violence: directions for future research and interventions Social Science & Medicine 50 459-478.
o Investing in gender equality: ending violence against women and girls. UNIFEM Brief, Oct. 2010.: WHO (2010).
o Addressing violence against women and HIV/AIDS: What works? Geneva, WHO.
o Dunkle KL, Head S, Garcia Moreno C. Current intervention strategies at the intersection of gender-based violence and HIV: A systematic review of the peer-reviewed literature describing evaluations of interventions addressing the interface between gender, violence and HIV. Geneva, WHO, 2009
Investing in gender equality: ending violence against women and girls. UNIFEM Brief, Oct. 2010.
WHO (2010). Addressing violence against women and HIV/AIDS: What works? Geneva, WHO.
Dunkle KL, Head S, Garcia Moreno C. Current intervention strategies at the intersection of gender-based violence and HIV: A systematic review of the peer-reviewed literature describing evaluations of interventions addressing the interface between gender, violence and HIV. Geneva, WHO, 2009, and Program on International Health and Human Rights at Harvard School of Public Health (2009). Gender-Based Violence and HIV, final draft report.
Maman, Suzanne, Jacquelyn Campbell, Michael D. Sweat, Andrea C. Gielen. (2000) The intersections of HIV and violence: directions for future research and interventions Social Science & Medicine 50 459-478.
Program on International Health and Human Rights at Harvard School of Public Health (2009). Gender-Based Violence and HIV, final draft report.
National Commitments and Policy Instrument (NCPI)
It measures progress in the development and implementation of national-level HIV and AIDS policies, strategies and laws.
This indicator tracks progress made in implementing the laws, regulations and policies necessary for an effective response to HIV.
The NCPI is the most comprehensive standardized questionnaire available to assess the policy, strategy, legal and programme implementation environment for the HIV response. Although the NCPI is generally referred to as an ‘indicator’ it is not used in that sense. The importance of the NCPI lies in the process of data collection and data reconciliation between different stakeholders, detailed analysis of the responses, and its use in strengthening the national HIV response. The NCPI process provides a unique opportunity for the variety of stakeholders to take stock of progress made and to discuss what still needs to be done to support an effective and efficient HIV response. When completed in a truly collaborative manner, inviting appropriate representation and respecting different views, the NCPI process can play an important role in strengthening in-country collaboration and increasing shared ownership of the HIV response.
It is important to analyse the data for each of the NCPI sections and include a write-up in the narrative section of the Country Progress Report in terms of progress made in (a) policy, strategy and law development and (b) implementation of these in support of the country’s HIV response. Comments on the agreements or discrepancies between overlapping questions in Parts A and B should also be included, as well as a trend analysis on the key NCPI data since 2003, where available.
Compare NCPI in Guidelines on construction of core indicators, UNAIDS 2002, 2005, 2007 and 2009 respectively, for selecting questions for which trends can be calculated.
Domestic and international AIDS spending by categories and financing sources
It measures how funds are spent at the national level and where those funds are sourced in an accurate and consistent manner.
As the national and international response to AIDS continues to scale up, it is increasingly important to accurately track in detail: i) how funds are spent at the national level and ii) where the funds originate. The data are used to measure annual global HIV expenditures, which is an important component of Monitoring the 2011 Political Declaration on HIV/AIDS. In addition, the data help national-level decision-makers monitor the scope and effectiveness of their programmes. When aggregated across multiple countries, the data also help the international community evaluate the status of the global response. This piece of strategic information supports the coordination role of the National AIDS Authority in each country and provides the basis for resource allocation and improved strategic planning processes.
Since different countries can choose among different methodologies and tools to monitor the flow of AIDS funding – i.e. National AIDS Spending Assessments (NASA), AIDS sub-account of the National Health Accounts (NHA) and ad hoc Resource Flows Surveys – the National Funding Matrix includes a spreadsheet that allows financial data from any of these three methodologies to be easily entered, reviewed and reported.
The financial data entered in the National Funding Matrix must be actual expenditures, not budgets or commitments. They must also include AIDS expenditures that were made as part of broader systems of service provision. For example, the diagnosis and treatment of opportunistic infections would require a special costing estimate to track the specific resources allocated to AIDS-related diagnosis and treatment. Similarly, prevention activities in schools may benefit from a detailed estimation to calculate actual expenditures on AIDS activities. The AIDS expenditures might occur outside the health system given the nature of expanded responses to AIDS.
Completing the National Funding Matrix will provide a more detailed picture of the situation at the country level, which is useful for both national and global decision-making.
For further information, please consult the following references and websites:
o UNAIDS (2009). National AIDS Spending Assessment (NASA): Classification taxonomy and Definitions. This publication is available at: http://www.unaids.org/en/dataanalysis/tools/nasapublications/
o UNFPA/UNAIDS/NIDI. Details on Resource Flows Surveys, survey instruments, countries sampled and more details on this tool are available at: www.resourceflows.org
o World Bank/WHO/USAID (2003). Guide to Producing National Health Accounts. This publication and other tools for National Health Accounts and AIDS sub-accounts can be found at: http://www.who.int/nha
o Health Systems 20/20/USAID (2004). Methodological Guidelines for Conducting a National Health Accounts Sub-analysis for HIV/AIDS. This publication can be found at: www.healthsystems2020.org
o USAID/Health Systems 20/20/UNAIDS (2009). Linking NASA and NHA Concepts and Mechanics. This publication is available at: http://www.unaids.org/en/dataanalysis/tools/nasapublications/
Percentage of adults and children with HIV known to be on treatment 12 months after initiation of antiretroviral therapy
It measures progress in increasing survival among infected adults and children by maintaining them on antiretroviral therapy.
One of the goals of any antiretroviral therapy. programme is to increase survival among infected individuals. As antiretroviral therapy. is scaled up in countries around the world, it is also important to understand why and how many people drop out of treatment programmes. These data can be used to demonstrate the effectiveness of those programmes and highlight obstacles to expanding and improving them.
Number of adults and children who are still alive and on antiretroviral therapy at 12 months after initiating treatment.
Explanation of Numerator:
The numerator requires that adult and child patients must be alive and on antiretroviral therapy at 12 months after their initiation of treatment. For a comprehensive understanding of survival, the following data must be collected:
• Number of adults and children in the antiretroviral therapy start-up groups initiating antiretroviral therapy at least 12 months prior to the end of the reporting period;
• Number of adults and children still alive and on antiretroviral therapy at 12 months after initiating treatment.
The numerator does not require patients to have been on antiretroviral therapy continuously for the 12-month period. Patients who may have missed one or two appointments or drug pick-ups, and temporarily stopped treatment during the 12 months since initiating treatment but are recorded as still being on treatment at month 12 are included in the numerator. On the contrary, those patients who have died, stopped treatment or been lost to follow-up at 12 months since starting treatment are not included in the numerator.
For example, for those patients who started antiretroviral therapy in May 2010, if at any point during the period May 2010 to May 2011 these patients die, are lost to follow-up (and do not return), or stop treatment (and do not restart), then at month 12 (May 2011), they are not on antiretroviral therapy, and not included in the numerator. Conversely, a patient who started antiretroviral therapy in May 2010 and who missed an appointment in June 2010, but is recorded as on antiretroviral therapy in May 2011 (at month 12) is on antiretroviral therapy and will be included in the numerator. What is important is that the patient who has started antiretroviral therapy in May 2010 is recorded as being alive and on antiretroviral therapy after 12 months, regardless of what happens from May 2010 to May 2011.
Total number of adults and children who initiated antiretroviral therapy who were expected to achieve 12-month outcomes within the reporting period,* including those who have died since starting antiretroviral therapy., those who have stopped antiretroviral therapy, and those recorded as lost to follow-up at month 12.
Explanation of Denominator
The denominator is the total number of adults and children in the antiretroviral therapy start-up groups who initiated antiretroviral therapy at any point during the 12 months prior to the beginning of the reporting period, regardless of their 12-month outcome.
For example, for the reporting period January 1 to December 31, 2010, this will include all patients who started antiretroviral therapy during the 12-month period from January 1 to December 31, 2009. This includes all patients, both those on antiretroviral therapy as well as those who are dead, have stopped treatment or are lost to follow-up at month 12.
At the facility level, the number of adults and children on antiretroviral therapy at 12 months includes patients who have transferred in at any point from initiation of treatment to the end of the 12-month period and excludes patients who have transferred out during this same period to reflect the net current cohort at each facility. In other words, at the facility level, patients who have transferred out will not be counted either in the numerator or the denominator. Similarly, patients who have transferred in will be counted in both the numerator and denominator. At the national level, the number of transferred-in patients should match the number of transferred-out patients. Therefore, the net current cohort (the patients whose outcomes the facility is currently responsible for recording—the number of patients in the start-up group plus any transfers in, minus any transfers out) at 12 months should equal the number in the start-up cohort group 12 months prior.
Using this denominator may underestimate true “survival”, since a proportion of those lost to follow-up are alive. The number of people alive and on antiretroviral therapy (i.e. retention on antiretroviral therapy) in a treatment cohort is captured here.
Priority reporting is for aggregate survival reporting. If comprehensive cohort patient registries are available then it is encouraged for countries to track retention on treatment at 24, 36, and 48 months and yearly thereafter. This will enable comparison over time of survival on ART. As it stands, it is possible to identify whether survival at 12 months increases or decreases over time. However, it is not possible to attribute cause to these changes. For example, if survival at 12 months increases over time, this may reflect an improvement in care and treatment practices or earlier initiation of ART. The retention on antiretroviral therapy at 12 months therefore needs to be interpreted in view of the baseline characteristics of the cohort of patients at the start of antiretroviral therapy: mortality will be higher in sites where patients accessed antiretroviral therapy at a later stage of infection. Therefore, collection and reporting of survival over longer durations of treatment outcomes may provide a better picture of the long-term effectiveness of ART.
Percentage of eligible adults and children currently receiving antiretroviral therapy
Progress towards providing antiretroviral therapy to all people eligible for treatment.
As the HIV epidemic matures, increasing numbers of people are reaching advanced stages of HIV infection. Antiretroviral therapy (ART) has been shown to reduce mortality amongst those infected and reduce transmission of HIV. Efforts are being made to make it more affordable and scale up ART within low- and middle-income countries. Antiretroviral therapy should always be provided in conjunction with broader care and support services including counseling for family caregivers.
Number of eligible adults and children currently receiving antiretroviral therapy
in accordance with the nationally approved treatment protocol (or WHO standards) at the end of the reporting period
Explanation of Numerator
The numerator can be generated by counting the number of adults and children who received antiretroviral therapy at the end of the reporting period.
The numerator should equal the number of eligible adults and children who ever started antiretroviral therapy minus those patients who are not currently on treatment prior to the end of the reporting period.
Patients not currently on treatment at the end of the reporting period, in other words, those who are excluded from the numerator, are patients who died, stopped treatment or are lost to follow-up.
Some patients pick up several months of antiretroviral drugs at one visit, which could include antiretroviral drugs received for the last months of the reporting period, but not be recorded as visits for the last months in the patient register. Efforts should be made to account for these patients, as they need to be included in the numerator.
Antiretroviral medicines taken only for the purpose of prevention of mother-to-child transmission and postexposure prophylaxis are not included in this indicator. HIV-positive pregnant women who are on lifelong antiretroviral therapy are included in this indicator.
The number of eligible adults and children currently receiving antiretroviral therapy can be obtained through data collected from facility-based antiretroviral therapy registers or drug supply management systems. These are then tallied and transferred to cross-sectional monthly or quarterly reports which can then be aggregated for national totals.
Patients receiving antiretroviral therapy in the private sector and public sector should be included in the numerator where data are available.
Estimated number of eligible adults and children
National criteria for ART eligibility varies by country. To make this indicator
comparable across countries global reports present the ART coverage for adults
based on the eligibility currently recommended by WHO. Enter into the online
tool the number of adults eligible for ART for both situations 1) based on national
eligibility criteria and 2) based on WHO eligibility criteria.
The denominator is generated by estimating the number of people with HIV infection eligible for antiretroviral therapy. This estimation must take into consideration a variety of factors including, but not limited to, the current numbers of people with HIV, the current number of patients on antiretroviral therapy, and the natural history of HIV from infection to enrolment into antiretroviral therapy.
Denominator estimates are most often based on the latest data available from sentinel surveillance used with a HIV modeling programme such as Spectrum. For further information on estimates of HIV need and the use of Spectrum please refer to the UNAIDS/WHO Reference Group on Estimates, Modelling and Projections methodology.15
This indicator permits monitoring trends in coverage but does not attempt to distinguish between different forms of antiretroviral therapy or to measure the cost, quality or effectiveness of, or adherence to the treatment regimen provided. These will each vary within and between countries and are liable to change over time.
The proportion of people needing antiretroviral therapy varies with the stage of the HIV epidemic, eligibility criteria, and the cumulative coverage and effectiveness of antiretroviral \ therapy among adults and children. As mentioned above, national criteria for ART eligibility varies by country. To make this indicator comparable across countries global reports present the ART coverage for adults based on the eligibility currently recommended by WHO.
The degree of utilization of antiretroviral therapy will depend on factors such as cost relative to local incomes, service delivery infrastructure and quality, availability and uptake of testing and counselling services, and perceptions of effectiveness and possible side effects of treatment.
The indicator measures the number of people provided with medication but does no measure whether the individual imbibed the medication thus it is not a measure of adherence.
Estimated percentage of child HIV infections from HIV-positive women delivering in the past 12 months
It measures progress towards eliminating mother-to-child HIV transmission.
Efforts have been made to increase access to interventions that can significantly reduce mother-to-child transmission, including combination antiretroviral prophylactic and treatment regimens and strengthened infant-feeding counselling. It is important to assess the impact of PMTCT interventions in reducing new paediatric HIV infections through mother-to-child transmission.
The percentage of children who are HIV-positive should decrease as the coverage of interventions for PMTCT and the use of more effective regimens increases.
The numerator is the estimated number of children who will be newly infected with HIV due to mother-to-child transmission among children born in the previous 12 months to HIV-positive women.
Estimated number of HIV positive women who delivered in the previous 12 months.
Over time, this indicator assesses the ability of PMTCT programmes by estimating the impact of increases in the provision of antiretroviral drugs and the use of more efficacious regimens and optimal infant feeding practice. This indicator is generated from a model, which provides estimates of HIV infection in children. The estimated indicator is reliant on the assumptions and data used in the model. The indicator may not be a true measure of mother-to-child transmission. For example, in countries where other forms of PMTCT (e.g. caesarean section) are widely practised, the indicator will overestimate mother-to-child transmission. It also relies on programme data that often captures antiretroviral drug regimens provided rather than taken, thus could underestimate mother-to-child transmission.
This indicator allows countries to assess the impact of PMTCT programmes by estimating the HIV transmission rate from HIV positive women to their children. It is difficult to follow up mother–children pairs, particularly at national level, because of the lag in reporting and the multiple health facility sites that mother-child pairs can visit for the wide range of PMTCT and child care interventions delivered over a timespan. In countries where data are available, facility attendance is high, and confirmatory tests are conducted systematically, efforts should be made to monitor the impact through directly assessing the percentage of children found to be HIV-positive among those born to HIV-positive mothers. All countries should make efforts to monitor the HIV status and survival of children born to HIV-positive women, gathered during follow-up health care visits.
Percentage of infants born to HIV-positive women receiving a virological test for HIV within 2 months of birth
It measures progress in the extent to which infants born to HIV-positive women are tested within the first 2 months of life to determine their HIV status and eligibility for ART, disaggregated by test results
Infants infected with HIV during pregnancy, delivery or early postpartum often die before they are recognized as having HIV infection. WHO recommends national programmes to establish the capacity to provide early virological testing of infants for HIV at 6 weeks, or as soon as possible thereafter to guide clinical decision-making at the earliest possible stage. HIV disease progression is rapid in children; they need to be put on treatment as early as possible because without early treatment almost 50% of children would be dead by the second year
Number of infants who received an HIV test within 2 months of birth, during the reporting period. Infants tested should only be counted once.
To be collected from databases held at EID testing laboratories. The numerator should represent the number of infants who received virologic testing within 2 months of birth; it should not represent the number of samples tested at the laboratory. Data should be aggregated from the laboratory data bases. Where possible, double counting should be minimized when aggregating data to produce national-level data. It is expected that the number of infants receiving more than one virologic test in thefirst 2 months of life will be low. Efforts should be made to include all public, private and NGO-run health facilities that are providing HIV testing for HIV-exposed infants.
If information is available about the test results (positive, negative, indeterminate, and rejected for testing by the laboratory) can also be reported. When reporting this information only the most recent test result for an infant tested in the first 2 months of life should be included.
Number of HIV-positive pregnant women giving birth in the last 12 months.
This is a proxy measure for number of infants born to HIV-positive women.
Two methods can be used to estimate the denominator:
a) Using a projection model such as the one provided by Spectrum software use the output "the number of pregnant woman needing PMTCT" as a proxy,
b) Multiplying the total number of women who gave birth in the last 12 months, (which can be obtained from central statistics office estimates of births or the UN Population Division estimates) by the most recent national estimate of HIV prevalence in pregnant women (which can be derived from HIV sentinel surveillance in ANC clinic and appropriate adjustments related to coverage of ANC surveys), if Spectrum projections are unavailable.
To ensure comparability the Spectrum output will be used for the denominator when global analyses are done.
This indicator allows countries to monitor progress in providing early HIV virologic testing to HIV-exposed infants aged 2 months or less, critical for appropriate follow-up care and treatment. By limiting the age to two months of life or less, the chance of repeat tests for the same infant which can lead to double counting is also eliminated. Viewing changes in this indicator over time can provide actionable indications related to PMTCT ARV coverage, and the relationship between PMTCT coverage and EID-coverage. The only three fields needed for this indicator: date of sample collection, age at collection (actual or calculated based upon date of birth), and results are systematically entered into central EID testing databases at testing laboratories. Due to the small number of testing laboratories, and the electronic format of testing databases, this indicator does not have a heavy collection burden. Data quality at the laboratories is generally high, resulting in a robust indicator. The indicator does not capture the number of children with a definitive diagnosis (i.e. of HIV infection), or measure whether appropriate follow-up services were provided to the child based on interpretation of test results. It also does not measure the quality of testing nor the system in place for testing. A low value of the indicator could, however, signal systemic weaknesses, including poor country-level management of supplies of HIV virologic test kits, poor data collection and mismanagement of testing samples. Disaggregation by test results cannot be used as a proxy for overall MTCT transmission rates. If either the EID coverage of national need or the EID testing coverage in the first two months of life is very low, low positivity rates among infants tested will not necessarily mean program success, as many other infants who are likely positive are not represented in this sample.
While early virological testing is a critical intervention for identifying infected infants, it is also important for countries to strengthen the quality of HIV-exposed infant follow-up and to train health providers to recognize signs and symptoms of early HIV infection among exposed infants, particularly where access to virological testing is limited. Inappropriate management of supplies can negatively affect the value of the indicator and significantly reduce access to HIV testing for infants born to HIV-positive women. Countries should ensure that appropriate systems and tools, particularly tools for LMIS, are in place to procure, distribute and manage supplies at facility, district and central level.
For further information, please consult the following reference and website:
o WHO, UNICEF, UNAIDS,Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report, September 2010 http://www.who.int/hiv/pub/2009progressreport/en/index.html
o PEPFAR, NEXT GENERATION INDICATORS REFERENCE GUIDE, 2009
o GFATM Monitoring and Evaluation Toolkit. Part 2: Tools for monitoring programs for HIV, tuberculosis, malaria and health systems strengthening, February, 2009
o WHO/UNICEF. MONITORING AND EVALUATING THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV
Percentage of HIV-positive pregnant women who received antiretrovirals to reduce the risk of mother-to-child transmission
It measures progress in preventing mother-to-child transmission of HIV during pregnancy and delivery through the provision of antiretroviral drugs.
This indicator allows countries to monitor the coverage of antiretroviral medicines to HIV-positive pregnant women to reduce the risk for transmission of HIV to infants during pregnancy and delivery. When disaggregated by regimen, this indicator can show increased access to more effective antiretroviral drug regimens for prevention of mother-to-child transmission of HIV, as well as ART. As the indicator measures antiretroviral drugs dispensed and not those consumed, it is not possible to determine adherence to the regimen in most cases.
The postpartum regimen, including ARV to reduce the risk of transmission during breastfeeding, is not captured by this indicator, but by other indicators (see indicator 3.7 (Percentage of infants born to HIV-infected women provided with ARV prophylaxis to reduce the risk of early mother-to-child transmission in the first 6 weeks) and 3.8 (Percentage of infants born to HIV-infected women who are provided with antiretrovirals to reduce the risk of HIV transmission during breastfeeding) in Part 2, the additional universal access health sector part of these guidelines)).
The risk for mother-to-child transmission can be significantly reduced by providing antiretroviral drugs (as lifelong therapy or as prophylaxis) for the mother during pregnancy and delivery, with antiretroviral prophylaxis for the infant, and antiretrovirals to the mother or child during breastfeeding (if breastfeeding), and use of safe delivery practices and safer infant feeding. The data will be used to track progress toward global and national goals towards elimination of mother-to-child transmission; to inform policy and strategic planning; for advocacy; and leveraging resources for accelerated scale up. It will help measure trends in coverage of antiretroviral prophylaxis and treatment, and when disaggregated by regimen type, will also assess progress in implementing more effective regimen and ART.
Number of HIV-positive pregnant women who received antiretroviral drugs
during the past 12 months to reduce the risk of mother-to-child transmission
during pregnancy and delivery. Global reports summarizing coverage of ARV
for PMTCT will exclude women who received single dose nevirapine as it is
considered a sub-optimal regimen. However the number of women who received
only a single dose of nevirapine should be reported by the country.
Explanation of Numerator
The numerator should be disaggregated by the four general regimens (the first three are recommended) for HIV-positive pregnant women for the prevention of mother-to-child transmission11:
1. Lifelong ART
a. newly initiated on ART during the current pregnancy
CD4 not known
b. already on ART at the beginning of the current pregnancy
2. Maternal triple ARV prophylaxis (prophylaxis component of WHO Option B)
3. Maternal AZT (prophylaxis component during pregnancy and delivery of WHO Option A or WHO 2006 guidelines)
4. Single dose nevirapine (with or without tail) ONLY
5. Other (please comment: e.g. specify regimen, uncategorized, etc.)
Estimated number of HIV-positive pregnant women within the past 12 months
Explanation of Denominator
Two methods can be used to estimate the denominator:
1. a projection model, such as Spectrum; use the output “number of pregnant woman needing PMTCT”; or
2. multiply the number of women who gave birth in the past 12 months (which can be obtained from estimates of the central statistics office or the United Nations Population Division or pregnancy registration systems with complete data) by the most recent national estimate of HIV prevalence in pregnant women (which can be derived from HIV sentinel surveillance in antenatal care clinics and appropriate adjustments related to coverage of ANC surveys.) if Spectrum projections are unavailable.
To ensure comparability the Spectrum output will be used for the denominator when global analyses are done.
This indicator allows countries to monitor the coverage with antiretroviral medicines of HIV-positive pregnant women to reduce the risk for transmission of HIV during pregnancy and delivery. When disaggregated, this indicator can show increased access to more effective antiretroviral drug regimens and ART for prevention of mother-to-child transmission of HIV in countries. As the indicator measures antiretroviral drugs dispensed and not those consumed, it is not possible to determine adherence to the regimen in most cases.
This indicator does not capture the use of appropriate postpartum regimens for the mother (to reduce transmission and viral resistance) and for the infant (to reduce peripartum transmission) or during breastfeeding (to reduce postpartum transmission through breastfeeding) which should accompany antiretroviral drug regimens to reduce peripartum mother-to child transmission. See indicator 3.7 (Percentage of infants born to HIV-infected women provided with ARV prophylaxis to reduce the risk of early mother-to-child transmission in the first 6 weeks) for the tail and indicator 3.8 (Percentage of infants born to HIV-infected women who are provided with antiretrovirals to reduce the risk of HIV transmission during breastfeeding) for coverage during breastfeeding in Part 2, the additional universal access health sector part, of these guidelines.
Countries are encouraged to track and report the actual number (or estimated percentage if actual data are unavailable) of women receiving the various regimens, so that the impact of antiretroviral drugs on mother-to-child transmission can be modelled on the basis of the efficacy of the regimens. When countries do not have a system for collecting and reporting data on the provision and coverage of different antiretroviral drug regimens for the prevention of mother-to-child transmission of HIV, they should establish such a system.