Evaluation of HIV & AIDS Surveillance System in Afghanistan

Afghanistan is a country with low HIV prevalence among general population. The prevalence of HIV is less than 0.1% among general population, 4.4% among People who Inject Drugs-PWID, 0.7% among prisoners, 0.4% among Men with High Risk Behavior-MHRB and 0.3% among Women with High Risk Behaviors-WHRB. To manage the response toward HIV epidemic sound data is needed but the reliable data on HIV prevalence is inadequate and not updated in the country as the last Integrated Behavioral and Biologic Survey-IBBS was conducted in 2012. The current evaluation intends to examine the strengths of the surveillance system, pinpoints its flaws, analyze its attributes and provide recommendations for improvement. The evaluation of HIV surveillance system in Afghanistan, conducted in line with the CDC updated guidelines for evaluating public health surveillance system from January to April 2018. Information on the operations, functionality and attributes of the HIV surveillance system was collected qualitatively using key informant interview+sessions. Afghanistan's HIV surveillance system measures the HIV incidence in injecting drug users, men with high risk behaviors, women with high risk behaviors and prisoners. The surveillance system largely focuses on assessing the risk behaviors among these groups which lead to burst the infection. Beside the HIV surveillance system, Afghanistan has a well-structured Health Management Information System-HMIS at national and provincial level. All health facilities report on HIV cases on monthly bases. 91.36% of resources for surveillance system are provided by Global Fund-GF, 6.82 by World Bank-WB and 1.82% by government of Afghanistan. The heavy reliance on donors' resources poses risk to the sustainability of the system. The HIV & AIDS surveillance has been used to increase investment for HIV response prioritize effective interventions, program scale up, extrapolation on size of different key populations. Data sets are accumulated in different departments and it makes it hard to obtain the overall picture of HIV response. Spot cross-checks at service delivery sites confirmed the existence of errors in recordings and transfer of data. The reported data have details to calculate performance indicators mostly related to the proportion of clients serviced but gives limited opportunity for more in-depth analysis. The demographic variable had high level of completeness but the completeness of clinical variables (screening, diagnosis and treatment) was somewhat lower. Confidentiality was an alarming challenge. The personal identifiable information is collected in the client/patient registration forms, registration books and transferred into the reporting forms. The reporting forms are sent to the data collection unit via email which increases the possibility of data leakage. The timeliness of cases confirmation and reporting to national program varied over provinces. The mean delay between initial diagnosis and final confirmation of cases ranged from 0 to 43 days across all provinces. The delay in confirmation cases was highest in Paktika. The average participation rate by different stakeholders in weekly surveillance working group is 72% and the report submission rate is 80%. The surveillance system is pathetic to generate reliable data. The data outputs include errors. Data quality in terms of confidentiality and accuracy is limited. The system struggles to identify all new cases. In some provinces the delay in reporting is unacceptably high. The quality of data needs to be systematically improved and the data quality assessment process should be a unique part of routine supervision.