Adjusting HIV prevalence data from a program for the prevention of mother-to-child transmission for surveillance purposes in Uganda

Evaluation of Senegal's prevention of mother to child transmission of HIV (PMTCT) program data for HIV surveillance

Background

With the expansion of Prevention of Mother to Child Transmission (PMTCT) services in Senegal, there is growing interest in using PMTCT program data in lieu of conducting unlinked anonymous testing (UAT)-based ANC Sentinel Surveillance. For this reason, an evaluation was conducted in 2011–2012 to identify the gaps that need to be addressed while transitioning to using PMTCT program data for surveillance.

Methods

We conducted analyses to assess HIV prevalence rates and agreements between Sentinel Surveillance and PMTCT HIV test results. Also, a data quality assessment of the PMTCT program registers and data was conducted during the Sentinel Surveillance period (December 2011 to March 2012) and 3 months prior. Finally, we also assessed selection bias, which was the percentage difference from the HIV prevalence among all women enrolled in the antenatal clinic and the HIV prevalence among women who accepted PMTCT HIV testing.

Results

The median site HIV prevalence using routine PMTCT HIV testing data was 1.1% (IQR: 1.0) while the median site prevalence from the UAT HIV Sentinel Surveillance data was at 1.0% (IQR: 1.6). The Positive per cent agreement (PPA) of the PMTCT HIV test results compared to those of the Sentinel Surveillance was 85.1% (95% CI 77.2–90.7%), and the percent-negative agreement (PNA) was 99.9% (95% CI 99.8–99.9%). The overall HIV prevalence according to UAT was the same as that found for women accepting a PMTCT HIV test and those who refused, with percent bias at 0.00%. For several key PMTCT variables, including “HIV test offered” (85.2%), “HIV test acceptance” (78.0%), or “HIV test done” (58.8%), the proportion of records in registers with combined complete and valid data was below the WHO benchmark of 90%.

Conclusions

The PPA of 85.1 was below the WHO benchmarks of 96.6%, while the combined data validity and completeness rates was below the WHO benchmark of 90% for many key PMTCT variables. These results suggested that Senegal will need to reinforce the quality of onsite HIV testing and improve program data collection practices in preparation for using PMTCT data for surveillance purposes.

Syphilis prevalence trends in adult women in 132 countries - estimations using the Spectrum Sexually Transmitted Infections model

We estimated national-level trends in the prevalence of probable active syphilis in adult women using the Spectrum Sexually Transmitted Infections (STI) model to inform program planning, target-setting, and progress evaluation in STI control. The model fitted smoothed-splines polynomial regressions to data from antenatal clinic surveys and screening and representative household surveys, adjusted for diagnostic test performance and weighted by national coverage. Eligible countries had ≥1 data point from 2010 or later and ≥3 from 2000 or later from adult populations considered representative of the general female population (pregnant women or community-based studies). Between 2012 and 2016, the prevalence of probable active syphilis in women decreased in 54 (41%) of 132 eligible countries; this decrease was substantive (≥10% proportionally, ≥0.10% percentage-point absolute difference and non-overlapping 95% confidence intervals in 2012 and 2016) in 5 countries. Restricting eligible data to prevalence measurements of dual treponemal and non-treponemal testing limited estimates to 85 countries; of these, 45 countries (53%) showed a decrease. These standardized trend estimates highlight the need for increased investment in national syphilis surveillance and control efforts if the World Health Organization target of a 90% reduction in the incidence of syphilis between 2018 and 2030 is to be met.

Can we replace HIV sentinel surveillance platform with prevention of parent-to-child transmission (PPTCT) program data to assess HIV burden and trends in India?

BACKGROUND

Estimates of HIV burden in India are based on HIV sentinel surveillance (HSS), which has limitations such as insufficient sample size for district level analysis and ethical concerns. We analysed prevention of parent-to-child transmission (PPTCT) program data, for its suitability for HIV surveillance in India.

METHODS

Correlation and differences in ante-natal clinic (ANC) attendees' HIV prevalence from the last four rounds of HSS (2007-2012) and PPTCT data for the corresponding years were analysed at national, state and district levels. Sensitivity and region wise analysis were also done.

RESULTS

The PPTCT program covered a higher number of districts and ANC attendees than HSS. Correlation of HIV prevalence from PPTCT data with HSS was high (0.99) at national level, moderate (0.66-0.86) at state level, and low (0.43-0.62) at district level. HIV prevalence levels from HSS were generally higher than those from PPTCT data. As the coverage of PPTCT program and HSS improved, the differences between HIV prevalence from these two data sources increased. Sensitivity analysis showed significant differences in ANC attendees' HIV prevalence from HSS and PPTCT, even among districts with high HIV test uptake level in PPTCT program.

CONCLUSIONS

PPTCT program data can be utilised for HIV surveillance in India as it has better coverage and will avoid ethical issues and expenditures related to HSS.

"The Cango Lyec Project - Healing the Elephant": HIV related vulnerabilities of post-conflict affected populations aged 13-49 years living in three Mid-Northern Uganda districts

BACKGROUND

The protracted war between the Government of Uganda and the Lord's Resistance Army in Northern Uganda (1996-2006) resulted in widespread atrocities, destruction of health infrastructure and services, weakening the social and economic fabric of the affected populations, internal displacement and death. Despite grave concerns that increased spread of HIV/AIDS may be devastating to post conflict Northern Uganda, empirical epidemiological data describing the legacy of the war on HIV infection are scarce.

METHODS

The 'Cango Lyec' Project is an open cohort study involving conflict-affected populations living in three districts of Gulu, Nwoya and Amuru in mid-northern Uganda. Between November 2011 and July 2012, 8 study communities randomly selected out of 32, were mapped and house-to-house census conducted to enumerate the entire community population. Consenting participants aged 13-49 years were enrolled and interviewer-administered data were collected on trauma, depression and socio-demographic-behavioural characteristics, in the local Luo language. Venous blood was taken for HIV and syphilis serology. Multivariable logistic regression was used to determine factors associated with HIV prevalence at baseline.

RESULTS

A total of 2954 participants were eligible, of whom 2449 were enrolled. Among 2388 participants with known HIV status, HIV prevalence was 12.2% (95%CI: 10.8-13.8), higher in females (14.6%) than males (8.5%, p < 0.001), higher in Gulu (15.2%) than Nwoya (11.6%, p < 0.001) and Amuru (7.5%, p = 0.006) districts. In this post-conflict period, HIV infection was significantly associated with war trauma experiences (Adj. OR = 2.50; 95%CI: 1.31-4.79), the psychiatric problems of PTSD (Adj. OR = 1.44; 95%CI: 1.06-1.96), Major Depressive Disorder (Adj. OR = 1.89; 95%CI: 1.28-2.80) and suicidal ideation (Adj. OR = 1.87; 95%CI: 1.34-2.61). Other HIV related vulnerabilities included older age, being married, separated, divorced or widowed, residing in an urban district, ulcerative sexually transmitted infections, and staying in a female headed household. There was no evidence in this study to suggest that people with a history of abduction were more likely to be HIV positive.

CONCLUSIONS

HIV prevalence in this post conflict-affected population is high and is significantly associated with age, trauma, depression, history of ulcerative STIs, and residing in more urban districts. Evidence-based HIV/STI prevention programs and culturally safe, gender and trauma-informed are urgently needed.

HIV surveillance in Rwanda: readiness assessment to transition from antenatal care-based to prevention of mother-to-child transmission program-based HIV surveillance

BACKGROUND

In 2013, the World Health Organization (WHO) recommended that for efficiency and ethical considerations, transitioning from antenatal clinic-based surveillance to prevention of mother-to-child transmission (PMTCT)-based routine data should be investigated. An assessment of the readiness for this transition was carried out in Rwanda in 2011 and 2013.

METHODS

This assessment applied the WHO recommended method. Individual HIV rapid testing at site was compared to antenatal surveillance results at all existing 30 sites, involving 13 292 women. In addition, PMTCT HIV testing quality assurance and PMTCT routine data quality were assessed at 27 out of the 30 sites.

RESULTS

All sentinel sites provided PMTCT services and had a high uptake of HIV testing (more than 90%). At all sites, PMTCT data were recorded in longitudinal and standardized antenatal clinic registers. Twenty-six out of 27 sites had HIV result completeness above 90%. A positive percentage agreement of 97.5% and negative percentage agreement of 99.9% were observed between routine PMTCT and sero-surveillance HIV test results. Of 27 sites, 25 scored more than 80% in all phases of HIV testing quality assurance.

CONCLUSIONS

According to WHO standards, Rwanda antenatal care HIV sero-surveillance is ready to transition to PMTCT-based sero-surveillance.

Lost in transition: HIV prevalence and correlates of infection among young people living in post-emergency phase transit camps in Gulu District, Northern Uganda

OBJECTIVE

Little is known about HIV infection and the related vulnerabilities of young people living in resource-scarce, post-emergency transit camps that are now home to thousands of Internally Displaced Persons (IDPs) following two decades of war in northern Uganda. The objective of this analysis was to assess the prevalence and correlates of HIV infection among young people living in post-conflict transition in Gulu District, northern Uganda.

METHODS

In 2010, a cross-sectional demographic and behavioural survey was conducted in two of Gulu District's sub-counties with 384 purposively selected transit camp residents aged 15 to 29 years. Biological specimens were collected for rapid HIV testing in the field and confirmatory laboratory testing. Multivariable logistic regression identified independent determinants of HIV infection.

RESULTS

HIV prevalence was alarmingly high at 12.8% (95% CI: 9.6%, 16.5%). The strongest determinant of HIV infection among young people was a non-consensual sexual debut (adjusted odds ratio [AOR], 9.88; 95% CI: 1.70-18.06). Residing in Awach sub-county (AOR, 2.93; 95% CI: 1.28-6.68), experiencing STI symptoms in the previous 12 months (AOR, 2.36; 95% CI: 1.43-6.17), and practicing dry sex (AOR, 2.31; 95% CI: 1.04-5.13) were other key determinants of HIV infection.

CONCLUSIONS

Study findings contribute to filling an important gap in epidemiological evidence and are useful for planning public health interventions in northern Uganda that effectively target young people in post-conflict transition and support them in the resettlement process. Findings serve to recommend reaching beyond traditional prevention programming in a way more effectively beneficial to young people in post-conflict settings by developing population-specific responses sensitive to local contexts and sufficient to address the underlying causes of the complex risk factors influencing the spread of HIV.

War and HIV: sex and gender differences in risk behaviour among young men and women in post-conflict Gulu District, Northern Uganda

Despite growing knowledge of the dynamics of HIV infection during conflict, far less is known about the period that follows cessation of hostilities and its implications for population health. This study sought to fill a lacuna in epidemiological evidence by examining HIV infection and related vulnerabilities of young people living in resource-scarce, post-emergency transit camps that are now home to thousands of displaced people following two decades of war in northern Uganda. In 2010, a cross-sectional demographic and behavioural survey was conducted with 384 transit camp residents aged 15-29 years old in Gulu District. Biological specimens were collected for rapid and confirmatory HIV testing. Separate multivariable logistic regression models by sex identified risk factors for HIV infection. HIV prevalence was 15.6% (95% confidence interval [CI]: 10.8%, 21.6%) among females and 9.9% (95% CI: 6.1%, 15.0%) among males. The strongest correlate of HIV infection among men was a non-consensual sexual debut (adjusted odds ratio [AOR] 3.24; 95% CI: 1.37-7.67), and having practiced dry sex (AOR 7.62; 95% CI: 1.56-16.95) was the strongest correlate among women. Conflict-affected men and women experience vulnerability to HIV infection in different ways than may have originally been understood. Post-conflict programme planners must therefore design and implement contextualised, evidence-based responses to HIV that are sensitive to gender and cultural issues.

Advances and future directions in HIV surveillance in low- and middle-income countries

PURPOSE OF REVIEW

To present recent advances in HIV/AIDS surveillance methods in low- and middle-income countries.

RECENT FINDINGS

From 2001 to 2008, 30 low- and middle-income countries implemented national population-based surveys with HIV testing. Antenatal clinic HIV sentinel surveillance sites in sub-Saharan Africa increased from just over 1000 in 2003-2004 to almost 2500 in 2005-2006, becoming more representative of rural areas. Between 2003 and 2007, at least 122 behavioral surveys in low- and middle-income countries used respondent-driven sampling for surveillance among high-risk populations, although many countries with concentrated epidemics continue to have major sentinel surveillance gaps. Improvements have been made in modeling estimates of number of persons HIV infected, and systems are now in place to measure HIV drug resistance. However, the reliable monitoring of trends and the measuring of HIV incidence, morbidity, and mortality is still a challenge.

SUMMARY

In the past 5 years, there have been substantial improvements in the quantity and quality of HIV surveillance studies, especially in the countries with high prevalence. Further efforts should be made in countries that lack fully implemented surveillance systems to improve HIV incidence, morbidity, and mortality surveillance and to use data more effectively.