Pilot Implementation of HIV Case-Based Surveillance in Mozambique: Process, Challenges, and Lessons Learned, 2023-2024 (Preprint)

BACKGROUND Mozambique has achieved substantial progress in HIV response since the first clinically diagnosed AIDS case in 1986, including expanded antiretroviral therapy (ART) coverage and strides toward the global 95-95-95 targets. However, the absence of a harmonized national system capable of tracking people living with HIV across provinces limits timely, data-driven decision-making and hinders monitoring along the continuum of care. HIV Case-Based Surveillance (CBS) offers a strategic approach to address the gaps in longitudinal monitoring of diagnosed cases. OBJECTIVE This study aimed to document the implementation process, operational adaptations, and lessons learned during the introduction of a pilot HIV-CBS system within routine health services in Mozambique. METHODS A pilot HIV-CBS system was implemented between May 2023 and January 2024, led by the National Institute of Health in collaboration with the Ministry of Health and partner organizations. Five health facilities in Maputo City and Maputo Province were selected based on predefined inclusion criteria to represent urban, peri-urban, and rural settings. Surveillance initially targeted newly diagnosed HIV cases and was later expanded to also include previously diagnosed individuals retesting (and reinitiating ART) following treatment interruption. Individual-level data were collected from HIV testing entry points using electronic tools and compiled into a centralized, de-identified longitudinal database. RESULTS The pilot demonstrated the feasibility and added value of implementing HIV-CBS within routine health services, based on key informant interviews with health facility staff alongside routine data quality assessments. CBS enabled near-real-time monitoring of HIV diagnoses, ART initiation, and return-to-care events that were not adequately captured through aggregate reporting systems. Key implementation challenges included inconsistent use of patient identifiers, data quality gaps, limited interoperability with existing electronic systems, and staff workload constraints. Adaptive measures, including refinement of case definitions, targeted training and supportive supervision, data triangulation, and improved data visualization, led to measurable improvements in data completeness, internal consistency, and analytical utility. CONCLUSIONS The pilot highlights the potential of HIV-CBS to strengthen HIV surveillance, improve longitudinal patient tracking, and support more responsive HIV programming in Mozambique. National scale-up of CBS, integrated with electronic patient monitoring systems and supported by standardized tools and unique patient identifiers, could substantially enhance epidemic monitoring and help sustain progress toward HIV epidemic control.