PEPFAR-Supported Countries Face Challenges Implementing Case-Based HIV Surveillance

Case-based surveillance of HIV is needed for public health planning around treatment and prevention of the epidemic. The US Centers for Disease Control and Prevention (CDC) has published a comprehensive, global assessment of HIV case-based surveillance implementation. The report examines 39 countries supported by the US President's Emergency Plan for AIDS Relief (PEPFAR).

Authors of the assessment, published in CDC’s Morbidity and Mortality Weekly Report (MMWR), note barriers in policy and technical infrastructure which need to be addressed in order to enhance national efforts surrounding the HIV epidemic.

The assessment sought to capture the facilitators and barriers challenging implementation of case-based HIV surveillance. Authors of the report distributed a survey between May and July 2019 to the 46 PEPFAR supported countries with CDC presence.

Among the 39 countries with responses, 20 had implemented case-based surveillance, 15 were planning implementation, and 4 were not planning implementation.

Countries which conducted case-based surveillance all reported capturing date of diagnosis information, with 17 also collecting sentinel event data. In 15 implementation countries, a health information system facilitated the case-based surveillance.

Of 15 countries planning to conduct case-based surveillance, 13 planned to collect date of diagnosis data and 11 planned to collect sentinel event data. Only 4 of these countries have the capability to use unique identifiers to link and deduplicate patient-level data.

Barriers to implementation were consistently reported among the countries surveyed. Criminalization and stigmatization of populations at high risk of HIV infection were reported by 6 of 20 countries that had implemented case-based surveillance, 6 of 15 planning implementation, and all 4 that were not planning implementation.

HIV was a nationally notifiable condition in 16 out of 20 countries implementing case based-surveillance, 5 of 15 countries planning to implement. None of the countries without plans to implement case-based surveillance consider HIV to be a nationally notifiable condition.

Of the 15 countries planning to implement case-based surveillance in the future, 10 reported a lack of national level policy/guidance as an important barrier. Countries not planning to implement reported barriers in dedicated human resources and funding.

Authors of the assessment noted that only half of countries implementing case-based surveillance use a unique identifier to match and deduplicate data, highlighting a need to improve understanding of the functional requirements of case-based surveillance among implementing countries.

In addition to policy barriers, authors pointed to challenges associated with the lack of universal adoption of security measures for electronic and paper records, a necessary component of case-based surveillance.

Authors explained several limitations to the findings, such as the several countries which did not complete the survey despite follow-up attempts, an inability to identify all possible facilitators and barriers, as well as different potential interpretations by different respondents. Despite this, the survey was the first comprehensive global assessment of case-based surveillance implementation in PEPFAR-supported countries.

The authors concluded by reiterating that case-based surveillance is important for all PEPFAR-supported countries in order to develop informed national responses to the HIV epidemic. The fact that many countries have not yet implemented case-based surveillance indicates a need for increased efforts addressing policy barriers and gaps in technical infrastructure.