Standards Evaluation Report Form (Years 2-5)

National HIV Surveillance System (NHSS)

Attachment 3e.
Standards Evaluation Report Form

Form Approved OMB No. 0920-0573
Exp. Date: XX/XX/XXXX

2018 Standards Evaluation Report (SER)
Process and Outcome Standards for Surveillance
Process Standards
A. Death Ascertainment
☐ We are a separately funded city AND all death ascertainment is done at the state level. (Skip to
section B: Laboratory).
☐ We are a state, territory, or separately funded city and perform our own death ascertainment. (Respond
to the questions below and complete the table).
Ascertain dates of deaths

Linked with deaths occurring through
Choose an item. Choose an item.

1

Vital statistics file loaded for deaths
OR
NDI-Plus early release file loaded for deaths

2

SSDMF loaded for deaths

Choose an item. Choose an item.

Ascertain causes of deaths

Choose an item.

Linked with deaths occurring through
☐Prohibited

Choose an item.
Vital statistics final file with cause-of-death information loaded for Choose an item. Choose an item.

3

NDI Plus final file with cause-of-death information loaded for deaths

4

deaths

Search for potentially unreported HIV cases
5

☐Prohibited

Searched all vital records deaths mentioning HIV infection and loaded
previously unreported cases

Linked with deaths occurring through
Choose an item. Choose an item.

If you did not load all of the required files in 1-5 above in accordance with the process standards outlined in the Death
Ascertainment Technical Guidance for HIV Surveillance Programs file, please discuss:
a. Why you did not load each file in accordance with the process standards.
b. Your plan to ensure your program loads each file in the next evaluation period in accordance with the process standards.

Public reporting burden of this collection of information is estimated to average 8 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may
not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to
CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0573).

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B. Laboratory
1. In 2018, did your surveillance program do an assessment to identify all laboratories (in state
and out of state) that conducted HIV-related testing for providers and facilities in your
jurisdiction using a method such as a lab survey, Centers for Medicare and Medicaid Services
(CMS) search, or state laboratory licensing office search? This must include more than just
counting the number of labs submitting HIV-related test results to the health department.
☐ Yes
• Number of laboratories? Click here to enter text.
o Please describe how your program obtained this number. Click here to enter text.
☐ No
• Based on eHARS data, what is the number of HIV-testing laboratories that reported at least
one HIV test result to your program during 2018?
o Number of laboratories: Click here to enter text.
2. Are you aware of any laboratories that conducted HIV-related testing for providers and
facilities within your jurisdiction that did not report any results to your program in 2018?
☐ Yes
• Approximately what percentage of your jurisdiction’s lab volume is missing because of this?
Click here to enter text.
☐ No
3. Of the laboratory data reported to your program during 2018, are you aware of any issues that
prevented your program from receiving all positive/reactive HIV detection test results, all CD4
results (<200 and ≥200), or all viral load results (detectable and undetectable) and resulted in
missing lab data in your December 2018 data transfer? For example:
a. Laboratory XYZ usually sends 500 viral load results each month, however, during
August, undetectable viral load results were not received from Laboratory XYZ and the
problem was not resolved by December 2018; or
b. Laboratory XYZ was transmitting all viral load result but the HL7 ELR
reader/transmitter in the health department did not send the test results to the HIV
program
☐ No
• In 2018, did your program monitor the quality of incoming reports of laboratory test results
(including test result volumes) on a quarterly basis or more frequently? ☐ Yes ☐ No
☐Yes
•
•
•

Approximately what percentage of all test results in a given year is
Click here to
typically reported by this laboratory or laboratories?
enter text.
Click here to
Approximately what percentage of the test results expected from this
laboratory or laboratories in 2018 was not received?
enter text.
Please describe the expected test results that were not received from this laboratory or
laboratories: Click here to enter text.

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4. By December 2018, did your surveillance program transfer to CDC via eHARS all CD4 (< 200
and ≥ 200) and viral load (detectable and undetectable) test results from laboratory reports
received from 2016-2018?

Year
reports
were
received

Yes

No

Yes

No

Viral load results
If “no”, what Describe type
% of results
of viral load
received have
results
been
received (e.g.,
transferred
Any result,
to CDC?
detectable)

Click here to
%
☐
☐
enter text.
Click here to
2017
%
%
☐
☐
☐
☐
enter text.
Click here to
2018*
%
%
☐
☐
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enter text.
*At minimum, reports received from January 2018 through September 2018
2016

☐

☐

CD4 results
If “no”, what
Describe type
% of results
of CD4 results
received have
received (e.g.,
been
All values,
transferred to
<500, <200)
CDC?
%

Click here to
enter text.
Click here to
enter text.
Click here to
enter text.

C. Pediatric/Perinatal

Perinatal HIV
Exposure Reporting

In 2018, did you link women with diagnosed HIV infection reported
to the surveillance system to state/local birth certificate data for all
2017 births to identify all perinatally exposed infants and infants with
HIV infection not reported to surveillance, and enter the results into
eHARS?
Did ≥ 85% of perinatally exposed infants born in 2017 have HIV
infection status determined by 18 months of age?

Number of perinatally
HIV exposed infants
for birth year 2017

Number of perinatally HIV exposed infants born in 2017 that were
identified through the match to birth certificates. *This should include
exposed infants previously known to the HIV surveillance program.

Birth Ascertainment

☐
No

☐
Yes

%

Click or
tap here
to enter
text.

D. Geocoding and Data Linkage
Submission of
Geocoded Data

In 2018, did you submit your geocoded data to CDC, per CDC
guidance and the joint MOU?

☐
Yes

☐
No

E. Cluster Detection and Response

1. In 2018, did your program develop a written plan for establishing and maintaining capacity
for cluster and outbreak detection and response and submit the plan to CDC?
2. In 2018, did your program analyze molecular data using CDC-recommended approaches at
least monthly to identify HIV transmission clusters and outbreaks?

Yes

No

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☐

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3. In 2018, did your program conduct time-space analysis using CDC-recommended
approaches at least monthly to identify HIV transmission clusters and outbreaks?

☐

☐

If you did not meet the standards in 1, 2, or 3 above, please discuss each unmet standard:
a. Why you did not meet the minimum standards for cluster detection and response in 2018.
b. Your plan to ensure your program meets this standard in 2019.

Outcome Standards for Surveillance
NOTE: All areas MUST run the CDC-supplied SAS program against the December 2018 frozen eHARS
SAS datasets to evaluate and report on your program’s outcome standards. In addition, all SAS table
output MUST be attached to your SER submission.
F. Submission of Required SAS Outcome Tables
Please confirm that you have attached the following SAS outcome tables to your SER submission. I
have attached:
Case ascertainment tables:
Intrastate case duplication rate tables:
Routine Interstate Duplicate Review tables:
Cumulative Interstate Duplicate Review table:
Risk factor ascertainment tables:
Completeness of laboratory tables:
Data quality tables:
Death ascertainment tables:
Geocoding:
Viral suppression for cluster members

Measure

Completeness and
Timeliness of Case
Ascertainment

Intrastate Duplicate
Review

☐
☐
☐
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Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

☐
☐
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No
No
No
No
No
No
No
No
No
No

Standard
Did your surveillance program ascertain at least (≥) 95% of the
expected number of persons newly diagnosed with HIV infection in
2017 by the end of December 2018?
Did your surveillance program ascertain at least (≥) 90% of the
expected number of persons newly diagnosed with HIV infection in
2017 within 6 months of date of diagnosis, assessed at the end of
December 2018?
Were there less than or equal to (≤) 1% duplicate case reports among
all (cumulative) cases reported to your surveillance program through
December 31, 2017 by the end of December 2018?

Result
%

%

%

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Routine Interstate
Duplicate Review
(RIDR)
Cumulative Interstate
Duplicate Review
(CIDR)
Risk Factor
Ascertainment

Completeness of
Initial CD4

Completeness of
Initial Viral Load
Timeliness of
Laboratory Reporting
Nucleotide Sequence
Antiretroviral History
Data Quality

Cause of Death
Geocoding

Previous Negative
HIV Test*

Viral suppression for
cluster members*

Were at least (≥) 98% of the pairs on your RIDR list received in
January 2018 resolved by June 30, 2018? ☐ N/A Done by state
Were at least (≥) 98% of the pairs on your RIDR list received in July
2018 resolved by December 31, 2018? ☐ N/A Done by state
Were at least (≥) 40% of the pairs on your CIDR list received in 2018
resolved by December 31, 2019? ☐ N/A Done by state
Did at least (≥) 80% of HIV cases newly reported to your surveillance
program in 2017 have sufficient risk factor information to be classified
into a known HIV transmission category by the end of December
2018?
Did at least (≥) 85% of adults and adolescents newly diagnosed with
HIV infection in 2017 have a CD4 count or percent based on a
specimen collected within one month following their initial diagnosis,
by the end of December 2018?
Did at least (≥) 85% of adults and adolescents newly diagnosed with
HIV infection in 2017 have a viral load based on a specimen collected
within one month following their initial diagnosis by the end of
December 2018?
Were at least (≥) 85% of all labs with a specimen collection date in
2017 loaded in the surveillance system within 60 days of the specimen
collection date, assessed at the end of December 2018?
Did at least (≥) 60% of cases diagnosed in 2017 have an analyzable
nucleotide sequence by the end of December 2018?
Did at least (≥) 70% of cases diagnosed in 2017 have prior
antiretroviral use history by the end of December 2018?
In 2017, did 97% of case records that meet the surveillance case
definition for HIV infection have no required fields missing and pass
all selected data edits by the end of December 2018?
Did at least (≥) 85% of the deaths that occurred in 2016 have an
underlying cause of death by the end of December 2018 (24 months
after the death year)?
Were at least (≥) 90% of HIV cases diagnosed in 2017 geocoded to the
census tract level by the end of December 2018?

Did at least (≥) 70% of cases diagnosed in 2017 have a known
value for previous negative HIV test by the end of December
2018?
Did at least (≥) 50% of cases diagnosed in 2017 with a previous
negative test have a valid date of documented negative test
result, assessed by the end of December 2018?
Did at least (≥) 60% of HIV-positive persons who were not
virally suppressed at identification as part of a cluster, achieve
viral suppression within 6 months (for persons identified as part
of a transmission cluster in 2017)?

%
%
%

%

%

%

%
%
%
%

%
%
%

%

%

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*If you did not meet the Previous Negative HIV Test or Viral Suppression for Cluster Members standard
above, please discuss:
a. Why you did not meet the minimum standards in 2018.
b. Your plan to ensure your program meets the standards in 2019.

G. Submission of Required Outcome Standards without SAS Tables
Measure

Testing/retesting of HIVnegatives and
persons with
unknown HIV
status

PrEP Referral

Standard
For partners of transmission cluster members who were
not known to be HIV positive at the time of cluster
identification, what percentage were tested or re-tested
within 6 months of identification as part of the risk
network (for persons identified as part of a risk network
in 2017)?
Persons with unknown HIV status:
Persons with negative HIV status:
Total:
For HIV-negative partners of transmission clusters not
on PrEP, what percentage were referred for PrEP within
6 months of identification as part of the risk network (for
persons identified as part of a risk network in 2017)?

Result
%

Numerator

Denominator

%
%
%

n
n
n

n
n
n

%

n

n

For the two Testing/re-testing and PrEP Referral standards above, please discuss how you plan to
improve testing/re-testing and PrEP referral outcomes for persons in clusters and risk networks in
2019.

H. Data Reporting and Dissemination
In 2018 did you develop and disseminate:
A comprehensive revision of your integrated HIV Epidemiologic Profile?
Updates to the HIV Epidemiologic Profile in the form of updates to core epidemiologic tables
and figures, fact sheets, supplemental reports, slide sets, or other publications (but not a
comprehensive revision)?
An annual HIV surveillance report?

Yes
☐

No
☐

☐

☐

☐

☐

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I. Security and Confidentiality

Yes No
Did your program provide a statement signed by the Overall Responsible
Party (ORP) certifying that your program was in full compliance with the
Data Security and Confidentiality Guidelines for HIV, Viral Hepatitis,
Sexually Transmitted Disease, and Tuberculosis Programs: Standards to
Facilitate Sharing and Use of Surveillance Data for Public Health Action
(2011)?
Did all persons with access to HIV data (including IT personnel) complete an
annual security and confidentiality training that is consistent with the
NCHHSTP guidelines, sign a confidentiality statement, and store it in the
personnel file?
Did your program conduct the required annual review of your written
security and confidentiality policies and procedures to assess whether
changes in legislation or regulations, technology, priorities, personnel, or
other situations require updates in policies and procedures?
Did your program complete (or participate in the completion of) an initial
assessment across relevant programs to identify policy and environmental
needs for implementing the Data Security and Confidentiality Guidelines for
HIV, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis
Programs: Standards to Facilitate Sharing and Use of Surveillance Data for
Public Health Action (2011)?
Security and Did your program apply the NCHHSTP guidelines to all sub-contractors and
Confidentiality sub-recipients funded through PS18-1802 that have access to or maintain
confidential HIV data?
Did your program implement secure procedures for data sharing, including
D2C activities, within the context of existing laws, including within your
public health program and with external partners as sub-recipients?
Did your program implement practices that support secure sharing and use of
HIV data across necessary programs within the health department, including
MMP (if applicable)?
Did any data security breach occur, whether it was of personally
identifiable information (PII) or a policy breach? (If yes, please answer a
and b below)
a. Did your program ensure documentation and reporting of the data
security breach with immediate investigation (regardless whether
there was the release of personal information)?
b. Did your program implement corrective actions to avoid breaches of
data security protocol?
Did any breach occur that resulted in the release of PII to unauthorized
persons? (If yes, please answer a and b below)
a. Did your program ensure that the breach that resulted in the release of
PII to unauthorized persons was reported to the ORP, to CDC, and, if
warranted to law enforcement agencies?
b. Did your program implement corrective actions to avoid breaches
that result in the release of PII to unauthorized persons?

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