Livia Montana

Comparison of HIV prevalence estimates from antenatal care surveillance and population-based surveys in sub-Saharan Africa

Objective: To compare HIV seroprevalence estimates obtained from antenatal care (ANC) sentinel surveillance surveys in Ethiopia, Kenya, Malawi, Tanzania and Uganda with those from population-based demographic and health surveys (DHS) and AIDS indicator surveys (AIS). Methods: Geographical information system methods were used to map ANC surveillance sites and DHS/AIS survey clusters within a 15-km radius of the ANC sites. National DHS/AIS HIV prevalence estimates for women and men were compared with national prevalence estimates from ANC surveillance. DHS/AIS HIV prevalence estimates for women and men residing within 15 km of ANC sites were compared with those from ANC surveillance. For women, these comparisons were also stratified by current pregnancy status, experience of recent childbirth and receiving ANC for the last birth. Results: In four of the five countries, national DHS/AIS estimates of HIV prevalence were lower than the ANC surveillance estimates. Comparing women and men in the catchment areas of the ANC sites, the DHS/AIS estimates were similar to ANC surveillance estimates. DHS/AIS estimates for men residing in the catchment areas of ANC sites were much lower than ANC surveillance estimates for women in all cases. ANC estimates were higher for younger women than DHS/AIS estimates for women in ANC catchment areas, but lower at older ages. In all cases, urban prevalence was higher than rural prevalence but there were no consistent patterns by education. Conclusions: ANC surveillance surveys tend to overestimate HIV prevalence compared to prevalence among women in the general population in DHS/AIS surveys. However, the ANC and DHS/AIS estimates are similar when restricted to women and men, or to women only, residing in catchment areas of ANC sites. Patterns by age and urban/rural residence suggest possible bias in the ANC estimates.

Family planning services quality as a determinant of use of IUD in Egypt

BackgroundBoth availability and quality of family planning services are believed to have contributed to increasing contraceptive use and declining fertility rates in developing countries. Yet, there is limited empirical evidence to show the relationship between the quality of family planning services and the population based prevalence of contraceptive methods. This study examined the relationship between quality of family planning services and use of intrauterine devices (IUD) in Egypt.MethodsThe analysis used data from the 2003 Egypt Interim Demographic and Health Survey (EIDHS) that included 8,445 married women aged 15–49, and the 2002 Egypt Service Provision Assessment (ESPA) survey that included 602 facilities offering family planning services. The EIDHS collected latitude and longitude coordinates of all sampled clusters, and the ESPA collected these coordinates for all sampled facilities. Using Geographic Information System (GIS) methods, individual women were linked to a facility located within 10 km of their community. A facility-level index was constructed to reflect the quality of family planning services. Four dimensions of quality of care were examined: counseling, examination room, supply of contraceptive methods, and management. Effects of quality of family planning services on the use of IUD and other contraceptive methods were estimated using multinomial logistic regression. Results are presented as relative risk ratios (RRR) with significance levels (p-values).ResultsIUD use among women who obtained their method from public sources was significantly positively associated with quality of family planning services (RRR = 1.36, p < 0.01), independent of distance to the facility, facility type, age, number of living children, education level, household wealth status, and residence. Quality of services related to counseling and examination room had strong positive effects on use of IUD (RRR = 1.61 for counseling and RRR = 1.46 for examination room). Obtaining IUD from a private source or using other contraceptive methods was not associated with quality of services.ConclusionThis study is one among the few that used geographic information to link data from a population-based survey with an independently sampled health facility survey. The findings demonstrate that service quality is an important determinant of use of clinical contraceptive methods in Egypt. Improving quality of family planning services may help further increase use of clinical contraceptive methods and reduce fertility.

Mapping populations at risk: improving spatial demographic data for infectious disease modeling and metric derivation.

The use of Global Positioning Systems (GPS) and Geographical Information Systems (GIS) in disease surveys and reporting is becoming increasingly routine, enabling a better understanding of spatial epidemiology and the improvement of surveillance and control strategies. In turn, the greater availability of spatially referenced epidemiological data is driving the rapid expansion of disease mapping and spatial modeling methods, which are becoming increasingly detailed and sophisticated, with rigorous handling of uncertainties. This expansion has, however, not been matched by advancements in the development of spatial datasets of human population distribution that accompany disease maps or spatial models.Where risks are heterogeneous across population groups or space or dependent on transmission between individuals, spatial data on human population distributions and demographic structures are required to estimate infectious disease risks, burdens, and dynamics. The disease impact in terms of morbidity, mortality, and speed of spread varies substantially with demographic profiles, so that identifying the most exposed or affected populations becomes a key aspect of planning and targeting interventions. Subnational breakdowns of population counts by age and sex are routinely collected during national censuses and maintained in finer detail within microcensus data. Moreover, demographic and health surveys continue to collect representative and contemporary samples from clusters of communities in low-income countries where census data may be less detailed and not collected regularly. Together, these freely available datasets form a rich resource for quantifying and understanding the spatial variations in the sizes and distributions of those most at risk of disease in low income regions, yet at present, they remain unconnected data scattered across national statistical offices and websites.In this paper we discuss the deficiencies of existing spatial population datasets and their limitations on epidemiological analyses. We review sources of detailed, contemporary, freely available and relevant spatial demographic data focusing on low income regions where such data are often sparse and highlight the value of incorporating these through a set of examples of their application in disease studies. Moreover, the importance of acknowledging, measuring, and accounting for uncertainty in spatial demographic datasets is outlined. Finally, a strategy for building an open-access database of spatial demographic data that is tailored to epidemiological applications is put forward.

Spatial modeling of geographic inequalities in infant and child mortality across Nepal

A survival regression model that allows for spatially correlated random effects is used to predict the hazard of dying among 12,714 children born between 1996 and 2006 in Nepal. The maps of fitted hazard rates show that even after accounting for individual and community-level covariates, a residual spatial pattern in infant mortality remains, with higher mortality concentrated in parts of Nepals Far-Western and Mid-Western development regions. Results suggest a need to consider health policies and programs that reach children in spatially concentrated high-mortality areas.

Comparison of HIV prevalence estimates from sentinel surveillance and a national population-based survey in Uganda, 2004-2005.

Objective:HIV programs in generalized epidemics have traditionally relied on antenatal clinic (ANC) sentinel surveillance data to guide prevention and to model epidemic trends. ANC data, however, come from a subset of the population, and their representativeness of the population has been debated. Methods:Data from a national population-based Uganda HIV/AIDS Sero-Behavioral Survey (UHSBS) were compared with those from ANC sentinel surveillance. Using geographic information system, UHSBS clusters within a 30 km radius of the ANC sites were mapped. Estimates of HIV prevalence from ANC surveillance were compared with those from UHSBS. Results:The ANC-based HIV prevalence, 6.0% [confidence interval (CI) 5.5% to 6.5%], was similar to that from UHSBS, 5.9% (CI 5.4% to 6.4%). The ANC-based estimate correlated with that of UHSBS catchment area women who were pregnant and those who had given birth in the 2 years preceding the survey. ANC data overestimated prevalence in the 15-year to 19-year age group, were similar to UHSBS for ages 20-29 years, and underestimated prevalence in older respondents. ANC data underestimated HIV prevalence among women (6.0% vs. 7.4%; CI 6.6% to 8.2%) and urban women (7.6% vs. 12.7%) but was similar for rural women (5.3% vs. 4.9%). Conclusions:ANC-based surveillance remains an important tool for monitoring HIV/AIDS programs. ANC and UHSBS data were similar overall and for 15-year to 29-year olds, women who were pregnant, and women who had a birth in the 2 years before the survey. ANC estimates were lower in those ≥30 years and in urban areas. Periodic serosurveys to adjust ANC-based estimates are needed.

Spatial modeling of HIV prevalence in Kenya.

A clear understanding of geographic distribution of HIV-infected people and maintaining up-to-date lists and locations of facilities providing HIV-related services are essential for monitoring the epidemic and for providing treatment care and support services to the infected and their families. In this study we model and map human immunodeficiency virus (HIV) prevalence in Kenya in relation to its spatial and behavioral determinants using data from the 2003 Kenya Demographic and Health Survey (DHS). The 2003 Kenya DHS is one of the first population-based national surveys to link individual HIV test results for both males (age 15-54) and females (age 15-49) with the full set of behavioral social and demographic indicators included in the survey. The survey also collected spatial coordinates of the communities where survey respondents lived. These coordinates have been used to estimate spatial indicators such as distance to roads distance to Lake Victoria and population density. Using these spatial social demographic and behavioral indicators we developed a model to predict HIV prevalence. We apply this model to map HIV concentration areas at sub-provincial level and we assess the existing HIV service coverage in relation to the spatial distribution of HIV prevalence. The study finds large subregional variations in the prevalence of HIV in Kenya. Areas of high concentration of HIV-infected people have a disproportionately low density of HIV-related services. (authors)The dramatic changes in the earths landscape have prompted increased interest in the links between population land use and land cover. Previous research emphasized the notion of population pressure (population pressure increases demands on natural resources causing changes in land use) overlooking the potentially important effects of changes in land use on humans. Using multiple data sets from the Chitwan Valley Family Study in Nepal we test competing hypotheses about the impact of land use on first birth timing. We argue that while agricultural land should encourage early childbearing land area devoted to public infrastructure should discourage it. The results show that individuals from neighborhoods with larger proportions of land under agriculture experienced first birth at rates higher than those from neighborhoods with smaller proportions. On the other hand individuals from neighborhoods with larger proportions of land under public infrastructure experienced first birth at rates lower than those from neighborhoods with smaller proportions. (authors)

Demand generation activities and modern contraceptive use in urban areas of four countries: a longitudinal evaluation

Demand generation activities that were significantly associated with increased use of modern contraception in India (Uttar Pradesh), Kenya, Nigeria, and Senegal included: (1) community outreach activities, such as home visits and group discussions about family planning; (2) local radio programs; and (3) branded slogans and print materials circulated widely across the city. Television programming was also significant in India and Nigeria. Exposure to more activities may increase womens likelihood of using contraception. Demand generation activities that were significantly associated with increased use of modern contraception in India (Uttar Pradesh), Kenya, Nigeria, and Senegal included: (1) community outreach activities, such as home visits and group discussions about family planning; (2) local radio programs; and (3) branded slogans and print materials circulated widely across the city. Television programming was also significant in India and Nigeria. Exposure to more activities may increase womens likelihood of using contraception. ABSTRACT Family planning is crucial for preventing unintended pregnancies and for improving maternal and child health and well-being. In urban areas where there are large inequities in family planning use, particularly among the urban poor, programs are needed to increase access to and use of contraception among those most in need. This paper presents the midterm evaluation findings of the Urban Reproductive Health Initiative (Urban RH Initiative) programs, funded by the Bill & Melinda Gates Foundation, that are being implemented in 4 countries: India (Uttar Pradesh), Kenya, Nigeria, and Senegal. Between 2010 and 2013, the Measurement, Learning & Evaluation (MLE) project collected baseline and 2-year longitudinal follow-up data from women in target study cities to examine the role of demand generation activities undertaken as part of the Urban RH Initiative programs. Evaluation results demonstrate that, in each country where it was measured, outreach by community health or family planning workers as well as local radio programs were significantly associated with increased use of modern contraceptive methods. In addition, in India and Nigeria, television programs had a significant effect on modern contraceptive use, and in Kenya and Nigeria, the program slogans and materials that were blanketed across the cities (eg, leaflets/brochures distributed at health clinics and the program logo placed on all forms of materials, from market umbrellas to health facility signs and television programs) were also significantly associated with modern method use. Our results show that targeted, multilevel demand generation activities can make an important contribution to increasing modern contraceptive use in urban areas and could impact Millennium Development Goals for improved maternal and child health and access to reproductive health for all.

HIV prevalence in voluntary counseling and testing centers compared with national HIV serosurvey data in Uganda.

Objectives:To compare HIV prevalence from routine voluntary counseling and testing (VCT) data with a population-based serosurvey in Uganda and to assess the utility of VCT data as a supplemental data source for HIV surveillance. Methods:We analyzed HIV testing data from 75,640 unique VCT clients aged 15-59 years collected from August 2004 to January 2005 at 160 VCT sites. We excluded clients who reported illness as the reason for testing. During the same time period, 18,525 adults aged 15-59 years were tested for HIV in the Uganda HIV/AIDS Sero-Behavioral Survey (UHSBS). We compared UHSBS HIV prevalence with age-standardized VCT prevalence, overall and among stand-alone and facility-based VCT sites. Results:HIV prevalence in urban areas was similar overall [UHSBS: 9.7%, 95% confidence interval (CI) 8.6 to 10.7; VCT: 10.1%, CI 9.8 to 10.5] and for both men (UHSBS: 6.3%, CI 4.9 to 7.6; VCT: 7.1, CI 6.6 to 7.5) and women (UHSBS: 12.2%, CI 10.6 to 13.7; VCT: 12.9%, CI 12.3 to 13.4). Urban prevalence from UHSBS (9.7%, CI 8.6 to 10.7), VCT stand-alone sites (10.3% CI 9.8 to 10.8), and VCT sites in health facility settings (10.0%, CI 9.5 to 10.4) was similar. However, in rural areas where VCT coverage is much lower than in urban areas (10% versus 31%), HIV prevalence was much higher among rural VCT clients (8.2%, CI 7.9% to 8.4%) than among rural UHSBS participants (5.2%, CI 4.8% to 5.5%). This resulted in overall higher HIV prevalence among all VCT clients (8.8%, CI 8.7 to 9.1) compared with all survey participants (5.9%, CI 5.6 to 6.2). Conclusions:After excluding clients who give illness as a reason for testing, VCT data may be used without further adjustment to monitor the HIV epidemic among urban Ugandans using either VCT data from stand-alone or health facility-based sites. However, monitoring rural and overall HIV prevalence using VCT data may not be appropriate until the uptake of VCT in rural areas is significantly improved or an adjustment factor is applied.

Impact of Migration on Fertility and Abortion: Evidence from the Household and Welfare Study of Accra

Over the last few decades, total fertility rates, child morbidity, and child mortality rates have declined in most parts of sub-Saharan Africa. Among the most striking trends observed are the rapid rate of urbanization and the often remarkably large gaps in fertility between rural and urban areas. Although a large literature has highlighted the importance of migration and urbanization within countries’ demographic transitions, relatively little is known regarding the impact of migration on migrants’ reproductive health outcomes in general and abortion in particular. In this article, we use detailed pregnancy and migration histories collected as part of the Household and Welfare Study of Accra (HAWS) to examine the association between migration and pregnancy outcomes among women residing in the urban slums of Accra, Ghana. We find that the completed fertility patterns of lifetime Accra residents are remarkably similar to those of residents who migrated. Our results suggest that recent migrants have an increased risk of pregnancy but not an increased risk of live birth in the first years post-move compared with those who had never moved. This gap seems to be largely explained by an increased risk of miscarriage or abortion among recent migrants. Increasing access to contraceptives for recent migrants has the potential to reduce the incidence of unwanted pregnancies, lower the prevalence of unsafe abortion, and contribute to improved maternal health outcomes.

The Art Advantage: Health Care Utilization for Diabetes and Hypertension in Rural South Africa

Background: The prevalence of diabetes and hypertension has increased in HIV-positive populations, but there is limited understanding of the role that antiretroviral therapy (ART) programs play in the delivery of services for these conditions. The aim of this study is to assess the relationship between ART use and utilization of health care services for diabetes and hypertension. Methods: Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa is a cohort of 5059 adults. The baseline study collects biomarker-based data on HIV, ART, diabetes, and hypertension and self-reported data on health care utilization. We calculated differences in care utilization for diabetes and hypertension by HIV and ART status and used multivariable logistic regressions to estimate the relationship between ART use and utilization of services for these conditions, controlling for age, sex, body mass index, education, and household wealth quintile. Results: Mean age, body mass index, hypertension, and diabetes prevalence were lower in the HIV-positive population (all P < 0.001). Multivariable logistic regression showed that ART use was significantly associated with greater odds of blood pressure measurement [adjusted odds ratio (aOR) 1.27, 95% confidence interval (CI): 1.04 to 1.55] and blood sugar measurement (aOR 1.26, 95% CI: 1.05 to 1.51), counseling regarding exercise (aOR 1.57, 95% CI: 1.11 to 2.22), awareness of hypertension diagnosis (aOR 1.52, 95% CI: 1.12 to 2.05), and treatment for hypertension (aOR 1.63, 95% CI: 1.21 to 2.19). Conclusions: HIV-positive patients who use ART are more likely to have received health care services for diabetes and hypertension. This apparent ART advantage suggests that ART programs may be a vehicle for strengthening health systems for chronic care.