Data on the prevalence of HIV and syphilis was collected from 24 ante-natal care clinic (ANC) sentinel sites in all 10 states of South Sudan during the three months September to December 2009. The overall sample size was 6175 pregnant women, however only 5913 samples were tested for HIV of which 176 (3%) were positive.
Interestingly, the age groups 15-24 years accounted for almost half (49.5%) of the overall sample size of this ANC 2009 Survey distributed between the age group 15-19 years with 18.6% of the overall sample and the age group 20-24 years accounting for 30.9% of the total sample size.
The prevalence of HIV was 2.3% (n=25) in the 15-19 year age group and 3.3% (n=59) in the 20-24 year age group. The prevalence of syphilis was 7.6% (n=74) in the 15-19 year age group and 9.6% (n=183) in the 20-24 year age group.
The HIV prevalence among the young women aged 15-24 years was 2.9% compared to the overall HIV prevalence among all age groups of 3%. Similarly the syphilis prevalence among 15-24 year old women was 28.4% compared to the overall survey syphilis prevalence of 9.9%.
In conclusion, the post conflict ANC surveillance showed an HIV prevalence of 3% and the experience has proved and disregarded a wide range of assumptions with regards to HIV distribution in the country. Despite all challenges, the routine ANC surveillance system, in the context of South Sudan, is very promising in provision of timely relevant information and can be used to monitor the trend over time.
Although the prevalence of HIV was estimated from 2007 data at only 3.1%1, the Ministry of Health decided to set up a surveillance system to periodically monitor the prevalence and trends of HIV/AIDS.
Data from South Sudan and other studies show that periodic estimates for HIV prevalence for pregnant women represent a suitable monitor to HIV trends overtime. However it often overestimates the general population prevalence. For this reason other studies should be conducted, triangulated and corroborated with it. The MOH has implemented the Second Sudan Household Health Survey (SHHS II); it is expected that the results will produce representative population based estimates for HIV in South Sudan with which data from ANC surveillance surveys will be corroborated.
With the signing of the Comprehensive Peace Agreement (CPA) in January 2005, 22 years of civil war in South Sudan officially ended. Since then the focus of health planning has shifted from relief to development. Even so the war, which has greatly affected South Sudan, left all segments of the population still facing formidable social problems including health related challenges such as HIV/AIDS.
The return of refugees from surrounding countries with higher HIV prevalence has increased the risk of HIV infection in South Sudan. High risk behaviours resulting from poverty and certain cultural practices of different communities including returnees and people from neighbouring countries, and high incidences of STIs aggravated by poor access to and/or low coverage of health services further contribute to the spread of the HIV. However, knowledge of prevention methods and where to get help is a critical first step towards addressing some of these key drivers.
Other effects of peace are increased trade and commercial activities across borders (especially increased traffic of trucks and other vehicles along the trans-African Highway), reconstruction and rehabilitation activities, relative peace and affluence coupled with cultural religious and tribal traditions all of which may contribute to the risk of HIV in the post war era.
1.6% tested positive in Tambura and 2% in Ezo.
Villages near the road had a higher prevalence (3.2%) compared with those further from it (1.1%). Yambio had the highest rate (7.2%), which ranged from 3% in peri-urban areas to 8.7 percent in Yambio town.
The Sudan Household Survey Report 2006 (3) indicated that the level of knowledge of how to prevent HIV transmission was staggeringly low among women aged 15-49 years in most States (i.e. 36% in Lakes, 8.9% in Jonglei and 9.7% in Warrap). However it was 64% in Central Equatoria.
HIV rates vary widely between different States.
Rates may be higher where there has been greater population mobility and contact with other countries.
Rates appear to be higher in towns than in rural areas.
Rates in women are markedly higher than those in men.
Compared to Rumbek, more participants in Yei had been displaced internally or as refugees but a history of displacement were not significantly associated with HIV status.
The overall objective of establishing ANC sentinel surveillance sites is to provide data for estimating HIV prevalence and so monitor the epidemic in different regions and overtime.
Provide estimates of the burden and distribution of HIV infection in the general population at least in areas where the surveillance is conducted, by extrapolating data from prevalence in pregnant women attending ANC clinics.
Support dissemination of sentinel surveillance information in order to advocate and plan more effective HIV prevention and control services.
Establish a review process for ANC surveillance data, triangulated with data from other sources that will achieve informed consensus about population prevalence.
Sentinel surveillance was conducted among pregnant women aged 15-49 attending ANC. Pregnant women were selected as a proxy for the general population and because they represent the sexually active population. Women recruitment in the survey depended on whether they were on their first ANC visit to the sentinel clinic for that pregnancy or the visit when blood testing was first done. They also had to be residents of the site’s catchment area and to have attended the clinic during the sentinel surveillance period.
Urban - 300 pregnant women/site in 14 sites.
Rural - 250 pregnant women/site in 10 sites.
It was impractical to have a site in all 79 counties. Potential sites were assessed based on: numbers attending in the previous three months, level of laboratory services and personnel, and ability to store and ship specimens. This resulted in the selection of 24 sites with at least one from each State - see Table 1.
refer clients to the laboratory for routine haemoglobin and syphilis tests.
transport them to the JTH laboratory.
Training emphasized ways to minimize risks in handling biological specimens and gave an overview of HIV/AIDS. Three laboratory technologists from JTH were trained for two weeks on DBS ELISA testing in Nairobi.
3-5ml of blood was taken from the arm by venepuncture using the vacutainer system, put into a purple EDTA anticoagulated tubes and mixed well. Prior to testing any identifiers on the samples were removed and replaced with pre-printed 8-digit surveillance code label. Demographic information was transferred from the laboratory request form to the surveillance form. Each day, a drop from the left over blood was placed on the three circles of the S & S 903 filter paper. The DBS filter papers were dried overnight, packaged according to the Standard Operating Procedures and shipped to JTH laboratory every two to three weeks.
take the data collection forms and DBS samples to the JTH laboratory.
The JTH coordinated all the laboratory logistics including securing and storage of supplies for the field laboratory activities, receiving, archiving and processing samples, testing, coordinating with the CDC quality assurance laboratory and dispatch of results to MOH Directorate of HIV/AIDS/STIs.
At JTH, laboratory staff checked the integrity of the samples and that they were accompanied by the surveillance forms. 95.77% of the DBS submitted were of adequate quality for testing. These were logged on a spread sheet and stored at -20ºC.
All the eligible samples were initially tested for HIV using Vironostika uniform II plus O ELISA kit. Quality control was done at JTH following the standard operating procedures and using known DBS controls. Results of HIV were crosschecked to ensure accuracy. All the reactive samples and 5% of randomly selected non-reactive samples were retested for quality assurance at the CDC laboratory in Kenya using the Murex HIV antibody kit. Specimens with discrepant results between the two laboratories were retested again at the CDC laboratory using the same algorithm. Specimens that were still discrepant after retesting were resolved by PCR at CDC QA lab.
Demographic data were entered in a spread sheet in the HIV Directorate and sample information was entered in JTH laboratory. All sheets were locked and computers were pass-worded protected. Data were analyzed using SPSS version 17.0. The standard formula for statistical methods (5) (6) was used to calculate the confidence interval for the observed prevalence for each site based on the sample size collected. It provides information on the relationship between surveillance sample sizes and statistical confidence intervals, for different HIV prevalence rates.
A total of 6175 pregnant women were recruited (see Table 2). Table 3 shows that 50% of respondents were aged 15- 24 years. 93.5% were married (60% in monogamous marriages and 33% in polygamous ones).
The HIV test was carried out on samples of only 5913 of the 6175 women recruited. 176 (3%) of these 5913 women were positive for HIV. However prevalence varied widely among the sites and States ranging from 7.2% in Western Equatoria to 0% in Northern Bahr El Ghazal. – see Figures 1 and 2.
The distribution of HIV results by ANC site is shown in Table 4. Meanwhile, Table 5 shows the sample size and the HIV prevalence in the different states. Table 6 show the age distribution of the HIV-positive women.
Table 7. Distribution of syphilis results among HIV positive clients by site.
3.3% (n=59) in the 20-24 year age group.
9.6% (n=183) in the 20-24 year age group.
The overall objective of establishing ANC sentinel surveillance system in South Sudan is to provide data for monitoring the epidemic in different regions of South Sudan over-time in addition to estimating HIV prevalence. Although South Sudan has conducted only two rounds of ANC Surveillance, an attempt has been made to compare and track the prevalence in the different sites taking into account the increasing number of sites in the subsequent round see Table 9.
Although the ANC surveillance provides results by sites, an aggregate by South Sudanese states was produced to inform and educate the different levels of local government in each state i.e. State, Counties and Payams. HIV results ranged from as high as 7.2% in Western Equatoria state to as low as no sero-positivity (0%) in Northern Bahr El Ghazal state. The sample sizes varied from one state to another according to the number of sites contributed to the survey.
Interestingly, the age group 15-24 years accounted for almost half (49.5%) of the overall sample size of this ANC 2009 survey. Within the overall sample 18.6% were in the 15-19 year age group and 30.9% in the 20-24 year age group.
The HIV prevalence among the young women aged 15-24 years was 2.9% compared to the overall HIV prevalence among all age groups of 3% - see Figure 3. Similarly the syphilis prevalence among 15-24 year old women was 28.4% compared to the overall survey syphilis prevalence of 9.9% - see Table 8.
In conclusion, the post conflict ANC surveillance experience in South Sudan has proved and disregarded a wide range of assumptions with regards to HIV distribution in the country. Despite all challenges, the routine ANC surveillance system, in the context of South Sudan, is very promising in providing timely relevant information and can be used to monitor the trend over time.
Strengthen Social Mobilization Campaigns in the communities to enhance uptake of ANC services especially during the sentinel surveillance periods.
Increase the reach of HIV prevention, treatment and care in areas where the prevalence is merely high.
Identify additional sites in the same geographical area (e.g. Yambio, Akobo etc…) where the desired sample size was not attained. And combine multiple sites to form one composite site for that geographical location. (Use all available date including VCT, PMTCT, ART to identify potential locations).
Increase surveillance sites to at least in one in each county in states where HIV prevalence has been highly detected like Western Equatoria State.
Involve NGO in planning and identification of new sites and implementation of the surveys. (One NGO running an ANC site was not initially cooperative in allowing the survey process in that specific location. This resulted in a delayed start and low sample attainment).
Ensure that all logistic are in place in subsequent rounds to avoid another major rejection of samples (262 samples were rejected due to improper packaging (26), missing (25), contamination (4) and improper sample preparation (3). Due to rain Yambio and Maridi were inaccessible in the first month of data collection so 199 samples had exceeded the allowed storage time at room temperature when they reached JTH). This will save a lot of energy, time, and resource and eventually increase precision of the results.
Compare the upcoming SHHS II results to the ANC surveillance results to obtain a more accurate national estimate.
More behavioural and biological research is recommended in areas where the prevalence appeared to be low to further complement the current results.
ANC surveillance only accounts for women, and specifically women who attend the ANC, so there is a bias towards those who have access to the service.
Some States have only one ANC site while others go up to 4 sites making a difference in the sample size per state; as a result further weighting can be calculated to precise the prevalence by state.
Although the study provided valuable biological indicators for HIV and syphilis, no behavioural information was generated and linked to the biological aspect in this study.
Based on calculations done by the South Sudan AIDS Commission in 2007. Derived from the 2007 ANC Surveillance conducted by US-CDC.
Kaiser R, Kedamo T, Lane J, Kessia G, Downing R, Handzel T, Marum E, Salama P, Mermin J, Brady W, Spiegel P. “HIV, syphilis, herpes simplex virus 2, and behavioural surveillance among conflict-affected populations in Yei and Rumbek, southern Sudan.” AIDS 2006 Apr 4;20(6):942-44.
Snedecor G. W. & Cochran W. G. Statistical methods 6th ed. Iowa: Iowa State University Press, USA, 1967.
Dr. Lul P. Riek Director General for HIV Directorate Ministry of Health for the strong leadership, guidance & commitment expressed. Mr. Gregory Wani, the laboratory focal person and his team in Juba Teaching Hospital. Ms. Elizabeth Novello Nylock, HIV/AIDS/STIS Surveillance officer for the extensive coordination and logistical support she provided during the trainings and the data collection. The ten States’ Ministries of Health and states HIV/AIDS/STIs Directors/Coordinators for providing direct support and supervision of data collection from the facilities. I would also like to acknowledge the quality of samples collected during the ANC surveillance survey 2009, and this goes to the laboratory staff in the 24 health facilities undertaken this survey round. For data entry Mr Eban Taban, Senior HIV/AIDS/ STIs Monitoring and Evaluation Specialist, Ms Idak Makur VCT Counselor and Ms. Golda Caeser, Surveillance officer. Dr. Emmanuel Lino, Deputy Director for HIV Clinical Management & Care, Mr. James Ayeiny, HIV/AIDS/STIS Surveillance officer. NGOs running the health facilities during this ANC surveillance survey 2009. Great Acknowledgment goes to Dr. Fazle Khan and Mr. Edwin Ochieng of CDC for the specialized technical, logistical support and quality assurance of the survey. Dr. Oivia Lomoro, the Undersecretary of the Ministry of Health for the political commitment and overall support. We register our acknowledgement to the Global Fund for making this survey a reality in the history of South Sudan.