An HIV Early-Warning System in Afghanistan
Innovative HIV surveillance program targeting high-risk group
As part of their longstanding and successful collaboration with the Afghanistan Ministry of Health, the Department's Health Systems faculty are designing innovative and low-cost methods to assess the HIV situation in the country Assistant Scientist Nhan Tran and Professor Gilbert Burnham have been working closely with the Ministry of Health and the National AIDS Control Program to monitor the epidemic in Afghanistan. Currently, they are providing technical assistance on a second round of surveys among high-risk groups that serve as an early warning system for the possible spread of HIV within the country.
While solid evidence was lacking, the consenus in the mid-2000s was that there was no generalized HIV epidemic in Afghanistan. Many believed, however, that high-risk groups may have a high prevalence rate and, that if left unchecked could eventually present a danger to the rest of the country's population. Through close consultation with Ministry of Health staff, leading NGO officers, and other public health experts, it was decided therefore that HIV surveillance should be limited to high-risk groups rather than expending scarce resources on a national survey. The country's National AIDS Control Program directly contracted with the Department to provide technical guidance on its first ever HIV surveillance program.
2009 HIV Surveillance
After careful consultation with political and health care leaders across the country, the regions and populations for the country's first HIV survey were determined. Both behavioral and biological data were collected. HIV results were given to participants immediately, and results for other sexually transmitted diseases could be obtained on a return visit.
Populations and Regions surveyed
- Truckers - along the border with Pakistan
- Prisoners - Kabul and Herat
- Intravenous Drug Users (IDUs) - Kabul, Herat, and Mazar
- Female Commercial Sex Workers (CSWs) - Kabul
Response Driven Sampling
Given that this was the first survey of its kind and focused on sensitive subjects, a sampling method that protected the identity of the participants was in order. Researchers decided to use Response Driven Sampling (RDS), which had been used successfully in Western countries to identify hidden populations such as commercial sex workers and drug users.
"Seed participants" are identified through local community members and organizations that have contact with the populations in question, such as commercial sex workers. These seed participants become the first in an anonymous referral system that is able to track networks within the participant population. After completing the survey, the participant is given two referral coupons, each with a unique number. The participant is asked to give a coupon to a peer who might also like to participate. When this new participant enrolls, she returns the coupon and, in turn, is given two new coupons with unique numbers that are linked to her and the participant who referred her. In this way, researchers are able to track the referrals from seed participants using no names or identifying information.
The survey confirmed that the HIV situation did not merit a national survey, but it did present several surprising and useful results.
- IDUs in Herat had the highest prevalence at 18 percent. Many of these were "returnees" who had previously fled to Iran.
- HIV was not found among commercial sex workers or truckers.
- High-risk behaviors were widespread, including among men who have sex with men (MSM).
- Commercial sex workers did not routinely use condoms,
Second Generation Surveillance
Due to the success and valuable information collected from the first survey, the Ministry of Health commissioned a follow-up survey, again with Hopkins faculty as chief technical assistance. The scope of this round was expanded to include men who have sex with men (MSM), and several additional regions have also been included.
This will be the first-ever survey of MSM in Afghanistan, and was possible in part because of the success implementing surveys with hard-to-reach populations including female sex workers, which was facilitated by the extensive engagement of local staff and stakeholders in the survey process. For example, two local groups IBn Sina and MRCA implemented the field work, and the project manager and chief surveillance officer are both Afghani.
Evidence-based Policy Making
Over the last decade, the Afghanistan NACP has tirelessly worked to build the evidence base for developing programs and policy to prevent the spread of HIV. Department faculty in their capacity as technical advisers are working with and training local professionals so that eventually their expertise will not be needed. The arrangement has been productive and rewarding on both sides. As Dr. Tran explains:
There is mutual respect at all levels between research staff and decision makers in the Ministry of Health. The Ministry is very keen to strengthen their own capacity and to incorporate sound evidence into their plans. Such close contact with the government allows us to see first-hand how evidence is used by policymakers and allows us to contribute to that process. For instance, our first round results have been cited in the development of new harm reduction programs for IDUs, and they were key in the decision to conduct the first MSM survey in the country.
The second round of surveys is currently in the field and results should be published later this year.
--Brandon Howard, February 2011