Triangulation of Routine Antenatal HIV Prevalence Data and Adjusted HIV Estimates in Mozambique

Author:

Stevens Oliver1ORCID,Boothe Makini2,Tiberi Orrin3,Mahy Mary4,Walker Patrick1,Glaubius Robert5,McOwen Jordan6,Couto Aleny3,Cunha Morais3,Imai-Eaton Jeffrey W.17

Affiliation:

1. MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom;

2. Data for Impact, The Joint United Nations Program on HIV/AIDS (UNAIDS), Maputo, Mozambique;

3. National STI and HIV/AIDS Control Program, Ministry of Health Maputo, Maputo, Mozambique;

4. Data for Impact, The Joint United Nations Program on HIV/AIDS (UNAIDS), Geneva, Switzerland;

5. Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT;

6. US Centers for Disease Control and Prevention, Maputo, Mozambique; and

7. Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA.

Abstract

Background: Routine health system data are central to monitoring HIV trends. In Mozambique, the reported number of women receiving antenatal care (ANC) and antiretroviral therapy for prevention of mother-to-child transmission (PMTCT) has exceeded the Spectrum-estimated number of pregnant women since 2017. In some provinces, reported HIV prevalence in pregnant women has declined faster than epidemiologically plausible. We hypothesized that these issues are linked and caused by programmatic overenumeration of HIV-negative pregnant women at ANC. Methods: We triangulated program-reported ANC client numbers with survey-based fertility estimates and facility birth data adjusted for the proportion of facility births. We used survey-reported ANC attendance to produce adjusted time series of HIV prevalence in pregnant women, adjusted for hypothesized program double counting. We calibrated the Spectrum HIV estimation models to adjusted HIV prevalence data to produce adjusted adult and pediatric HIV estimates. Results: ANC client numbers were not consistent with facility birth data or modeled population estimates indicating ANC data quality issues in all provinces. Adjusted provincial ANC HIV prevalence in 2021 was median 45% [interquartile range 35%–52% or 2.3 percentage points (interquartile range 2.5–3.5)] higher than reported HIV prevalence. In 2021, calibrating to adjusted antenatal HIV prevalence lowered PMTCT coverage to less than 100% in most provinces and increased the modeled number of new child infections by 35%. The adjusted results better reconciled adult and pediatric antiretroviral treatment coverage and antenatal HIV prevalence with regional fertility estimates. Conclusions: Adjusting HIV prevalence in pregnant women using nationally representative household survey data on ANC attendance produced estimates more consistent with surveillance data. The number of children living with HIV in Mozambique has been substantially underestimated because of biased routine ANC prevalence. Renewed focus on HIV surveillance among pregnant women would improve PMTCT coverage and pediatric HIV estimates.

Publisher

Ovid Technologies (Wolters Kluwer Health)

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