1. Assessing the Utility of Prevention of Mother To Child Transmission (PMTCT) Program Data for HIV Surveillance in Kenya
Esther Munyisia (NASCOP, Kenya)
Nicole Seguy (CDC)
Wolfgang Hladik (CDC)
Lawrence Marum (CDC-Kenya)
September 2004

2. Acknowledgments NASCOP, MOH Kenya Peter Cherutich Mary Wangai
Boaz Cheluget
CDC/ GAP Kenya
Lucy Nganga
Dorothy Mbori-Ngacha
CDC/ GAP Atlanta
Omotayo Bolu
Theresa Diaz
Stefan Wiktor
Nathan Shaffer
Meade Morgan

3. Ante-natal Clinic (ANC) Based HIV Surveillance
Core surveillance system for generalized epidemics (HIV prevalence in adults > 1%)
Strength: Testing without informed consent on left-over blood – minimal self-selection bias
Weakness: HIV test result not used for counseling, care, treatment

4. PMTCT Programs Target same group (ANC clients)
Rapid expansion in many countries – vast amount of testing data
Opportunity to use PMTCT testing data for surveillance
Limited information on comparability of HIV prevalence estimates from PMTCT programs to those in ANC sentinel surveillance
Testing with informed consent – self selection bias >> refusers may differ in HIV-status from consenters

5. Study Rationale - Kenya
Generalized HIV epidemic
National HIV prevalence in ANC clients: 9.4% (2003)
Rapid expansion of PMTCT
<10 sites (2001)
130 (2003)

6. Objectives To describe availability and quality of PMTCT data
To compare HIV prevalence estimates from PMTCT program data to those from ANC surveillance data
To identify determinants for differences between PMTCT and ANC surveillance based HIV estimates

7. HIV Sentinel Surveillance System in Kenya
Annual surveys in 42 ANC sites
Women sampled at first ANC visit; >10,000 in 2003
HIV testing:
Blood left over after routine syphilis testing
Unlinked Anonymous Testing (UAT) without informed consent
Determine ® rapid test
Transcribed data: age, marital status, education, urban/rural residence, # abortions, # live births, syphilis test result

8. PMTCT Services in Kenya
130 clinics
HIV testing:
Based on voluntary counseling and testing
ANC clients may accept HIV testing at any visit
ANC clients may refuse HIV testing
HIV testing algorithm: Determine ® and Unigold ® rapid tests in parallel

9. Methods (1)
Six clinics selected where both ANC surveillance and PMTCT programs present in 2003:
Located in 4 of 6 Kenyan provinces
3 urban, 2 rural, 1 “mixed” site
ANC surveillance data (2003): provided by National AIDS and STIs Control Program
PMTCT data:
Line list data not routinely available
Captured data by digital photography
PMTCT sampling period = ANC surveillance period

10. Methods (2)
Line list PMTCT data entered (Epi info) for all ANC attendees with first ANC visit during UAT sampling period
Where Unigold ® and Determine ® discordant, Determine ® result entered
HIV testing uptake for PMTCT =
# ANC attendees with test result
# first ANC visits during study period
Compared PMTCT data with ANC surveillance data

11. PMTCT Counseling Logbook
ANCNo
PMTCT No
Age
Marital Status
Determine
Unigold

12. Results Availability and Quality of Line List PMTCT Data
Data recorded in 2 or 3 logbooks
Limited access - permanently in use
Logbook format lacked standardization
Number and order of variables varied by site and over time within same site

13. Accepted PMTCT HIV testing Refused PMTCT HIV testing
Groups compared
PMTCT
N=2,239
UAT
N=1,852
Accepted PMTCT HIV testing
N= 1258
Refused PMTCT HIV testing
N= 981
Reference group - all tested for HIV

14. HIV Testing Uptake in PMTCT Group

15. HIV Testing Uptake by Site
Overall HIV testing uptake= 56%

16. Variables Associated with HIV Testing Uptake (4 sites)
Accepted
HIV testing
Crude OR
95% CI
Age group
12-24 yrs
25-49 yrs
68.7%
62.6%
1.3
Gravidity
Primigravida
Multigravida
71.5%
63.4%
1.4
UAT HIV prevalence
>10%
<=10%
69.6%
50.8%
2.2

17. Variables Associated with HIV Testing Uptake (4 sites)
Accepted
HIV testing
Crude OR
95% CI
Adj. OR*
Age group
12-24 yrs
25-49 yrs
68.7%
62.6%
1.3
1.1
Gravidity
Primigravida
Multigravida
71.5%
63.4%
1.4
UAT HIV prevalence
>10%
<=10%
69.6%
50.8%
2.2
2.1
* Logistic regression

18. HIV Prevalence in ANC Surveillance (UAT) and in PMTCT Program Data

19. UAT and PMTCT HIV Prevalence by Age Group (all Sites)

20. UAT and PMTCT HIV prevalence by site

21. UAT and PMTCT HIV Prevalence by Testing Uptake Group

22. Limitations Study limited to 6 sites
ANC clients in UAT and PMTCT data set
not linkable
not 100% identical
Small variability in HIV testing uptake across sites
Limited number of variables
Several factors influencing HIV testing uptake not explored (stigma, maturation of PMTCT services)

23. Conclusion
At most sites PMTCT data over-estimated HIV prevalence compared to UAT data
Line list PMTCT data
varied in accessibility and quality
laborious to use for analysis
Factors influencing HIV testing uptake for PMTCT:
Gravidity
Level of HIV prevalence in the area

24. Conclusion/Recommendations
In Kenya PMTCT data can currently complement but not replace UAT data
Improving line list PMTCT data quality necessary for use in surveillance
Standardization of logbook format recommended

25. Thank You