Abstract
ObjectiveThe objective was to assess whether HIV prevalence measured among women attending antenatal clinics (ANCs) are representative of prevalence in the local area, or whether estimates may be biased by some women’s choice to attend ANCs away from their residential location. We tested the hypothesis that HIV prevalence in towns and periurban areas is underestimated in ANC sentinel surveillance data in Zimbabwe.MethodsNational unlinked anonymous HIV surveillance was conducted at 19 ANCs in Zimbabwe in 2000, 2001, 2002, 2004, 2006, 2009, and 2012. This data was used to compare HIV prevalence and nonlocal attendance levels at ANCs at city, town, periurban, and rural clinics in aggregate and also for individual ANCs.ResultsIn 2000, HIV prevalence at town ANCs (36.6%, 95% CI 34.4–38.9%) slightly underestimated prevalence among urban women attending these clinics (40.7%, 95% CI 37.6–43.9%). However, there was no distortion in HIV prevalence at either the aggregate clinic location or at individual clinics in more recent surveillance rounds. HIV prevalence was consistently higher in towns and periurban areas than in rural areas. Nonlocal attendance was high at town (26–39%) and periurban (53–95%) ANCs but low at city clinics (<10%). However, rural women attending ANCs in towns and periurban areas had higher HIV prevalence than rural women attending rural clinics, and were younger, more likely to be single, and less likely to be housewives.ConclusionsIn Zimbabwe, HIV prevalence among ANC attendees provides reliable estimates of HIV prevalence in pregnant women in the local area.
Highlights
Since the beginning of the 1990s, HIV prevalence estimates used to monitor the progression of the epidemic in countries with generalized epidemics have been estimated from antenatal clinic sentinel surveillance data (ANC SS) [1,2,3]
In the 2000 antenatal clinics (ANCs) survey, HIV prevalence in town clinics (36.6%, 95% confidence intervals (CIs): 34.4–38.9%) was lower than HIV prevalence among women attending a town ANC for the first time during their current pregnancy and who are resident in a town (40.7%, 95% CI: 37.6–43.9%) (Table 1)
In all individual clinics with a high proportion (>20%) of women attending from nonlocal areas, overall HIV prevalence was similar to that among locally resident attendees for the three most recent surveillance rounds combined (Supplemental Table 3, http:// links.lww.com/QAD/B15, results presented for individual clinics in a town or periurban area)
Summary
Since the beginning of the 1990s, HIV prevalence estimates used to monitor the progression of the epidemic in countries with generalized epidemics have been estimated from antenatal clinic sentinel surveillance data (ANC SS) [1,2,3]. Pregnant women from rural areas often attend ANCs in urban areas – for reasons including availability of a better quality of care [8,9,10] – which could result in underestimates of HIV prevalence in these urban locations as prevalence generally is lower in rural areas than in urban centres [11,12,13] This pattern was seen in a recent small-scale study in east Zimbabwe [14] and could distort national HIV prevalence estimates, because the UNAIDS Spectrum software (Avenir Health, Glastonbury, Connecticut, USA) used to generate these estimates typically is applied to model urban and rural epidemics within a country separately (Stover et al in this supplement), before these are combined to produce a national estimate [15]. It is not known whether the finding from east Zimbabwe is generalizable to the rest of the country
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