Imperial College London

MissKanikaDharmayat

Faculty of MedicineSchool of Public Health

Research Postgraduate
 
 
 
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+44 (0)20 7594 9988kanika.dharmayat13

 
 
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Reynolds BuildingCharing Cross Campus

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Summary

 

Publications

Publication Type
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13 results found

Vallejo-Vaz AJ, Stevens CAT, Lyons ARM, Dharmayat KI, Freiberger T, Hovingh GK, Mata P, Raal FJ, Santos RD, Soran H, Watts GF, Abifadel M, Aguilar-Salinas CA, Alhabib KF, Alkhnifsawi M, Almahmeed W, Alnouri F, Alonso R, Al-Rasadi K, Al-Sarraf A, Al-Sayed N, Araujo F, Ashavaid TF, Banach M, Béliard S, Benn M, Binder CJ, Bogsrud MP, Bourbon M, Chlebus K, Corral P, Davletov K, Descamps OS, Durst R, Ezhov M, Gaita D, Genest J, Groselj U, Harada-Shiba M, Holven KB, Kayikcioglu M, Khovidhunkit W, Lalic K, Latkovskis G, Laufs U, Liberopoulos E, Lima-Martinez MM, Lin J, Maher V, Marais AD, März W, Mirrakhimov E, Miserez AR, Mitchenko O, Nawawi H, Nordestgaard BG, Panayiotou AG, Paragh G, Petrulioniene Z, Pojskic B, Postadzhiyan A, Raslova K, Reda A, Reiner Ž, Sadiq F, Sadoh WE, Schunkert H, Shek AB, Stoll M, Stroes E, Su T-C, Subramaniam T, Susekov AV, Tilney M, Tomlinson B, Truong TH, Tselepis AD, Tybjæg-Hansen A, Vázquez Cárdenas A, Viigimaa M, Wang L, Yamashita S, Tokgozoglu L, Catapano AL, Ray KK, Kastelein JJP, Bruckert E, Vohnout B, Schreier L, Pang J, Ebenbichler C, Dieplinger H, Innerhofer R, Winhofer-Stöckl Y, Greber-Platzer S, Krychtiuk K, Speidl W, Toplak H, Widhalm K, Stulnig T, Huber K, Höllerl F, Rega-Kaun G, Kleemann L, Mäser M, Scholl-Bürgi S, Säly C, Mayer FJ, Sablon G, Tarantino E, Nzeyimana C, Pojskic L, Sisic I, Nalbantic AD, Jannes CE, Pereira AC, Krieger JE, Petrov I, Goudev A, Nikolov F, Tisheva S, Yotov Y, Tzvetkov I, Baass A, Bergeron J, Bernard S, Brisson D, Brunham LR, Cermakova L, Couture P, Francis GA, Gaudet D, Hegele RA, Khoury E, Mancini GBJ, McCrindle BW, Paquette M, Ruel I, Cuevas A, Asenjo S, Wang X, Meng K, Song X, Yong Q, Jiang T, Liu Z, Duan Y, Hong J, Ye P, Chen Y, Qi J, Liu Z, Li Y, Zhang C, Peng J, Yang Y, Yu W, Wang Q, Yuan H, Cheng S, Jiang L, Chong M, Jiao J, Wu Y, Wen W, Xu L, Zhang R, Qu Y, He J, Fan X, Wang Z, Chow E, Pećin I, Perica D, Symeonides P, Vrablik M, Ceska R, Soska V, Tichy L, Adamkova V, Franekova J, Cifkova R, Kramet al., 2021, Global perspective of familial hypercholesterolaemia: a cross-sectional study from the EAS Familial Hypercholesterolaemia Studies Collaboration (FHSC), The Lancet, ISSN: 0140-6736

BackgroundThe European Atherosclerosis Society Familial Hypercholesterolaemia Studies Collaboration (FHSC) global registry provides a platform for the global surveillance of familial hypercholesterolaemia through harmonisation and pooling of multinational data. In this study, we aimed to characterise the adult population with heterozygous familial hypercholesterolaemia and described how it is detected and managed globally.MethodsUsing FHSC global registry data, we did a cross-sectional assessment of adults (aged 18 years or older) with a clinical or genetic diagnosis of probable or definite heterozygous familial hypercholesterolaemia at the time they were entered into the registries. Data were assessed overall and by WHO regions, sex, and index versus non-index cases.FindingsOf the 61 612 individuals in the registry, 42 167 adults (21 999 [53·6%] women) from 56 countries were included in the study. Of these, 31 798 (75·4%) were diagnosed with the Dutch Lipid Clinic Network criteria, and 35 490 (84·2%) were from the WHO region of Europe. Median age of participants at entry in the registry was 46·2 years (IQR 34·3–58·0); median age at diagnosis of familial hypercholesterolaemia was 44·4 years (32·5–56·5), with 40·2% of participants younger than 40 years when diagnosed. Prevalence of cardiovascular risk factors increased progressively with age and varied by WHO region. Prevalence of coronary disease was 17·4% (2·1% for stroke and 5·2% for peripheral artery disease), increasing with concentrations of untreated LDL cholesterol, and was about two times lower in women than in men. Among patients receiving lipid-lowering medications, 16 803 (81·1%) were receiving statins and 3691 (21·2%) were on combination therapy, with greater use of more potent lipid-lowering medication in men than in women. Median LDL cholesterol

Journal article

Watkinson F, Dharmayat K, Mastellos N, 2021, A mixed-method service evaluation of health information exchange in England: technology acceptance and barriers and facilitators to adoption, BMC Health Services Research, Vol: 21, Pages: 1-13, ISSN: 1472-6963

Background The need for information exchange and integrated care has stimulated the development of interoperability solutions that bring together patient data across the health and care system to enable effective information sharing. Health Information Exchange (HIE) solutions have been shown to be effective in supporting patient care, however, user adoption often varies among users and care settings. This service evaluation aimed to measure user acceptance of HIE and explore barriers and facilitators to its wider uptake. Methods A mixed-method study design was used. A questionnaire was developed using the Unified Theory of Acceptance and Use of Technology and administered to HIE users to assess technology acceptance. Pearson Chi² tests were used to examine differences in acceptance between user groups and care settings. Web-based, semi-structured interviews were conducted drawing on the Normalisation Process Theory to explore barriers and facilitators to adoption. Interview data were analysed thematically using the Framework Approach. Results A total of 105 HIE users completed the survey and another 12 participated in the interviews. Significant differences were found in HIE acceptance between users groups and care settings, with high adopters demonstrating higher acceptance and social care users showing lower acceptance. Participants identified several drivers to adoption, including increased information accessibility, better care coordination, informed decision-making, improved patient care, reduced duplication of procedures, and time and cost savings. However, they also highlighted a number of barriers, such as lack of awareness about the solution and its value, suboptimal communication strategies, inadequate training and lack of resources for knowledge dissemination, absence of champions to support the implementation, lack of end-user involvement in the implementation and evaluation of HIE, unclear accountability and responsibility for the overall success

Journal article

Brandts J, Dharmayat KI, Vallejo-Vaz AJ, Azar Sharabiani MT, Jones R, Kastelein JJP, Raal FJ, Ray KKet al., 2021, A meta-analysis of medications directed against PCSK9 in familial hypercholesterolemia, Atherosclerosis, Vol: 325, Pages: 46-56, ISSN: 0021-9150

BACKGROUND AND AIMS: Several medications targeting PCSK9 reduce LDL-cholesterol (LDL-C) in heterozygous familial hypercholesterolemia (HeFH). We aimed to assess in patients diagnosed clinically as HeFH, whether LDL-C reduction varied by different therapeutic approaches to PCSK9-targeting or by the underlying genetic variant. METHODS: We conducted a random-effects meta-analysis of randomised clinical trials assessing PCSK9-targeting therapies, namely alirocumab, evolocumab and inclisiran, in patients with clinically diagnosed HeFH and restricted analyses to those patients in whom genotypic data were available. A search of MEDLINE and Embase identified eligible trials published between inception and June 29, 2020. We included trials of sufficient duration to allow for a stable treatment effect: ~12 weeks for monoclonal antibodies (mAbs) (alirocumab, evolocumab) and ~1 year for small interfering RNA (siRNA) (inclisiran). Single-moderator meta-regression comparing mean percentage LDL-C reduction between mAbs and siRNA as well as PCSK9-targeting therapies between different genotypes was used to assess heterogeneity. RESULTS: Eight trials of HeFH met our inclusion criteria, including 1887 genotyped patients. Among monogenic HeFH cases (N = 1347) the LDL-C reduction from baseline was 46.12% (95%CI 48.4-43.9) for siRNA and 50.4% (59.3-41.4) for mAbs compared to control, without evidence of significant heterogeneity between treatment (QM = 0.32, df = 1, p = 0.57). Irrespective of therapeutic approach to PCSK9-targeting, reductions in LDL-C were generally consistent across genetic variants (LDL-Receptor variants, LDL-Receptor variants of unknown significance, Apolipoprotein B variants, two variants and no variant) (QM = 8.3, df = 4, p = 0.08). CONCLUSIONS: Among patients with HeFH, the LDL-C-lowering effect of PCSK9-targeting medications did not show statistical heterogeneity across different drug-classes a

Journal article

Dharmayat K, Woringer M, Mastellos N, Cole D, Car J, Ray S, Khunti K, Majeed A, Ray KK, Seshasai SRKet al., 2020, Investigation of Cardiovascular Health and Risk Factors Among the Diverse and Contemporary Population in London (the TOGETHER Study): Protocol for Linking Longitudinal Medical Records (Preprint), JMIR Research Protocols, ISSN: 1929-0748

<sec> <title>BACKGROUND</title> <p>Global trends in cardiovascular disease (CVD) exhibit considerable interregional and interethnic differences, which in turn affect long-term CVD risk across diverse populations. An in-depth understanding of the interplay between ethnicity, socioeconomic status, and CVD risk factors and mortality in a contemporaneous population is crucial to informing health policy and resource allocation aimed at mitigating long-term CVD risk. Generating bespoke large-scale and reliable data with sufficient numbers of events is expensive and time-consuming but can be circumvented through utilization and linkage of data routinely collected in electronic health records (EHR).</p> </sec> <sec> <title>OBJECTIVE</title> <p>We aimed to characterize the burden of CVD risk factors across different ethnicities, age groups, and socioeconomic groups, and study CVD incidence and mortality by EHR linkage in London.</p> </sec> <sec> <title>METHODS</title> <p>The proposed study will initially be a cross-sectional observational study unfolding into prospective CVD ascertainment through longitudinal follow-up involving linked data. The government-funded National Health System (NHS) Health Check program provides an opportunity for the systematic collation of CVD risk factors on a large scale. NHS Health Check data on approximately 200,000 individuals will be extracted from consenting general practices across London that use the Egton Medical Information Systems (EMIS) EHR software. Data will be analyzed using appropriate statistical techniques to (1) determine the cross-sectional burden of CVD risk factors and their prospective association with CVD outcomes

Journal article

Brandts J, Dharmayat KI, Ray KK, Vallejo-Vaz AJet al., 2020, Familial hypercholesterolemia: is it time to separate monogenic from polygenic familial hypercholesterolemia?, Current Opinion in Lipidology, Vol: 31, Pages: 111-118, ISSN: 0957-9672

PURPOSE OF REVIEW: This review explores the concepts of monogenic and the so-called polygenic familial hypercholesterolemia and how the identification of familial hypercholesterolemia as a monogenic condition and its separation from polygenic primary hypercholesterolemia may have implications for clinical practice. RECENT FINDINGS: Through genetic testing, a mutation in any of the three known autosomal dominant familial hypercholesterolemia-causing genes is found in 60-80% of cases with a clinical diagnosis of definite familial hypercholesterolemia. As individuals with a polygenic basis for their hypercholesterolemia do not follow the same inheritance pattern observed in monogenic familial hypercholesterolemia, the use of family-based cascade screening in individuals with a polygenic origin is not recommend, as only 30% of relatives have an elevated LDL-C compared to the 50% in monogenic families. The presence of a causative monogenic mutation associates the highest cardiovascular risk vs. not having a mutation or having a polygenic background, providing prognostic information independent of LDL-C. It may also help assess intensity of interventions. Treatment adherence also seems to be higher after monogenic confirmation of hypercholesterolemia. SUMMARY: Knowledge about the genetic status of an individual with clinical familial hypercholesterolemia (monogenic vs. polygenic) can provide a more informed understanding to evaluating risk, managing disease and opportunities for screening strategies.

Journal article

Hu P, Dharmayat KI, Stevens CAT, Sharabiani MTA, Jones RS, Watts GF, Genest J, Ray KK, Vallejo-Vaz AJet al., 2020, Prevalence of familial hypercholesterolemia among the general population and patients with atherosclerotic cardiovascular disease: a systematic review and meta-analysis., Circulation, Vol: 141, Pages: 1742-1759, ISSN: 0009-7322

Background:Contemporary studies suggest that familial hypercholesterolemia (FH) is more frequent than previously reported and increasingly recognized as affecting individuals of all ethnicities and across many regions of the world. Precise estimation of its global prevalence and prevalence across World Health Organization regions is needed to inform policies aiming at early detection and atherosclerotic cardiovascular disease (ASCVD) prevention. The present study aims to provide a comprehensive assessment and more reliable estimation of the prevalence of FH than hitherto possible in the general population (GP) and among patients with ASCVD.Methods:We performed a systematic review and meta-analysis including studies reporting on the prevalence of heterozygous FH in the GP or among those with ASCVD. Studies reporting gene founder effects and focused on homozygous FH were excluded. The search was conducted through Medline, Embase, Cochrane, and Global Health, without time or language restrictions. A random-effects model was applied to estimate the overall pooled prevalence of FH in the general and ASCVD populations separately and by World Health Organization regions.Results:From 3225 articles, 42 studies from the GP and 20 from populations with ASCVD were eligible, reporting on 7 297 363 individuals/24 636 cases of FH and 48 158 patients/2827 cases of FH, respectively. More than 60% of the studies were from Europe. Use of the Dutch Lipid Clinic Network criteria was the commonest diagnostic method. Within the GP, the overall pooled prevalence of FH was 1:311 (95% CI, 1:250–1:397; similar between children [1:364] and adults [1:303], P=0.60; across World Health Organization regions where data were available, P=0.29; and between population-based and electronic health records–based studies, P=0.82). Studies with ≤10 000 participants reported a higher prevalence (1:200–289) compared with larger cohorts (1:365–407; P<0.001). The pooled pre

Journal article

Dharmayat K, Tran T, Hardy V, Chirambo G, Thompson M, Ide N, Carlsson S, Andersson B, O'Donoghue J, Mastellos Net al., 2019, Sustainability of ‘mHealth’ interventions in sub-Saharan Africa: a stakeholder analysis of an electronic community case management project in Malawi, Malawi Medical Journal, Vol: 31, Pages: 177-183, ISSN: 1995-7270

BackgroundThe global health community as well as the funding agencies are currently engaged in ensuring a greater focus on worthwhile research-based programmes are sustainable. Despite its importance, few studies have analysed the sustainability of global health interventions. In this paper, we aim to explore the barriers and facilitators for the wider implementation and sustainability of a mobile health (mHealth) intervention (Supporting LIFE Community Case Management programme) in Malawi, Africa.MethodsBetween January to March 2017, a qualitative approach was employed involving 13 in-depth semi-structured interviews with key stakeholders across all levels of healthcare provision in Malawi to explore their perceptions on the implementation and sustainability of the mHealth programme. Data were analysed thematically by two reviewers. ResultsThe findings indicate that, overall, the programme was successful in achieving its goals. However, absence of monetary resources, the limited visibility outside the healthcare sector, the lack of integration with community-based and nationwide programmes, services and information and communication technologies, and the limited local capacity in relation to the maintenance, further development, and management of the programme present challenges to its wider implementation and sustainability.ConclusionsFuture developments should be aligned with the strategic goals and interests of the Ministry of Health and engage with national and international stakeholders to develop shared goals and strategies for nationwide scale-up. They should also focus on building local capacity through training of trainers and ensure that training methods and guidelines are appropriately accredited based on national policies. These findings provide a framework for a variety of stakeholders who are engaged in sustaining mHealth programmes in resource-poor settings and can be used to inform evidence based policy in utilising technology for healthcare deliver

Journal article

Ide N, Hardy V, Chirambo B-G, Heavin C, O'Connor Y, O'Donoghue JM, Mastellos N, Dharmayat K, Andersson B, Carlsson S, Adamson MS, Thompson Met al., 2019, "People welcomed this innovation with two hands”: A qualitative report of an mHealth intervention for community case management in Malawi, Annals of Global Health, Vol: 85, Pages: 61-70, ISSN: 2214-9996

IntroductionCommunity Case Management (CCM) aims to improve outcomes among children under-5 with malaria, diarrhea, and pneumonia, but its effectiveness in Malawi is limited by inconsistent standards of delivery, characteristic of paper-based interventions. This may lead to negative impacts on child health outcomes and inefficient use of health system resources. This study evaluated the acceptability and impact of the Supporting LIFE Community Case Management App (SL eCCM App) by Health Surveillance Assistants (HSAs) and caregivers in two districts of Northern Malawi. MethodsData were collected through semi-structured interviews with HSAs and caregivers as part of a nested study within a larger trial. We used deductive and inductive approaches to data analysis. Relevant constructs were identified from the Consolidated Framework for Implementation Research and combined with emerging concepts from the data. The Framework Method was used to chart and explore data, leading to the development of themes. Results17 HSAs and 28 caregivers were interviewed. Participants were generally enthusiastic about the SL eCCM App. Nearly all HSAs expressed a preference for the App over routine paper-based CCM. Most HSAs claimed the App was more reliable and less error prone, facilitated more accurate diagnoses and treatment recommendations, and enhanced professional confidence and respect in the community. Some HSAs believed additional features would improve usability of the App, others identified mobile network or electricity shortages as barriers. Not all caregivers understood the purpose of the App, but most welcomed it as a health and technological advancement. ConclusionThe SL eCCM App is acceptable to both HSAs and caregivers, and in most cases, preferred, as it was believed to foster improvements in CCM delivery. Our findings suggest that mobile health interventions for CCM, such as the SL eCCM App, may have potential to improve the effectiveness and efficiency of care to chil

Journal article

Woringer M, Dharmayat KI, Greenfield G, Bottle A, Ray KKet al., 2019, American Heart Association's Cholesterol CarePlan as a smartphone-delivered web app for patients prescribed cholesterol-lowering medication: Protocol for an observational feasibility study, JMIR Research Protocols, Vol: 8, ISSN: 1929-0748

Background: Adoption of healthy lifestyle and compliance with cholesterol-lowering medication reduces the risk of cardiovascular disease (CVD). The use of digital tools and mobile technology may be important for sustaining positive behavioral change.Objective: The primary objective of this study is to evaluate the feasibility and acceptability of administering the Cholesterol CarePlan Web app developed by the American Heart Association aimed at improving lifestyle and medication adherence among patients prescribed cholesterol-lowering medication. The secondary objective is to assess the Web app’s efficacy.Methods: A prospective, observational feasibility study will be conducted to demonstrate whether the Web app may be successfully taken up by patients and will be associated with improved clinical and behavioral outcomes. The study will aim to recruit 180 study participants being prescribed cholesterol-lowering medication for at least 30 days across 14 general practices in London, England. Potentially eligible patients will be invited to use the Web app on a smartphone and visit general practice for three 20-minute clinical assessments of blood pressure, height, weight, smoking, and nonfasting cholesterol over 24 weeks. The feasibility of administering the Web app will be judged by recruitment and dropout statistics and the sociodemographic and comorbidity profile of consenting study participants, consenting nonparticipants, and all potentially eligible patients. Acceptability will be assessed using patients’ readiness to embrace new technologies, the usability of the Web app, and patient satisfaction. The efficacy of the Web app will be assessed by changes in medication adherence and clinical risk factors by levels of the Web app compliance.Results: This study is currently funded by the American Heart Association. Initial study recruitment will take place between February and July 2018 followed by patient follow-up. Patient level data will be obtained i

Journal article

Woringer M, Dharmayat KI, Greenfield G, Bottle A, Ray KKet al., 2018, American Heart Association’s Cholesterol CarePlan as a Smartphone-Delivered Web App for Patients Prescribed Cholesterol-Lowering Medication: Protocol for an Observational Feasibility Study (Preprint), JMIR Research Protocols, ISSN: 1929-0748

<sec> <title>BACKGROUND</title> <p>Adoption of healthy lifestyle and compliance with cholesterol-lowering medication reduces the risk of cardiovascular disease (CVD). The use of digital tools and mobile technology may be important for sustaining positive behavioral change.</p> </sec> <sec> <title>OBJECTIVE</title> <p>The primary objective of this study is to evaluate the feasibility and acceptability of administering the Cholesterol CarePlan Web app developed by the American Heart Association aimed at improving lifestyle and medication adherence among patients prescribed cholesterol-lowering medication. The secondary objective is to assess the Web app’s efficacy.</p> </sec> <sec> <title>METHODS</title> <p>A prospective, observational feasibility study will be conducted to demonstrate whether the Web app may be successfully taken up by patients and will be associated with improved clinical and behavioral outcomes. The study will aim to recruit 180 study participants being prescribed cholesterol-lowering medication for at least 30 days across 14 general practices in London, England. Potentially eligible patients will be invited to use the Web app on a smartphone and visit general practice for three 20-minute clinical assessments of blood pressure, height, weight, smoking, and nonfasting cholesterol over 24 weeks. The feasibility of administering the Web app will be judged by recruitment and dropout statistics and the sociodemographic and comorbidity profile of consenting study participants, consenting nonparticipants, and all potentially eligible patients. Acceptability will be assessed using patients’ readiness to embrace new technologies, the usa

Journal article

Mastellos N, Tran T, Dharmayat K, Cecil E, Hsin-yi L, Wong C, Mkandawire W, Ngalande E, Wu JT-S, Hardy V, Chirambo BG, O'Donoghue JMet al., 2018, Training community healthcare workers on the use of information and communication technologies: a randomised controlled trial of traditional versus blended learning in Malawi, Africa, BMC Medical Education, Vol: 18, ISSN: 1472-6920

Background: Despite the increasing uptake of information and communication technologies (ICT) within healthcare services across developing countries, community healthcare workers (CHWs) have limited knowledge to fully utilise computerised clinical systems and mobile apps. The ‘Introduction to Information and Communication Technology and eHealth’ course was developed with the aim to provide CHWs in Malawi, Africa, with basic knowledge and computer skills to use digital solutions in healthcare delivery. The course was delivered using a traditional and a blended learning approach. Methods: Two questionnaires were developed and tested for face validity and reliability in a pilot course with 20 CHWs. Those were designed to measure CHWs’ knowledge of and attitudes towards the use of ICT, before and after each course, as well as their satisfaction with each learning approach. Following validation, a randomised controlled trial was conducted to assess the effectiveness of the two learning approaches. A total of 40 CHWs were recruited, stratified by position, gender and computer experience, and allocated to the traditional or blended learning group using block randomisation. Participants completed the baseline and follow-up questionnaires before and after each course to assess the impact of each learning approach on their knowledge, attitudes, and satisfaction. Per-item, pre-post and between-group, mean differences for each approach were calculated using paired and unpaired t-tests, respectively. Per-item, between-group, satisfaction scores were compared using unpaired t-tests.Results: Scores across all scales improved after attending the traditional and blended learning courses. Self-rated ICT knowledge was significantly improved in both groups with significant differences between groups in seven domains. However, actual ICT knowledge scores were similar across groups. There were no significant differences between groups in attitudinal gains. Satisfaction

Journal article

Cowling TE, Richards EC, Gunning E, Harris MJ, Soljak MA, Nowlan N, Dharmayat K, Johari N, Majeed Aet al., 2015, Online data on opening hours of general practices in England: a comparison with telephone survey data, British Journal of General Practice, ISSN: 1478-5242

Journal article

Gregson S, Dharmayat K, Pereboom M, Takaruza A, Mugurungi O, Schur N, Nyamukapa CAet al., 2015, Do HIV prevalence trends in antenatal clinic surveillance represent trends in the general population in the antiretroviral therapy era? The case of Manicaland, East Zimbabwe, AIDS, Vol: 29, Pages: 1845-1853, ISSN: 0269-9370

Objective: National estimates of HIV trends in generalized epidemics rely on HIV prevalence data from antenatal clinic (ANC) surveillance. We investigate whether HIV prevalence trends in ANC data reflect trends in men and women in the general population during the scale-up of antiretroviral therapy (ART) in Manicaland, Zimbabwe.Methods: Trends in HIV prevalence in local ANC attendees and adults aged 15–49 years in towns, agricultural estates, and villages were compared using five rounds of parallel ANC (N = 1200) and general-population surveys (N = 10 000) and multivariable log-linear regression. Changes in the age pattern of HIV prevalence and the age distribution of ANC attendees were compared with those in the general population. Age-specific pregnancy prevalence rates were compared by HIV infection and ART status.Results: Cumulatively, from 1998–2000 to 2009–2011, HIV prevalence fell by 60.0% (95% confidence interval, 51.1–67.3%) in ANC surveillance data and by 34.3% (30.8–37.7%) in the general population. Most of the difference arose following the introduction of ART (2006–2011). The estates and villages reflected this overall pattern but HIV prevalence in the towns was lower at local ANCs than in the general population, largely because of attendance by pregnant women from outlying (lower prevalence) areas. The ageing of people living with HIV in the general population (52.4% aged >35 years, 2009–2011) was under-represented in the ANC data (12.6%) because of lower fertility in older and HIV-infected women.Conclusion: After the introduction of ART in Manicaland, HIV prevalence declined more steeply in ANC surveillance data than in the general population. Models used for HIV estimates must reflect this change in bias.

Journal article

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