Early warning indicators

Monitoring the extent to which ART sites function to minimize preventable HIV drug resistance (HIVDR) is the highest priority. The HIVDR early warning indicators (EWI) are ART site-based indicators associated with HIVDR prevention. Data are abstracted from medical and pharmacy records for a limited time period each year; ARV prescribing practices, on-time ART drug pick-up and clinic appointment-keeping, percentages of patients lost to follow-up and still on first-line ART at 12 months, and ARV drug stock-outs and shortages, are monitored. Data collection may be integrated with other monitoring of ART or assessing ART data quality.

Reports

HIV drug resistance early warning indicators guidance

Tools

HIV drug resistance early warning indicators abstraction and calculation tools

Revised versions coming soon.

Country reports

2008 status update

As a supplement to these surveys WHO has developed ART site quality assurance tools: the HIVDR Early Warning Indicators (EWI). With the EWI, a larger number of representative ART sites are assessed than with the genotyping surveys. The EWI assess the extent to which sites are functioning optimally to prevent HIVDR. These indicators evaluate issues known to be associated with the emergence or prevention of HIVDR at the ART site level, including prescribing practices, losses to follow-up during the first year of ART the extent to which patients pick up their ARV drugs on time, and ARV drug shortages at the site level. EWI monitoring evaluates the key factors in ART sites without the expense of HIVDR testing, and results can be used to optimize both ART site and national ART program functioning. EWI are abstracted retroactively so that results are available for analysis more quickly than for the prospective surveys. WHO recommends monitoring six EWI (plus two optional EWI) to supplement results from HIVDR monitoring surveys at sentinel ART sites.

WHO provided training and technical assistance in nine new countries in 2008 for the planning and development of protocols for HIVDR monitoring surveys. These countries included Burkina Faso, Ghana, Haiti, Kenya, Rwanda, Senegal, Ukraine, Vietnam, Zimbabwe. In many of the countries protocols are still under ethics committee review but implementation of HIVDR monitoring surveys began in Burkina Faso, Mozambique, Nigeria, Swaziland, Uganda and Zambia in 2008. This adds to those countries in which this was achieved for the first year of the project namely Burundi, India, and Malawi thus bringing the total number of countries implementing monitoring surveys to nine since starting the project.

Only basic demographic data, pre-ART clinical data, baseline genotyping data and data on experience with ARVs before ART start are available for the surveys implemented so far. Data cleaning is currently taking place. None of the surveys including those which started in 2007, has reached endpoint, because patients are enrolled over three to six months in order to reach the optimum sample size and must be followed for up to 15 months.

For the EWI training, site selection, and review of medical records to evaluate feasibility of indicator collection took place in 15 countries: Burkina Faso, Burundi, Cambodia, Ethiopia, Ghana, Haiti, Indonesia, India, Malawi, Swaziland, Tanzania, Uganda, Vietnam, Zambia, and Zimbabwe. Monitoring of EWI were implemented in Burkina Faso, Ethiopia, Ghana, Haiti, Malawi, Mozambique, Swaziland, Zambia, and Zimbabwe. Malawi's results were published in Antiviral Therapy in May 2008 and reported at the International AIDS Conference in Mexico City, August 2008.