2023 Standards Evaluation Report (SER)

National HIV Surveillance System (NHSS)

Attachment 3(d)
Standards Evaluation Report Form

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

2023 Standards Evaluation Report (SER)
Surveillance Program Performance
Jurisdiction’s name: ______________________
Provide the following:
1. Primary Surveillance Contact:
2. Secondary Surveillance Contact:
3. S&C Overall Responsible Party:

Name

email

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).

1
2
3
4

Ascertain dates of deaths
Linked with deaths occurring through
Vital statistics file loaded for deaths
OR
NDI-Plus early release file loaded for deaths
☐Prohibited
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
for deaths

Search for potentially unreported HIV cases
Searched all vital records deaths mentioning HIV infection and
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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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B. Laboratory
1. In 2022, 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
•
☐ 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.

2. In 2022 did your surveillance program conduct an assessment of 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
☐ 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 2022
data transfer? Please include lapses in laboratory reporting to CDC, including those attributed
to 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
Year of
Approximately what percentage of your
Approximately what percentage of your total
specimen total jurisdiction’s laboratory volume is
jurisdiction’s CD4 results (< 200 and ≥ 200) and
collection missing for the calendar year indicated?
viral load results (detectable and undetectable) are
missing for the calendar year indicated?
2022*
2021
*At a minimum, lab results through September 2022
☐ No
• In 2022, 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

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C. Pediatric/Perinatal
1A. In 2022, did you link women with diagnosed HIV infection reported to
the surveillance system to state/local/territory birth certificate data for all
2021 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 2022 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]
Provide the number of perinatally HIV exposed infants born in 2021 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 2021

Does this match with the number of perinatally exposed infants reported to
CDC through your final December 2022 data transfer?
☐ Yes
☐ No
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).

Perinatal HIV
Exposure Reporting

Provide percentage of perinatally HIV exposed infants born in 2020 who
have HIV infection status determined by 18 months of age (Standard: 85%):

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D. Geocoding and Data Linkage
Submission of
Geocoded Data

In 2022, 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. In 2022, did your program analyze molecular data using CDC-recommended approaches at
least monthly to identify HIV transmission clusters and outbreaks?
2. In 2022, did your program conduct time-space analysis using CDC-recommended
approaches at least monthly to identify HIV transmission clusters and outbreaks?

Yes

No

☐

☐

☐

☐

F. Submission of Required Outcome Standards with SAS Tables
NOTE: All areas MUST run the CDC-supplied SAS programs against the December 2022 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.
SAS outcome table
Completeness and
timeliness tables

Intrajurisdiction case
duplication rate table
RIDR progress summary
tables

CIDR progress summary
table
Risk factor ascertainment
tables

Lab reporting tables

Included indicators
- Of the expected number of persons whose HIV infection was
diagnosed during 2021, at least (≥) 95% are reported in the local
HIV surveillance system, assessed December 2022
- Of the expected number of persons whose HIV infection was
diagnosed during 2021, at least (≥) 90% are reported in the local
HIV surveillance system within six months of the diagnosis,
assessed December 2022
- Of all persons with diagnosed HIV infection who were reported
to the local surveillance program through the end of 2021
(cumulative), less than or equal to (≤) 1% have duplicate case
reports, assessed December 2022
- Of all pairs on the Routine Interstate Duplicate Review (RIDR)
list received January 2022, at least (≥) 98% were resolved by
June 30, 2022
- Of all pairs on the Routine Interstate Duplicate Review (RIDR)
list received July 2022, at least (≥) 98% were resolved by
December 31, 2022
- Of all pairs on the Cumulative Interstate Duplicate Review
(CIDR) list received January 2018, 100% are resolved by
December 31, 2022
- Of all persons with diagnosed HIV infection who were first
entered in the local HIV surveillance system during 2021, at
least (≥) 80% have sufficient risk factor information to be
classified into a known transmission category, assessed
December 2022
- Of all persons aged 13 years or older with HIV infection
diagnosed during 2021, at least (≥) 85% have a CD4 count or

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percent based on a specimen collected within one month
following HIV diagnosis, assessed December 2022
- Of all persons aged 13 years or older with HIV infection
diagnosed during 2021, at least (≥) 85% have a viral load based
on a specimen collected within one month following HIV
diagnosis, assessed December 2022
- Of all laboratory test results entered into eHARS in 2021 for
persons with HIV infection diagnosed during 2021, at least 85%
were entered into eHARS within 60 days of the specimen
collection date, assessed December 2022
- Of all persons with HIV infection diagnosed during 2021, at
least (≥) 60% have an analyzable nucleotide sequence, assessed
December 2022
- Of all persons with HIV infection diagnosed during 2021, at
least (≥) 70% have a known value for previous negative HIV
test result, assessed December 2022
- Of all persons with HIV infection diagnosed during 2021 who
have a previous negative test result, at least (≥) 50% have a valid
date of documented negative test result, assessed December
2022
- Of persons with diagnosed HIV infection who were identified as
part of a cluster during 2021 and were not virally suppressed at
the time of identification, at least (≥) 60% achieved viral
suppression within 6 months of cluster identification, assessed
December 2022
Data quality tables
- Of all persons with HIV infection diagnosed during 2021, at
least (≥) 97% have no required fields missing and pass all
standard data edit checks, assessed December 2022
- Of all persons with HIV infection diagnosed during 2021, at
least (≥) 70% have prior antiretroviral use history, assessed
December 2022
Death ascertainment tables
- Of all deaths that occurred during 2020, at least (≥) 85% have an
underlying cause of death, assessed December 2022
GDL eval outcome tables
- Of all persons with HIV infection diagnosed during 2021, at
least (≥) 90% have their residence at diagnosis geocoded to the
census tract level, assessed December 2022
Outcome indicator
- Summarizes all indicators above (excluding RIDR, CIDR, and
summary
GDL)
Required only for Ending the HIV Epidemic in the US (EHE) priority jurisdictions:
(EHE jurisdictions and jurisdictions with EHE counties: Alabama, Arizona, Arkansas, California, Chicago, District of Columbia, Florida,
Georgia, Houston, Indiana, Kentucky, Los Angeles, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Missouri, Nevada, New
Jersey, New York City, North Carolina, Ohio, Oklahoma, Philadelphia, Puerto Rico, San Francisco, South Carolina, Tennessee, Texas,
Washington)

PS20_2010 HIV case report
timeliness tables

-

PS20_2010 Laboratory
results report timeliness
tables

-

Of all persons with diagnosed HIV infection whose diagnoses
were first entered into the local HIV surveillance system during
2022, at least (≥) 75% were first entered within (≤) 30 days after
the date of diagnosis.+
Of all laboratory test results that were entered into the HIV
surveillance system during 2022, at least (≥) 75% were entered
within (≤) 14 days after the date of specimen collection.+

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

+

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 2021)?
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 2021)?

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 2022 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
☐

☐

☐

☐

☐

Yes

No

☐

☐

☐

☐

I. Security and Confidentiality
In 2022:
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?

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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 for collaboration with the
Medical Monitoring Project (MMP) (if applicable)?
☐Not 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 of 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?

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