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:
o http://www.unicef.org/aids/index_documents.html

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.

Further Information
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.

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.

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.

Further Information
http://www.who.int/hiv/topics/treatment/en/index.html

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.

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.

Further Information
o http://www.who.int/hiv/pub/me/en/index.html

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

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.

In theory, assessing progress in reducing the occurrence of new infections is best done through monitoring changes in incidence over time. However, in practice, prevalence data rather than incidence data are available.

In analysing prevalence data of people who inject drugs for the assessment of prevention programme impact, it is desirable not to restrict analysis to young people but to report on those persons who are newly initiated to behaviours that put them at risk for infection (e.g. by restricting the analysis to people who have initiated injecting drug use within the last year). This type of analysis also has the advantage of not being affected by the effect of ART in increasing survival and thereby increasing prevalence.

If prevalence estimates are available disaggregated by greater than and less than one year of injecting drugs countries are strongly encouraged to report this disaggregation in their Country Progress Report, and to use the comments field for this indicator in the reporting tool to present disaggregated estimates.

Due to difficulties in accessing people who inject drugs, biases in sero-surveillance data are likely to be far more significant than in data from a more general population, such as women attending antenatal clinics. If there are concerns about the data, these concerns should be reflected in the interpretation.

An understanding of how the sampled population(s) relate to any larger population(s) sharing similar risk behaviours is critical to the interpretation of this indicator. The period during which people belong to a key population is more closely associated with the risk of acquiring HIV than age. Therefore, it is desirable not to restrict analysis to young people but to report on other age groups as well.

Trends in HIV prevalence among people who inject drugs in the capital city will provide a useful indication of HIV-prevention programme performance in that city. However, it will not be representative of the situation in the country as a whole.

The addition of new sentinel sites will increase the samples representativeness and will therefore give a more robust point estimate of HIV prevalence. However, the addition of new sentinel sites reduces the comparability of values. As such it is important to use consistent sites when undertaking trend analyses.

Accessing and/or surveying people who inject drugs can be challenging. Consequently, data obtained may not be based on a representative sample of the national, people who inject drugs being surveyed. If there are concerns that the data are not based on a representative sample, these concerns should be reflected in the interpretation of the survey data. Where different sources of data exist, the best available estimate should be used. Information on the sample size, the quality and reliability of the data, and any related issues should be included in the report submitted with this indicator.

Tracking people who inject drugs over time to measure progress may be difficult due to mobility and the hard-to-reach nature of these populations with many groups being hidden populations. Thus, information about the nature of the sample should be reported in the narrative to facilitate interpretation and analysis over time.

To maximize the utility of these data, it is recommended that the same sample used for the calculation of this indicator be used for the calculation of the other indicators related to these populations.