Studying dynamics of the HIV epidemic: population-based data compared with sentinel surveillance in Zambia

Objectives: To establish population-based HIV survey data in selected populations, and to assess the validity of extrapolation from HIV sentinel surveillance amongst antenatal clinic attenders (ANC) to the general population. Methods: in a population survey, adults aged greater than or equal to 15 years were selected by stratified random cluster sampling (n = 4195). The survey was carried out in catchment populations of clinics used for national HIV surveillance. The methodology allows detailed comparisons of HIV infection patterns to be made in two areas (urban and rural). Whereas the sentinel surveillance used serum-based HIV testing, the population survey used saliva (93.5% consented to provide a saliva sample). Results: Surveillance of ANC tended to underestimate the overall HIV prevalence of the general population, but differences were not statistically significant. In the urban area, the adjusted overall HIV prevalence rate of ANC (aged 15-39 years) was 24.4% [95% confidence interval (CI), 20.9-28.0] compared with 26.0% (95% CI, 23.4-28.6) in the general population. The respective rural estimates were 12.5% (95% CI, 9.3-15.6) versus 16.4% (95% CI, 12.1-20.6). Age-specific prevalence rates showed ANC to overestimate infection in teenagers (aged 15-19 years), whereas in the reverse direction of those aged greater than or equal to 30 years. Teenagers analysed by single year of age revealed both ANC and women in the general population with about the same steep increase in prevalence by age, but the former at consistently higher rates. Extrapolations might be biased substantially due to the higher pregnancy rates amongst uninfected individuals. Conclusions: ANC-based data might draw a rather distorted picture of current dynamics of the HIV epidemic. Even though representing an obvious oversimplification, extrapolations of overall prevalence rates may correlate with that of the general population. (C) 1998 Lippincott-Raven Publishers.