Table 3.

Factors affecting the feasibility of case-based surveillance.

Factors	Tanzania	South Africa	Kenya
Data management	Currently de-duplication is performed only by clinical identifier. Although DQAa policies are in place, they are not fully implemented.	Roll out of a patient health registration system with a unique identifier is in progress. The NHLSb de-duplicates data utilizing an algorithm. DQA policies are in place and variably implemented for the PMSc.	In a recent CBSd pilot, de-duplication was performed using an algorithm. The new EMRe data warehouse de-duplicates data based on clinical identifier. Limited DQA is being conducted at facilities.
Policies	There are no policies for HIV reporting, data security, and confidentiality. Policies in place for data quality are often not being followed.	There are no policies that mandate HIV reporting. Policies are in place for data quality, security, and routine program data management. There is a policy impasse around access by health department to vital registration data.	Policies are in place for infectious disease reporting, but not specific to HIV. There are gaps in policies for data security, confidentiality, and purpose and utilization of EMRs, LIMSf, and the data warehouse.
Information technology	The majority of care facilities enter data into an electronic database; the database does not have connectivity and data are extracted on a quarterly basis and sent to the national level. The PMS database is national; therefore, interoperability is thought to be unnecessary. Although there is a pharmacy module in the CTCg system, it is rarely utilized. Various LIMS exist although are not connected to the CTC. Internet connectivity limited in rural areas.	TIER.Neth is a national system that limits interoperability issues. It is implemented off-line with quarterly dispatches sent centrally. The national LIMS captures the majority of laboratory tests, which are then checked for duplications. Regional laboratories all utilize the same LIMS to reduce interoperability issues. Internet connectivity is limited in rural areas. Staff shortages impact the quality of the implementation of the TIER.Net system.	Four main EMRs are operating at health facilities. The EMRs are not interoperable. Backup of the data varies between facilities. The quality of data in EMR systems has not been evaluated. A system is in the pilot phase to pull data from each type of EMR for CBS. Internet connectivity is limited in rural areas. Power outages are common; larger health facilities have a generator.

^aDQA: data quality assurance.

^bNHLS: National Health Laboratory System.

^cPMS: patient monitoring system.

^dCBS: case-based surveillance.

^eEMR: electronic medical record.

^fLIMS: laboratory information management system.

^gCTC: care and treatment clinic.

^hTIER.Net: Three Interlinked Electronic Registers.