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Guidelines for Second Generation HIV Surveillance: An Update: Know Your Epidemic. Geneva: World Health Organization; 2013.

Cover of Guidelines for Second Generation HIV Surveillance

Guidelines for Second Generation HIV Surveillance: An Update: Know Your Epidemic.

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1.1. What is second generation surveillance?

First generation surveillance relied solely on data on AIDS cases and some sentinel studies on HIV prevalence. In 2000, a new strategy named second generation surveillance (SGS) was promoted to tailor surveillance systems to the epidemic state of a country (1). More specifically, the strategy proposed the following:

  • to concentrate strategic information resources where they would yield information that is useful in reducing the spread of HIV and in providing care for those affected;
  • to concentrate data collection in key populations at higher risk of HIV exposure, such as populations with high levels of risk behaviour that places them at increased risk or young people at the start of their sexual lives;
  • to compare information on HIV prevalence and on the behaviours that spread the infection to build up an informative picture of changes in the epidemic over time;
  • to make the best use of other sources of information, such as communicable disease surveillance and reproductive health surveys, to increase understanding of the HIV epidemic and the behaviours that spread it.

The components of HIV second general surveillance remain similar as presented in figure 1.

Figure 1. Components of HIV second generation surveillance.

Figure 1

Components of HIV second generation surveillance.

1.2. Purpose of this document

This document describes a process that would enable countries to respond more effectively to their respective HIV epidemics. Using this process, they will be able:

  • to review and analyse surveillance efforts already undertaken in the country
  • to describe the trends of the epidemic
  • to provide recommendations to policy-makers, and
  • to design methods for additional data collection to strengthen ongoing surveillance systems.

1.3. Background

Since 2000, countries have focused resources and attention on implementing HIV second generation surveillance. Increasingly, the critical information needed for countries to stay ahead of their epidemics is being gathered, collected, interpreted and applied.

An update was needed to the 2000 guidelines to incorporate the experiences of countries implementing second generation surveillance over the past 10 years. Field experience and new challenges, including important changes in survey methodology and laboratory diagnostics, have been presented at two global conferences on HIV surveillance methods and tools (2,3,4).

Countries have gained experience in when and how data collection activities for surveillance and monitoring and evaluation (M&E) can be designed so that they are complementary (5). These data collection activities have some overlaps.

  • The main objective of surveillance is to track how the epidemic in a country is changing.
  • The main objective of M&E is to track how effectively programmes are responding to the epidemic, and whether the outcomes and outputs correspond to the activities planned.

When conducting surveillance activities, universal ethical principles should be taken into consideration. Ethical issues are complex and require discussion and agreement. The following paragraph highlights only some of the issues that should be considered when implementing surveillance activities.

Ethical considerations

The collection and use of HIV-related data raise many critical ethical issues. One must address these issues in the design and implementation of surveillance activities. Given below are some of the key ethical concerns to think about:

  • Obtain true informed consent when collecting data that are not routine or primarily for the benefit of patient management or evaluation of services.
  • Be cautious with the reporting of data on the size and location of persons who engage in HIV-related risk behaviours, such as sexual practices that put them at higher risk for HIV exposure or illicit substance use. Avoid their unwarranted harassment or detention by local authorities.
  • Protect confidentiality of data on HIV testing and status. Avoid reporting results of surveillance data from small geographical units or small populations.
  • Avoid stigmatizing surveillance subjects with sexually transmitted infections (STIs) such as syphilis, gonorrhoea, chlamydia and HIV.
  • Provide participants in HIV prevalence surveys with access to test results and referrals for services or treatment, especially those individuals who are HIV-positive.
  • Use the results of surveillance for policy-making and improving the response to the HIV epidemic.

Surveillance protocols for any method, whether case reporting, surveys or sentinel surveillance, must address the relevant ethical issues. More detailed guidance is provided in Ethical principles when conducting HIV surveillance activities for second generation surveillance (6).

1.4. What this update includes

This update:

  • re-emphasizes the key approaches to conducting HIV surveillance;
  • highlights new methods, tools and thinking to make second generation surveillance more critical and relevant to a country's response to the HIV epidemic;
  • gives guidance on using and interpreting surveillance data more effectively.

Since the Guidelines on second generation surveillance were published in 2000 (1), a number of other detailed technical guidelines have been developed on specific surveillance topics. These are listed in Appendix B and should be referred to for more detailed information on specific issues related to surveillance. Throughout this update, references are given to technical documents that expand the application of surveillance methods.

1.5. Process (→ “From start to finish: the process of HIV surveillance”?)

To address any epidemic, one must first Know your epidemic (4), then use the results of the analysis to provide services to areas and groups that require them the most. This document provides guidance on how to use second generation surveillance techniques to learn where most new HIV infections arise and to assess the direction of the epidemic.

Figure 1.1 shows a general process for conducting HIV surveillance activities. It is important to remember that because most countries have already developed HIV surveillance activities, all countries have some data from past surveillance activities.

Figure 1.1. Process for implementing enhanced second generation surveillance techniques.

Figure 1.1

Process for implementing enhanced second generation surveillance techniques. The numbers in the process below refer to the sections and subsections of this document.

The remainder of this document discusses the process shown in Figure 1.1.

Copyright © World Health Organization 2013.

All rights reserved. Publications of the World Health Organization are available on the WHO web site ( or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857;e-mail: tni.ohw@sredrokoob).

Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (

Bookshelf ID: NBK158983


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