2021 Standards Evaluation Report (SER)

Form Approved OMB No. 0920-0573
Exp. Date: 11/30/2022

2022 Standards Evaluation Report (SER)
Process and Outcome Standards for Surveillance
Jurisdiction name: ______________________
Primary Surveillance Contact: _________________ Overall Responsible Party: _____________
Secondary Surveillance Contact: _________________
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
Vital statistics file loaded for deaths
1 OR
NDI-Plus early release file loaded for deaths

Linked with deaths occurring through

☐Prohibited

2 SSDMF loaded for deaths
Ascertain causes of deaths

Linked with deaths occurring through

NDI Plus final file with cause-of-death information loaded for
☐Prohibited
deaths
Vital statistics final file with cause-of-death information loaded
4 for deaths
3

Search for potentially unreported HIV cases
Searched all vital records deaths mentioning HIV infection and
5
loaded previously unreported cases

Linked with deaths occurring through

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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Form Approved OMB No. 0920-0573
Exp. Date: 11/30/2022

B. Laboratory
1. In 2021, did your surveillance program develop and/or update the list of all laboratories (in
jurisdiction and out of jurisdiction) that conducted HIV-related testing for persons who reside
in your jurisdiction using a method such as Centers for Medicare and Medicaid Services (CMS)
search, or evaluation of your electronic laboratory report (ELR) program baseline
spreadsheet?
☐ Yes
• Did you identify new laboratories that conduct HIV testing for persons who reside in your
jurisdiction?
☐ Yes
☐ No

•

What is the total number of laboratories that report HIV-related test results for persons who
reside in your jurisdiction? Click here to enter text.
o Please describe how your program obtained this number. Click here to enter text.

☐ No
2. Since 2018, did your surveillance program conduct an assessment on laboratories that conduct
HIV-related testing for persons who reside in your jurisdiction? This assessment is to maintain
documentation, such as types of tests performed and LOINC usage, by all laboratories that
report to your jurisdiction.
☐ Yes
• What year(s)? Click here to enter text.
☐ No
3. Are you aware of any laboratory reporting lapses of HIV-related test results for persons who
reside within your jurisdiction that resulted in missing laboratory data in your December 2021
data transfer? Please include lapses attributed to either the laboratory not reporting test results
or because the HL7 reader/transmitter in the health department did not send the results to HIV
surveillance.
☐ Yes
• Approximately what percentage of your total jurisdiction’s laboratory volume is missing
because of this? Click here to enter text.
• Approximately what percentage of all CD4 results (< 200 and ≥ 200), or all viral load results
(detectable and undetectable) are missing because of this? Click here to enter text.
☐ No
• In 2021, 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
4. By December 2021, 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 2019-2021?
Year
reports

CD4 (<200 and ≥200)

Viral load tests (detectable and
undetectable)

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Form Approved OMB No. 0920-0573
Exp. Date: 11/30/2022

were
received

Yes

No

Describe type of CD4
results received

Yes

No

Describe type of viral
load results received

☐

☐

Click here to enter text.

☐

☐

Click here to enter text.

2019
2020

☐

☐

Click here to enter text.

☐

☐

Click here to enter text.

2021*
Click here to enter text.
☐
☐ Click here to enter text.
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*At a minimum, reports received from January 2021 through September 2021

C. Pediatric/Perinatal
1A. In 2021, did you link women with diagnosed HIV infection reported to
the surveillance system to state/local/territory birth certificate data for all
2020 births to identify all perinatally exposed infants with a residence of
birth in your jurisdiction?
☐ Yes
☐ No
1B. If no to 1A, please describe why you did not link with all
state/local/territory birth certificate data.
[Free text]

Birth Ascertainment

1C. If yes to 1A, did you enter all information identified from the linkage to
state/local/territory birth certificate data into eHARS before your final
December 2021 data transfer to CDC?
☐ Yes
☐ No
ID. If no to 1C, please describe why you did not enter all information
identified from the link to state/local/territory birth certificate data into
eHARS.
[Free text]
Number of perinatally HIV exposed infants born in 2020 that were identified
through the match to birth certificates. *This should include exposed infants
previously known to the HIV surveillance program.

Number of
perinatally HIV
exposed infants for
birth year 2020

Does this match with the number of perinatally exposed infants reported to
CDC through your final December 2021 data transfer?
☐ Yes
☐ No

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Form Approved OMB No. 0920-0573
Exp. Date: 11/30/2022

If this does not match, please describe the reasons the numbers do not match
(e.g., X perinatally exposed infants reported to health department that were
not in the state/local birth certificate data because the infant was a resident of
another jurisdiction).

D. Geocoding and Data Linkage
Submission of
Geocoded Data

In 2021, did you submit your geocoded data to CDC, per the
Geocoding and Data Linkage Technical Guidance for HIV
Surveillance Programs file and the joint MOU?

☐
Yes

☐
No

E. Cluster Detection and Response

1. Did your program submit a final written plan for establishing and maintaining capacity for
cluster and outbreak detection and response according to the guidance in Detecting and
Responding to HIV Transmission Clusters: A Guide for Health Departments by July 15,
2021?
2. In 2021, did your program analyze molecular data using CDC-recommended approaches at
least monthly to identify HIV transmission clusters and outbreaks?
3. In 2021, did your program conduct time-space analysis using CDC-recommended
approaches at least monthly to identify HIV transmission clusters and outbreaks?

Yes

No

☐

☐

☐

☐

☐

☐

If you did not meet the standards in 1 - 3 above, please discuss each unmet standard:
a. Why you did not meet the minimum standard for cluster detection and response in 2021.
b. Your plan to ensure your program meets this standard in 2022.

Outcome Standards for Surveillance
NOTE: All areas MUST run the CDC-supplied SAS program against the December 2021 frozen eHARS
SAS datasets to evaluate and report on your program’s outcome standards. In addition, all SAS table
output MUST be included with your SER submission.
F. Submission of Required Outcome Standards with SAS Tables
Please confirm that you have attached the following SAS outcome tables to your SER submission.
I have attached:
Completeness and timeliness tables:
☐ Yes
☐ No
Intrajurisdiction case duplication rate tables:
☐ Yes
☐ No
RIDR progress summary tables:
☐ Yes
☐ No
CIDR progress summary table:
☐ Yes
☐ No
Risk factor ascertainment tables:
☐ Yes
☐ No

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Lab reporting tables:
Data quality tables:
Death ascertainment tables:
GDL eval outcome tables:

☐
☐
☐
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Yes
Yes
Yes
Yes

☐
☐
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Form Approved OMB No. 0920-0573
Exp. Date: 11/30/2022

No
No
No
No

Required only for Ending the HIV Epidemic in the US (EHE) priority jurisdictions1:
PS20_2010 HIV case report timeliness tables
☐ Yes
☐ No
PS20_2010 Laboratory results report timeliness tables ☐ Yes
☐ No
1

EHE jurisdictions and jurisdictions with EHE counties: Alabama, Arizona, Arkansas, California, Chicago, District of Columbia, Florida,
Georgia, Houston, Illinois, Indiana, Kentucky, Los Angeles, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Missouri, Nevada, New
Jersey, New York, New York City, North Carolina, Ohio, Oklahoma, Pennsylvania, Philadelphia, Puerto Rico, San Francisco, South Carolina,
Tennessee, Texas, Washington

Measure

Completeness and
Timeliness of Case
Ascertainment

Intrastate Duplicate
Review
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

Standard
Did your surveillance program ascertain at least (≥) 95% of the
expected number of cases diagnosed with HIV infection in 2020 by
the end of December 2021?
Did your surveillance program ascertain at least (≥) 90% of the
expected number of cases diagnosed with HIV infection in 2020
within 6 months of date of diagnosis, assessed at the end of December
2021?
Were there less than or equal to (≤) 1% duplicate case reports among
all (cumulative) cases reported to your surveillance program through
December 31, 2020 by the end of December 2021?
Were at least (≥) 98% of the pairs on your RIDR list received in
January 2021 resolved by June 30, 2021? ☐ N/A Done by state
Were at least (≥) 98% of the pairs on your RIDR list received in July
2021 resolved by December 31, 2021? ☐ N/A Done by state
Were at least (≥) 80% of the pairs on your CIDR list received in 2018
resolved by December 31, 2021? ☐ N/A Done by state
Did at least (≥) 80% of HIV cases newly reported to your surveillance
program in 2020 have sufficient risk factor information to be classified
into a known HIV transmission category by the end of December
2021?
Did at least (≥) 85% of cases among those 13+ years diagnosed with
HIV infection in 2020 have a CD4 count or percent based on a
specimen collected within one month following their initial diagnosis,
by the end of December 2021?
Did at least (≥) 85% of cases among those 13+ years diagnosed with
HIV infection in 2020 have a viral load based on a specimen collected
within one month following their initial diagnosis by the end of
December 2021?
Were at least (≥) 85% of all labs with a specimen collection date in
2020 among cases diagnosed in 2020, loaded in the surveillance
system within 60 days of the specimen collection date, assessed at the
end of December 2021?

Result
%

%

%
%
%
%

%

%

%

%

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Nucleotide Sequence
Antiretroviral History
Data Quality

Cause of Death

Did at least (≥) 60% of cases diagnosed in 2020 have an analyzable
nucleotide sequence by the end of December 2021?
Did at least (≥) 70% of cases diagnosed in 2020 have prior
antiretroviral use history by the end of December 2021?
In 2020, 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 2021?
Did at least (≥) 85% of the deaths that occurred in 2019 have an
underlying cause of death by the end of December 2021 (24 months
after the death year)?

Were at least (≥) 90% of HIV cases diagnosed in 2020 geocoded to the
census tract level by the end of December 2021?
Did at least (≥) 70% of cases diagnosed in 2020 have a known value
for previous negative HIV test by the end of December 2021?
Previous Negative
Did at least (≥) 50% of cases diagnosed in 2020 with a previous
HIV Test*
negative test have a valid date of documented negative test result,
assessed by the end of December 2021?
Did at least (≥) 60% of HIV cases that were not virally suppressed at
Viral suppression for
identification as part of a cluster, achieve viral suppression within 6
cluster members*
months (for cases identified as part of a transmission cluster in 2020)?
Perinatal HIV
Did ≥ 85% of perinatally exposed infants born in 2019 have HIV
Exposure Reporting infection status determined by 18 months of age?
Required only for Ending the HIV Epidemic in the US (EHE) priority jurisdictions1:
Did ≥75% of all HIV cases whose diagnoses were first entered into
Enhanced case
eHARS during 2021, get first entered within 30 days after the date of
reporting timeliness
diagnosis?+
Priority EHE area 1:__________________
Priority EHE area 2:__________________
Priority EHE area 3:__________________
Priority EHE area 4:__________________
Priority EHE area 5:__________________
Priority EHE area 6:__________________
Priority EHE area 7:__________________
Priority EHE area 8:__________________
Did ≥75% of all laboratory test results entered into eHARS during
Enhanced laboratory
2021, get entered within 14 days after the date of specimen collection?
reporting timeliness
(assessed at state level and Puerto Rico and DC) +
Geocoding

%
%
%

%
%
%
%

%
%

%
%
%
%
%
%
%
%
%

1

EHE jurisdictions and jurisdictions with EHE counties: Alabama, Arizona, Arkansas, California, Chicago, District of Columbia, Florida,
Georgia, Houston, Illinois, Indiana, Kentucky, Los Angeles, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Missouri, Nevada, New
Jersey, New York, New York City, North Carolina, Ohio, Oklahoma, Pennsylvania, Philadelphia, Puerto Rico, San Francisco, South Carolina,
Tennessee, Texas, Washington

+

Among cases with person view status = ‘A’ or ‘W’.

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Form Approved OMB No. 0920-0573
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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 standard in 2021.
b. Your plan to ensure your program meets the standard in 2022.

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 2020)?
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 2020)?

Result
%

Numerator

Denominator

%
%
%

n
n
n

n
n
n

%

n

n

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

H. Data Reporting and Dissemination
In 2021 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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Form Approved OMB No. 0920-0573
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I. Security and Confidentiality
In 2021:
1. 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); hereafter referred to as the NCHHSTP guidelines?
2. Did your program ensure 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?
3. 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?
4. Did your program apply the NCHHSTP guidelines to all sub-contractors and subrecipients funded through PS18-1802 that have access to or maintain confidential HIV
data?
5. Did your program implement secure procedures for data sharing, including Data to Care
(D2C) activities, within the context of existing laws, including within your public health
program and with external partners (such as sub-recipients)?
6. Did your program implement practices that support secure sharing and use of HIV data
across necessary programs within the health department, including the Medical
Monitoring Project (MMP) (if applicable)?
7. 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?
8. 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?

Yes

No

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