ANC surveillance research

1. ANC surveillance research Yusufu Kumogola, Emma Slaymaker, Raphael Isingo, Julius Mngara, Basia Zaba, John Changalucha and Mark Urassa TAZAMA / NACP seminar, Dar-es-Salaam, September 19th 2008

2. Structure of presentation • “Added value” of surveillance research: topics investigated, methods and clinics used • Specific aims and results from rounds 1 & 2 • Specific aims and results from round 3 • Plans for round 4 • Policy implications of findings and suggestions for NACP surveillance

3. Overview of surveillance research GENERAL AIMS • To put the Kisesa sero-survey findings into a wider context • To generate HIV surveillance data to complement NACP activities • To discover biases affecting national ANC surveillance • To evaluate and extend service availability in ANC • To explore possibilities of adding extra data to national surveillance SPECIAL TOPICS • 2000 & 2002: establish baseline and investigate sexual behaviour • 2006: travel to clinics and type of service provided • 2008: use of family planning in the context of PMTCT

4. How the ANC clinics were chosen • The 2000/02 studies used a “convenience sample” 11 ANC clinics in Magu district and eastern part of Mwanza city which already did routine syphilis tests or in which it was feasible to introduce syphilis testing • The 2006 study added all other ANC clinics in Magu district and eastern Mwanza that had started providing syphilis tests (2 clinics) or VCT (1 clinic) • The 2006 study also added 11 other clinics in which lab tests were not available, but which were located within a 20 km radius of clinics providing HIV or syphilis tests – women in these clinics were interviewed but not tested • The 2008 study is using all the clinics that were able to provide lab tests in the previous rounds

5. Our basic questionnaire Background: date of birth, residence, education, parity, date of last birth, survival of last born Clinic choice: previous clinic attendance, transport, reason for using this clinic Father of the baby: is she married to father, his age and residence, does he have other wives / girlfriends Sexual behaviour: age at first sex, age at first marriage, other partners apart from father of the baby Test history: ever had VCT or syphilis test before

6. Use stickers to link data and specimens no names used ! Questionnaire completed in clinic RPR test done in clinic HIV test done at NIMR

7. Aims of 2000/02 survey • Establish HIV infection levels and trends in urban, roadside and remote clinics • Measure extent of co-infection with syphilis by type of clinic • Describe patterns of sexual behaviour in young pregnant women • Identify behavioural risk factors for HIV infection

8. Findings from 2000/02 rounds HIV prevalence was higher in rural roadside clinics and Mwanza city (10% to 13%) than in remote rural clinics and Magu town (6% to 9%) But syphilis was more prevalent in remote rural and roadside clinics (15% to 21%) compared to city and town clinics (9% to 10%): suggesting higher use of antibiotics in urban areas?

9. HIV prevalence in ANC women by years of sexual activity before and after marriage Women who spent more years sexually active before getting married were at higher risk of HIV infection. Simple questions about age at first sex and age at first marriage can provide useful data for community advocacy

10. Aims of 2006 study • To measure the proportion of women accepting VCT in ante-natal clinics that offered the service • To find out which kind of women received VCT during pregnancy • To identify clinics with high unmet need for VCT services for pregnant women • To establish the extent of travel to non-local ANC clinics in this population. • To assess whether travel to non-local clinics affects HIV prevalence estimates

11. Location of clinics used in 2006 ANC surveillance study and other health facilities in Mwanza region

12. Use of VCT • 88% of women attending VCT clinics accepted counselling • About 70% of women attending clinics that did not provide VCT were attending their nearest clinic; 40% of those attending VCT clinics were attending nearest clinic • Important predictors of VCT use (after allowing for clinic location) were: • urban residence (AOR 8.6, CI 7.2 – 10.2) • primary or higher education (AOR 1.8, CI 1.4 – 2.4) • never married (AOR 1.5, CI 1.1 – 2.0) • age group 20-29 (AOR 1.2, CI 1.0 – 1.4)

13. Results of surveillance: HIV prevalence by clinic location

14. HIV prevalence by PMTCT provision

16. HIV prevalence in women whose nearest clinic provided syphilis testing but not VCT

18. How far do women travel?  

19. Aims of 2008 ANC survey & follow-up • Describe Family Planning (FP) use before pregnancy and in post partum interval • Assess if prior FP use differs by HIV status • Assess if post partum FP use differs by HIV status in women who had VCT • Test the efficacy of added FP counselling added to VCT and tailored to status • Evaluate uptake of PMTCT by infected women who had VCT

20. NACP surveillance advice • There is no evidence of new bias introduction into surveillance estimates of HIV prevalence, due to clinic choice by pregnant women • To maintain bias-free surveillance in PMTCT clinic, do not include tests on women who have been referred from other clinics • Questions on residence will help map HIV prevalence with less dependence on clinic location • Questions on re-marriage, survival of last born child, and length of birth interval are easy to ask in all ANC and can be used to identify pregnant women who are at high risk of HIV infection

21. Policy implications • High prevalence of syphilis in rural areas suggests screening and treatment is an important priority: treatment is cheap and impact on infant mortality is high • Extending syphilis testing to rural areas also provides more opportunities for anonymous HIV surveillance • Volume of HIV positive tests per week in clinics doing only anonymous testing is a good guide for prioritising VCT roll-out • Women who are identified as high risk in ANC clinics that do not offer VCT should be referred for PMTCT