Scientific Advisory Committee by sdfwerte

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									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
      Structure of presentation

1. “Added value” of surveillance research: topics
   investigated, methods and clinics used
2. Specific aims and results from rounds 1 & 2
3. Specific aims and results from round 3
4. Plans for round 4
5. Policy implications of findings and suggestions
   for NACP surveillance
    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
   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
        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
  Use stickers to link data and specimens

                                      no names used !




  Questionnaire       RPR test done       HIV test done
completed in clinic     in clinic           at NIMR
       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
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?
                  HIV prevalence in ANC women by years of
                   sexual activity before and after marriage
                 0.35

                                                                        Women who spent
                 0.30
                                pre-marital                             more years sexually
                                                                        active before getting
                 0.25                                                   married were at
                                post marriage
HIV prevalence




                                                                        higher risk of HIV
                 0.20                                                   infection.
                                                                        Simple questions
                 0.15
                                                                        about age at first sex
                                                                        and age at first
                 0.10
                                                                        marriage can provide
                                                                        useful data for
                 0.05                                                   community advocacy

                 0.00
                        0   1    2       3      4      5    6   7   8
                                        years of exposure
          Aims of 2006 study
1. To measure the proportion of women accepting
   VCT in ante-natal clinics that offered the service
2. To find out which kind of women received VCT
   during pregnancy
3. To identify clinics with high unmet need for VCT
   services for pregnant women
4. To establish the extent of travel to non-local
   ANC clinics in this population.
5. To assess whether travel to non-local clinics
   affects HIV prevalence estimates
Location of clinics used in 2006 ANC surveillance study
      and other health facilities in Mwanza region
                        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)
   Results of surveillance: HIV prevalence by clinic location

                    20
                    18
                    16
HIV prevalence, %




                    14
                    12
                    10
                     8
                     6
                     4
                     2
                     0
                     2000     2002               2004           2006
                                Surveillance year
                            Urban     Roadside          Rural
                         HIV prevalence by PMTCT provision

                    20
                    18
HIV prevalence, %



                    16
                    14
                    12
                    10
                     8
                     6
                     4
                     2
                     0
                     2000              2002               2004               2006
                                         Surveillance year

                    Started PMTCT between 2002 and 2006      Not yet started PMTCT
                                             Type of clinic attended
                                        by nearest clinic type and location
1,000 1,500 2,000 2,500




                                                                                          Clinic
                                                                                         attended


                                                                                         None


                                                                                         Anon
                          500




                                                                                         VCT
                                0




                                    VCT Anon None     VCT Anon None      VCT Anon None
                                       Urban            Roadside              Rural

                                            Type and location of nearest clinic
                   HIV prevalence in women whose nearest clinic
                        provided syphilis testing but not VCT
                 0.20



                 0.15
HIV prevalence




                 0.10



                 0.05



                 0.00
                                All          In study area   Out of study area

                        Type of clinic attended     VCT      Anon
                   Reasons for clinic attendance
                    by clinic type and proximity
2,500
2,000




                                                             Main reason
                                                                  none
                                                                  referred
1,500




                                                                  personal
                                                                  HIV test
1,000




                                                                  STD test
                                                                  good
                                                                  access
        500




                                                                  close
              0




                  VCT   Anon no test   VCT    Anon no test
                        further              nearest
           How far do women travel?
              Distance travelled by area of residence,
               type of clinic attended and HIV status

           VCT
  Urban
           Anon                                                 HIV
                                                               status
           VCT
Roadside
           Anon                                               Negative


           VCT                                                Positive
   Rural
           Anon


                  0           5           10             15

                      Average distance travelled (kms)
 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
      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
            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

								
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