A narrative review of HIV surveillance strategies used in selected sub-Saharan African countries

Background Over the last two decades, new HIV infections and AIDS-related deaths have declined significantly through expansion of access to HIV testing, treatment, and prevention services. Data to monitor epidemic trends and program coverage have been central to driving progress. We describe HIV surveillance indicators and methods that countries use to monitor the HIV epidemic and impact of programs in selected African countries. Methods We conducted a review of global and national HIV surveillance guidelines. We extracted information on (1) indicators used to monitor HIV epidemic changes, and (2) activities countries conduct to measure these. We conducted an in-depth document analysis for five selected African countries: Ghana, Kenya, Lesotho, Malawi, and Zimbabwe. Results We identified 66 documents that inform HIV surveillance plans at national or global levels. Documents from the five selected countries reflected a range of 80 to 103 HIV indicators per country compared to 128 from a consolidated list of indicators in global guidance documents. The largest proportion of reported national indicators was for integrated services and non-biomedical measures such as HIV stigma and knowledge, with these accounting for a range of 22.8% (21/92) in Ghana to 64.1% (66/103) in Lesotho. Measuring incidence and mortality relied predominantly on mathematical modeling. Activities such as community and facility-based mortality surveillance, HIV drug resistance surveys and bio-behavioral surveys were specified in strategic plans but were partially implemented or not documented. Conclusion HIV surveillance among selected African countries primarily used mathematical models for estimating HIV incidence and mortality and heavily depended on infrequent household surveys for quantifying epidemic burden. Strategy documents named many HIV indicators and surveillance activities, which were inconsistently implemented. Countries could reassess suitability of current indicators and activities and streamline these for efficient estimation of HIV burden.