Acknowledgements

HIV case

surveillance form

The purpose of the case surveillance form is to standardise the information that is collected on all reported HIV cases.

• 
  collect information that promotes understanding of HIV infection, morbidity and mortality
  
• 
  facilitate reporting an HIV case (person diagnosed with HIV)
  
• 
  define minimum variables to be collected
  
• 
  standardise collecting of variables.
  

Timing of HIV

case surveillance
A patient should be reported when:

• 
  the person is diagnosed with HIV infection, regardless of clinical status
  
• 
  an HIV patient progresses to clinical stage 3 or CD4 less than 350 (advanced HIV disease)
  
• 
  an HIV patient progresses to clinical stage 4 or CD4 less then 200 (AIDS)
  
• 
  an HIV-infected person dies.
  

Elements of a case

surveillance form

The elements of a case surveillance form include the following:

1. 
   Information for tracking of reporting
   
   • 
     Date form completed (with report date)
     
   • 
     Date received by national surveillance unit
     
   • 
     Type of report: new or update
     

2. 
   Information concerning the person reporting the case
   
   • 
     Name of reporting source facility
     

• 
  Name of person reporting the case
  
• 
  Address of person reporting the case
  
• 
  Telephone number of person reporting the case
  
• 
  Email address of person reporting the case
  

3. 
   Information concerning the diagnosis facility
   

• 
  Name of diagnosing facility
  
• 
  Facility record number
  
• 
  Address of diagnosing facility
  
• 
  Diagnosis facility type
  

4. 
   Information concerning the patient
   

• 
  Patient first name*
  
• 
  Patient’s last name*
  
• 
  Patient’s maiden name, if applicable *
  
• 
  Patient’s coded identifier (if used)*
  
• 
  Date of birth* (actual or estimated)
  
• 
  Sex*
  
• 
  Current city/town of residence
  
• 
  Current country of residence
  
• 
  Country of birth
  
• 
  Current pregnancy status (for females only)
  
• 
  Current (vital) status: Alive, dead, unknown
  
• 
  Date of death, if applicable
  
• 
  Cause of death: HIV related or other/unknown
  

5. 
   Risk factors/exposures
   

• 
  Sex with males(s)
  
• 
  Sex with female(s)
  
• 
  Sex with person(s) of known HIV-positive status
  
• 
  Sex with sex worker(s)
  
• 
  Injected non-prescription drugs
  
• 
  Perinatal exposure to HIV
  
• 
  Received transfusion(s) of blood, blood products or clotting factors
  
• 
  Received a transplant of tissue or organ or artificial insemination
  
• 
  Occupational exposure while working in a healthcare setting or laboratory, or provided safety or emergency services
  

6. 
   Laboratory results
   
   • 
     Type(s) of confirmatory HIV-positive test
     

• 
  Date specimen was obtained from patient*
  

• 
  Test result dates*
  
• 
  Date healthcare provider received confirmed HIV result
  

7. 
   Clinical/immunological information
   

• 
  Date of first WHO HIV clinical stage 1 or 2 diagnosis
  
• 
  Date of first WHO HIV clinical stage 3 diagnosis
  
• 
  Date of first WHO HIV clinical stage 4 diagnosis
  

• 
  Date of specimen collection for first CD4 test
  
• 
  Date of specimen collection for first CD4 count <350
  
• 
  Date of specimen collection for first CD4 count <200
  

* These variables are required for a case to be counted.

Completing a

case surveillance

form

Anyone who provides services to an HIV-infected patient may complete an HIV case surveillance form. HIV infected persons access diagnostic, support, care and treatment from the following facilities/programmes:

• 
  programmes for prevention of mother-to-child HIV transmissions
  
• 
  voluntary counselling and testing facilities
  
• 
  tuberculosis clinics
  
• 
  general health clinic
  
• 
  antenatal clinics
  
• 
  clinics for Sexually Transmitted Infections (STI)
  
• 
  private healthcare provider
  
• 
  facilities that provide antiretroviral therapy
  
• 
  laboratories
  

Note: Laboratories may have a different mechanism of reporting HIV cases than other health providers, and may not have access to the minimum data elements to count a case. You should establish reporting procedures mechanism with your laboratories to ensure timely reporting of HIV cases.

piloting the

case surveillance

form

You must ensure that the language used in your case surveillance form is relevant to your country and that the flow and layout of the document is understandable and user-friendly.

Protection of

confidentiality

To achieve acceptance of HIV case surveillance, national and sub-national surveillance programs must ensure the confidentiality of patient information and must have the public’s trust in that confidentiality. Confidentiality is essential, not only for effective surveillance, but also to protect patients’ rights to privacy and prevent any potential for disclosure or discrimination. In addition to the potential for adverse consequences for the individual, any breach of confidentiality from the HIV surveillance registry could impact the public’s confidence in public health systems and compromise the completeness of case surveillance (See Unit 7 on Confidentiality and Data Security).

• 
  HIV surveillance includes a variety of activities that provide information about:
  
  • 
    the number and characteristics of persons with HIV, advanced HIV disease, and AIDS
    
  • 
    the impact of antiretroviral therapy
    
  • 
    the impact that treatment has on HIV/AIDS-related and mortality.
    

• 
  The WHO recently revised the surveillance case definition and clinical staging system to include the following components:
  
  • 
    advanced HIV disease includes clinical stages 3 and 4
    
  • 
    AIDS (clinical stage 4) can continue to be reported
    
  • 
    countries should move toward reporting of all HIV cases, regardless of the clinical stage.
    

• 
  Focal persons for communicable disease surveillance must be identified at each level: health facility, sub-national (if applicable) and national.
  

• 
  A standardised reporting format must be developed for use at all levels: reporting health facilities, sub-national (if applicable) and national level. Sample forms and guidelines for modification are provided in Appendix H.
  

• 
  Data should be analysed, interpreted and used at the local level for public health action, as well as at national level.
  

• 
  With expanded efforts to provide antiretroviral therapy (ART) to persons with advanced HIV disease, HIV surveillance activities can include monitoring the number of persons receiving ART and the impact of ART on morbidity and mortality.
  

• 
  Improvements in the recording of vital events provide the opportunity to document deaths caused by HIV disease.
  

Year	Number of cases
2008	450
2009	623
2010	757
2011	650
2012	576

Data from advanced HIV disease case reporting are available for three years. Reporting was from three facilities and the data obtained had more detail.

Male	65
Female	77

Mother To Child	16
Injection Drug Use
Homosexual/Bisexual
Blood Or Blood Products
Heterosexual	122
Other (Please Specify)
DNK

Weight loss  10% / abnormally slow growth
Chronic diarrhoea  1 month	20
Prolonged fever  1 month(intermittent or constant)	73
Persistent cough  1 month
Generalised pruritic dermatitis	15
History of herpes zoster
Oropharyngeal candidiasis
Chronic progressive or disseminated herpes simplex virus
Generalised lymphadenopathy	36
Recurrent episodes of severe pneumonia	44
Kaposi’s sarcoma
Cryptococcal meningitis
Tuberculosis	60
Invasive cervical cancer
Disabling neurologic impairments

Antiretroviral/HAART	47
Prophylaxis	98
Anti-TB prophylaxis or treatment	53
Treatment for opportunistic infections	68

Male	125
Female	132

Mother To Child	12
Injection Drug Use
Homosexual/Bisexual
Blood Or Blood Products
Heterosexual	198
Other (Please Specify)
DNK	28

Weight loss  10% / abnormally slow growth	25
Chronic diarrhoea  1 month	42
Prolonged fever  1 month (intermittent or constant)	29
Persistent cough  1 month	11
Generalised pruritic dermatitis
History of herpes zoster
Oropharyngeal candidiasis	24
Chronic progressive or disseminated herpes simplex virus
Generalised lymphadenopathy	32
Recurrent episodes of severe pneumonia	58
Kaposi’s sarcoma
Cryptococcal meningitis
Tuberculosis	93
Invasive cervical cancer
Disabling neurologic impairments	2

Antiretroviral/HAART	156
Prophylaxis	230
Anti-TB prophylaxis or treatment	156
Treatment for opportunistic infections	204

Male	112
Female	173

Mother To Child	10
Injection Drug Use
Homosexual/Bisexual
Blood Or Blood Products
Heterosexual	228
Other (Please Specify)
DNK	38

Weight loss  10% / abnormally slow growth	38
Chronic diarrhoea  1 month	64
Prolonged fever  1 month (intermittent or constant)	38
Persistent cough  1 month	15
Generalised pruritic dermatitis
History of herpes zoster
Oropharyngeal candidiasis	44
Chronic progressive or disseminated herpes simplex virus
Generalised lymphadenopathy	35
Recurrent episodes of severe pneumonia	78
Kaposi’s sarcoma
Cryptococcal meningitis
Tuberculosis	89
Invasive cervical cancer
Disabling neurologic impairments

Antiretroviral/HAART	202
Prophylaxis	253
Anti-TB prophylaxis or treatment	178
Treatment for opportunistic infections	256

Male	60
Female	76

Mother To Child	10
Injection Drug Use
Homosexual/Bisexual
Blood Or Blood Products
Heterosexual	112
Other (Please Specify)
DNK

Weight loss  10% / abnormally slow growth
Chronic diarrhoea  1 month	180
Prolonged fever  1 month (intermittent or constant)	70
Persistent cough  1 month
Generalised pruritic dermatitis	8
History of herpes zoster
Oropharyngeal candidiasis
Chronic progressive or disseminated herpes simplex virus
Generalised lymphadenopathy	39
Recurrent episodes of severe pneumonia	43
Kaposi’s sarcoma
Cryptococcal meningitis
Tuberculosis	65
Invasive cervical cancer
Disabling neurologic impairments

Antiretroviral/HAART	42
Prophylaxis	102
Anti-TB prophylaxis or treatment	50
Treatment for opportunistic infections	72

Unit 4 Case Study, continued

Male	96
Female	144

Mother To Child	10
Injection Drug Use
Homosexual/Bisexual
Blood Or Blood Products
Heterosexual	206
Other (Please Specify)
DNK	13

Weight loss  10% / abnormally slow growth	45
Chronic diarrhoea  1 month	52
Prolonged fever  1 month (intermittent or constant)	13
Persistent cough  1 month	21
Generalised pruritic dermatitis
History of herpes zoster
Oropharyngeal candidiasis	29
Chronic progressive or disseminated herpes simplex virus
Generalised lymphadenopathy	38
Recurrent episodes of severe pneumonia	56
Kaposi’s sarcoma
Cryptococcal meningitis
Tuberculosis	98
Invasive cervical cancer
Disabling neurologic impairments

Antiretroviral/HAART	166
Prophylaxis	225
Anti-TB prophylaxis or treatment	158
Treatment for opportunistic infections	208

Unit 4 Case Study, continued

Male	12
Female	144

Mother To Child	9
Injection Drug Use
Homosexual/Bisexual
Blood Or Blood Products
Heterosexual	239
Other (Please Specify)
DNK	48

Weight loss  10% / abnormally slow growth	28
Chronic diarrhoea  1 month	75
Prolonged fever  1 month (intermittent or constant)	34
Persistent cough  1 month	26
Generalised pruritic dermatitis
History of herpes zoster
Oropharyngeal candidiasis	49
Chronic progressive or disseminated herpes simplex virus
Generalised lymphadenopathy	46
Recurrent episodes of severe pneumonia	79
Kaposi’s sarcoma
Cryptococcal meningitis
Tuberculosis	78
Invasive cervical cancer
Disabling neurologic impairments

Antiretroviral/HAART	205
Prophylaxis	238
Anti-TB prophylaxis or treatment	157
Treatment for opportunistic infections	246

Unit 4 Case Study, continued

Male	43
Female	51

Mother To Child	6
Injection Drug Use
Homosexual/Bisexual
Blood Or Blood Products
Heterosexual	80
Other (Please Specify)
DNK

Weight loss  10% / abnormally slow growth
Chronic diarrhoea  1 month	16
Prolonged fever  1 month (intermittent or constant)	33
Persistent cough  1 month
Generalised pruritic dermatitis	9
History of herpes zoster
Oropharyngeal candidiasis
Chronic progressive or disseminated herpes simplex virus
Generalised lymphadenopathy	31
Recurrent episodes of severe pneumonia	39
Kaposi’s sarcoma
Cryptococcal meningitis
Tuberculosis	52
Invasive cervical cancer
Disabling neurologic impairments

Antiretroviral/HAART	27
Prophylaxis	68
Anti-TB prophylaxis or treatment	43
Treatment for opportunistic infections	48

Unit 4 Case Study, continued

Male	74
Female	91

Mother To Child	13
Injection Drug Use
Homosexual/Bisexual
Blood Or Blood Products
Heterosexual	154
Other (Please Specify)
DNK	11

Weight loss  10% / abnormally slow growth	23
Chronic diarrhoea  1 month	33
Prolonged fever  1 month (intermittent or constant)	21
Persistent cough  1 month
Generalised pruritic dermatitis
History of herpes zoster
Oropharyngeal candidiasis	13
Chronic progressive or disseminated herpes simplex virus
Generalised lymphadenopathy	38
Recurrent episodes of severe pneumonia	68
Kaposi’s sarcoma
Cryptococcal meningitis	1
Tuberculosis	63
Invasive cervical cancer
Disabling neurologic impairments

Antiretroviral/HAART	147
Prophylaxis	166
Anti-TB prophylaxis or treatment	142
Treatment for opportunistic infections	154

Unit 4 Case Study, continued

Male	110
Female	128

Mother To Child	9
Injection Drug Use
Homosexual/Bisexual
Blood Or Blood Products
Heterosexual	212
Other (Please Specify)
DNK

Weight loss  10% / abnormally slow growth	27
Chronic diarrhoea  1 month	53
Prolonged fever  1 month (intermittent or constant)	31
Persistent cough  1 month	9
Generalised pruritic dermatitis	2
History of herpes zoster	9
Oropharyngeal candidiasis	40
Chronic progressive or disseminated herpes simplex virus
Generalised lymphadenopathy	55
Recurrent episodes of severe pneumonia	68
Kaposi’s sarcoma
Cryptococcal meningitis
Tuberculosis	86
Invasive cervical cancer
Disabling neurologic impairments

Antiretroviral/HAART	197
Prophylaxis	233
Anti-TB prophylaxis or treatment	165
Treatment for opportunistic infections	213

Unit 4 Case Study, continued

Data from routine HIV testing of TB patients. Reporting was from five sites.

2004 569 547 270

2005 479 445 238

2006 510 503 214

2007 499 489 189