title: Does nonlocal women's attendance at antenatal clinics distort HIV prevalence surveillance estimates in pregnant women in Zimbabwe?
abstract: The objective was to assess whether HIV prevalence measured among women attending antenatal clinics (ANCs) are representative of prevalence in the local area, or whether estimates may be biased by some women's choice to attend ANCs away from their residential location. We tested the hypothesis that HIV prevalence in towns and periurban areas is underestimated in ANC sentinel surveillance data in Zimbabwe.
  
  
  
  National unlinked anonymous HIV surveillance was conducted at 19 ANCs in Zimbabwe in 2000, 2001, 2002, 2004, 2006, 2009, and 2012. This data was used to compare HIV prevalence and nonlocal attendance levels at ANCs at city, town, periurban, and rural clinics in aggregate and also for individual ANCs.
  
  
  
  In 2000, HIV prevalence at town ANCs (36.6%, 95% CI 34.4-38.9%) slightly underestimated prevalence among urban women attending these clinics (40.7%, 95% CI 37.6-43.9%). However, there was no distortion in HIV prevalence at either the aggregate clinic location or at individual clinics in more recent surveillance rounds. HIV prevalence was consistently higher in towns and periurban areas than in rural areas. Nonlocal attendance was high at town (26-39%) and periurban (53-95%) ANCs but low at city clinics (<10%). However, rural women attending ANCs in towns and periurban areas had higher HIV prevalence than rural women attending rural clinics, and were younger, more likely to be single, and less likely to be housewives.
  
  
  
  In Zimbabwe, HIV prevalence among ANC attendees provides reliable estimates of HIV prevalence in pregnant women in the local area.
authors.affiliation: aDepartment of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, W2 1PG, UK bAIDS and TB Department, Zimbabwe Ministry of Health and Child Care cBiomedical Research and Training Institute, Harare, Zimbabwe.
authors.forename: Katherine C
authors.initials: KC
authors.lastname: Wilson
authors.forename: Mutsa
authors.initials: M
authors.lastname: Mhangara
authors.forename: Janet
authors.initials: J
authors.lastname: Dzangare
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Eaton
authors.forename: Timothy B
authors.initials: TB
authors.lastname: Hallett
authors.forename: Owen
authors.initials: O
authors.lastname: Mugurungi
authors.forename: Simon
authors.initials: S
authors.lastname: Gregson
mesh_terms: D000293:Adolescent; D000328:Adult; D062665:Epidemiological Monitoring; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000453:epidemiology*; D006801:Humans; D008875:Middle Aged; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis / Q000453:epidemiology*; D011295:Prenatal Care; D015995:Prevalence; D055815:Young Adult; D015030:Zimbabwe / Q000453:epidemiology