FROM HIV DIAGNOSIS TO VIRAL SUPPRESSION: RETHINKING CARE-CASCADE FAILURE THROUGH ACTIONABLE SURVEILLANCE, EARLY WARNING, AND TARGETED INTERVENTION

Background: Despite highly effective antiretroviral therapy (ART), substantial losses persist between HIV diagnosis, linkage to care, retention, and durable viral suppression. Conventional care-cascade indicators remain indispensable, but they largely describe attrition after it has occurred, limiting their usefulness for timely intervention. Objective: To examine HIV care-cascade failure through a prospective, response-oriented lens and to ask how surveillance systems can identify emerging vulnerability before adverse outcomes become entrenched. Methods: Structured narrative review of peer-reviewed literature, national surveillance reports, and public-health guidance on care-cascade disruption, HIV surveillance, cluster detection and response, data integration, predictive analytics, and engagement interventions. Findings: Cascade failure is cumulative and multilevel, arising from interacting clinical, structural, and health-system factors rather than individual adherence alone. Surveillance data can be used to relink people to care, and cluster detection and response offers an organisational template in which predefined signals trigger investigation and proportionate action. Predictive models of disengagement show promise, but evidence that they improve outcomes is scarce, and data incompleteness, poor calibration, algorithmic bias, and privacy risk can undermine both effectiveness and equity. Conclusions: We propose a Surveillance-to-Suppression Framework comprising seven interconnected functions Detect, Anticipate, Triage, Intervene, Re-engage, Suppress, and Learn that reconceptualises the linear cascade as a learning system in which intervention outcomes continuously inform surveillance and response. Durable viral suppression will require a shift from descriptive cascade monitoring toward anticipatory, actionable, and equitable surveillance that is matched by investment in response capacity.

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