Changing rates of male circumcision may or may not be the result of a programme. For example, changing societal norms not due to a programme may be leading to changing rates of male circumcision. This indicator measures total change in the population, whatever the reason(s).

Existing population-based surveys (such as DHS) may not accurately measure true male circumcision status because of a lack of knowledge of what male circumcision is, confusion about circumcision status, or perceived social desirability of circumcision status. Other approaches to determining circumcision status might be used, e.g. the use of pictures or drawings (drawings may be more culturally appropriate), prompts or even direct examination. Modelling the potential impact of changing rates of male circumcision on HIV incidence requires accurate knowledge of male circumcision status over time.

Further Information
For further information on Male Circumcision indicators, see A guide to indicators for male circumcision programmes in the formal health care system, WHO, UNAIDS, 2009 http://whqlibdoc.who.int/publications/2009/9789241598262_eng.pdf

The existence of a written infection control policy that addresses TB and is consistent with international guidelines is the first basic step in ensuring TB infection control in health-care facilities providing (ART) services for people living with HIV. However, the existence of a policy does not mean that it is effectively implemented. Further inquiry will be needed to establish whether the infection control policy is implemented and adhered to. Analysis of policy involves subjective judgment, which can limit its use in cross-national comparisons and for capturing trends over time.
This indicator goes a step beyond measuring the simple existence of an infection control policy by defining the standards that must be met in order for there to be an acceptable practice that addresses the issue of control of TB infection in health-care facilities providing (ART) services for people living with HIV according to international guidelines, thus eliminating some, though not all, subjective judgment.

Additional considerations: Responsibility: HIV programmes

Data utilization: 100% target; all health facilities that offer antiretroviral therapy should have implemented TB infection control to prevent the transmission of TB from person to person

Other References: Guide to monitoring and evaluation for collaborative TB/HIV activities available at:
http://whqlibdoc.who.int/publications/2009/9789241598194_eng.pdf

This indicator provides valuable information about the availability of ART services in health facilities, but it does not capture information about the quality of services provided. Antiretroviral therapy itself is complex, and it should be delivered as part of a package of care interventions, including the provision of cotrimoxazole prophylaxis, the management of opportunistic infections and comorbidities, nutritional support and palliative care. Simple monitoring of ART availability does not ensure that all ART-related services are adequately provided to those who
need them. Nevertheless, it is important to know what percentage of health facilities provide ART services in order to plan for service expansion as needed to meet universal access targets.

Additional considerations
• One strategy to scale up ART services is to make ART available in more health facilities. This may be achieved by decentralizing ART services from tertiary facilities (e.g., hospitals) to primary or secondary-level health facilities. Greater availability of ART services provides crucial support to the goal of universal access to HIV treatment by 2010.
• Depending on the country's epidemic type, the denominator may not be as relevant if the HIV program strategy aims to target a limited number of sites to offer ART in.

Data utilization: To look at progress in the percentage of health facilities which provide antiretroviral therapy. Analyzing the data geographically and by type of health facilities, and triangulating the data with estimates of HIV density can provide insight into where there is a need to increase availability of ART services.

The continuation of ART is mostly related to survival (but also willingness to continue). Survival might reflect the services offered but also depends on the baseline characteristics of the patients started on ART. Clinical, immunological and virological staging are independent predictors of survival under ART. Baseline characteristics of the cohort of patients should help in interpreting the results and, in particular, comparing ART sites.

Additional considerations:
If data on 24-month or 60-month retention are not available for patients that initiated antiretroviral therapy in 2010 or 2007, respectively, but available for patients that initiated antiretroviral therapy during an earlier time period (e.g. 2009 or 2008, or 2006 or 2005), please specify the period in the comment field: e.g. "Started antiretroviral therapy between [month]/[year] and [month]/[year]”.
The numerator does not require patients to have been on antiretroviral therapy continuously for the 24 month or 60 month period. For example, patients who may have missed one or two appointments or drug pick-ups, and temporarily stopped treatment since initiating treatment but are recorded as still being on treatment at month 24 or 60 are included in the numerator. On the contrary, those patients who have died, stopped treatment or been lost to follow-up at 24 or 60 months since starting treatment are not included in the numerator.
In countries where this indicator is not produced in all ART sites but in a sub-set of facilities, data should be interpreted keeping in mind the representativeness, and this should be stated in the Comments box.

Data utilization: Note any particularly low retention and assess reasons behind it, by analysing the distribution of those who are not on ART: dead, stopped, loss to follow up. If data is available, try to assess the lost-to-follow-up population to see if they are likely to be dead, stopped, or transferred out. Compare cohorts.

This indicator does not measure the quality of the virological testing at sites, nor the quality of the system in place, including length of turnaround time, stock-outs of DBS or virological testing reagents, and other bottlenecks in the system.

Additional considerations for countries:
In addition to monitoring the expansion of virological testing capacity at health facilities, countries may wish to periodically monitor bottlenecks in the system to expand testing capacity, including national, district level or facility level stock outs of testing materials; turnaround times for test results; human resource availability and trainings conducted; and tools available to appropriately track samples and receipt of results.

Data utilization: Look at trends overtime. Review where services are available and identify any gaps. Explore further data available on the average time it takes for test results.

This indicator provides valuable information about the availability of paediatric ART services in health facilities, but it does not capture information about the quality of services provided. Antiretroviral therapy itself is complex, and it should be delivered as part of a package of care interventions, including the provision of cotrimoxazole prophylaxis, the management of opportunistic infections and comorbidities, nutritional support and palliative care. Simple monitoring of ART availability does not ensure that all ART-related services are adequately provided to those who need them.
Nevertheless, it is important to know what percentage of health facilities provide ART services in order to plan for service expansion as needed to meet universal access targets.
One potential limitation to facility surveys or censuses is that they are usually only conducted once every few years and may not capture the latest information especially in setting with recent intensified scale-up.

Additional considerations:
• One strategy to scale up ART services is to make ART including paediatric ART services available in more health facilities. This may be achieved by decentralizing ART services from tertiary facilities (e.g. hospitals) to primary or
secondary-level health facilities. Greater availability of paediatric ART services provides crucial support to the goal of universal access to HIV treatment.
Depending on the country's epidemic type, the denominator may not be as relevant if the HIV program strategy aims to target a limited number of sites to offer paediatric ART in.

Data utilization: Look at trends overtime. Explore the number of facilities that provide ART in relation the estimated number of children in need of ART.

This indicator is intended to monitor availability of TC services as countries continue to expand TC. It does not intend to capture quality of TC services provided.

To look at progress in the number of health facilities which provide testing and counselling. Analyzing the data geographically and by type of health facilities, and triangulating it with population data, can provide insight into where there is a need to increase availability of TC services.

It is recommended that every health facility has the capacity to offer testing and counselling in generalized epidemics. In low-level and concentrated epidemics, the goal may not be to have TC services available in every facility.

This indicator is intended to monitor availability of TC services as countries continue to expand TC. It does not intend to capture quality of TC services provided.

To look at progress in the number of health facilities which provide testing and counselling. Analyzing the data geographically and by type of health facilities, and triangulating it with population data, can provide insight into where there is a need to increase availability of TC services.

It is recommended that every health facility has the capacity to offer testing and counselling in generalized epidemics. In low-level and concentrated epidemics, the goal may not be to have TC services available in every facility.