National Survey of HIV and Syphilis Prevalence Among

AIDS & TB PROGRAMME 2013 i Contents

Foreword i Acknowledgements iii Executive Summary iv Acronym v 1. INTRODUCTION 1 1.1 Country Profile 1 1.2 Background 2 2: OBJECTIVES 6 2.1 Broad Objectives 6 2.2 Specific objectives 6 3: METHOD 3.1 Survey design 6 3.2 Sampling 7 3.2.1 Sentinel population 7 3.2.2 Selection of survey population 7 3.2.3 Selection of sentinel surveillance sites 7 3.3 Sample size determination 7 3.6 Summary of Survey Operational Procedures 9 3.7 Laboratory procedures 10 3.7.1 Laboratory Methods 10 3.7.3 Quality Assurance of HIV Testing 11 3.8 Data entry and management 12 3.9 Data analysis 12 3.10 Overall quality assurance 12 4. RESULTS 13 4.1 Population characteristics 13 4.2 Distribution of HIV Prevalence in the fifty-three sentinel sites 17 4.3 Trends in HIV Prevalence 2002 -2012, For All Women 15-49 years in Nineteen Sentinel Sites 2002 -2012 29 4.4 HIV Prevalence and trends, Women age 15-24 years in Nineteen Sentinel Sites, 2002 -2012 36 4.5 Results of Syphilis 42 5. DISCUSSION AND CONCLUSIONS 44 5.1 Lessons Learnt 46 6. RECOMMENDATIONS 46 References 47

APPENDICES 48 Appendix 1: 2012 Sentinel Survey Sites Province and Sentinel Site Classification 48 Appendix 2: 2012 ANC Surveillance Form 50 Appendix 3: Laboratory HIV Parallel Testing Algorithm 53 Appendix 4: ANC Sentinel Surveillance Sites Since 2002 54

ii National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 List of Tables and Figures Tables Table 1: Summary of Zimbabwe Population in 2012 1 Table 2: Health and Socio-Economic Indicators 1 Table 3: Distribution of clients by residential classification 13 Table 4: Distribution of client characteristics 16 Table 5: HIV Prevalence by Sentinel Site,2012 18 Table 6: Distribution of HIV prevalence by exposure to PMTCT services 26 Table 7: Overall HIV prevalence statistics 29

Figures Figure 1: Overall HIV pooled prevalence for women 15-49 years, 2012 17 Figure 2: HIV prevalence by sentinel site location, 2012 20 Figure 3: Median HIV prevalence by province, 2012 20 Figure 4: HIV prevalence by age-group among ANC attendees, 2012 21 Figure 5: Urban-rural comparison of HIV prevalence among ANC attendees 15-49 years, 2012 21 Figure 6: HIV prevalence by education level, 2012 22 Figure 8: HIV Prevalence by occupation, 2012 24 Figure 9: HIV Prevalence by gravidity among ANC attendees, 15-49 years 25 Figure 10: HIV Prevalence by number of abortions and still-births, 2012 25 Figure 11: Prevalence of HIV by history and presence of GUD 26 Figure 12: HIV prevalence by partner’s occupation 27 Figure 13: HIV prevalence by partner’s place of residence 28 Figure 14: HIV prevalence by partner’s level of education 28 Figure 15: Overall HIV prevalence trends 29 Figure 16: HIV prevalence trends by age-group 30 Figure 17: HIV prevalence trends by level of education 31 Figure 18 : HIV prevalence trends by occupation 32 Figure 19: Trends in HIV prevalence by sentinel site location 33 Figure 20: Trends in HIV prevalence by occupation 33 Figure 21: HIV prevalence trends by province 2012 34 Figure 22: Overall HIV prevalence trends by young women (15 -24 years) 36 Figure 23: HIV prevalence trends in young women 15-24 years by site 37 Figure 24: HIV prevalence in young women by age-group 39 Figure 25: Trends in HIV prevalence by education level in young women 15-24 years 39 Figure 26: HIV prevalence trends by sentinel location 15-24 years 40 Figure 27: HIV prevalence trends by province 15 -24 years 41 Figure 28: Percentage RPR Positive among, women, 15-49 years, and 2012 42 Figure 29: Percentage RPR Positive by Age-Group, Among ANC Attendees, 15-49 years, 2012 42 Figure 30: Prevalence of RPR positive by gravidity 43

AIDS & TB PROGRAMME 2013 iii Appendices

Appendix 1: Sentinel Sites Classification 59

Appendix 2: 2012 ANC Surveillance Form 61

Appendix 3: Laboratory Testing Algorithm 63

Appendix 4: Parallel Testing Algorithm 64

Appendix 5 : Report on Evaluation of Rapid HIV test Kits using ELISA HIV test Kits 68

Appendix 6: Comparison of 2008 PMTCT data and 2009 ANC Site Prevalence data 75

Appendix 7: Trends in HIV Prevalence all women 15-49 years, Genescreen HIV Test 76

Appendix 8: List of ANC Survey Participants 77

iv National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 Foreword

The 2012 ANC sentinel surveillance report is a follow up on the 2009 ANC survey. HIV prevalence has declined from 16.1% in 2009 to 15.9% in 2012 among pregnant women 15-49 years old.

While prevalence in most sentinel sites has continued to decline, some sentinel sites registered notable increases in HIV prevalence. High HIV infection rates were observed among women 35-39 (26.7%) and 40-44 (26.0%) years of age. HIV prevalence has remained high at sites classified as ‘Other’, (growth points, border posts, mining and resettlement farms) compared to the urban and rural areas.

Although the observed decreasing trend is encouraging, overall HIV sero-prevalence among women attending ANC in Zimbabwe remains high. Although there has been a significant decrease in HIV prevalence in the 15-24 year age group (11.6% in 2009 to 9.85% in 2012), increased efforts to scale up prevention campaigns targeting youth are still needed.

The positive signs in our fight against HIV and AIDS should spur every Zimbabwean to re- double their efforts and commitment to further reduce the burden of HIV and AIDS.

Brigadier General (Dr.) G. Gwinji Permanent Secretary, Ministry of Health and Child Care Zimbabwe

AIDS & TB PROGRAMME 2013 v

This project has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through Cooperative between the Centers for Disease Control and Prevention and the University of Zimbabwe Department of Community Medicine SEAM Project under the terms of Cooperative Agreement Number: 1U2GGH000315-01

vi National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 Acknowledgements

The Ministry of Health and Child Care would like to extend its gratitude to all the onsite health care workers, including the sentinel site staff, midwives, as well as their provincial and national supervisors who participated in the Antenatal Clinic Survey for the year 2009. Their hard work and dedication ensured the success of the survey.

We would also like to acknowledge the National AIDS Council (NAC) for collaborating with the AIDS and TB Unit in training and data abstraction and to the National Microbiology Reference Laboratory (NMRL) for testing and providing quality assurance for all the survey samples.

We wish to express our gratitude to: Central Statistical Office (CSO), Centers for Disease Control and Prevention, Zimbabwe (CDC Zimbabwe), Imperial College London, Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Children Emergency Fund (UNICEF), United Nations Population Fund (UNFPA), World Health Organization (WHO) and Elizabeth Glazier Paediatric AIDS Foundation (EGPAF) supporting the conduct of the survey and providing assistance with data analysis and report writing.

Finally, we would like to express our appreciation and gratitude to the pregnant women who participated anonymously in this study, without whom this survey would not have taken place.

Dr. Owen Mugurungi Director AIDS and TB Unit

AIDS & TB PROGRAMME 2013 vii Executive Summary

In 2012, the Ministry of Health and Child Care (MOHCC), AIDS and TB unit conducted HIV sero-prevalence survey of women attending antenatal clinics (ANC) to monitor the level and trends in HIV prevalence. A total of 54 sentinel sites were selected to participate in the survey using probability proportional to size sampling method to represent 10 provinces in the country. A total of 18,437 ANC clients were consecutively enrolled in the survey over a period of four months. Leftover blood specimens collected from pregnant women for routine screening at their first ANC visit were used for HIV antibody testing. All personal identifiers were removed from the specimens ensuring that testing was unlinked and anonymous.

The highest HIV prevalence was observed in Matabeleland South 23.8% while the lowest was in Harare 10.8%. The prevalence in the other eight provinces was; Matabeleland North 19.6%, Mashonaland East 17.6%, Midlands 17.2%, Bulawayo 17.1%, Mashonaland West 15.6% Masvingo 14.6%, Manicaland 13.9% and Mashonaland Central 12.4% .The national median HIV prevalence was 15.9%. HIV prevalence among women 15-49 years was slightly higher among women who accessed services in urban sentinel sites (16.1%) as compared to the rural sentinel sites 15.7%.

There was a gradual increase in HIV prevalence with age group from 5.6% in the 15-19 years peaking to 26.7% in the 35-39 year old group followed by a decline to 23.1% in the 45-49 year old group. HIV prevalence was highest among women who had not received any form of education, those who were not married, those employed in the informal sector and those with previous history of sexual transmitted infection.

The HIV prevalence among pregnant women 15-49 years has declined from 16.1 % in 2009 to 15.9% in 2012. A similar trend was observed in the 15-24 age group where HIV declined from 11.6% in 2009 to 9.85% in 2012. Significant declines were at the following provinces: Mashonaland Central (25.5% in 2002 to 12.4% in 2012), Mashonaland West (27.1% in 2002 to 15.6% in 2012) and Manicaland (25.6% in 2002 to 13.9% in 2012). There were some increases in prevalence in Matabeleland South, Bulawayo, Midlands and Mashonaland East in 2012 compared to 2009.

The ANC survey was suppose to test for current syphilis infection using RPR screening tests and the TPHA confirmatory test but however only RPR was done due to the shortage of TPHA kits. This survey was therefore unable to provide the prevalence of syphilis among pregnant women.

In conclusion, HIV prevalence among pregnant women 15-49 years still remains unacceptably high. The prevalence of HIV has however shown a decline in 2012 as compared to previous years showing that the current preventive efforts are bearing fruits. There is a need to invest in the scale up of prevention strategies targeting all women of child bearing age in order to reduce the incidence of HIV infection.

viii National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 Acronym

Acronym Full name

ANC Antenatal Clinic AIDS Acquired Immune Deficiency Syndrome CDC-Zimbabwe Centers for Disease Control and Prevention Zimbabwe DBS Dried Blood Spot EIA Enzyme Immunoassay EQA External Quality Assurance HIV Human Immunodeficiency Virus NMRL National Microbiology Reference Laboratory MLS Medical Laboratory Scientist MOHCC Ministry of Health and Child Care PCR Polymerase Chain Reaction PITC Provider Initiated Testing and Counseling PNO Provincial Nursing Officer PMLS Provincial Medical Laboratory Scientist PMTCT Prevention of Mother to Child Transmission of HIV RPR Rapid Plasma Reagin TPHA Treponema Pallidum Haemaglutination Assay VCT Voluntary Counseling and Testing ZINQAP Zimbabwe National Quality Assurance Program

AIDS & TB PROGRAMME 2013 ix x National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 1.0 INTRODUCTION

1.1 Country Profile Zimbabwe has a male to female ratio of 93:100 (Table 1)

Table 1: Summary of Zimbabwe Population in 2012

Number

Male 6 234 931

Female 6 738 877

Total 12 973 808

Zimbabwe Population Census 2012 The country reported low socio-economic indicators with only 66% of births attended by skilled health worker in the last 5 years (Table 2)

Table 2: Health and Socio-Economic Indicators Indicator Value

Total Fertility rate (ZDHS 2010) 4.1%

Expected live births, 2011 (Health Information, Ministry of 412, 122 Health and Child Care Zimbabwe) Percentage of women who received ANC care from a skilled health personnel for a live birth in the last 5 years (ZDHS 90% 2010) Births attended by a skilled health worker for a birth in the 66% last 5 years (ZDHS 2010)

1.2 Background

Zimbabwe is experiencing a declining HIV epidemic although HIV prevalence remains high. This decline has been noted in biannual antenatal clinic surveillance (ANC) conducted in 2002, 2004, 2006 and 2009 and the HIV and AIDS estimates from modeling. These findings were corroborated by population based estimates from the Zimbabwe Demographic and Health Surveys of 2005/6 and 20101.

In line with international standards for monitoring the HIV epidemic Zimbabwe has used both population based and ANC sentinel surveillance to collect critical information for informing policy makers and planners of the status of the HIV epidemic. Surveillance of pregnant women who routinely attend ANC sentinel sites has provided valuable information about the burden of HIV and trends in HIV prevalence2,3 ANC sentinel surveillance (ANC HSS) is conducted using unlinked anonymous testing (UAT), in which leftover blood from routine testing at ANC clinics (usually syphilis testing) is stripped of all personal identifiers and used for HIV surveillance. In UAT-based ANC HSS, informed consent is not obtained from pregnant women and test results

AIDS & TB PROGRAMME 2013 1 are not returned, thus eliminating a potential source of selection bias due to non-consent. When testing is based on informed consent individuals refusing testing may be at lower or higher risk of HIV infection than consenters. The main advantages of using ANC data include lower cost of data collection compared to population surveys and accessibility of populations. The lack of universal coverage of ANC services in developing countries, exclusion of non-pregnant women and exclusion of men tend to make these data less representative of the general population and this has been documented by Brockmeyer and others4. On the other hand, HIV testing in Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS)provide nationally representative estimates of HIV prevalence in the general population and have the advantage of linking socio-demographic and behavioral data to Sero-status of individuals. These surveys, however, are affected by non-response bias, exclude non-household populations, and are relatively more expensive and not conducted annually.

Over the last decade, expanded access to HIV prevention, care and treatment interventions has highlighted ethical issues inherent in UAT-based ANC HSS. The conduct of ANC HSS using UAT raises ethical concerns given that this methodology does not obtain informed consent from pregnant women, provide them with their HIV testing results or refer them to HIV care, treatment, and prevention interventions if test results are positive5,6.[8, 9]. A growing consensus has reported that, in the context of ART and PMTCT expansion, alternative surveillance methods and data sources are increasingly available and should be explored to address ethical issues associated with UAT-based ANC HSS.

1.3 Antenatal clinic and PMTCT services in Zimbabwe

Zimbabwe provides antenatal care in all its 1643 public health facilities. According to the ZDHS, 90% of women age 15- 49 years who gave birth in the five years preceding the survey received antenatal care from a skilled provider during pregnancy of their most recent birth. There was a slight decline from the 94% reported in 2005/6 to 90% in 2010 ZDHS and this was attributable to high user fees personal socio-economic factors such as high transport costs.

The Ministry of Health and Child Care has mandated all facilities in Zimbabwe to offer Provider Initiated Testing and Counseling (PITC) services. PMTCT services are integrated in ANC services at all sites. The PMTCT programme has rapidly expanded since its nationwide roll- out in 2002; with 1560 out of the 1643 facilities (95%) in the public sector offering PMTCT services. An increase in the proportion of PMTCT sites offering comprehensive services was noted from 77% (1200) in 2010 to 89% (1390) in 2011.

Pregnant women are encouraged to visit the ANC/PMTCT clinic at 12 weeks of pregnancy. The initial visit involves recording of demographic characteristics of patient in the ANC register and the issuance of a personal booking card. The women are physically examined and screening tests such as for syphilis, blood grouping are conducted. With integration of PMTCT services to ANC, in theory, all women are offered individual counseling and testing, but can “opt- out”. Women who refuse HIV testing at their first booking can access these services on a voluntary basis at subsequent visits. HIV positive pregnant women are prioritized for access to antiretroviral therapy.PMTCT sites provide a short course of Nevirapine and dual combination therapy of Zidovudine and Lamivudine prophylaxis in addition to other routine PMTCT services.Of the 412, 122 estimated pregnancies in 2011, 403 938 (96%) presented for first ANC booking; and out of these, 341 725 (85%) accepted HIV test in PMTCT7 (PMTCT REPORT 2011).

2 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 1.4 ANC Sentinel Surveillance

Since 1989, Zimbabwe has conducted HIV surveillance of pregnant women who routinely attend ANC sentinel sites to provide valuable information about the burden of HIV and trends in HIV prevalence. ANC sentinel surveillance (ANC HSS)is conducted using unlinked anonymous testing (UAT), in which leftover blood from routinesyphilis testingis stripped of all personal identifiers and used for HIV surveillance. Pregnant women presenting for the first timewith their current pregnancy at the participating ANC sites during the survey period are enrolled in the anonymous unlinked Sero-survey. A minimum set of data are extracted from antenatal clinic booking cards and entered into the ANC survey form. The use of informed consent is not obtained and test results are not provided to participating women.ANC surveys were conducted in 2000, 2001, 2002, 2004, 2006 and 2009. Nineteen sentinel sites have participated since 2002 to 2009 and the testing algorithm was standardized. The HIV prevalence among pregnant women 15-49 years has declined from 25.7 (95% CI 24.7 -26.7) in 2002 to 16.1% (95% CI 15.3-17.0) in 2009. The decline was significant (p <0.001). A similar trend was observed in the 15-24 age-group where HIV declined from 20.8% (95% CI 19.8 -21.8) in 2002 to 11.6% (95% CI 10.6 -12.6%) (p<0.001) in 2009.

In order to provide provincially representative estimates of HIV prevalence, the surveillance group conducted the 2012 HIV surveillance in 54 provincially representative ANC/PMTCT sites. These sentinel ANC sites include clinics in rural areas, growth points, commercial farms, mining areas, and urban areas.

Laboratory testing using ELISA tests kits and confirmatory Western Blot were performed at the National Microbiology Reference Laboratory (NMRL) due to lack of capacity in some of the district laboratories.

The data from the 2012 ANC Survey were used by the Ministry of Health and Child Care (MOHCC) to establish the prevalence and trends of HIV and syphilis infection among antenatal clinic attendees at the sentinel sites. In addition, the ANC Surveillance data and other available HIV prevalence data were used by the MOHCC and the Estimates Working Group to generate national HIV and AIDS estimates for Zimbabwe using the Spectrum software.

Although ANC sentinel surveillance utilizing this method of unlinked anonymous testing (UAT) is currently the mainstay for analyzing HIV trends over time in many Sub-Saharan African countries, there are ethical considerations inherent in this method. Unlinked anonymous testing does not provide women with HIV counseling,or inform women of their test result or provide linkages to care and treatment for women who test positive. Further, as a separate and additional data collection activity involving ELISA, RPR and TPHA HIV testing, UAT-based ANC sentinel surveillance can consume significant resources. In the light of a growing PMTCT program in Zimbabwe, this survey also evaluated the utility of using PMTCT data in replacing anonymous unlinked Sero-surveillance and results are reported elsewhere(Y).

AIDS & TB PROGRAMME 2013 3 2.0 OBJECTIVES

2.1 Broad Objectives The broad objective of the 2012 ANC survey was to establish the HIV and syphilis prevalence among antenatal clinic clients in order to monitor the HIV and AIDS epidemic and to develop and plan interventions for HIV and AIDS prevention and control in Zimbabwe.

2.2 Specific objectives • To determine the prevalence and incidence of HIV and syphilis among women (15-49 years) attending sentinel antenatal clinics in Zimbabwe; • To describe HIV and syphilis infection among sub-populations of these women; • To describe the recent trends in the prevalence of HIV among women attending sentinel antenatal clinics; • To provide information for planning integrated activities for prevention and control of HIV and AIDS for groups with HIV infection and AIDS and those not infected; and • To store data and specimens for additional studies related to understanding the HIV AND AIDS epidemic in Zimbabwe.

4 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 3.0 METHODS

3.1 Survey design The national antenatal HIV and syphilis prevalence was an anonymous, unlinked, cross- sectional survey targeting pregnant women attending antenatal clinics in the public health sector. This survey expanded its sample size to 18 500 pregnant women recruited from 54 health facilities which formed the primary sampling units (PSU) compared with 7 363 women recruited from 19 sites in 2009. This has expanded geographic coverage considerably to include clients from all the ten provinces, making it possible to generate national and provincial HIV estimates using the EPP spectrum model. The survey was conducted over a period of sixteen weeks starting in June of 2012.

3.2 Sampling 3.2.1 Sentinel population Pregnant women (15-49 years) attending ANC services at public health facilities for the first time with current pregnancy were used as the target population to minimize the chances of obtaining information from the same woman more than once.

3.2.2 Selection of survey population Inclusion criteria

All pregnant women aged 15 – 49 years attending antenatal care services for the first time during their current pregnancy were eligible for inclusion.

Exclusion criteria

Pregnant women who had previously visited the ANC clinic during their current pregnancy during the survey period were excluded from participation on the basis of their known status

3.2.3 Selection of sentinel surveillance sites The basic goal was to select 55 national sentinel surveillance sites representative for the population size estimate of the province while maintaining the 19 traditional sites which are used in the trend analysis. The 36 additional sentinel sites were selected using the ‘Probability Proportional to size’ (PPS) method based on the reported 2011 facility list first ANC booking to give a total of 55 sites.

3.3 Sample size determination

Sample size was calculated to be 18,500 using the Fleiss formula at 95% confidence interval, with a precision of 0.05, statistical power (β) of 80% and a significance level (α)of P<0.05 determining a statistically significant decline in HIV prevalence of 10% from 16.1% to 14.5%.

Sample size for all other sites except for city sites was calculated to be 330 per site to ensure that the true prevalence will be captured 95% of the time. Sample size for the cities i.e. Kuwadzana, Nkulumane, and St. Mary’s Clinics was higher at 550 in order to allow for estimation of HIV prevalence among urban young women below the age of 25 years in an attempt to assess recent infection, since there were few urban clinics in the sample.

AIDS & TB PROGRAMME 2013 5 3.4 Training and Supervision

All survey staff (sentinel supervisors, midwives and laboratory staff) were trained at a central place. Members of the technical working group participated in the training of staff in the survey procedures. Supervisory visits were conducted during the survey period. Special support was provided to sites that were facing challenges.

3.6 Summary of Survey Operational Procedures

• History taking on all ANC booking cards • Selection of pregnant women on first antenatal booking for inclusion in the survey • Transfer of demographic information from ANC booking card to ANC survey form • Drawing of blood for routine antenatal tests, i.e., ABO blood grouping, Rhesus typing, or syphilis testing and labeling for routine tests. Remnant blood was placed in a survey tube and labeled using a bar code • Preparation and labeling of dried blood spots • All DBS specimens were left to dry for at least 3 hours in a horizontal position then placed in a zip lock bag with a desiccant pack and stored at 4oC • Samples were initially sent to a separating laboratory, spun and separated. Survey serum was placed into 1.8 ml cryo-tubes and stored in the freezer (-13oC), until ready for transport to the testing laboratory. • All samples were transported to the testing laboratory, the National Microbiology Reference Laboratory (NMRL), in Harare, while maintaining the cold chain.

3.7 Laboratory procedures

3.7.1 Laboratory Methods

The sentinel site ANC nurse collected five milliliters (5ml) of whole blood by venipuncture. From the 5 ml tube, 2.5 ml was transferred to a plain tube for routine blood typing and other tests. The remaining 2.5 ml, five (5) drops were placed on blotting paper to be stored as dried blood spots (DBS) for the survey. The test tube and DBS and corresponding forms were labeled with preprinted barcode stickers to ensure correct linkage of test results with survey data collection forms. All DBS specimens were left to dry for at least 3 hours in a horizontal position then placed in a zip lock bag with desiccant pack to maintain integrity before and during transportation.

The completed survey forms were sent with the DBS to the NMRL using EMS envelopes or site-specific transportation logistics to ensure timely transportation. A tally sheet was sent with the specimens to ensure all survey specimens were accounted for. All forms were scanned into an electronic database at the NMRL.

6 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 3.7.2 Laboratory testing Samples were tested using two Enzyme Immuno-Assay (EIA) test kits, AniLabsytems (AniLabsystems Ltd, Finland)1 which has been used since 2002 and the newly introduced Enzygnost Anti HIV 1/ 2 plus (Siemens Healthcare products, Munich Germany)2. Discordant samples results were re-tested using the same test kits. Samples that remained discordant were then tested using Western Blotting, New Lav Blot 1 (Biorad, France). The Western Blot was used to resolve discordant results. In order for a person to be considered HIV positive, using the Western blot test they needed to have either antibodies against one of the envelope proteins and one of the core proteins, or against one of the enzymes. The proteins are listed below3 • Proteins from the HIV envelope: gp41, and gp120/gp160. • Proteins from the core of the virus: p17, p24, p55 • Enzymes that HIV uses in the process of infection: p31, p51, p66 Polymerase chain reaction by ROCHE4 was then used resolve the indeterminate samples. The full testing algorithm is referenced in Appendix 3.

3.7.3 Quality Assurance of HIV Testing Internal quality assurance was conducted at the NMRL. External quality assurance on 10% of the samples was conducted by Zvitambo. All samples passed the external quality assurance and all results from the NMRL were accepted for analysis.

The results of the parallel testing algorithm were used to describe the overall and detailed trends from 2002 through 2012.

3.7.4 Testing for Syphilis

The Immutrep Rapid Plasma Reagin (RPR) testing kit5 was used to screen all women for syphilis.Samples that were reactive for RPR were further tested with the Omega Diagnostics Immutrep Treponema pallidumhaem-agglutation (TPHA) testing kit6. Samples that were reactive for both RPR and TPHA were considered positive for current infection with syphilis.

The RPR kit is a non-treponema method for the serological detection of syphilis. The antigen is a particulate carbon suspension coated with lipid complexes that agglutinate in the presence of plasma reagins. Reagins are antibodies present in the sera of syphilitic patients. Visible agglutination in the form black clumps which was viewed macroscopically, and this indicated the presence of such antibodies in the sample that was being tested. The Omega Diagnostics Immutrep TPHA comprises T. pallidum sensitized formolised tanned fowl erythrocytes; unsensitisedformolised tanned fowl erythrocytes, diluent and control sera. When diluted positive samples are mixed with sensitized erythrocytes, antibody to the sensitizing antigen causes agglutination of the cells. The cells form a characteristic pattern of cells in the bottom of a micro-titration plate well. In the absence of antibody, they form a compact button in the well and provide conclusive results for the presence of current syphilis infection.

1 http://www.anilabsystems.com/anilabsystems/pdfs/HIVFebr2008.pdf 2 http://healthcare.siemens.com/clinical-specialities/infectious-disease/infectious-diseases-hiv 3 http://www.bio-rad.com/prd/en/US/CDG/PDP/M4T5SX15/GS-HIV-1-Western-Blot 4 http://molecular.roche.com/About/pcr/Pages/PCRProces.aspx 5 http://www.biokits.com/field/201/Medical%20Science/Rapid-Plasma-Reagin-RPR-Test-Kits 6 http://www.eugene-chen.com.tw

AIDS & TB PROGRAMME 2013 7 3.8 Data entry and management

Data was first collated by the NMRL database officer. Forms with all laboratory results were forwarded to the data entry team. Data collection forms received from the NMRL were checked for completeness, errors and inconsistencies as part of the data cleaning process.

Forms were entered into a database using teleform scanning software by site. The scan system created an access database. All scanned entries were checked by another data entry clerk. The dataset were cleaned and an analysis dataset constructed using Microsoft Access. All outlying data were verifiedusing the original data collection form. An electronic data set was stored on Ministry of Health and Child Care servers for security of data storage. After completion of data entry, the forms were stored for safekeeping in a locked room at the Ministry of Health and Child Care, AIDS and TB Unit.

3.9 Data analysis

The primary outcome of the ANC data analysis was to determine HIV prevalence of all women attending sentinel antenatal clinics in Zimbabwe. All analysis was conducted in STATA Intercooled Version 10. Confidence intervals and p values were calculated to test for significance.

One secondary outcome of the data analysis was to generate data for the national estimates process. ANC site level data were used with other national survey and monitoring data to estimate the current impact of the HIV epidemic. These estimates are presented in the HIV Estimates Report of 2013.

3.10 Overall quality assurance

The overall oversight of the 2012 ANC Survey was provided by the ANC Technical Working Group in consultation with the national surveillance officer who provided coordination and communication between the different people responsible for completing the survey. This group with assistance from the national survey team, coordinated data collection, analysis and report production.

8 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 4.0 RESULTS

4.1 Population characteristics

A total of 18437 ANC clients contributed to the 2012 national Sero-surveillance. Most women visiting a sentinel site reported that they resided in the clinic’s catchments area (Table 3). Most of the ANC attendees resided in towns and rural areas (39.8% each). The other attendees resided in farming areas 8.26%, growth points 4.3%, mining areas 1.71% and a minority had their place of residence classified as missing 0.986%

AIDS & TB PROGRAMME 2013 9 Table 3: Distribution of clients by residential classification Farm Growth Point Mine Rural Town or City Missing Province Site name Total n (%) n (%) n (%) n (%) n (%) n (%) Bulawayo Nkulumane 1 (0.2) 2 (0.3) 0 (0.0) 7 (1.2) 581 (96.8) 9 (1.5) 600 Chitungwiza St Marys 5 (0.8) 3 (0.5) 0 (0.0) 9 (1.5) 582 (97.0) 1 (0.1) 600 Harare Hatcliffe 5 (1.5) 6 (1.8) 1 (0.3) 9 (2.7) 317 (93.2) 1 (0.3) 340 Glenview 0 (0.0) 1(0.3) 0 (0.0) 0 (0.0) 328 (98.2) 5 (1.5) 334 Kuwadzana 4 (0.7) 0 (0.0) 0 (0.0) 0 (0.0) 593 (98.8) 3 (0.5) 600 Manicaland Hauna 23 (10.3) 17 (7.6) 8 (3.6) 165 (73.7) 10 (4.5) 1 (0.5) 224 Murambinda 5 (1.5) 37 (10.9) 2 (0.6) 283 (83.5) 11 (3.2) 1 (0.3) 339 Mutambara 4 (1.3) 10 (3.2) 0 (0.0) 282 (90.7) 4 (1.3) 11 (3.5) 311 Nyanga 21 (7.6) 2 (0.7) 0 (0.0) 167 (60.7) 62 (22.6) 1 (0.36) 275 Rusape 25 (21.1) 3 (2.5) 1 (0.8) 17 (14.3) 51 (42.9) 1 (0.84) 119 Sakubva 0 (0.0) 0 (0.0) 0 (0.0) 3 (0.9) 337 (99.1) 0 (0.0) 340 Mashonaland Central Bindura 133 (39.7) 1(0.3) 15 4.5) 77(23.0) 108(32.2) 1(0.3) 335 Chimhanda 2(0.6) 16 (4.8) 0 (0.0) 308 (93.1) 2 (0.6) 3 (0.9) 331 Concession 206 (61.1) 23 (6.8) 21 6.2) 2 (0.6) 83 (24.6) 2 (0.6) 337 Guruve 51 (15.1) 40 (11.9) 2 (0.6) 233 (69.1) 3 (0.9) 3 (0.9) 337 Karanda 1 (0.3) 6 (1.8) 0 (0.0) 326 (95.9) 4 (1.2) 2 (0.6) 340 Shamva 57 (16.9 9 (2.7) 29 8.6) 162 (47.9) 54 (16.0) 8 (2.8) 338 St Alberts 50 (15.9) 3 (1.0) 0 (0.0) 206 (65.6) 27 (8.6) 1 (0.3) 314 Mashonaland East Epworth clinic 0 (0.0) 2 (0.6) 0 (0.0) 1(0.3) 336 (98.8) 1(0.3) 340 Hwedza 34 (10.1) 30 (8.9) 0 (0.0) 223 (66.0) 9 (2.6) 1 (0.3) 338 Makumbe 60 (18.1) 5 (1.5) 0 (0.0) 216 (65.1) 42 (12.7) 1 (0.3) 332 Marondera 83 (24.6) 8 (2.4) 0 (0.0) 117 (34.7) 127 (37.7) 2 (0.6) 337 Murehwa 28 (9.3) 58 (19.3) 0 (0.0) 171 (57.0) 7 (2.3) 2 (0.7) 300 Mutoko 14 (4.1) 116 (34.1) 1 0.30) 181 (53.2) 4 (1.2) 3 (0.9) 340 Sadza 18 (5.3) 7 (2.1) 0 (0.0) 122 (36.0) 110 (32.5) 2 (0.6) 339 Mashonaland West Banket 236(70.6) 0 (0.0) 0 (0.0) 89(26.7) 1(0.3) 8(2.4) 334 Chinhoyi 29 (8.7) 2 (0.6) 17 5.1) 2 (0.6) 268 (80.0) 3 (0.9) 335 Kadoma 46 (13.7) 7 (2.1) 16 4.8) 7 (2.1) 224 (66.7) 7 (2.1) 336 Kariba 14 (4.1) 0 (0.0) 0 (0.0) 126 (37.2) 195 (57.5) 2 (0.6) 339 Karoi 111 (32.7) 2 (0.6) 0 (0.0) 21 (6.2) 198 (58.2) 1 (0.3) 340 Matebeleland North Binga 0 (0.0) 16 (4.8) 0 (0.0) 313 (93.4) 4 (1.2) 2 90.6) 335 Chinotimba 1(0.3) 4 (1.2) 0 (0.0) 28 (8.3) 295 (87.0) 0 (0.0) 339 Inyathi 17 (5.0) 7 (2.0) 49 (14.3) 223 (65.0) 8 (2.3) 4 (1.17) 343 Nkayi 0 (0.0) 45 (17.5) 0 (0.0) 203 (79.0) 1 (0.4) 1 (0.4) 257 Nyamandlovu 63 (18.6) 20 (5.9) 0 (0.0) 165 (42.8) 3 (0.9) 2 (0.6) 338 Matebeleland South Beitbridge 5(1.5) 14 (4.2) 1(0.3) 38 (11.4) 252 (75.7) 22 (6.6) 333 Filabusi Hospital 11 (3.3) 41 (12.2) 10 (2.8) 200 (59.5) 5 (1.5) 3 (0.9) 336 Gwanda 8 (2.4) 0 (0.0) 68 (20.1) 63 (18.6) 191 (56.3) 1 (0.3) 339 Plumtree 4 (1.2) 6 (1.8) 0 (0.0) 201 (60) 119 (35.5) 2 (0.6) 335 Masvingo Chiredzi 72 (21.7) 3 (0.9) 0 (0.0) 19 (5.7) 178 (53.6) 4 (1.2) 332 Chivi 1(0.3) 32 (9.5) 0 (0.0) 286 (84.6) 7 (2.1) 4 (1.2) 338 Gutu 3 (0.9) 91 (26.8) 0 (0.0) 198 (58.2) 4 (1.2) 0 (0.0) 340 Morgenster 7 (2.1) 6 (1.8) 9 (2.7) 125 (37.0) 183 (54.1) 3 (0.9) 338 Neshuro 1 (0.3) 14 (4.1) 2 (0.6) 265 (77.9) 1 (0.3) 7 (2.1) 340 Ndanga 11 (3.3) 0 (0.0) 0 (0.0) 222 (65.7) 3 (0.9) 3 (0.9) 338 Silveira 2 (0.6) 26 (7.7) 1 (0.3) 296 (87.3) 5 (1.5) 6 (1.8) 339 Midlands Gokwe 2 (0.6) 13 (3.9) 0 (0.0) 250 (74.4) 70 (20.8) 1(0.3) 336 Gweru 7 (20.6) 3 (0.9) 0 (0.0) 6 (1.8) 321 (94.4) 0 (0.0) 340 Kwekwe 12 (3.5) 1 (0.3) 22 (6.5) 9 (2.7) 291 (85.8) 0 (0.0) 339 Musume 0 (0.0) 8 (2.4) 1 (0.3) 295(87.02) 4 (1.8) 6 (1.7) 339 Mvuma 11 (3.3) 9 (2.7) 9 (2.7) 146 (43.2) 62 (18.3) 0 (0.0) 338 Shurugwi 11 (3.3) 21 (6.2) 30 (8.9) 216 (64.1) 45 (13.4) 0 (0.0) 337 Zvishavane 6 (1.8) 2 (0.6) 1 (0.3) 39 (11.5) 284 (84.0) 0 (0.0) 338 Total 1522 (8.3) 799 (4.3) 316 (1.7) 7338 (39.8) 7338 (39.8) 158 (0.9) 18,131

10 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 Table 4: Distribution of client characteristics Variables n=18131 % Variables n=18131 % Variables n=18131 %

Age group Level of education Currently on ART

<15 17 0.1 None 113 0.6 Yes 765 4.2

15-19 3508 19.3 Primary 4049 22.3 No 17037 94.0

20-24 5502 30.3 Secondary 13535 74.7 Missing 329 1.8 Women offered PMTCT HIV test - 25-29 4342 23.9 Tertiary 358 2.0 Current visit Missing 30-34 2824 15.6 76 0.4 Yes 17206 94.9 education 35-39 1399 7.7 Place of usual residence No 891 4.9

40-44 280 1.5 Growth point 790 4.4 Missing 34 0.2 Women accepted PMTCT HIV test - 45-49 22 0.1 Mine 313 1.7 Current visit Resettlement <15 17 0.1 2451 13.5 Yes 16914 93.3 farm/farm 15-24 9010 49.7 Rural 7209 39.8 No 122 0.7

15-29 9117 50.3 Town or city 6974 38.5 N/A 712 3.9 Missing 15-49 18113 99.9 156 0.9 Missing 383 2.1 residence Missing 18 0.1 Site classification Obstetric Information

Marital status Rural 8594 47.4 Gravida

Married 16754 92.4 Urban 9300 51.3 0 32 0.2 Divorced/ 127 0.7 Missing 237 1.3 1 5443 30.0 Separated Single 831 4.6 History of GUD in the last 12 months 2-3 8586 47.4

Widowed 43 0.2 Yes 321 1.8 4+ 3674 20.3

Missing 139 0.8 No 17435 96.2 Missing 159 0.9

Type of occupation Missing 217 1.2 Still births

Student 147 0.8 Presence of GUD 0 17289 95.4

Housewife 14130 77.9 Yes 136 0.8 1+ 393 2.2

Unemployed 1526 8.4 No 16976 93.6 Missing 449 2.5 Employed 2289 12.6 Missing 861 4.7 Abortions (Formal/Informal) Previously HIV tested and received Missing 39 0.2 0 16350 90.2 results Parity Yes 10115 55.8 1+ 1347 7.4

0 5967 32.9 No 987 5.4 Missing 434 2.4

1-2 8385 46.2 Missing 6871 37.9

3+ 3199 17.6

Missing 23 0.1

AIDS & TB PROGRAMME 2013 11 Partner information Distribution of clients by Sites

Partner’s place of residence Banket 333 1.8 Distribution of clients Sites continued...

Growth point 107 0.6 Beitbridge 331 1.8 Murehwa 300 1.7

Mine 106 0.6 Bindura 333 1.8 Musume 278 1.5 Resettlement 414 2.3 Binga 334 1.8 Mutambara 299 1.6 farm/farm Rural 792 4.4 Chimhanda 324 1.8 Mutoko 340 1.9

Town or city 1267 7.0 Chinhoyi 332 1.8 Mvuma 332 1.8

Partner’s type of occupation Chinotimba 339 1.9 Ndanga 337 1.9

working 1924 10.6 Chiredzi 319 1.8 Neshuro 331 1.8

not working 779 4.3 Chivi 323 1.8 Nkayi 265 1.5

Student 4 0.0 Concession 334 1.8 Nkulumane 596 3.3 Missing type of 0 0.0 Epworth 340 1.9 Nyamandlovu 334 1.8 occupation N/A 0 0.0 Filabusi 334 1.8 Nyanga 274 1.5

Partner’s Education Level Glenview 333 1.8 Plumtree 334 1.8

None 19 0.1 Gokwe 336 1.9 Rusape 114 0.6

Primary 369 2.0 Guruve 330 1.8 Sadza 339 1.9

Secondary 2250 12.4 Gutu 340 1.9 Sakubva 336 1.9

Tertiary 95 0.5 Gwanda 331 1.8 Shamva 337 1.9

Distribution of clients by Province Gweru 340 1.9 Shurugwi 321 1.8

Bulawayo 596 3.3 Hatcliffe 339 1.9 Silveira 326 1.8

Chitungwiza 600 3.3 Hauna 224 1.2 St Alberts 314 1.7

Harare 1271 7.0 Hwedza 337 1.9 St Marys 600 3.3

Manicaland 1586 8.7 Inyathi 339 1.9 Zvishavane 338 1.9 Mashonaland 2311 12.7 Kadoma 332 1.8 Total 18131 100.0 Central Mashonaland 2319 12.8 Karanda 339 1.9 East Mashonaland 1672 9.2 Kariba 336 1.9 West Masvingo 2314 12.8 Karoi 339 1.9 Matebeleland 1611 8.9 Kuwadzana 599 3.3 North Matebeleland 1330 7.3 Kwekwe 340 1.9 South Midlands 2284 12.6 Makumbe 326 1.8

Marondera 337 1.9

Morgenster 338 1.9

Murambinda 339 1.9

12 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 The majority of the women, 74.5% (13495) were in the 15-29 year age group. Nearly all women (93.7%) were married and unemployed (77.9%). The majority of the women (94.0%) had ever received testing for HIV in PMTCT settings. Slightly more than half (56.3%) had received their results in post- test counseling but a significant proportion (38.2%) had missing information on this variable. A very low proportion 4.31 % of women reported having received antiretroviral therapy (Table 4).

About 40.5% of pregnant women stayed in rural areas, while 45.6% of partners resided in towns or cities. Most partners (68.8%) were employed and a high proportion (81.7%) had at least secondary level education.

4.2 Distribution of HIV Prevalence in the fifty-three sentinel sites

Figure 1: Overall HIV pooled prevalence for women 15-49 years, 2012

The overall median HIV prevalence for women 15-49 years was 15.9% (IQR: 12.6%- 19.3%).

AIDS & TB PROGRAMME 2013 13 Table 5: HIV Prevalence by Sentinel Site, 2012 Total Province Site Total (N) Prevalence C.I positive Bulawayo Nkulumane Clinic 596 102 17.1 14.1-20.1 Chitungwiza St Marys Clinic 600 67 11.2 8.6-13.7 Kuwadzana Clinic 599 70 11.7 9.1-14.3 Harare Hatcliffe Clinic 339 33 9.7 6.5-12.9 Glenview 333 34 10.2 6.9-13.5 Murambinda District Hospital 339 59 17.4 13.3-21.5 Mutambara Mission Hospital 299 26 8.7 5.4-11.9 Rusape District Hospital 114 25 21.9 14.2-29.6 Manicaland Sakubva Clinic 336 48 14.3 10.5-18.0 Hauna District Hospital 224 23 10.3 6.2-14.3 Nyanga District Hospital 274 40 14.6 10.3-18.8 Shamva District Hospital/Wadzanayi Clinic 337 53 15.7 11.8-19.6 Bindura Chipadze Clinic 333 62 18.7 14.4-22.8 St Alberts Hospital 314 26 8.3 5.2-11.3 Mashonaland Central Guruve Hospital/Bepura Clinic 330 38 11.5 8.0-14.9 Concession District Hospital / Mvurwi Clinic 334 53 15.9 11.9-19.8 Karanda Mission Hospital 339 24 7.1 4.3-9.8 Chimhanda District Hospital 324 31 9.6 6.3-12.7 Sadza District Hospital 339 50 14.8 10.9-18.5 Makumbe Mission Hospital 326 63 19.3 15.0-23.6 Hwedza District Hospital 337 58 17.2 13.2-21.3 Mashonaland East Marondera Hospital /Chihota Hospital 337 65 19.3 15.1-23.5 Murehwa District Hospital / Nhowe Mission hospital 300 52 17.3 13.0-21.6 Epworth clinic 340 67 19.7 15.5-24.0 Mutoko District Hospital 340 52 15.3 11.4-19.1 Karoi District Hospital 339 59 17.4 13.3-21.5 Kadoma District Hospital 332 50 15.1 11.2-18.9 Mashonaland West Kariba Hospital/ Nyamhunga Hospital 336 49 14.6 10.8-18.4 Chinhoyi Provincial Hospital 332 47 14.2 10.4-17.9 Banket District Hospital 333 55 16.5 12.5-20.5 Binga District Hospital 334 27 8.1 5.1-11.0 Inyathi Mission Hospital 339 69 20.4 16.0-24.6 Matebeleland North Chinotimba Clinic 339 80 23.6 19.1-28.1 Nkayi District Hospital 265 58 21.9 16.8-26.9 Nyamandlovu District Hospital 334 82 24.6 19.9-29.2 Beitbridge District Hospital 331 74 22.4 17.8-26.9 Plumtree District Hospital 334 78 23.4 18.8-27.9 Matebeleland South Gwanda Provincial Hospital 331 86 26.0 21.2-30.7 Filabusi Hospital 334 78 23.4 18.8-27.9 Silveira/Mashoko Mission Hospital 326 41 12.6 8.9-16.2 Chiredzi District Hospital 319 53 16.6 12.5-20.7 ChiviHospital / Gundu RHC 323 39 12.1 8.5-15.6 Masvingo Gutu Mission Hospital 340 54 15.9 11.9-19.8 Morgenster Mission Hospital 338 52 15.4 11.5-19.3 Neshuro Hospital 331 43 13.0 9.3-16.6 Ndanga Hospital 337 56 16.6 12.6-20.6 Mvuma District Hospital 332 64 19.3 15.0-23.4 Gokwe District Hospital 336 38 11.3 7.9-14.7 Gweru Provincial Hospital 340 66 19.4 15.1-23.6 Midlands Kwekwe Hospital / Mbizo B 340 50 14.7 10.9-11.5 Musume Mission Hospital 278 51 18.4 13.7-22.9 Zvishavane District hospital 338 72 21.3 16.9-25.7 Shurugwi District Hospital 321 52 16.2 12.1-20.2 14 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 There were variations in HIV prevalence in fifty- three sentinel sites ranging from 7.08 (Karanda) to 26% (Gwanda Provincial Hospital. Other sites that had notably high prevalence figures were Nyamadhlovu 24.6%, Filabusi 23.4%, Plumtree 23.4% and Beitbridge 22.4%.

Figure 2: HIV prevalence by sentinel site location, 2012

HIV prevalence among women 15-49 years was slightly higher among women who accessed services in urban sentinel sites (16.1%) as compared to the rural sentinel sites 15.7%.

Figure 3: Median HIV prevalence by province, 2012

The highest HIV prevalence was observed in Matabeleland South 23.8% while the lowest Harare 10.8%.The national median HIV prevalence was 15.9 (Q1:12.6; Q3=19.3)

AIDS & TB PROGRAMME 2013 15 Figure 4: HIV prevalence by age-group among ANC attendees, 2012

There was a gradual increase in HIV prevalence with age group peaking in the 35-39 year old group followed by a decline. Despite this, the prevalence remained significantly high in the older age groups.

Figure 5: Urban-rural comparison of HIV prevalence among ANC attendees 15-49 years, 2012

Overall, HIV prevalence was highest, 16.2% among women accessing services in urban sentinel sites. HIV prevalence in the rural areas was highest in the 35-39 years age group 27.8% while the HIV prevalence in urban areas was highest in the 40-44 years age group 29.9%.

16 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 Figure 6: HIV prevalence by education level, 2012

HIV prevalence was highest among women who had not received any form of education 21.7% (n=113) while it was lowest among those who had tertiary education.

When comparing HIV positive status with marital status we found that the HIV prevalence was lowest among those women who were married (15.5%) as compared to those who were not married (22%).

Figure 7: HIV Prevalence by occupation, 2012

AIDS & TB PROGRAMME 2013 17 The highest HIV prevalence was among women that reported their occupation as being employed in the informal sector 20.3%, and the lowest was among students 11%.

Figure 8: HIV Prevalence by gravidity among ANC attendees, 15-49 years

There was a corresponding increase in HIV prevalence with increasing gravidity.

Figure 9: HIV Prevalence by number of abortions and still-births, 2012

There was a higher HIV prevalence for women who had 1+ abortions (18.9%) compared to those who had no previous abortions 15.8%. There was a higher HIV prevalence 18.5% among women who had 1+ still births compared to those who had no previous stillbirths 15.9%.

18 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 Figure 10: Prevalence of HIV by history and presence of GUD

HIV prevalence among women reporting history or presence of genital ulcer disease (GUD) was almost three times higher than that of prevalence among women without GUD.

Table 6: Distribution of HIV prevalence by exposure to PMTCT services

Total Total History Prevalence C.I (N) positive Previously HIV tested and received results Yes 10115 1872 18.5 17.8 -19.3 No 987 133 13.5 11.3 - 15.6 Missing 6871 845 12.3 11.5 – 13.1 Currently on ART Yes 755 714* 91.6 89.7 - 93.6 No 17037 2124 12.5 12.0 - 13.0 Missing Women who accepted PMTCT HIV

test - Current visit Yes 16914 2132 12.6 12.1 - 13.1 No 122 74 60.7 51.9 - 69.5 N/A 712 583 81.9 79.1 - 84.7

* It is expected that all 755 clients who reported to be on ART should be HIV positive

The majority of women had previously been tested and received results for an HIV test. Among these women, the HIV prevalence was 18.5%. At least 41 patients who reported being currently on ART had an HIV negative result when tested at the Reference laboratory and confirmed by DNA Polymerase Chain Reaction Test.. Only 122 women did not accept an HIV test in their current PMTCT visit.

AIDS & TB PROGRAMME 2013 19 4.2: HIV prevalence by partners’ characteristics among ANC attendees, 15-49 years in Zimbabwe

Figure 11: HIV prevalence by partner’s occupation

The lowest HIV prevalence was among women whose partners were still students whereas the highest HIV prevalence was among women whose partners were informally employed.

Figure 12: HIV prevalence by partner’s place of residence

The prevalence was highest among women whose partners resided in the mining areas 24.6% and lowest among women whose partners resided in growth points.

20 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 Figure 13: HIV prevalence by partner’s level of education

The HIV prevalence among 19 clients who reported that their partners had no primary education was 20.7%. HIV prevalence decreased with higher level of partners’ education.

4.3 Trends in HIV prevalence 2002-2012, for all women 15-49 years in nineteen sentinel sites 2002 -2012

Nineteen sites have contributed to ANC trend data since 2002 (Appendix 4). Trends determined in this section are based on pooled HIV prevalence from the 19 sites. Since 2002, HIV prevalence is based on results from the parallel testing algorithm

Figure 14: Overall HIV prevalence trends

HIV prevalence among all pregnant women 15-49 years declined sharply between 2002 and 2006.

AIDS & TB PROGRAMME 2013 21 Table 7: Overall HIV prevalence statistics

Year Positive CI 2002 25.7 24.7 - 26.7 2004 21.3 20.4 -22.3 2006 17.7 17.1 - 18.8 2009 16.1 15.3 - 17.0 2012 15.9 15.0-16.9

Between 2009 and 2012, there is no significant decline in HIV prevalence.

Figure 15: HIV prevalence trends by age-group

HIV prevalence was lowest in the 15-19 years age group across all the years in the period 2002 -2012. HIV prevalence generally increased with increase in age up to 35-39 years. HIV prevalence in older women remained significantly high across all the years with a marked increase in prevalence of 44.4% for the age group 45-49 years in 2012.

Figure 16: HIV prevalence trends by level of education

22 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 There was a general trend of decline in the HIV prevalence for women who had attained primary, secondary and tertiary education over the years 2002-2012. Although a general trend of decline occurred in HIV prevalence among women without an education from 2002-2006, a sharp increase occurred in 2009 (30%) followed by a marked prevalence decline in 2012 (13.9%).

Figure 17: HIV prevalence trends by occupation

HIV prevalence continued to decline across all years for the employed and housewives, however for the students there was a slight increase in prevalence from 2009- 2012 although a general trend of decline had been observed in the previous years. For the unemployed the HIV prevalence has been showing a swinging trend with the highest prevalence being noted in 2002 (25.6%) followed by 2012 (20.3%).

Figure 18: Trends in HIV prevalence by sentinel site location

AIDS & TB PROGRAMME 2013 23 HIV prevalence among women 15-49 years was highest among women who accessed services in sentinel sites classified as other across all survey years 2002 -2012. Sites from growth points, border posts, and mining & resettlement farms are classified as ‘other’.

Figure 19: Trends in HIV prevalence by occupation

24 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012

Figure 20: HIV prevalence trends by province 2012 by province trends prevalence 20: HIV Figure provinces: following the at were declines Significant 2012. to 2002 from continued that prevalence HIV in decline a experienced have provinces 2012). most in 2002, Since 13.9% to 2002 in (25.6% Manicaland and 2012) in 15.6% to 2002 in (27.1% West Mashonaland 2012), in 12.4% to 2002 in (25.5% Central Mashonaland There were some increases in prevalence Matebeleland South, Bulawayo, Midlands and Mashonaland East 2012 compared to 2009. prevalence and trends, women age 15-24 years in nineteen sentinel sites, 2002 -2012 4.4 HIV AIDS & TB PROGRAMME 2013 25 Figure 21: Overall HIV prevalence trends by young women (15 -24 years)

There was a continued decline in trends of HIV prevalence among women age 15-24 years from 29.6% in 2002 to 9.85% in 2012.

Table 8: Overall HIV Trends Statistics, young women 15-24 years

Percentage HIV Year CI positive 2002 20.8 19.8 - 21.8

2004 17.4 16.3 - 18.5

2006 12.5 12.3-14.3

2009 11.6 10.6-12.6 2012 9.9 8.2 – 12.0

The decline in HIV prevalence among young women 15 -24 years is statistically significant.

26 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 Figure 22: HIV prevalence trends in young women 15-24 years by site

Site 2002 2004 2006 2009 2012 Banket 19.9 25 19.3 15.3 13.0 Beitbridge 24.5 17.1 19.2 16.3 18.4 Bindura 25.3 18.6 11.8 9 16 Binga 20 8.2 5.6 5 3.7 Chiredzi 24.8 14.4 12.5 21.5 11.5 Gutu 16.3 23.6 15.3 10.7 12.2 Gwanda 25.7 21 18.9 12.4 22.8 Kadoma 17.9 14.6 19.6 10.4 13.2 Karanda 14.6 6.9 5.6 6 4.5 Kuwadzana 14.8 18 9.3 9.7 8.9 Mkoba 17.1 13.6 10.8 9.7 15.7 Murambinda 15.6 13.6 11.1 17.7 9.9 Musume 18.8 21.6 15.6 12.9 14.4 Mutoko 15.2 14.9 11.5 10.2 11.5 Nkulumane 21.9 16.2 10.4 9.6 14.7 Sadza 35.2 19.2 13.6 8 12.8 Sakubva 15.3 13.1 11.7 9.7 13.4 St. Mary’s 22 18.8 9.3 8.2 10.3 Victoria Falls 30.8 30.5 15.9 19.5 17.4

Across the four survey years and across all ages, HIV prevalence shows a general trend of decline young women except in the 23 year age-group where there is a slight increase from 14.3% to 14.6 %.

Figure 23: HIV prevalence in young women by age-group

HIV prevalence was highest in the 20-24 years age-group.

AIDS & TB PROGRAMME 2013 27 Figure 24: Trends in HIV prevalence by education level in young women 15-24 years

HIV prevalence increased among women who reported not having any education (26.5 % in 2002 to 33.3% in 2009); however there was a decline in 2012 to 14.9%.There was a general trend of decline in HIV prevalence for women who had attained primary, secondary and tertiary level education.

Figure 25: HIV prevalence trends by sentinel location 15-24 years

There was decline in HIV prevalence among young women residing in both urban and rural areas from the years 2004 to 2009. However there was an increase in prevalence for women residing in both rural and urban areas from 2009 to 2012.

28 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012

2012

9.6

11.5

13.2

17.4 18

2009

18.2

14.3

19.1

18.9 25.1

2006

8.1

13.1

2012 11

19.9 25.8

2004

9.9

16.8

13.9

19 20.5

2002

9.6

12.6

19.4

24 years,2002 - Zimbabwe24 18.9

10.2

9.2

12.6

16.9 24.9

Provinces

7.7

7.5

8.9

13.2

20.3

9.3

13.7

11.4

13.3

15.5

5.8

9.7

9.3

18 14.8

Positive by Province Among ANC15 ProvinceAttendees Among by Positive

7.8

8.1

12.7

18.8

11.3

9.6

Percentage HIV Percentage 10.4

16.2 21.9

5 0

30 25 20 15 10

Positive - HIV Percentage Figure 26: HIV prevalence trends by province 15 -24 years Figure 26: HIV 12.4% Gwanda sites: following the in occurred increases Notable 2012. to 2009 from prevalence HIV the in increase general a showed (12/19) sites sentinel Most and Murambinda 17.7% to 9.9%. to 22.8 %, Nkulumane 9.6% 14.7% and marked decline occurred in Chiredzi 21.5% 11.5% AIDS & TB PROGRAMME 2013 29 4.5 Results of syphilis

Figure 27: Percentage RPR Positive among, women, 15-49 years, and 2012

The Rapid RPR percentage positive was 1.8% among all women. TPHA confirmatory test were not done by sites due to the absence of the testing kit.

Figure 28: Percentage RPR Positive by Age-Group, Among ANC Attendees, 15-49 years, 2012

The prevalence of syphilis rose with increasing age with a peak in 45-49 years age group. The lowest prevalence was found among the 15-19 years age group.

30 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 Figure 29: Prevalence of RPR positive by gravidity

Women who had had four or more pregnancies had the highest RPR positive prevalence (2.9%) while those who were in their first pregnancy had the lowest prevalence 1.0%.

AIDS & TB PROGRAMME 2013 31 5.0 Discussion and Conclusions

The HIV prevalence among pregnant women 15-49 years has slightly declined from 16.1% in 2009 to 15.9% in 2012 in Zimbabwe. However the difference is not statistically significant. A similar trend was observed in the 15-19 age group where HIV prevalence declined from 6.8% in 2009 to 5.6% in 2012 which may reflect a reduction in the HIV incidence. Though minor this decline in HIV prevalence among female adolescents may suggest changes in sexual behaviors in the 15-19 years age group. Comparison with the findings of the ZDHS 2010-11 we noted that there was a decline in HIV prevalence in Zimbabwe in keeping with the findings of this survey. This decline has been attributed to intensification of HIV prevention strategies and behavioral change in communities at large.

There was a notable increase in the prevalence of HIV in women aged between 35-49 years in 2012 compared to 2009. Similarly the HIV prevalence among those aged 25 years and older was rising in South Africa from 2010 to 2011 peaking in the 35-39 years age group. The increase in this age group could be due to increased fertility in HIV positive women on treatment whose physiological function is improving or reduced adherence to dual contraception by those already infected. The main feature of the HIV Sero-prevalence trends in ANC attendees has been the decline in HIV prevalence in the young pregnant women, with slightly increasing rates of HIV infection in older age groups suggesting change in sexual norms and behaviors in the groups.

Generally provinces in the southern region; Matabeleland South, Matabeleland North, Bulawayo and Midlands had a higher prevalence of HIV than provinces in the northern region. This difference may be due to the high number of mobile populations in the Southern region which increases risk of acquiring HIV. Mobility has been shown to be correlated HIV infection in many countries.

Mobile populations were shown to be at high risk of HIV in a study conducted in nine African countries including Zimbabwe1. An ANC HIV survey done in 2011 in South Africa showed that the prevalence of HIV was high in the Limpopo Province which is on the Zimbabwean border with South Africa. This prevalence rose from 21.4% in 2010 to 22.1% in 20115. Migrants in South Africa were reported to be having multiple sexual partners6.

Those staying in urban areas had a higher HIV prevalence (16.6%) as compared to those in rural areas (15.2%). This is consistent with the previous ANC HIV Sero-survey in 2009 where the prevalence was slightly higher in urban areas compared to rural areas2. A study in Manicaland showed a higher prevalence of HIV among urban dwellers as compared to rural dwellers10.

A similar observation was observed in the Tanzania ANC study where the prevalence was higher in the city clinics, compared to rural clinics3. This difference in prevalence maybe alluded to life style differences between the two regions. Changing protective cultural practices may be a factor in behavioural changes between rural and urban residence. Since the difference is minor it may point towards urbanization of the rural communities.

Lower levels of educations were associated with higher prevalence of HIV in this survey. According to a studies conducted by Michelo et al and Fylkesnes et al higher educational level was associated with reduced risk for HIV infection7, 8. In essence women with higher levels of

32 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 education are more likely to delay in sexual debut, to understand HIV prevention strategies better and to make better informed sexual decisions than those with lower or no education.

Married women had a lower prevalence of HIV as compared to those who were not married. The ZDHS of 2010-11 had similar findings9. These findings may be due to reason that women who are not married are more likely to engage in unstable risky behaviours as compared to their married counterparts.

This is in keeping with results of similar ANC surveillance from rural Malawi where being in a stable first marriage appeared to be protective against HIV infection for young women4. These finding are different from the previous similar study done in 2009 which showed that prevalence among married women was not significantly different from those who were not married1 . This may spells the need for specific approaches targeting these women who are not married.

Women who are informally employed had the highest positivity rate. Lifestyle issues which include long separation with spouses may predispose them to HIV. This may make it difficult to target these women who may not be accessible as compared to employed women in one place.

There was no significant difference in the prevalence of HIV among women with thefirst pregnancy and those with the forth and subsequent pregnancies. This suggests need to strengthen prevention strategies in all women of childbearing age and to promote all women to know their HIV status before falling pregnant.

The study revealed those who were HIV positive were more likely to have had a history of miscarriage and still births than those who were HIV negative. This relationship between HIV and bad obstetric outcomes has been shown in other studies. In contrast an ANC study in Tanzania stillbirth was independent of HIV status3.

The positive correlation between STIs and HIV is further strengthened by findings in this study. Genital Ulcer Disease has been shown to predispose one to HIV hence the need for health workers to fully examine pregnant women at every visit to exclude genital ulcer disease and to strengthen STI prevention strategies.

In conclusion the prevalence of HIV has shown a decline in 2012 as compared to previous years. High prevalence of HIV was found among women who were older than 25 years, living in the southern provinces, living in urban areas, with lower levels of education, informally employed and with history of STIs.

5.1 Lessons Learnt

1. Training all health workers working in FCH and ANC on methodology of the survey enables continuity of the study in the face of staff rotation and absenteeism.

2. Lack of or inadequate cascading of clear policy on HIV testing and retesting guidelines in ANC might leave some facilities retesting women with a known HIV status at booking.

AIDS & TB PROGRAMME 2013 33 6.0 Recommendations

1. Intensify health education on behavioural change targeting older women for safer sexual practices – District Health Promotion Officers (DHPO).

2. There is need for strengthening of HIV prevention strategies among women of childbearing age with special emphasis on those; 35– 39 age group, women employed in informal sector, lower educational status and those with genital ulcer disease, i.e. high risk groups - DHPO.

3. There is need to training health workers on site on how the survey would be conducted. This allows all staff on site to be trained thus enabling continuity of survey in the absence of the key staff and also consistence of data – Data Quality Specialist, Surveillance Officer.

4. Further research to determine factors affecting the prevalence of HIV in older women – Public Health Officers.

34 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 References

1. National survey of HIV and syphilis prevalence among women attending antenatal clinics in Zimbabwe, 2009 2. Changalucha J,Kimaro D, Kumogola Y et al, 2010. Trends in HIV & syphilis prevalence and correlates of HIV infection: results from cross- sectional surveys among women attending ante-natal clinics in Tanzania. BioMed Central Public Health, 10-553 3. Crampin A, Jahn A, Kondowe M et al, 2008. Use of ANC surveillance to assess the effect of sexual behaviour on HIV prevalence in young women in Karonga district, Malawi. Journal of Acquired Immuno Deficiency Sydromes; 48:196-202 4. Harriss K, Marston M, Slaymaker E, 2008. Non-response bias in estimates of HIV prevalence due to the mobility of absentees in national population-bases surveys: a study of nine national survey. Sex Transmission Infection;84(suppl 1): i71-i77 5. Dept of Health. The 2011 National Antenatal Sentinel HIV and Syphilis Prevalence Survey in South Africa. 2012 6. Hargreaves JR, Bonell CP, Morison LA, Kim JC, Phetla G, Porter JDH, Watts C, Pronyk PM. Explaining continued high HIV prevalence in South Africa: socioeconomic factors, HIV incidence and sexual behaviour change among a rural cohort, 2001-2004. AIDS. 2007; 21(S7): S39-48 7. Michelo C, Sandoy IF, Fylkesnes K. Marked HIV prevalence declines in higher educated young people: evidence from population-based surveys (1995-2003) in Zambia. AIDS. 2006; 20: 1031-1038 8. Fylkesnes K, Musonda RM, Sichone M, Ndhlovu Z, Tembo F, Monze M. Declining HIV prevalence and risk behaviours in Zambia: evidence from surveillance and population based surveys. AIDS. 2001; 15: 907-916 9. Zimbabwe National Statistics Agency (ZIMSTAT) and ICF International. Zimbabwe Demographic and Health Survey 2010-11. 2012. Calverton, Maryland, ZIMSTAT and ICF International Inc. 10. Marsh KA, Nyamukapa CA, Donnelly CA, Garcia-Calleja, Mushati P, Garnett GP, Mpandaguta E, Graccly NC, Gregson S. Monitoring trends of HIV prevalence among young people, aged 15 to 24 years, in Manicaland, Zimbabwe. Journal of the International AIDS Society. 2011; 14: 27

AIDS & TB PROGRAMME 2013 35 7.0 APPENDICES

Appendix 1: 2012 Sentinel Survey Sites Province and Sentinel Site Classification Site Province District Site classification Rural/Urban Bulawayo Bulawayo Nkulumane Clinic Urban Chitungwiza Chitungwiza St Marys Clinic Urban Kuwadzana Clinic Urban Harare Harare Hatcliffe Urban Glenview Urban Buhera Murambinda Hospital Rural Chimanimani Mutambara Hospital Rural Makoni Rusape Hospital urban Manicaland Mutare Sakubva Clinic urban Mutasa Hauna Hospital rural Nyanga Nyanga Hospital rural Shamva Shamva Hospital/Wadzanayi Clinic rural Bindura Bindura Chipadze Clinic urban Centenary St Alberts Hospital rural Mashonaland Central Guruve Guruve Hospital/Bepura Clinic rural Mazowe Concession Hospital/Mvurwi clinic rural Mt Darwin Karanda Mission Hospital rural Rushinga Chimhanda District Hospital rural Chikomba Sadza District Hospital rural Goromonzi Makumbe Mission Hospital rural Hwedza Hwedza District Hospital rural Mashonaland East Marondera Marondera Provincial Hospital/Chihota Hospital urban Murehwa Murehwa District Hospital/ Nhowe Mission hospital rural Seke Epworth clinic urban Mutoko Mutoko District Hospital rural Hurungwe Karoi District Hospital urban Kadoma Kadoma District Hospital urban Mashonaland West Kariba Kariba Hospital/ Nyamhunga Hospital urban Makonde Chinhoyi Hospital urban Zvimba Banket District Hospital rural

36 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 Binga Binga District Hospital rural Bubi Inyathi Mission Hospital rural Matebeleland North Hwange Chinotimba Clinic urban Nkayi Nkayi District Hospital rural Umguza Nyamandlovu District Hospital rural Beitbridge Beitbridge District Hospital urban Bulilima/Mangwe Plumtree District Hospital urban Matebeleland South Gwanda Gwanda Provincial Hospital urban Insiza Filabusi District Hospital rural Bikita Silveira/Mashoko Hospital rural Chiredzi Chiredzi District Hospital urban Chivi Chivi Hospital / Gundu RHC rural Gutu Gutu Mission Hospital rural Masvingo Morgenster Hospital rural Masvingo Masvingo Provincial Hospital urban Mwenezi Neshuro Hospital rural Zaka Ndanga Hospital rural Chirumanzu Mvuma District Hospital rural Gokwe Gokwe District Hospital urban Gweru Gweru Provincial Hospital urban Midlands Kwekwe Kwekwe Hospital/Mbizvo B urban Mberengwa Musume Mission Hospital rural Zvishavane Zvishavane District Hospital urban Shurugwi Shurugwi Hospital urban

AIDS & TB PROGRAMME 2013 37 Appendix 2: 2012 ANC Surveillance Form

38 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 AIDS & TB PROGRAMME 2013 39 Appendix 3: Laboratory HIV Parallel Testing Algorithm

2 EIA Kits

Concordant Discordant (Agreement) (Disagreement)

Concordant Western Blot (Agreement)

Indeterminate

Polymerase Chain Reaction

REPORT

40 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012 Appendix 4: ANC Sentinel Surveillance Sites Since 2002

AIDS & TB PROGRAMME 2013 41 42 National Survey of HIV and Syphilis Prevalence among Women attending Antenatal Clinics in Zimbabwe 2012